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Based on review of Hospital policies, transfer request forms and staff interview, it was determined that for 1 of 6 (Pt. #1) patient transfer requests reviewed, the Hospital ( a level I Trauma Center that provides pediatric orthopedic services) failed to ensure for 6 of 61 days (March 18, 19, 20, 2011 and July 8, 9, 10, 2011), the Pediatric Orthopedic Surgeon on call had the level of expertise to meet patients' needs (A2404-A); the Hospital failed to ensure stabilizing treatment for an emergency medical condition was not delayed, in order to inquire about the patient's ability to pay (A2408-A); and the Hospital failed to ensure ED to ED transfer request for higher level of care was not denied (A2411-A).
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A. Based on review of the Call Center Transfer Request Form, Transfer Center Patient Transfer Request Questionnaire, Transfer Center on-call list, on-call schedule, personnel file and staff interview, it was determined that for 6 of 61 days, March 18, 19, 20, 2011 and July 8, 9, 10, 2011 the Hospital ( a Level 1 Trauma Center that provides pediatric orthopedic services) failed to ensure that the Pediatric Orthopedic Surgeon on-call, had the expertise to meet patients needs.
Findings include:

1. Hospital A's Call Center transfer request form, for Pt. #1, was reviewed on 7/21/11. Pt. #1 was 7 year old male seen at Hospital B, on 7/8/2011, with a primary diagnosis of Grade 3 Supracondylar Humerus Fracture. The transfer request form completed by Hospital A, dated 7/8/11 at 8:37 PM indicated that Pt. #1's current level of care at the time of the request was in Hospital B's " Emergency Department. " According to the transfer request form, Hospital A cancelled the transfer request on 7/8/11 with the following notes: "Pt. denied, no PHOR on-call this weekend according to Dr. ... in ... ER."

2. A second form titled, "Transfer Center Patient Transfer Request Questionnaire" dated 7/8/11 at 8:37 PM, included a notation that there was no orthopedist on-call.

3. Hospital A's Orthopedic Surgery on-call schedules from January 1, 2011 to July 31, 2011 were reviewed on 7/21/11. On January 1, 2011 to July 31, 2011, E#1, a Faculty orthopedic surgeon was on the on-call schedule 22 times. E#1 was the on-call Pediatric Orthopedic surgeon 6 of the 22 times. On each of the 6 days as E#1, there were on-call surgeons scheduled the same time with specialty in Upper Extremity Surgery as follow: 1 Jr. Resident, 1 Senior Resident, 1 Faculty and 1 Faculty Hand.

4. Hospital A's July, 2011 Orthopedic Surgery on-call list was reviewed on 7/21/11 at approximately 11:00 AM. The list indicated that E#1 was on call for (6 of 61 days) March 18, 19, 20, 2011 and July 8, 9, 10, 2011 for both adult and pediatric patients. The on-call schedule for 7/8/11 also included E#1 as the attending physician for both adult and pediatric patients.

5. E #1's personnel file was reviewed on 7/21/11 at approximately 2:30 PM. E#1, the Ortho Physician on call on 7/8/11 applied for and was granted Orthopedic Surgery core privileges in May 2010, which includes: "the performance of surgical procedures (including related admission, consultation, work-up, pre and post operative care) to correct or treat various conditions, illnesses and injuries of the: 1. Bone, 2. Joints, 3. Skin and soft tissues, 4. Musculotendinous unit & sheaths, 5. Peripheral nerves and vessels, multisystem trauma, 7. Care of critically ill and /or injured patients with underlying surgical conditions in the Emergency Department."

6. Hospital A's Orthopedic Surgeon (E #1) on-call for adult and pediatric patients on 7/8/11 was interviewed by phone, on 8/2/11, at approximately, 10:40 AM. E #1 indicated that he is a Board Certified Orthopedic surgeon, and he specializes in lower extremities, mostly foot and ankle injuries on adult and adolescent. He indicated that he was on-call on 7/8/11; however, he could not take Pt. #1 with the Supracondylar Humerus Fracture because he had not "worked on" such cases since 1997, as a resident. He indicated that he did not have the level of expertise or the repetitive experience to perform a complicated procedure required for fractured elbows, and that he would not have a back-up surgeon to call on if he did the procedure and "got stuck" in the process. E #1 also indicated that he was on-call for both the adults and the pediatric ortho cases because the pediatric ortho physicians for Hospital A were out of town.

