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Review of the medical staff rules and regulations for Titus Regional Medical Center on January 12, 2010 in the facility the scope of services, states the hospital shall accept patient for care and treatment, except for those procedures and within those specialties not available at the facility. The facility provides specialty services in anesthesia, cardiology, ENT, medical, surgical, pediatric, ob/gyn, urology, orthopedic, ophthalmology, neurology, radiology, psychiatric, dental, oncology, pulmonology and surgical oncology. Because of the services provided by the facility, the facility failed to accept the responsibilities as the recipient hospital with capabilities and capacity for the transfer of an individual(s) in need of a higher level of care.

Review of patient #1 ' s medical record (nurses notes) received from transferring hospital A, on January 12, 2010 revealed that patient #1 was a walk in to hospital A at 0700 on January 10, 2010. Patient was diagnosed by physician #2 (hospital A) of possible appendicitis, patient and family informed and requested transfer to Titus Regional Medical Center. Titus Regional Medical Center is the closet facility with a surgeon. At 1140 employee #1 (transferring hospital A) contacted Titus Regional Medical Center (TRMC) emergency department and spoke with employee #2 (TRMC). Notes reflect transferring hospital A was told by employee #2 (TRMC) they could not accept the transfer unless the surgeon on call accepted the patient and that they would contact the surgeon on call and then contact transferring hospital A. At 1205 no response had been received from TRMC or from the on call surgeon for TRMC, physician #2 (transferring hospital A) called TRMC regarding transfer of patient #1. In an interview with physician #1 (transferring hospital A) on January 13, 2010 at 0900 he stated when he called TRMC he was told they did not accept transfers and that the on call surgeon would have to accept the patient. Physician #1 (transferring hospital A) was then placed on hold but no one ever came back to the phone at which point he began making other arrangements for the patient. Physician #1 (transferring hospital A) added that to his knowledge they had not ever received a call back from TRMC or the on call physician and the patient was eventually transferred to another facility.

Interview on January 13, 2010 with employee #2 (TRMC) in the conference room he stated he received a phone call on January 10, 2010 from transferring hospital A about a possible acute appendicitis and stated he told her " I would take her number and get the right person to call her back. " He added " Employee #3(TRMC) our ward clerk was on her lunch break. I took the message about a possible transfer for appendicitis and left it on the ward clerks ' desk. I never got back involved with it anymore. " When asked about the protocol when a request for a transfer in is received, employee #2 (TRMC) replied, he was not sure, " the ward clerk handles all of it. "

Interview on January 13, 2010 with CNO employee #4 (TRMC) in the conference room revealed she received a call from the House Supervisor about the phone call from hospital A, and their quoting the EMTALA laws about transfer. She stated " I called physician #3(TRMC) and asked if he had received a call from hospital A, he stated " no " . The house supervisor called physician #3 (TRMC) also to see if hospital A had contacted him, and he replied " no " they had not. During our conversation physician #3(TRMC) asked if he could get a face sheet on the patient before accepting them to see if they had insurance. I told him this would have to be something we checked on. " When asked about how transfer requests are received, the CNO stated the requesting hospital is given the contact information of the on call physician.

Interview on January 13, 2010 with ED director employee #5(TRMC) in the conference room revealed employee #3(TRMC) called about the phone call she received from physician #2(transferring hospital A) concerning an EMTALA. Employee #5 (TRMC) said physician #2 (hospital A) was yelling at employee #3 (TRMC) saying, " I don ' t have to speak to the physician I have the EMTALA laws right in front of me " . Employee #3 (TRMC) said she called physician #3 (TRMC) to see if hospital A had called him and he said " no " . Employee #5 (TRMC) stated she was not sure why the calling service had not contacted physician #3 (TRMC), also hospital A was given the name of the surgeon and who to speak with. When asked what is the protocol when a hospital is trying to get a patient transferred into the facility for an emergency employee #5 (TRMC) stated the physician, case manager or whoever calls is transferred to the operator to have whatever service (physician) paged, to call the sending physician.

An interview on January 13, 2010 with physician #3(TRMC) in the conference room when asked if physician #3 received a page or phone call from the emergency room director about a transfer on January 10, 2010, physician #3 (TRMC) replied, " No " . When asked if he talked with the CNO about the transfer in of a patient on January 10, 2010, physician #3 (TRMC) replied, " I talked with the CNO on January 10, 2010 but not about a specific patient " . Physician #3 (TRMC) stated that he is not really a referral center for the transfer of patients. When asked what is the protocol for being contacted when he is on call for a patient needing his service, physician #3 (TRMC) stated his office phones are turned over to an answering service, so he is not sure how it is handled. When asked if he received a phone call from the House Supervisor on January 10, 2010 he said yes, she called to see if he had heard anything about a patient from hospital A and " I said, No " .

