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Based on policy and procedure review, medical record review, and interview, it was determined the facility failed to accept an appropriate transfer for one of one (#1) patient requiring specialized vascular services not offered by the transferring facility. By not accepting Patient #1 the facility delayed the specialized treatment needed for Patient #1. The failed practice had the likelihood to affect any patient needing the specialized services provided by the facility. Findings follow:

A. Review of Policy and Procedures of the Baptist Health Medical Center - Little Rock, "EMTALA Guidelines," dated 05/2022, showed capacity means the ability for the Facility to accommodate treatment for a transferred individual such as availability of qualified staff, beds, and equipment.

B. Review of Policy and Procedures of the Baptist Health Medical Center - Little Rock, "Responsibility Statement," dated 09/2022, showed the following: "When a referral from outside hospital (OSH), the Access Nurse will confirm the status of the patient to determine if ED (Emergency Department) to ED transfer is appropriate. In all cases where there is a procedure or condition mentioned during the intake call, where there is a question as to whether (Baptist Health Medical Center - Little Rock) does those procedures, or cares for those medical conditions, call the ED physician in (Named City), to make that determination prior to acceptance."

C. Review of Policy and Procedures of the Baptist Health Medical Center - Little Rock "Responsibility Statement," revised 08/2023, showed, "Vascular: should the on call (Baptist Health Medical Center - Little Rock Vascular Surgeon) decline the patient, contact Dr. (Medical Director of ED) before contacting Dr. (Vascular Surgery) Group. Dr. (Medical Director of ED) will review the case and potentially request a 3-way call with Dr. (Named Facility Vascular Surgeon) to determine nest steps."

D. During an interview on 09/07/23 at 1:30 PM, Director Patient Command Center and Help Line confirmed the findings in A to C.

