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Based on review of facility documents, on-call schedules, and staff interviews (EMP), it was determined that the facility failed to have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control.

Findings include:

Review of the " UPMC Bedford Memorial Department of Emergency Medicine, Rules and Regulations," dated 08, 208 [sic], revealed " ... The call roster currently contains sections for: Primary Care: General Medicine-Hospitalist, Obstetrics, Pediatrics; Other: Anesthesiology, Cardiology; Surgery and Surgical Subspecialties: ENT [Ear Nose Throat], General Surgery, Ob-Gyn [Obstetrics Gynecology], Ophthalmology, Oral-Maxillofacial, Orthopedic Surgery; Medical Imaging; Pathology; Podiatry; and Urology ... The use of specialized consultation and transfer will adhere to hospital policy and meet the requirements of existing statute. No patient will be transferred without being accepted for transfer by the receiving attending physician and institution. If a patient is transferred, the EDP/ED-PE must complete the appropriate Transfer Form (s). In the case of the transfer form(s) being completed by and ED-PE, the form (s) will be co-signed by the on-duty EDP. Transfer agreements have been made with other hospitals in order to comply with EMTALA when the need arises to expeditiously transfer an unstable patient ... ."
Review of "UPMC Policy and Procedure Policy: HS-LE000: Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011 I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC 1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals. Each hospital may develop its own procedures for implementing this policy, provided that such procedures are consistent with the policy ... 5. Following the Medical Screening Exam, a patient may be transferred if requested by the patient or their representative, after being notified of the risks and benefits of the transfer. If the hospital determines that it does not have appropriate medical and/or staffing resources to properly stabilize the patient, transfer to an appropriate facility may be made if a physician certified in writing that the medical benefits of the transfer are expected to outweigh the risks of transfer; or if a QMP certifies in writing that the benefits of transfer are expected to outweigh the risks of transfer, and such certification is co-signed by a physician. When a patient is transferred the consent of the receiving hospital to accept the transfer must be first obtained and documented in the medical record. In the case of transfer from UPMC facility, the UPMC facility shall send to the receiving facility, copies of all pertinent medical records available the time of transfer, and affect the transfer through qualified personnel and transportation equipment ... Each UPMC hospital's Emergency Department [ED] shall maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition. Physicians on-call are required to personally attend to the patient when requested to do so by the treating physician ... 13. Each UPMC hospital shall maintain policies and procedures to (a) respond to situations in which a particular specialty physician is not available or if on-call physician is not able to respond due to circumstances beyond his or her control; and (b) provide that emergency services are available if the hospital elects to permit its on-call physicians to schedule elective surgery during the time that they are on call or permit physicians to participate in simultaneous on-call service ... ."

1) A review of MR1 revealed the patient presented post motor vehicle accident with left arm deformity, and confirmed fracture and foreshortening of the radius and ulna and a distal fracture of the radius. Physician documentation in the medical record revealed that the Orthopod was out of town. Documentation in the medical record indicated that the patient was medicated for pain, and a splint was applied. The patient was provided with X-rays and stated that the patient was traveling home and going right to the ER [Emergency Room] to be evaluated. The physician documented that they did not believe at this time, patient needs to have surgery emergently ... ."
2) Review of the On-Call Schedule for Orthopedics for June 17, 2011, revealed the physician was "semi-available," but not on call.
3) Interview was conducted with EMP6 on June 28, 2011, at 1:28 PM. EMP6 was queried in regard to Emergency Department policy and procedure to direct staff on the process of what to do in the event that an on call specialist is unavailable. EMP6 confirmed that there is no ED policy and procedure to assist staff in the event a specialist physician is unavailable. EMP6 stated, "I do not know of that being in any of our bylaws [ED Bylaws], but it could be in the specialist bylaws. When required to take call, they are very good about it. We have no problem with coverage. If a specialist is unavailable, the staff would call a referral hospital."

