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Based on reviews of clinical records, hospital documents including policies and procedures, audio recording from the hospital's Transfer Center, and staff and physician interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases as evidenced by:

Tag A-2411: A hospital physician declined to receive Patient #1 in transfer from another acute care hospital. Patient #1 was diagnosed with a bowel perforation at the requesting hospital, and they did not have operating room staff on-call coverage. St. Mary's Hospital had the staff and capacity to provide emergent surgery and postoperative care. This deficient practice poses the risk of harm to a patient who requires emergent treatment.

Based on reviews of clinical records, policies and procedures, logs, other pertinent hospital documentation, Call Center audio recordings, and interviews, it was determined the hospital declined to receive Patient #1 in transfer from another acute care hospital who requested the transfer (Hospital #1). Patient #1 presented to Hospital #1's Emergency Department (ED) and was diagnosed with a bowel perforation and required emergent surgery. Hospital #1 did not have operating room (OR) staff on-call coverage. St. Mary's Hospital had the staff and capacity to provide emergent surgery and postoperative care. This deficient practice poses the risk of harm to a patient who requires emergent treatment.

Findings include:

The Professional Staff Rules and Regulations for Carondelet St. Mary's Hospital included: "The Medical Staff shall abide by the Emergency Medical Treatment and Active Labor Act (EMTALA) laws and regulations. Violations of such laws and regulations shall be reported to Risk Management."

The hospital's policy and procedure titled, "EMTALA" included: "To the extent that the Hospital has specialized capabilities (including capabilities available through the Hospital's on-call roster) or facilities, such as a burn unit, a shock-trauma unit or a neonatal intensive care unit, that are not available at the transferring facility, the Hospital must accept appropriate transfers of an individual needing such specialized capabilities or facilities if the Hospital has the capacity to treat the individual....All Hospital staff and Medical Staff whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, including the Medical Staff Bylaws, Rules and Regulations."

Patient #1 presented to Hospital #1's ED on 9/27/2019 at 12:56 a.m. Documentation in that clinical record revealed the patient presented to the hospital's Emergency Department (ED) the prior day with abdominal pain and was discharged home with antibiotics after imaging and labwork were obtained and reviewed. The patient returned to the ED with complaints of worsening abdominal pain and inability to eat or drink fluids. Another CT scan of the patient's abdomen and pelvis was obtained and compared with the scan performed the prior day. The result of the second CT scan included: "1. Interval development of moderate free intraperitoneal air, consistent with hollow viscus perforation, most likely small bowel in etiology. 2. Diffuse severe inflammatory changes involving the small bowel have significantly progress, with additional distention of the small bowel loops which may represent superimposed ileus. 3. A rounded, 2.4 cm structure is present in the right lower quadrant...4. Small to moderate free fluid throughout the abdomen and pelvis." The ED Physician documented: "Contacted Dr. (name of general surgeon who was on-call for Hospital #1), who recommends patient be transferred for emergency surgical intervention since there is no surgical team at night...Contacted (Physician #2, General Surgeon on-call) at St. Mary's who declined to accept patient because she works at this facility and she knows there is an OR team available to have patient operated at [initials for name of hospital # 1].' I will contact another facility as per instructions by Dr. (on-call surgeon for Hospital #1). I explained to (Physician #2) that a team is not available at night, to which she replied that is not correct. I confirmed with (staff name), charge nurse, that the facility does not indeed have a surgical team available for emergency surgery of the patient...Patient accepted by...(name of Hospital #2). Patient to be sent directly to the OR for surgical intervention."

Documentation in the patient's clinical records from Hospital #2 revealed the patient was taken emergently to the OR for an exploratory laparotomy and small bowel resection for a perforated ileal mesenteric diverticulum. Documentation in the operative report from Hospital #2 included: "Initially on entering the abdomen, both gas and bile-stained fluid was encountered...On delivering the small bowel into the wound, it was obvious that the patient had an inflammatory mass on the mesenteric side of the ileum approximately 10 inches proximal to the ileocecal valve...A limited small bowel resection was then carried out."

