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Based on staff interviews, Emergency Department's (ED) policy and procedures, and ED patient record reviews, the hospital failed to comply with 42 CFR § 489.24 - Special Responsibilities of Medicare Hospitals in Emergency Medical Treatment and Active Labor Act (EMTALA).

This failure resulted in the transfer of one patient (Patient 100) to a facility which did not have the capabilities to provide higher level of care for her condition and could potentially affect other ED patients who needed to be transferred to other facilities.

Findings:

During an EMTALA Survey on 9/24/25 to 9/25/24, the surveyor determined the ED failed to ensure one patient (Patient 100) was provided an appropriate transfer when the transferring physician provided an incomplete report of Patient 100's condition to the physician at the accepting facility. Patient 100's CT scan finding at the ED was significant enough to escalate to an even higher level of care needed than previously discussed with Hospital 2, and its omission in the report resulted in Patient 100 be transferred to a facility which did not have the capabilities to care for her condition. (Cross Reference A-2409).

Based on interview and record review, the facility failed to ensure a complete interfacility physician-to-physician reporting, which included critical patient information for one of 21 sampled Emergency Department (ED) patients (Patient 100). This failure did not comply with the facility policies and procedures, and resulted in Patient 100 being transferred to a facility which did not have the capabilities to care for her condition and for her to experience a subsequent transfer to another facility within hours.

Findings:

During an interview on 9/24/24 at 11:30 a.m., the Complainant stated Patient 100 was inappropriately transferred from Hospital 1 ED to Hospital 2 ED. The Complainant stated, while at the Hospital 1 ED, Patient 100 had a Computed Tomography (CT) scan (a medical imaging procedure) that showed an ascending aorta dissection (a life-threatening condition wherein there is a tear in the inner layer of the large blood vessel branching off the heart). The Complainant stated Hospital 1's ED Physician was aware of the CT scan finding but did not disclose this information to the ED Physician at Hospital 2. The Complainant stated Patient 100 was accepted at Hospital 2, though Hospital 2 did not have the capabilities to care for her aortic dissection.

During an interview on 9/24/24 at 2:05 p.m., the ED Registered Nurse (RN) stated the ED Physician identified a patient's need to be transferred to another facility. The ED RN stated, due to the small size of Hospital 1, patient transfers occurred often. The ED RN stated patients got transferred to other facilities when Hospital 1 did not have an available bed to admit a patient, and/or when a patient required a higher level of care and specialty services. The ED RN stated part of the transfer process was a discussion of the patient's condition between the transferring and accepting Physicians.

During an interview on 9/24/24 at 2:39 p.m., the ED Tech stated a patient's transfer got initiated when the ED Physician determined if a patient needed to be transferred. The ED Tech stated she would then start contacting hospital transfer centers (services that triage requests made by Physicians needing to transfer a patient). The ED Tech stated transfer centers would call the hospital back, and a physician-to-physician report would occur. The ED Tech stated after the report, the transferring facility had to confirm whether the patient was accepted or not.

A review of Patient 100's, "Emergency Room Outpatient Record," indicated she was brought in by ambulance to Hospital 1's ED on 9/12/24 at 9:44 p.m., for chief complaints of increasing shortness of breath and rib pain after a fall. Patient 100's, "Radiology Report," dated 09/12/24, indicated chest x-ray (an imaging of the heart, lungs and bones) findings that included pneumonia (an inflammation of the lungs caused by an infection), and small bilateral pleural effusions (fluid buildup in the thin cavity between both sides of the lungs and chest wall). Further review of Patient 100's Radiology Report include a chest CT scan, dated 9/12/24, which indicated, "There are bilateral pleural effusions. Appears to be a large pulmonary embolus (a life-threatening blockage in a lung artery caused by a blood clot) in the main pulmonary artery and right pulmonary artery right pulmonary artery is nearly occluded [sic] ... Also appears to be a possible dissection involving the ascending aorta ... [ED Physician A] was told these findings at 11:55 p.m., September 12, 2024."

A review of Patient 100's, "Emergency Note," dated 9/12/24, indicated, "Medical Decision Making: ... Patient's chest x-ray ... consistent with pneumonia ... suggestive of non-STEMI (a type of a heart attack) ... will need transfer to a higher level of care for cardiology ... CT of the chest shows a pulmonary embolism on the right side which is large ..." The Emergency Note, signed by ED Physician A, did not mention the aortic dissection.

A review of Patient 100's, "Patient Transfer Communication," indicated an initial call was made to Hospital 2's transfer center on 9/12/24 at 11:07 p.m., and provided details of, "DX (Diagnosis): NSTEMI, BILATERAL PNEUMONIA, PE (pulmonary embolism) ... NEEDS: CARDIOLOGY ... BED: ICU (Intensive Care Unit) ..." There was no documentation of the aortic dissection among Patient 100's diagnoses in the document. Further review of the document indicated that on 9/12/24 at 12:56 a.m., Hospital 2 called back and requested a, "doc to doc," then the call was transferred to ED Physician A. The document further indicated that on 9/13/24 at 1:05 a.m., an acceptance information was received from Hospital 2, with ED Physician B as the accepting Physician.

A review of Patient 100's, "Interfacility Transfer Form," dated, "9/13/24," indicated, "Reason for Transfer: NEEDS CARDIOLOGY NONE @ [HOSPITAL 1] ... Pt (Patient) Diagnosis: NSTEMI, BILATERAL PNEUMONIA ..." The aortic dissection was not included among the list of diagnoses in the document.