Based on review of facility documents, review of closed medical records (MR), and staff interviews (EMP), it was determined that the facility failed to maintain a central log on each individual who comes to the dedicated emergency department, as defined in 489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

Findings include:

Review of "Review of "UPMC Policy and Procedure Policy: HS-LE007, Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011 I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC 1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals ... 12. Each hospital facility shall maintain a central log in the Emergency Department identifying each individual that seeks emergency medical treatment at that facility, and indicate whether they refused treatment, or whether they were transferred, admitted, or discharged. These logs shall be retained for three (3) years. 13. Each UPMC hospital shall maintain policies and procedures to (a) respond to situations in which a particular specialty physician is not available or if on-call physician is not able to respond due to circumstances beyond his or her control; and (b) provide that emergency services are available if the hospital elects to permit its on-call physicians to schedule elective surgery during the time that they are on call or permit physicians to participate in simultaneous on-call service. Off Campus Locations 1. For off-campus sites that do not meet the definition of a Dedicated Emergency Department, the site personnel should activate their local EMS process and render appropriate assistance. 2. A log of all emergency events will be maintained at each off campus site and a copy submitted to the Hospital Compliance Officer, or designee, on a quarterly basis. ... ."

Review of the "UPMC Bedford Memorial Department of Emergency Medicine, Rules and Regulations," dated 08, 208 [sic], revealed, " ... A control register log will be maintained in the ED. An entry will be made for any patient who utilizes the services of the ED. All times will noted in military time. The log will contain, at a minimum, the following information on each patient visit: patient identification data, date and time of arrival, time seen by physician, time of disposition, disposition, final ED diagnosis, name of treating physician, and any consultants, etc, triage level, charge level, diagnostic studies, by department ... 4. Patient Care. Upon presentation to the ED, patients will be triaged by the nursing staff ... ."

Review of Department Of Emergency Services Policy and Procedure "Title: OB Patients Presenting To The Emergency Department, Date Issued 9/1996, Reviewed: ... 2/10 ... Procedure: 1. Any pregnant female presenting at 16 weeks gestation or later and is reporting vaginal bleeding, ruptured membranes, or contractions is taken immediately to the OB Department for evaluation. 2. The Emergency Department Staff will contact the OB Department with the patient's name, OBMD, chief complaint, and date of confinement."

1) A review of the OB "Register of Visits" dated May 1, 2011, to June 27, 2011, revealed no documented evidence if a patient was scheduled or unscheduled when presenting to the OB department. Further observation of the Register of Visits revealed that the register did not indicate whether the patients were transferred, stabilized and transferred, or discharged.

Interview with EMP8 confirmed the above findings.

2) Review of the scheduled appointment log book for outpatient testing was reviewed. During an interview with EMP8, on June 27, 2011, at approximately 02:00 PM, revealed "This is an incomplete log book, we cannot tell who was emergent and who was scheduled. The nurses do not always enter the patients into the log book."

3) Review of the OB "Register of Visits" dated June 1, 2011, to June 27, 2011, revealed that 98 patients presented to the OB department. The register revealed that seventeen of the ninety-eight patients were admitted to the unit. Of the ninety-eight patients, the register did not reveal if the patients were scheduled or unscheduled in presenting to the unit. The register was also inconsistent in documentation of "reason" of why the patient presented.

Interview with EMP8, Unit Manager on June 27, 2011, at approximately 11:00 AM, revealed, "We have no policy on the log book. We just keep it for us. We cannot pull up a log of patients on the computer. There is no way to tell where they (patients) came from. You can't tell if they were in the emergency department. We register them here."

4) The facility determined and it was confirmed by EMP 2, that on May 2011, 40% of the patients that presented to the OB department were unscheduled visits. In June 2011, 30% of the patients that presented to the OB department were unscheduled visits.

EMP2 confirmed the above findings and revealed "We [staff] went through every medical record on the register to determine if it was scheduled or unscheduled."

Based on review of facility documents, closed medical records (MR) and staff interviews (EMP), it was determined that the facility failed to provide an appropriate medical screening examinations for two of ten OB medical records (MR) reviewed (MR2, MR3).

Findings include:

Review of "UPMC Policy and Procedure Policy: HS-LE000: Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011 I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals. 3. Medical Screening Exam (MSE) is an appropriate exam within the capacity of the hospital to determine whether an emergency medical condition exists. ... 5. Qualified Medical Person ("QMP") is defined as a licensed physician or other appropriately qualified individual as determined by each hospital in their respective by-laws or rules and regulations. V. Procedure 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a shall offer a Medical Screening Exam to such person. ... ."

