HospitalInspections.org

Based on review of medical records, facility's transfer logs, phone audio recordings, physician on- call schedules, staffing schedules, bed availability sheets, staff and physician interviews, policy and procedures and credential files it was determined that the facility failed to ensure compliance with 42 CFR 482.24, Special Responsibilities of Medicare Participating Hospitals in Emergency cases.

Findings were:

Cross refer to A2411 as it relates to the facility refusal to one (1) of the twenty-one (21) sampled (#21) patients when the facility had the specialized capabilities and capacity on 4/22/2012.

Based on review of the facility transfer logs, transferring facility's medical record, phone audio recordings, staff and physician interviews, policy and procedures and credential files.


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Based on review of medical records, facility's transfer logs, phone audio recordings, bed availability sheets, physician on-call schedules, staffing schedules, staff and physician interviews, policy and procedures and credential files it was determined that the facility failed to document and accept a transfer of patient #21, who needed the hospital's specialized vascular capabilities and capacity.
Findings were:

A review of patient #21's medical record from the transferring hospital revealed that the patient a 73 year old presented to the hospital ' s emergency department (ED) via emergency medical system (EMS) ambulance on 4/22/2012, with a chief complaint of pain in the back and pain and numbness in the right leg. Diagnostic studies (Ultrasound and CT scan) were performed and identified a massive aortic abdominal aneurysm (AAA- a swelling or bulging of the body's largest blood vessel, the aorta, in the abdominal area which can become life threatening if a rupture occurs). The studies also indicated that the patient ' s aneurysm had ruptured. Further documentation by the ED physician at the referring hospital revealed in part, " The patient appears to be cold, acutely ill appearing, and there is word from EMS that he spent the last 10 days in a tent in a campground. . . . Medical Decision Making: I (ED physician at referring hospital) felt the patient immediately needed to be transferred for definitive care, specifically surgery, but we needed a CT scan (specialized x-ray). .. Immediately I went to CT with him Blood pressure waxed and waned, sometimes going down to the 80's and 90's which required fluid boluses (rapid infusion of intravenous fluid), otherwise I would cut the fluid off so that we would not over resuscitate him causing him to bleed more." The radiologist confirmed that the patient had a massive ruptured AAA with significant bleeding and no blood flow to the iliac arteries (arteries below the umbilicus that branch off the aorta to the left and right) of femoral arteries (vessels that supply blood to the legs). Additionally, the ED physician documented in part, " at 2:17 p.m., radiologist called me stating that there was evidence of COPD (Chronic obstructive Lung Disease- this disease limits airflow to and from the lungs causing shortness of breath) from the CT scan, coronary artery disease and left kidney appeared to be quite abnormal, and there was bleeding towards and around it. . . I had received my call from vascular surgeon on call on 4/22/2012(interviewee #2 (credential File #2) from Northeast Georgia, at 1:26 p.m. while I was still speaking with the radiologist, (interviewee #2 (Credential file #2) accepted the patient. At this point, we notified the helicopter service to lift off. They are only several minutes away. I also gave (Interviewee #2, credential file #2) phone number to the radiologist who is going to look at the CT, in more detail. I came back prepped the patient, and the helicopter is on its way. I got a copy of CT, filled out the all of the EMTALA transfer paperwork. At 1:40 p.m., I received a phone call from ...case management with Northeast Georgia, who stated there were no ICU beds, and the patient was now declined.
Reviewed with ER Director (employee file #1) the facility's "Patient Activity by Hour of Day", main campus bed log revealed that the ICU(Intensive Care Unit) held 32 (thirty two) beds and the CCU(Cardiac Intensive Care Unit) held 17 beds. The patient activity log indicated that on 04/22/12 between 11:00 p.m. to 2:00 p.m. revealed there was at least one (1) bed available in the ICU and 8 (eight) CCU beds available on those units. The ER director agreed that the patient activity log was accurate and there were beds available. The hospital failed to accept an appropriate transfer of patient #21 who required the specialized vascular capability and capacity to treat this patient with an identified emergency medical condition on 4/22/2012. Patient #21 was finally accepted at another acute care hospital transported via helicopter and taken emergently surgery.

Review of the facility policy entitles, "COBRA - EMTALA", revised 04/11 indicated that the facility had an obligation to accept appropriate transfers to the extent that the medical center has specialized capabilities or facilities not available at another facility that has asked the Medical Center to accept the transfer of an individual needing those capabilities or facilities, the Medical Center shall accept appropriate transfers of such individuals if the Medical Center has the capacity to treat the individual.