7. The on-call list and schedules were confirmed with VP of Risk Management on 7/21/11, at approximately 1:45 PM.

A. Based on review of the Patient Case Specialist (PCS) Transfer Center Scripting, and the Transfer Center audio recording, Pt. #1's face sheet from Hospital B (transferring Hospital), Hospital A's (Hospital refusing transfer) ortho on-call list, Hospital A's staff interview, and the clinical record from Hospital C (receiving Hospital), it was determined that for 1 of 6 (Pt. #1) patient transfer requests reviewed in July 2011, the Facility failed to ensure stabilizing treatment for an emergency medical condition for a transfer patient needing a higher level of care was not delayed in order to inquire about the patient's ability to pay.

Findings include:

1. The Hospitals' "PCS Transfer Center Scripting" was reviewed on 7/21/11 at approximately 11:00 AM. The Script included, " ...May I take the initial information from you to initiate your transfer (or referral) request. *(before taking the information, ask if the patient is in the ER or Inpatient; Pediatric or Adult) ...*(For outside doctors) IF the patient is in the ER, Please obtain fax # and fax EMTALA form to doctor, do not request face sheet unless instructed by the nurse. If patient is Inpatient, request a copy of the face sheet be faxed. "

2. The audio recording, reviewed at Hospital A on 7/21/11 at approximately 1:45 PM, contained a request for transfer from Hospital B, for a 7 year old male (Pt. #1), with a diagnosis of a Grade 3 Supracondylar Left Humerus Fracture on 7/8/11. A Transfer Center Representative (TCR) of Hospital A asked the requesting physician (RP), of Hospital B for the patients' name, birth date, diagnosis, whether it was a trauma, for a call back number, and the patients face sheet (demographic information). The TCR requested the face sheet before asking if the patient was located in the ER, or an inpatient at Hospital B.

3. Pt. #1's face sheet from Hospital B was attached to the transfer request form dated 7/8/11 at 8:37 PM and reviewed on 7/21/11 at approximately 10:30 AM. The face sheet included the following medical insurance coverage for Pt. #1: Advantage HMO/Self pay.

A subsequent recording of the follow up call by Hospital B's RP to Hospital A's TCR was as follows:

RP: "Hi. Dr. B ... from... I was wondering about the transfer I called about the 7 year old patient ... "
TCR: "Yes, I'm trying to get verification of the financial data for the HMO that the patient has. We usually don't take HMO, and they can't be verified in the evening so I'd have to get administrative approval. So until I get that, I can't ..., I can't take it any further until we get the financial end taken care of."
RP: "Financial end of ...that's an EMTALA violation. If you have the capability and the beds to take care of the patient then the financial end does not matter ...That's an EMTALA."
TCR: "ok so, this patient, you don't have a ..., let me ask you these questions."
RP: "The reason I was calling is that I need a higher level of care, and I don't have an Orthopedist in my institution. So if you are going to tell me that you can't take this patient because of financial reason, that's an EMTALA violation."
TCR: "Ok, I guess I was given misinformation, I do apologize. A, you don't have an Orthopedic, a Pediatric physician there?"
RP: "I don't have an Orthopedist on-call, I talked to 2 of our Orthopedist and they are either out of town or can't take the case."
TCR: "Ok I'll give this to our physician and have them contact you."

The follow up conversation between Hospital A's Aeromedical Network and Hospital B's RP went as follows:

Network: "...I'm calling on behalf of (TCR name mentioned), she's tied up. She called over to our Comer ER and they don't have a peds ortho on-call this weekend, he's out of town. Just wanted to let you know, to see what you want to do.
RP: "I guess we won't be able to transfer if you don't have somebody to take him then, right?"
Network: "Right "
RP: "Ok"
Network: "Ok"

4. The on-call schedule for Orthopedic Surgery for 7/8/11 was reviewed on 7/21/11 at approximately 11:00 AM. The schedule included the name of an attending Physician (E #1) for both the adult and pediatric patients.