1) Review of MR 2 dated March 25, 2011, revealed no documented evidence of patient receiving a medical screen from physician. Further review of MR2 revealed, " ... Complaint "I've had on-going GB [Gall Bladder] issues with this pregnancy, and it really hurts now. I am to see Dr.[surgeon] General Surgeon, from Summit Health next week for my GB and couldn't wait. I had an US [Ultrasound] done last week of my GB, and my doctor is sending me to the surgeon" ... Orders Received Yes ... Phoned Dr. ... with pt update. Strip reactive, has some slight uterine irritability which pt does not feel. As baby appears fine on strip. Dr. ... advised pt to go to ... regular OB dept, for them to help facilitate ... seeing the surgeon ASAP. ... Discharge Instructions ... go there now Follow-UP at: Chambersburg Hospital."

Interview with EMP8 on June 28, 2011, at 1:50 PM confirmed the above findings of MR2 and revealed "There is no documentation that the physician saw this patient."

2) Review of MR3 dated May 19, 2011, revealed no documented evidence of a medical screen from a physician. Further review of MR3 revealed "Obstetric Evaluation Summary ... To: 208 D By: Walk ... From X Home ... Evaluation, Procedure(s): ... X Unscheduled X NST ... Indication(s): MVA today ...Notes: MVA 1040 today - was stopped to yield onto the bypass another car hit her from the rear, no injury to self or vehicle, denies any contracts. 1330 Infant very active ... no contractions seen. Dr called - orders obtained to D/C home ... initials of EMP22. ... Orders ... NST v/o Dr. .../EMP22 D/C home to be seen in office tomorrow. T/O Dr. ... /EMP22. ... ."

Interview with EMP8 on June 28, 2011 at 2:00 PM confirmed the above findings of MR3 and revealed, "there is no medical screening by a physician."

Additional Findings:

Based on review of facility documents, closed medical records (MR), and staff interviews (EMP), on August 2, 2011, it was determined that the facility failed to provide an appropriate medical screening examination for one of nine OB medical records reviewed. (MR1)