Telephone interview with employee #1(transferring hospital A), on January 13, 2010 at 9:30 am, she stated " patient had some abdomen pain and CT showed acute appendicitis. Family requested to go to Titus Regional Medical Center, I called the hospital and was told by employee #2 (TRMC) that the emergency room could not accept her; they would have to contact the on call surgeon. After 15-20 minutes of not hearing back, physician #2 (transferring hospital A) called and was told by a nurse that he had to get the surgeon on call to accept the patient, he was then put on hold or hung up on, one or the other. "

An interview on January 13, 2010 with employee #3 (TRMC) in the conference room confirmed, she received a phone call from transferring hospital A. Employee #3 (TRMC) stated she answered the phone and identified herself. The person on the line stated they were physician #2 (transferring hospital A) and asked to speak with the ER physician, she stated she explained he was not at the desk at this time and was then asked about the transfer of the patient. She stated she explained the ER physicians could not accept transfers. She stated physician #1 (transferring hospital A) became upset and talked about EMTALA, she asked that he hold on while she located her supervisor. She said she placed him on hold and called the house supervisor, she returned to the phone and he had hung up. The house supervisor came down to the ER and suggested she call her supervisor, employee #5 (TRMC). She talked with her supervisor and was told by employee #5 (TRMC) told to call physician #3 (TRMC) and see if he was expecting a patient from transferring hospital A. She stated she called his home but there was no answer so she had the switchboard page him. When she talked with him she asked if he had gotten a call from hospital A about a transfer patient and he said " no " and then he asked to be transferred to the house supervisor. When employee #3 (TRMC) was asked by the surveyor about the protocol for when a patient needs to be transferred to the facility she stated " I will transfer the person to the answering service and they will handle it that way. The house supervisor or physician will call me to let me know the patient is coming. "

Review of patient #2 ' s medical records (physician notes) received from hospital A, on January 12, 2010, patient presented to hospital A emergency department on June 11, 2008 at 17:27, clinical impression/ diagnosis threatened abortion. At 1840 physician #2 (transferring hospital A) spoke with emergency department physician #4(TRMC) to have patient transferred. Physician #4 (TRMC) declined to accept patient and directed physician #2 (transferring hospital A) to page the physician on call through the hospital page operator, physician #5 (TRMC) was paged. 1848 physician #5 (TRMC) returned call saying physician #6 (TRMC) is the OB on call for the hospital. At 1852 the answering service for physician #6 (TRMC) called transferring hospital A and said physician#6 (TRMC) was not accepting any new patients.

When questioned about patient #2, physician #2 (hospital A) stated, the patient came in with her mother for vaginal bleeding (threatened abortion) and needed GYN care. The family requested to be transferred to Titus Regional Medical Center. A call was placed to TRMC and physician #4 (TRMC) stated ED can only accept if the GYN accepts. Physician #2 (hospital A) stated he was told that GYN would call. He stated " on the call back I was told that physician #6 (TRMC) was on call, not physician #5 (TRMC). I got a call from physician #6 (TRMC) answering service and was told he was not taking any new patients. I called physician #4 (TRMC) back about specialty not accepting the patient and this was a life threatening situation. After TRMC refused transfer , hospital A began making other transfer arrangements.

Telephone interview with physician #4 (TRMC) on January 13, 2010 in the conference room about patient #2, he stated he received a phone call from (hospital A), about a patient needing ob/gyn care. In interview he stated " I explained that I could not accept in the ED it would be up to the specialist. I explained physician #6 (TRMC) was specialist on call. The physician on the other line became upset because physician #6 (TRMC) stated he was not accepting new patients. I later got a phone call from physician #6 (TRMC) and he was upset I gave his information out. He said I did not have any business telling who was on call. I tried to explain that was common knowledge to give out who is on call. "

Interview on January 13, 2010 in the conference room with physician #6 (TRMC) about patient #2, physician #6 (TRMC) stated he was not aware that he was on call for hospital A. He stated " They have a big sister hospital that can take on the responsibility of taking their patients. I was not aware that I had to accept their patients if they called. I am on call for Titus Regional Medical Center not for hospital A "