A review of Patient 100's, "ED: Nursing Progress and Discharge Notes," indicated Patient 100 was transferred out to Hospital 2 on 9/13/24 at 1:34 a.m.

A review of Patient 100's transfer records to Hospital 2 indicated, "Diagnosis: ...NSTEMI, bilateral pneumonia, PE ... Reason: Higher Level of Care ... Service: Cardiology ..." The document included a timeline which indicated, "9/13 0102 (1:02 a.m.) ... spoke with [ED Physician B] and was able to connect him with a Peer to peer with [ED Physician A]. [ED Physician B] accepted patient ..."

A review of Patient 100's, "ED Provider Notes" at Hospital 2, dated "9/13/24", indicated, "0230 (2:30 a.m.): I have reviewed material sent from [Hospital 1] on the patient and the patient's CTA of the chest shows a large PE in the main and right pulmonary artery. Patient also has a dissection of the ascending aorta ... I have called and discussed with cardiothoracic surgeon, [Cardiothoracic Physician C] who recommends ... that the patient should be transferred to [Hospital 3] ..."

During an interview on 9/25/24 at 2:08 p.m., ED Physician B stated recalling Patient 100. ED Physician B stated he was the accepting Physician and confirmed having a peer-to-peer discussion with ED Physician A. ED Physician B stated he was notified of Patient 100 having pneumonia and pulmonary emboli, and her needing cardiology services and an ICU bed. ED Physician B stated the aortic dissection was not mentioned during the discussion. ED Physician B stated he discovered the dissection during his review of Patient 100's medical records after her arrival at Hospital 2. ED Physician B stated he consulted with a Radiologist and Hospital 2's on-call Cardiothoracic Physician C, who both reviewed the CT scan and confirmed the aortic dissection. ED Physician B stated management of the aortic dissection became the top priority for Patient 100, and stated Cardiothoracic Physician C recommended a transfer to Hospital 3 for higher level of care. ED Physician B stated he would not have accepted Patient 100's transfer had he been notified of the aortic dissection during the peer-to-peer discussion.

During an interview on 9/25/24 at 4:26 p.m., ED Physician A stated recalling Patient 100 as, "very complicated," and confirmed himself as the transferring Physician. ED Physician A stated was aware of the dissection, but for an unknown reason, missed mentioning it during his discussion with ED Physician B. ED Physician A stated recalling the radiologist's concern over the large pulmonary emboli, and stated he, "may have been affected by it," making him focus on the management of the emboli over the more critical aortic dissection. ED Physician A stated Patient 100's CT scan finding required a cardiothoracic service and not just cardiology. ED Physician A stated he should have consulted with a Cardiothoracic Physician before transferring Patient 100 to Hospital 2.

Further review of Patient 100's, "ED Provider Notes," at Hospital 2, dated "9/13/24," indicated, "0425 (4:25 a.m.): Patient was accepted for transfer to [Hospital 3] CT surgery [Cardiothoracic Physician D] who will take the patient directly to OR ... [Patient 100] presented with concern for imminent decline requiring constant monitoring and attendance of care. The patient has had a high probability of imminent deterioration threatening life or limb ..." The document was signed by ED Physician B.

A review of Patient 100's, "Transfer Consent," at Hospital 2, indicated she was transferred to Hospital 3 on 9/13/24 at 6:17 a.m., approximately four hours since her transfer to Hospital 2, via an air ambulance.

During an interview on 9/25/24 at 4:40 p.m., Hospital 1's Chief Nursing Officer (CNO) stated she was familiar with the process of transferring patients out of the ED as she had also functioned as a hospital provider. The CNO stated, after a Physician determined a patient needed to be transferred, the patient was notified, and a consent obtained. The CNO stated staff, usually the ED Tech, would call transfer centers with the patient information such as the diagnoses and specialty or level of service needed. The CNO stated the transferring and accepting Physicians conducted a, "doc-to-doc," report. The CNO stated this allowed the transferring Physician to give as many details as possible about the patient and helped the accepting Physician decide whether to accept the patient. The CNO stated ED Physician A should have included a significant finding of an aortic dissection in his discussion with ED Physician B.

During an interview on 10/1/24 at 11 a.m., Cardiothoracic Physician C stated he became aware of Patient 100 when ED Physician B requested a consult and a review of Patient 100's CT scan. Cardiothoracic Physician C stated he confirmed the findings of an ascending aorta dissection. Cardiothoracic Physician C stated the usual protocol for aortic dissections was to take them in for an immediate surgery. Cardiothoracic Physician C stated Hospital 2 normally would have been able to accept patients with aortic dissections, but they were incapable of providing care for Patient 100 at the time as they had limited manpower in the facility. Cardiothoracic Physician C stated that if he been consulted while the transfer was being arranged, he would have notified ED Physician A of their inability to accept Patient 100 at the time.

A review of the facility policy titled, "Interfacility Patient Transfer & Transfers for Testing or Off-Premises Services," last reviewed, "1/22," indicated, "Patients are not transferred except upon patient request, upon request of the responsible party acting on behalf of the patient, or upon the written certification of the physician that the risks of transfer outweigh the reasonably anticipated benefits of proper treatment at another facility, consistent with the procedures set forth ... Patient Dispensation: A process that determines continued patient care or discharge conducted by a qualified medical provider who has primary responsibility to assure that all referrals, follow-up care and/or transfer requirements are met and documented ... The transferring provider makes provider to provider contact to explain the case and obtain provider acceptance of the patient ..."