Review of "UPMC Policy and Procedure Policy: HS-LE000: Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011 I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals. 3. Medical Screening Exam (MSE) is an appropriate exam within the capacity of the hospital to determine whether an emergency medical condition exists. ... 5. Qualified Medical Person ("QMP") is defined as a licensed physician or other appropriately qualified individual as determined by each hospital in their respective by-laws or rules and regulations. V. Procedure 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a shall offer a Medical Screening Exam to such person. ... 3. If necessary, following the Medical Screening Exam, Qualified Medical Personnel shall offer further medical examination and such treatment as may be required to stabilize the medical condition within the hospital ' s resources ... ."
Review of UPMC Bedford Memorial's policy entitled "Vaginal Exams", dated June 2011, revealed "Policy: Vaginal examinations to assess the progress of labor by determining dilatation, station, and effacement are performed by Registered Nurses who have been trained by experienced Obstetrical nurses during orientation with physicians' assistance ... ."
Review of UPMC Bedford Memorial's "Department of Obstetrics/Gynecology Rules and Regulations", dated January 2008, revealed "... I. Type of Patient ...C. Obstetrical Hold for Observation Patients. 1. Patients that present with obstetrical problems are evaluated by the obstetrical nurse. These patients do not have to be evaluated by the attending physician/midwife. This applies to patients presenting with problems that the OB RN is competent to evaluate. The Obstetrician must be notified of all patients presenting for obstetrical care and disposition determinations are made by the physician. The Physician may make the care determination based on the information given by the Obstetrical Nurse ... ."
Review of UPMC Bedford Memorial policy entitled "Obstetrical Medical Screening", dated July 19, 2011, revealed "Purpose: To ensure that every patient that presents with a medical emergency receive a proper medical screening exam by a qualified provider/evaluator prior to leaving the hospital. Scope: Obstetric staff and Emergency Department staff. Policy: The pregnant patient will be screened to determine the appropriateness of services in either the Emergency Department or in Labor and Delivery. Definitions: A. Dedicated Emergency Department is any department or facility of the hospital, whether on or off campus that: (a) is licensed by the State as an emergency department; or (b) is held out to the public as a place that provides care for emergency medical conditions without an appointment; or (c) based on a representative sample of patient visits during the previous calendar year, provides at least one-third (1/3) of all its outpatient visits for the treatment of emergency medical conditions without an appointment. B. Emergency Medical Condition is "a medical condition manifesting itself by acute symptoms of sufficient severity ... such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; or with respect to a pregnant woman who is having contractions that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or the unborn child ". C. Medical Screening Exam (MSE) is an appropriate exam within the capability of the hospital to determine whether an emergency medical condition exists ... E. Qualified Medical Provider/Evaluator (QMP) is: 1. A licensed Obstetrician or Emergency Physician with staff privileges at this hospital. 2. A licensed or Certified Nurse Midwife with midwifery privileges at this hospital. 3. A registered nurse who has completed the probationary period and initial competencies in the Obstetrical Department. Procedure: Medical Screening of the OB Patient A. A pregnant patient 16 weeks or greater presenting with possible labor or having abdominal or vaginal symptoms will be escorted to the Obstetrical Department after the maternity nurses have been notified and will be given appropriate treatment: 1. Patients reporting to the OB Department may be evaluated by a qualified evaluator using the standard OB Evaluation form. 2. The patient will be scored as indicated on the OB Evaluation form and the score documented. Use the last value obtained for an item for the purpose of scoring. 3. If a patient is expected to deliver immediately, the OB Evaluation form need not be completed. 4. If the results of any scoring indicate that a physician exam is required , a MSE needs to be completed by the Obstetrician or Midwife. 5. Regardless of the score on any box, the Nurse Evaluator may request a physician exam for the purpose of patient safety. 6. Patients not requiring a physician exam may be discharged upon phone orders from the Obstetrician or Midwife. The patient should be given appropriate discharge instructions prior to leaving. The patient will be provided with a copy of the instructions and a singed and dated copy of the instructions will be placed in the medical record. 7. All phone contacts with the physician will be appropriately documented in the medical record. 8. Patients after exam by a physician or midwife as indicated by the scoring criteria, may be discharged upon the written order of a physician if: a. Delivery is not expected in the next 6 hours b. Discharge poses no risks to the mother or fetus 9. The patient should be given appropriate discharge instructions prior to leaving. The patient will be provided with a copy of the instructions and a signed and dated copy of the instructions will be placed in the medical record. 10. Nursing observation and nursing care will be documented in the medical record. Physician orders and exams will be documented in the medical record. B. A pregnant patient less than 16 weeks with abdominal or vaginal symptoms will be evaluated in the Emergency Department: 1. Fetal heart tones will be assessed with a Doppler stethoscope. 2. The ED physician shall complete the MSE and notify the Obstetrician as appropriate. C. A pregnant patient 16 weeks or greater presenting to the ED with medical problems or traumatic injuries not related to the pregnancy will be evaluated by the Emergency physician and given appropriate treatment: 1. The ED physician shall complete the MSE and notify the obstetrician as appropriate. 2. ED physician will treat medical condition and/or traumatic injuries. 3. ED nurses, OB nurses, and/or physician will assess fetal heart tones with a Doppler, as needed. D. A pregnant patient 16 weeks or greater presenting unscheduled directly to the OB department will be given the appropriate treatment: 1. The Qualified Nurse Evaluator will perform an initial assessment on the patient. 2. If it is determined that the patient is not experiencing a pregnancy related problem the patient may be safely escorted to the Emergency Department to receive a MSE by the ED physician as appropriate ... Documentation ...B. All medical screening exams must be documented."
