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Based on interview and record review, the hospital failed to abide by the provider's agreement that required a hospital to comply with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The Hospital A was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements, citing 1 of 2 patients (Patient #1) that presented in the emergency department on 05/18/18 and was not appropriately transferred to Hospital B that had the capability to conduct further evaluation of Patient #1's hand injury.

Cross Refer to Tag 2409

Based on interview and record review, Hospital A failed to appropriately transfer 1 of 2 patients (Patient #1) that presented on 05/18/18 with a right hand injury.

Findings included:

Patient #1 presented in Hospital A's emergency department (ED) on 05/18/18. At 3:47 PM the patient was triaged. The triage assessment reflected "Complaint: laceration to hand ...Patient reports that yesterday he was working as painter using a pressurized paint gun. It slipped and sprayed paint and pressure to right palm of hand ...No prior treatments prior to arrival. Pain Assessment: 4..."

At 3:50 PM Nursing Assessment by Personnel #12 reflected "EXTREMITY UPPER...Pain exacerbated by flexion, movement, range of motion. Pain relieved by: position change, to the hand, on the right...patient rates pain as 4...RIGHT UPPER EXTREMITY...capillary refill less than 2 seconds...Skin temperature to hand warm...Inspection findings include puncture wound, to right palm of hand, from pressurized paint, Inspection findings include signs of infection, to right hand, Inspection findings include swelling, to right posterior hand."

At 4:17 PM Physician #11 noted "PHYSICAL EXAM...upper extremity...R-hand swelling and erythema...SKIN...puncture wound to R-palm..."

At 4:19 PM Physician #11 noted "DOCTOR NOTES Transfer offered, but patient decided to opt out and drive to the nearest hospital immediately leaving this facility. Puncture wound to R hand yesterday, obvious paint impeded within palm, moderate swelling of entire hand and painful with any finger movement."

At 4:30 Personnel #12 noted "Called Hospital B. They have a hand specialist on-call. Map and directions provided to patient to hospital. Patient advised not to eat or drink. Patient understands instructions."

Prior to Patient #1 leaving Hospital A, Physician #11 provided "INSTRUCTION Discharge: Foreign body, puncture wound. SPECIAL: GO TO THE NEAREST FACILITY WITH A HAND SURGEON UPON LEAVING THIS ER."

During a phone interview on 05/18/18 at 12:43 PM, Personnel #12 confirmed the above findings. Personnel #12 stated she did not talk to a nurse at Hospital B because the transfer wasn't "official." The surveyor asked Personnel #12 why the transfer wasn't "official." Personnel #12 replied it wasn't "official" because the physician didn't initiate the transfer by calling Hospital B and doing a doctor to doctor phone call regarding Patient #1. Personnel #12 was asked if she gave Patient #1 his medical record. Personnel #12 replied she could not remember.

During a phone interview on 05/30/18 at 10:08 AM, Physician #11 confirmed the above findings and stated this was not a transfer because Patient #1 refused the transfer. Patient #1 did not want to ride an ambulance and preferred to use his own vehicle. Physician #11 stated "I discharged the patient and told him to immediately go to the hospital or he might lose the function of his hand." The surveyor told Physician #11 the facility log for MOTs was reviewed and other physicians transferred patients via private cars. Physician #11 replied "I don't do MOT for private vehicles." Physician #11 stated he was responsible for the patient from the time he left the ED up until the receiving physician took over the care. "What if the patient had an accident or the patient did not go to the facility immediately and his condition deteriorated? I will still be responsible for this."

Policy reference #7082 "EMTALA Compliance" approved 08/15/17 required "The hospital is committed to compliance with the provisions of the Emergency Medical Treatment and Labor Act (EMTALA) and its implementing regulations. This policy exists to provide guidelines ...transfer of individuals ...of a potential emergency medical condition."