A telephone interview was conducted on 11/20/2019, with the ED Physician at Hospital #1 (Physician #1). Physician #1 reported Hospital #1 does not have an OR team available at night. He contacted their on-call surgeon who recommended the patient be transferred to another hospital because of that. Physician #1 called Hospital #2 and was put through to their on-call general surgeon (Physician #2). Physician #2 told Physician #1 she had worked at or covered at Hospital #1 and knew they had OR coverage. He reiterated that Hospital #1 did not have OR coverage at night, and Physician #2 responded, "I know better than that. You need to keep the patient there." At that point Physician #1 stated they started calling other hospitals. Documentation from Hospital #1 revealed there was no OR staff on-call between the hours of 9 p.m. and 6:30 a.m. on 9/27/2019.

The "Carondelet Transfer Center - Inbound" receives and coordinates calls from outside providers requesting to transfer a patient to St. Mary's Hospital. The incoming calls are documented on a log and the actual calls are recorded. The Transfer Center's audio recording of the conversation between Physician #1 and Physician #2 on 9/27/2019 at approximately 3:35 a.m. revealed Physician #1 presented the patient's work-up to Physician #2 and asked if he could send the patient to Hospital #2. Physician #2 responded: "Where are your surgeons? Physician #1 tried to explain that there was no surgical team during the night. Physician #2 interrupted him and said, "Yes you do! She again asked about Hospital #1's general surgeons. Dr. #2 said she worked at Hospital #1 and insisted there was a full surgical team on-call that could be called in. Physician #1 asked Physician #2 if she was declining the patient and she responded that she was declining the patient because they had a surgeon. Physician #1 again told her that although there was a surgeon, there was not a surgical team that could come in. Physician #2 continued insisting Hospital #1 had a full surgical team that could be called in. Physician #1 responded: "No ma'am. That's fine. I'm just trying to help the patient. I talked to (name of their general surgeon) and she tells me we don't have a surgical team and requested transfer. If you don't think you can take the patient I'll be glad to call another facility." Physician #2 said: "Yes. Sure. Go ahead and do that because Dr. (name) needs to come in and do that case." Physician #1 said: "Ok, thank you, ma'am." and then he hung up. Physician #1's tone during the conversation was professional and respectful. St. Mary's Hospital On-Call Schedule for General Surgery revealed Physician #2 was on call from 7 a.m. on 9/26/2019 to 7 a.m. on 9/27/2019.

Staff #1 was interviewed on 12/3/2019, and acknowledged the incident was escalated within hours to hospital leadership including the Chief Medical Officer. Staff #1 stated he met with Physician #2 early in the week of 9/30/2019, to discuss the incident. He said a conference call was held on 10/2/2019, with the Chief Medical Officer, himself and another hospital leadership staff member to discuss the incident and further action that may be in order. No further action had taken place as of the dates of this investigation.

Physician #2 was interviewed on 12/3/2019. She reported she used to do surgery there until two other general surgeons "took over." She said Physician #1 was "rude" and hung up on her. She said Physician #1 told her there was a surgeon available but no OR team available. She told him she knew that there was an OR team available because she used to work there and actually was there earlier that day working clinic. She said she called Hospital #1 the next day and talked to the interim director of the OR who confirmed they stopped OR coverage after 9 p.m. She blamed Hospital #1, and stated Hospital #1 should have notified St. Mary's Hospital in writing about the OR changes. She said to the Surveyor, "I'm sorry, but I'm not sorry." They brought this on themselves and are wasting everybody's time including yours."

Staff #3 confirmed the hospital had the capacity to accept Patient #1 in transfer on 9/27/2019, when the hospital's call center received the request from Hospital #1. It was also reported that all St. Mary's physician staff received EMTALA training.