Review of UPMC Bedford Memorial's policy entitled "OB Patients Presenting to the Emergency Department", dated July 2011, revealed "Procedure: 1. Any pregnant patient 16 weeks or greater presenting with possible labor or having abdominal or vaginal symptoms will be escorted to the Obstetrical Department after the maternity nurse have been notified by ED personnel ... 2. Any pregnant patient 16 weeks or greater presenting to the ED with medical problems or traumatic injuries not related to pregnancy will be evaluated by the Emergency physician and given appropriate treatment ... 3. Any pregnant patient 16 weeks or less presenting with abdominal or vaginal symptoms will be evaluated in the Emergency Department ... 4. All OB transfers will be documented in the Emergency Department Log if they are transferred to the OB department for further treatment."
1) A review of the document entitled "Appendix F UPMC Bedford Obstetric /EMTALA Department Patient Log" was completed on August 2, 2011, The log revealed that PT1 presented to the Obstetrics Department on July 24, 2011 at 2010 via ambulance. The log indicated that PT1 was unscheduled, and had not been seen by qualified medical personnel/evaluator. The log also indicated that PT1 was discharged to home.
A review of the patient's (PT1) "Obstetric Evaluation" contained within MR1 dated July 24, 2011, at 8:15 PM revealed, " ... OTH1, Patient: PT1, Regardless of score in any box, the nurse may request a physician exam for patient safety, Evaluator's Signature: [unmarked], Box A Checklist B/P 140/90 or > ... No, Headache ... No, Vomiting ... No, Visual Difficulties ... No, Epigastric Pain ... No, Total Box A ... 0. If patient has established objective labor pattern no contractions B/P stable low. ... Criteria Yes = 1. ... 2 or more = physician exam. ... Box B Checklist PARA ... 0, Duration LAST labor [unmarked], Prior C-Section ... No, Prenatal Care ... No, Prior Fetal Demise ... No, Multiple Gestation ... No, Cerclage or incompetent cervix ... No, Gestational Age 36 weeks, Total Box B, If patient has established objective labor pattern . ... Criteria ... 34-38 weeks = 2, Score 2 ... 3 or more = physician exam. ... Box C Checklist [unmarked]. ... "
Continued review of MR1 revealed EMS documentation dated July 24, 2011, which revealed, " ... Raystown Ambulance ... Dispatch: 19:33 ... Scene Information: Description: Pt sitting on bridge on side of road, holding abdomen. Husband with. ... Chief Complaint ... pt in labor. Duration: 2 hours ALS Assessment: Completed for Suspected Illness, History of Present Illness Dispatched by 911 for immediate response for 33 y/o female pt with chief complaint of being in labor. Pt is 35 weeks pregnant. Has been punched in the abdomen about 3-4 weeks ago with some bleeding. Non stress test done. Pt went home. Started with labor pains several hours ago. No discharge, water has not broken. Pt to cot, secured. To ambulance. VS taken. HPI and pMHX obtained. IV started kvo and pt placed on 3 l/m n/c. Contractions in ambulance were 2 in number, and lasted about 1-1 ? minutes. Medical command notified of patient condition with ETA of 5 minutes. Pt to go directly to OB floor. VS rechecked. No more contractions. Pt transported to UPMC Bedford without incident. To OB and report to staff RN. ... ."
Review of MR1 also revealed "LD-Flowsheet" nursing documentation dated July 24, 2011, at 8:11, which stated, "Stage of Pregnancy OB Triage ... Uterine Activity Monitor Mode-UA External, Contraction Frequency (min) none seen, Fetal Assessment Monitor Mode-Fetus A, FHR Baseline Rate 140, FHR Baseline Changes No Baseline Change, Variability Moderate 6-25bpm, Accelerations 15 x 15, Decelerations None. ... . 7/24/11 Annotation Comment ... 2027 Pt states (the patient's) had diarrhea x 2 days now. Last time today at 1700, denies eating spicy or greasy foods ... 20:38 Paged OTH1 who was on call and report given on findings with this pt. Orders received to do Q 15 min B/P/s x 2, if stable may go home and be seen by (the patient's) Dr. in Chambersburg this week. Orders for clean catch u/a to check for bacteria and ketones. Call back to OTH1 if u/a positive, otherwise if negative and b/p stable, pt. may go home. ... 7/24/11 Annotation Comment 21:53 report of u/a results called to OTH1, verbal orders to discharge pt to home. FOB (father of baby) wanted to talk to the Dr. insisting they want the baby taken tonight. Explained (the patient) is not in labor and we don't take or induce 36 week preg. unless medically indicated. Told to go home, drink lots of fluids and follow up with (the patient's) Dr. in Chambersburg with next appointment on Aug 2, or before if necessary. ... ."
Interview with EMP2 on August 2, 2011, at 2:25 PM, revealed " the evaluation is a medical screen for labor. That is all the nurses are doing. If it something more, the doc comes in or they come to the ED. " Regarding the Obstetrical Evaluation Tool, EMP2 stated that they are completed on every unscheduled patient and no matter what the nurse would have to talk to the physician.
Review of MR1 was conducted with EMP1 on August 2, 2011, at approximately 3:45 PM. EMP1 stated that this patient did not meet criteria to see the physician. EMP1 stated "I was on vacation when this patient was here. I probably would have had (the patient) see a doctor."