Review of the facility's CCRC (Customer Care Resource Center) Transfer log sheet for cardiac and none cardiac patients revealed the patient was not listed as being accepted or denied for a transfer from another facility.

Review of the facility's policy entitled, "Transfer From Other Hospitals", revised 03/10 indicated the physician would accept a patient from another hospital. The policy further stated that the physician should advise the referring physician that the patient is accepted subject to approval by NGMC. The policy further stated case management or nursing supervisor and/or Senior Management would decide to accept or reject the request for transfer, document the decision, and notify the parties concerned accordingly.

Review of the facility's call log audio recording for 04/22/12 revealed that Air Life (helicopter medical transportation) had prepared to transfer a patient requested by the transferring facility to the accepting hospital. The Air Life personnel requested a transfer for a patient who needed vascular surgery services and had identified a vascular surgeon (credential file #2) who accepted the patient to the facility. Review of the audio recordings indicated that the casemanager (interviewee #7) was the staff who had received the call from Air Flight about transferring the patient. The Air Flight representative had given the casemanager information concerning the patient and the name of the vascular surgeon who accepted the patient. The casemanager was unaware of the transfer and he/she called the vascular surgeon to verify accepting the transfer. The vascular surgeon verified that he/she accepted the patient and would need a ICU(Intensive Care Unit) bed for the patient. The casemanager then while on the phone with the surgeon was making transfer arrangements had spoken with another hospital personnel who stated the facility had no ICU beds. The vascular surgeon was informed about the bed availability situation and requested the casemanager to relay that information to the transferring hospital's emergency room physician that there were no ICU beds. The casemanager called the facility and explained that the hospital had no ICU bed availability and they could not accept the patient.

An interview #7 was conducted on 11/14/15 at 1:30 p.m. in the conference room by phone with the CCRC casemanager who was on duty. The casemanager indicated he/she could not remember if a request was made on behalf of the patient for vascular surgery services and that the transfer request was not listed on the hospital's transfer call log.

An interview (credential file #2) was conducted on 11/13/12 at 3:00 p.m. in the conference room with the vascular surgeon. The surgeon stated he/she had spoken with the physician who requested a patient transfer to the facility for a leaking aneurysm. The surgeon stated he/she was somewhat familiar with the request and remembered that he/she accepted the patient and believed he/she had asked for a operating room for the patient. The surgeon indicated that after he/she accepted the patient he/she had not seen the patient or performed surgery on the patient or heard anything else about the patient. The surgeon explained the proper procedure was that when someone requested a transfer to the facility they called the One Call Center and the representative notified the appropriate physician then both parties along with the call center's representative accepted or denied the transfer. The surgeon stated he/she was aware of the on-call center process.

An interview #3 )was conducted on 11/13/12 at 3:17 p.m. in the administrative conference room with the CCRC manager. The manager stated that the patient's name was not listed on the facilities transfer logs into the facility on 4/22/12 and the information collected had not indicated the staff was involved with a transfer for the patient. The manager stated that when the request for transfer was made the case management was involved for vascular surgery patients and there would be a three(3) way conversation that included a CCRC representative, the accepting and the transferring facility physicians. The manager explained according to the transfer log the vascular surgeon or ER (Emergency Room) physician had not called and asked for the patient to be transferred to the facility. The CCRC manager stated if the facility had no beds then the transferring facility was instructed if the patient was stable to hold the patient until a a bed was available and if the patient was unstable the patient may be transferred to the emergency room first. The manager explained he/she sent out information concerning the process. The hospital staff and the contracted physician services received training and he/she sent information about the CCRC process last year September 2011.

Review of the facility's original On-Call schedule for the Vascular Surgery services revealed interviewee #2 (credential file #2) was scheduled on-call for 04/22/12.

Staffing schedule for CCRC revealed the casemanager (interviewee #) was on duty the day the transfer request was called to the facility.

Reviewed with ER Director (employee file #1) the facility's "Patient Activity by Hour of Day", main campus bed log revealed that the ICU(Intensive Care Unit) held 32 (thirty two) beds and the CCU(Cardiac Intensive Care Unit) held 17 beds. The patient activity log indicated that on 04/22/12 between 11:00 p.m. to 2:00 p.m. revealed there was at least one (1) bed available in the ICU and 8 (eight) CCU beds available on those units. The ER director agreed that the patient activity log was accurate and there were beds available.

Review of the credential files for the Medical Director of the ED (credential file #1) and Vascular Surgeon (credential file #2) revealed both physicians had evidence of required EMTALA training and signed attestations of awareness and compliance with facility policies regarding EMTALA. Credential file #2 revealed specialized training for vascular surgery procedures.