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On the days of the Emergency Medical Treatment and Labor Act (EMTALA) investigation based on review of the hospital's Emergency Department (ED) log, staff interviews, review of hospital medical staff by-laws and rules and regulation, and review of hospital policies and procedures, the hospital failed to ensure that its own policies and procedures were followed by failing to accept the transfer of a patient with an emergency medical condition that required specialized services from another hospital for one (#33) of thirty three sampled patients.

The findings included:


Cross reference A 2406: The hospital failed to ensure that hospital by-laws or rules and regulations determined the qualifications of the QMP (qualified medical personnel) that may conduct medical screening examinations.

Cross reference A 2411: The hospital failed to ensure that patients referred from other hospitals, with an emergency medical condition, were not refused acceptance (Patient #33).

On the days of the Emergency Medical Treatment And Labor Act (EMTALA) investigation based on interviews, review of hospital policies and procedures, and review of the hospital's medical staff bylaws rules and regulation, the hospital failed to ensure that hospital by-laws or rules and regulations determined the qualifications of the QMP (qualified medical personnel) that may conduct medical screening examinations.

The findings included:

On 3/9/10 at 0900, a review of the Medical Staff Bylaws and Rules and Regulations and hospital policies and procedures revealed no written documentation of the qualifications for Qualified Medical Personnel. On 3/9/10 0840, an interview was conducted with the hospital's Emergency Department's Medical Director who stated that physicians and physician assistants are the QMPs (qualified medial personnel) allowed to perform medical screening examinations but the hospital had no written documentation of the qualifications for Qualified Medical Personnel. On 3/10/10 at 1010, the Vice President of Quality and Risk stated the hospital had no written documentation for the qualifications for Qualified Medical Personnel.

On the days of the Emergency Medical Treatment And Labor Act (EMTALA) investigation based on staff interviews, review of medical records, on call lists, Medical Staff Policy and hospital policies and procedures, the hospital (Hospital #1) failed to ensure that a patient who had an emergency medical condition and in need of an appropriate transfer for specialized treatment was accepted through a referral made to the hospital's emergency department from another hospital's (Hospital #2) emergency department for one of 33 patient medical records reviewed (Patient #33).

The findings included:

Patient #33's medical record from the transferring hospital was reviewed. The medical record indicated that patient #33's date of service was 9/22/2009 at 12:44 a.m., and chief complaint was " testicular (scrotal) pain. " Documentation by the emergency department physician revealed in part, " 2:30 a.m., Medical Screening exam (examination) . . . 22 year old presents to the emergency department with ... acute right scrotal/testicular pain. The onset was around 11:30 p.m. (9/21/2009). . . . no history of acute trauma fall or injury. . . Exam: Genital: ... markedly swollen tender right testicle. " The ED physician wrote orders for the placement of an intravenous line, obtain blood for laboratory wok, and to have an ultrasound (high-frequency sound waves to look at organs and structures inside the body) of the patient ' s scrotum. The results of the ultrasound specified in part, " IMPRESSION: No flow demonstrated in the right testicle highly suspicious for testicular torsion. " (When the spermatic cord to a testicle twists, cutting off the blood supply- a true urologic emergency). Further documentation by the ED physician specified in part, " I (ED physician) received communication from the ultrasound technician that the right testicle appears swollen and there is no evidence of vascular (blood) flow, suggesting and acute testicular torsion, and this would be consistent with clinical exam. Review of the on call coverage at (transferring Hospital), reveals no urological (medical specialty concerned with the urinary system in the male and female and genital organs). I have contacted the general surgeon. . . and discussed this with him. He indicated that he did not have this specialized training and that the patient would likely need orchiopexy (Surgery to move an undescended testicle into the scrotum) as well and requested that we refer this to an appropriate urologist(A physician who specializes in diseases of the urinary organs in females and the urinary tract). I then contacted the nearest hospital with urological services. Beaufort Memorial Hospital and spoke with emergency department physician, Dr ..... and explained this patient's presentation and requested an opportunity to speak with their on-call urologist. He stated that he would be happy to accept this patient but would have to speak with their on-call urologist. Their on call urologist is Dr ..... Dr. (from Beaufort County Memorial Hospital) returned my call stating Dr. Urologist on call at Beaufort Memorial Hospital has refused to accept this patient in transfer and has recommended that I contact another acute care hospital. I have contacted (another acute care hospital) and received a return phone call urologist Dr ... who has accepted this patient in transfer. " Review of the transferring facility " Pt (patient) Transfer acknowledgement form " indicated that transfer of patient #33, " to an appropriate medical facility that has the expertise to manage this urological emergency is warranted." Beaufort County Memorial Hospital failed to ensure that an appropriate transfer was accepted on 9/22/2009 from a referring hospital for patient #33 who required the hospital's specialized urologic capability and capacity to treat the identified emergency medical condition. The medical record from the receiving hospital was reviewed. Review of the History and Physical dated 9/22/09 indicated that patient #33 was taken to the operating room. The operative report revealed that on 9/22/2009 the surgical procedure performed was " Right scrotal exploration with detorsion of right testes and bilateral orchiopexy. "