Based on review of facility documents, closed medical records (MR), and staff interviews (EMP), it was determined the facility failed to execute an appropriate transfer for two of 33 patients who had presented to the Emergency and Obstetrics Department, for treatment. (MR1, MR2)

Findings:

Review of "UPMC Policy and Procedure Policy: HS-LE000: Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011, I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals. Each hospital may develop its own procedures for implementing this policy, provided that such procedures are consistent with the policy ... 5. Following the Medical Screening Exam, a patient may be transferred if requested by the patient or their representative, after being notified of the risks and benefits of the transfer. If the hospital determines that it does not have appropriate medical and/or staffing resources to properly stabilize the patient, transfer to an appropriate facility may be made if a physician certified in writing that the medical benefits of the transfer are expected to outweigh the risks of transfer; or if a QMP certifies in writing that the benefits of transfer are expected to outweigh the risks of transfer, and such certification is co-signed by a physician. When a patient is transferred the consent of the receiving hospital to accept the transfer must be first obtained and documented in the medical record. In the case of transfer from UPMC facility, the UPMC facility shall send to the receiving facility, copies of all pertinent medical records available the time of transfer, and affect the transfer through qualified personnel and transportation equipment ... 13. Each UPMC hospital shall maintain policies and procedures to (a) respond to situations in which a particular specialty physician is not available or if on-call physician is not able to respond due to circumstances beyond his or her control; and (b) provide that emergency services are available if the hospital elects to permit its on-call physicians to schedule elective surgery during the time that they are on call or permit physicians to participate in simultaneous on-call service ... ."

Review of Administrative policy and procedure "Title: Transfer Policy/Procedure (Also See HS-LE007 EMTALA) Date Issued 11/91, ... Section General, Policy G34 ... Revised: ... 12/10 Policy: It is the policy of UPMC Bedford Memorial to comply with all applicable laws and regulations when initiating an interfacility transport of a patient. UPMC Bedford Memorial follows the UPMC Health System Policy HS-LE007. This policy address the UPMC Bedford Memorial specific procedures. Procedures: 1. Initiation of a patient transfer - The decision to transfer a patient is the ultimate responsibility of the physician. The patient should ideally be stable at the time of transfer. On recognizing the need for transfer: A) The physician will: 1) Determine the receiving hospital and verify a receiving physician. 2) Exchange clinical information with the receiving physician. 3) Determine the necessary level of medical care and life support equipment necessary during transfer. 4) Determine time frame for and order classification of transfer based on time elapsed from order given to patient leaving: a) Emergent (immediate) b) Urgent (within 1-2 hours), or c) Non-urgent 5. Determine and order mode of transfer: a) ALS or BLS Ground ambulance, or b) Helicopter 6) Explain the risks and benefits of transfer to the patient and family. Complete the physician section of the Transfer Form. B) The primary RN, charge RN, or his/her designee will: 1) Notify the agency of transport along with a report on all transfers. Emergency and Urgent Transfers a) Land Transfers-Call ambulance; Call County control at ... b) Helicopter - verify that arrangements have been confirmed. Non-Urgent Transfers a) Call ambulance; Call county Control if unable to secure an ambulance. B) Coach is called for non-urgent when appropriate. 2) Verify that the Transfer Form is completed. 3) Ensure the entire current chart is copied to send with the patient. 4) Verify time and bed availability with admissions office of receiving facility. 5) Give verbal report to transport staff. 6) Call report to nursing unit receiving the patient prior to their arrival. 7) Ensure all pre-transfer orders are carried out. 8) Notify the Nursing Supervisor. II Documentation of patient transfer - A) Physician documentation must include: 1) Informed risks and benefits of transfer, benefits must outweigh the risks except in a patient initiated transfer. 2) Chief Complaint, History & Physical, working diagnosis, and current status note. 3) Documentation of discussions with patient and/or family. 5) Transfer order 6) Ambulance Medical Necessity Form. 7) Physician section of the Transfer Form. B) Primary or Charge RN documentation must include: 1) Treatment given to patient and the patient's response. 2) Completion of the nursing section of the Transfer Form. 3) Documentation of report being called to nursing unit. 4) Continued to monitor and document changes in the patient's condition until the moment of transfer. ... D) Physician Not Present At Time of Transfer 1) Physician must discuss the risks/benefits with the patient or responsible party. 2) A verbal order for transfer may be taken from the physician if and only if: a) The discussion with the patient/family has taken place via telephone, and b) The physician is not present in the institution. 3) The verbal order section on the Transfer from must be completed by nursing. 4) The physician ordering transfer must co-sign the order. 5) Forms may be faxed per policy. E) Nondiscrimination A participating hospital that has specialized capabilities or facilities shall not refuse to accept an appropriate transfer of a patient who requires such specialized capabilities. There will be no delay of medical screening or transfer order to inquire about the individual's method of payment or insurance status. Should an institution refuse to accept such a patient the institution shall be reported within 72 hours and as per HS-LE007."
1) A review of the patient's medical records from UPMC Bedford (MR1) and York Hospital (MR 34) was completed.
MR1 revealed the patient presented post motor vehicle accident with left arm deformity, and confirmed fracture and foreshortening of the radius and ulna and a distal fracture of the radius. Physician documentation in the medical record revealed that the orthopod was out of town. Documentation in the medical record indicated that the patient was medicated for pain and a splint was applied. The patient was provided with xrays and stated that the patient was traveling home and going right to the ER [Emergency Room] to be evaluated. The physician documented that they did not believe at this time, patient needs to have surgery emergently.