E. Review of Patient #1's Clinical record from the transferring facility CHI St. Vincent Hot Springs ED showed the following:
1) Admission was from 05/18/23 at 10:58 AM to 05/19/23 at 10:39 AM.
2) Provider Note dated 05/18/23 at 10:58 AM, by Physician #2 showed "History of significant peripheral vascular disease and cold right foot. Hx (History) of pvd (Peripheral Vascular Disease), about 1 month ago showed diffuse disease. Patient was on Eliquis. Skin was positive for color change and wound. Radial and femoral pulses normal. He did not get right dorsalis pedis pulse on palpation or Doppler. Faint right posterior tibial pulse. The dorsal and plantar surface of the right foot is cool to touch. Cap (Capillary) refill delayed over 5 seconds. Patient evaluated at the bedside by (Physician) interventional radiologist on call. He evaluated the patient and reviewed patient's CTA (Computerized Tomography Angiography) of his abdomen with runoff. He recommended transfer to facility with vascular surgery as he thinks patient may need surgical bypass versus a profundoplasty. He stated they had been unsuccessful in the past trying to get blood flow in this patient's lower leg and he was concerned that they could potentially make something worse. Discussed with patient, spouse, interventional radiologist at the bedside and they agreed with plan of care.
3) On 05/18/23 at 3:51 PM, APRN (Advanced Practice Registered Nurse) Provider Note showed, "The patient had critical ischemia of the RLE (Right Lower Extremity), was sent to the ED from wound care with acute onset of discoloration to the dorsum aspect of the right foot. Has a non-healing wound to the lateral aspect of the right foot that has been present for at least 6 months. The foot is purple in color, patient reports the color change began today. The dorsum aspect of the foot and the toes are cool. Cap refill severely delayed. He had a very faint intermittent PT (Popliteal) signal, unable to obtain a DP (dorsalis pedis) signal. He has a history of PAD (Peripheral Artery Disease), sip attempted RLE and LLE (Left Lower Extremity) arteriogram per (Named MD) in 2020, both unsuccessful as he was unable to get wires passed the chronic occlusions. Also had an attempted RLE arteriogram per (Named MD) in August of 2022. He was on Eliquis, last dose this morning. Was receiving a Heparin drip. CTA with runoff completed today, findings of multifocal high-grade stenosis in the SFA's (Superficial Femoral Arteries) bilaterally with two vessel runoffs, unchanged from the CTA completed in April. (Named MD) present for exam. Recommend transferring to Baptist Health Medical Center - Little Rock City for vascular surgeon consult/ work up."
4) Clinical Notes dated 05/18/2023 11:41 AM, showed (Named) RN #1 "The patient c/o (complaints of) Bilateral foot wounds has had for several months today when at wound clinic nurse was concerned about not feeling a pulse and coldness to foot. Bilateral feet slightly purple in color hx of this and neuropathy. MD at bedside with doppler."
5) Clinical Notes dated 05/18/2023 2:00 PM showed (Named) RN #2 "Patient arrived with complaints of wounds to lower legs, worse on the right side. Patient reports he has had wounds and has been seen by wound care. Reports neuropathy in bilateral legs, reports changed in color to legs x 2 weeks."
6) Provider Note dated 05/18/23 at 11:18 PM, (Named Referring Physician) #1 showed, "Patient checked out to (Named Referring Physician) #1 with transfer pending. (Named Referring Physician) #2 had initiated attempt to transfer the patient to Baptist Health Medical Center - Little Rock in (Named City). At the time of initial transfer attempt their facility was on delay and therefore they were unable to accept the patient. Their facility called back and (Named Referring Physician) #1 spoke with the transfer center when they came off the delay who connected me with the vascular surgeon on-call, (Named Receiving Provider) #1who states he thinks the patient should be transferred to hospital within our system. I explained to him that Baptist Health Medical Center - Little Rock has been contacted and did not have vascular surgery on-call and therefore they were unable to set the patient. I (Named Referring Physician) #1 have explained to (Named Receiving Physician) #1 that the patient had findings concerning for acute on chronic peripheral vascular disease and evidence of ischemia with a cool right foot with intractable pain however (Named Receiving Physician) #1 stated that (Named Referring Physician) #1 should discharge the patient to be seen in clinic. (Named Referring Physician) #1 explained the patient is on a Heparin infusion for management of the findings and that multiple physicians have evaluated the patient and feel he is appropriate for transfer and requires vascular surgeon including the prior (Named Referring Physician) #2 and interventional radiology. (Named Receiving Physician) #1 declined this transfer despite having capacity to accept the patient at the time of the initiation of our conversation. For the time being they continued to treat this patient with Heparin infusion. He continued to have pain. Patient continued to have temperature change to the foot concerning for ongoing ischemia supported by his imaging performed by prior (Named Referring Physician) #2. (Named Referring Physician) #1 continued pain control and treatment with heparin while attempting transfer elsewhere."

F. During interview on 09/07/23 at 1:30 PM, with Director Patient Command Center and Help Line, when Surveyor asked the Director Patient Command Center and Help Line the following:
1) Explain the difference in delay and diversion, he stated, "The ED will be placed on delay and the inpatient care areas (Intensive Care and Medical Surgical Units) will be put on diversion when they are at capacity."
2) Explain the decision to delay and place facility on diversion, he stated, "Once a decision is made to put the ED on delay or a unit on diversion, there is a 30-minute span that it takes to get in entered into the Baptist Health Medical Center - Little Rock system and the Trauma system."
3) Explain the process of escalating a phone call once a patient has been denied transfer from an outside facility, he stated, "Recently, there was a situation where a patient was referred to Baptist Health Medical Center - Little Rock but the hospital was off and on delay for several hours. Unfortunately, a patient was being referred during that time period and a policy change was necessary to prevent further unwanted issues."

G. During interview on 09/06/23 at 2:30 PM, with Director of Vascular Surgery when Surveyor asked for the process of accepting a vascular transfer, she said, "After hours there will be a Resident MD on call for all consults and possible transfers. Once the Resident MD reviews all images and medical documentation, a decision between the Resident MD and their Attending MD will be made to accept or deny the transfer of the patient."