5. The Hospital A's Orthopedic Surgeon (E #1) on-call for adult and pediatric patients on 7/8/11 was interviewed by phone on 8/2/11 at approximately 10:40 AM. E #1 indicated that he is a board certified orthopedic surgeon, and he specializes in lower extremities, mostly foot and ankle injuries on adult and adolescent. He indicated that he was on-call on 7/8/11, however he could not take Pt. #1 with supracondylar humerus fracture because he had not "worked on" such cases since 1997, as a resident. He indicated that he did not have the level of expertise or the repetitive experience to perform a complicated procedure required for fractured elbows, and that he would not have a back-up surgeon to call on if he did the procedure and "got stuck" in the process. E #1 also indicated that he was on-call for both the adults and the peds ortho because the pediatric ortho physicians for Hospital A were out of town.

6. The audio recordings were reviewed with the VP of Risk Management and the Executive Director of Bed Access on 7/21/11, at approximately 1:45 PM. The VP and the Director confirmed the audio recording as that of Pt. #1's transfer request on 7/8/11.

7. The clinical record of Pt. #1 from Hospital C was reviewed on 8/2/11 at 9:00 AM. Pt. #1 was transferred to Hospital C and arrived on 7/8/11 at 11:25 PM. the operative report from Hospital C indicated the following surgical procedure was performed on 7/9/11: "Open reduction, release of entrapped neurovascular bundle, and pin fixation of supracondylar fracture of left elbow." The operative report further indicated that: "Based on the preoperative examination of neurovascular compromise, open reduction was felt to be necessary." Pt. #1 was discharged to home from Hospital C on 7/10/11 at 8:30 AM.

A. Based on review of a Transfer Request Form, Patient Transfer Request Questionnaires, Hospital A's Emergency Department (ED) Physicians' on-call list, and staff interview, it was determined that for 1 of 6 (Pt. #1) patient transfer requests reviewed in July 2011, the Hospital (a Level I Trauma Center that provides pediatric orthopedic services and has specialized capabilities), failed to ensure an ED to ED transfer required for higher level of care, was not denied.

Findings include:

1. The transfer request form for Pt. #1 was reviewed on 7/21/11. Pt. #1 was 7 year old male who presented at Hospital B on 7/8/2011, with a primary diagnosis of Grade 3 Supracondylar Humerus Fracture. Hospital A (Hospital refusing transfer) received a transfer request from Hospital B for Pt. #1. The Transfer request form completed by Hospital A indicated that Pt. #1's current level of care at the time of the request was in Hospital B's "Emergency Department". According to the transfer request form, Hospital A cancelled the transfer request on 7/8/11 with the following notes: "Pt. denied, no POR on-call this weekend, according to Dr. ... ER."

2. The Patient Transfer Request Questionnaire from the Transfer Center, dated 7/8/11 at 8:37 PM, included a notation that there was no orthopedist on call.

3. Pt. #1 was subsequently transferred to Hospital C on 7/8/11 at 10:48 PM and the operative report from Hospital C indicated the following surgical procedure was performed on 7/9/11: "Open reduction, release of entrapped neurovascular bundle, and pin fixation of supracondylar fracture of left elbow." The operative report further indicated that: "Based on the preoperative examination of neurovascular compromise, open reduction was felt to be necessary." Pt. #1 was discharged to home from Hospital C on 7/10/11 at 8:30 AM.

4. The Hospital A's 7/8/11 on-call Orthopedic Surgery Schedule was reviewed on 7/21/11 at approximately 11:00 AM. The schedule included the name of an Orthopedic Surgeon (E #1) for the adult and the pediatric patients. In addition, the following categories of surgeons were on call and listed: 1 Jr. Resident, 1 Senior Resident, 1 Faculty, and 1 Faculty Hand.

5. The above finding was confirmed with the VP of Risk Management and Patient Safety and Compliance, during an interview on 7/21/11 at approximately 11:20 AM.