Review of MR34, dated June 17, 2011, through June 18, 2011, revealed, "ED Phys Note: ... Time seen 6/17/2011 8:03 PM, seen with [OTH1] ... Arrival mode: Private vehicle ... Additional Information: Chief complaint from Nursing Triage Note: Chief Complaint, 6/17/2011 7:07 PM Chief complaint: Pt states restrained driver involved in MVC in Bedford, PA. ... Pt seen in ER in Bedford. Xrays with pt. Pt states L arm fx and requiring surgery. Pt states L arm pain 10/10. ... History of Present Illness ... Additional history: Pt was at UPMC Bedford this afternoon s/p MVC. [Pt] was unable to see an orthopedist s/p L arm fracture and was told that [MR34] may follow-up with [MR34] local trauma hospital today. [MR34] fracture was not reduced and was splinted. ... Addendum Teaching-Supervisory Addendum Brief ... Notes: Patient in MVC in Western Pennsylvania. Seen in ED at UPMC Bedford and x-rays show multiple fractures of the left arm. Apparently no orthopedic surgeon there so patient d/c to drive back to York to see orthopedics. Segmental fxs, of radius and ulnar fx as well. Patient with no orthopedic preference. ... Pt reports [MR34] has a comminuted fracture of the L forearm and there was no orthopedist available to treat [MR34]. Therefore, pt was splinted without reduction and given percocet at discharge with instructions to follow-up with [MR34] local trauma center.

Telephone interview with EMP24 on June 30, 2011, at 10:40 AM, revealed, "[Patient] had a bad fracture. Our Orthopod was out of town. I told the Orthopod that [patient] would need surgery but it was not emergent. [Patient] said they were going to go to [patient's] own hospital or ED. I didn't diagnose an open fracture. If it was, it would have required antibiotics and would need fixed. There could have been a tiny open fracture that I missed, that would require more to be done. We discussed [patient] going to a trauma center, but after reviewing everything, [patient] was discharged stable knowing that they would need more attention to the arm."

Telephone interview with EMP13 on June 30, 2011, at 11:10 AM, revealed, " ... He contacted the ortho specialist in [patient's] area. [Patient's] main concern was that [patient] wanted to go back home to [patient's] area. The patient stated that [patient] wanted to go back home because they were on the way home when the accident happened. I don't recall any conversation about going to a trauma center. ... [Patient] was discharged from our emergency room with the understanding that [patient] was going straight to [patient's] hospital. We gave [patient] specific instructions that [patient] needed to be seen.

Telephone interview with EMP26 on June 30, 2011, at 12:45 PM, revealed , "... [Patient] was discharged after that as far as I know. I thought [EMP24] said something about a trauma center. The daughter, I guess it was the daughter, didn't want to go to Johnstown and wanted to go closer to home. The patient was a little out of it because of the pain.

2) Review of MR2 dated March 25, 2011, revealed no documented evidence of patient
receiving a medical screen from physician. Further review of MR2 revealed " ... Complaint: "I've had on-going GB issues with this pregnancy, and it really hurts now. I am to see Dr.[surgeon] General Surgeon, from Summit Health next week for my GB and couldn't wait. I had an US done last week of my GB, and my doctor is sending me to the surgeon" ... Orders Received Yes ... : Phoned Dr. ... with pt update. Strip reactive, has some slight uterine irritability which pt does not feel. As baby appears fine on strip. Dr. ... advised pt to go to ... regular OB dept, for them to help facilitate ... seeing the surgeon ASAP. ... Discharge Instructions ... : go there now Follow-UP at: Chambersburg Hospital."

Interview with EMP8 on June 28, 2011 at 1:50 PM confirmed the above findings of MR2 and revealed "There is no documentation that the physician saw this patient."