Beaufort Memorial Hospital Physician County Call-list dated 9/21/2009 was reviewed. The Physician Call-List revealed that on 9/21/2009 from " 7A (a.m.) to 7A (a.m.)" (9/21/2009 7 a.m. to 9/22/2009 7 a.m. 24 hour call), a Urologist was on call.

Review of Hospital #1's Policy, "Patient Admission Process (Bed Assignment), original date 3/09, reads, "Purpose: .....plans for a safe and efficient admission process to the hospital. Patients with comparable needs receive the same standard of care, treatment and services throughout the hospital. Policy: .... receives admission from physician's offices, the Emergency Department (ED), post-surgical (PACU) or procedural areas, or referring facilities based on established admitting criteria. B .... will not refuse to accept a patient from a referring hospital if .... has the capabilities and available space to meet the patient needs.... If the patients requires immediate attention, the patient will be processed through the ED...:"

Review of Hospital #1's Medical Staff Policy, "ER Communication with Medical Staff", original date 2/01, reviewed 3/09, reads, " Policy: The purpose of this policy is to ensure that physician are available to provide consultations and stabilizing treatment in a timely manner for individuals presenting at the ED requesting examination and treatment for medical conditions and to accept referrals of unassigned patients. Policy: Physicians' on-call shall be available to provide consultations and treatment to their own patients as well as to unassigned patients..."



On 3/10/10 at 0845, a face-to-face interview was conducted with Hospital #1's Emergency Department (ED) physician (Physician #1) who was on duty in the hospital's Emergency Department on 9/21/09. Physician #1 reported that Hospital #1 received a telephone call from Hospital #2 requesting the transfer of a patient with an emergency medical condition,Testicular Torsion, stated in part, " I think it was in the middle of the night ." Hospital #2 did not have any urologists on call to treat the condition. According to Physician #1, Hospital #2 reported that the hospital had made several unsuccessful attempts to contact the urologist on-call at Hospital #1 regarding treatment for patient #33 who had been diagnosed with testicular torsion. Physician #1 who was on duty in the Emergency Department of Hospital #1 reported that he/she contacted the urologist on-call at Hospital #1 concerning the telephone call request from Hospital #2 for the acceptance and transfer of the patient. Physician #1 reported that the urologist on-call for Hospital #1 refused to accept the patient, and stated that he/she was not on-call for Hospital #2. Physician #1, the Emergency Department physician at Hospital #1 reported that he/she contacted Hospital #2 to inform the hospital that the on-call urologist at Hospital #1 had refused to accept the patient.

On 3/11/10 at 0916, a telephone interview was conducted with Physician #2 who was on duty at the receiving hospital, Hospital #3, which was the hospital that had accepted the patient from Hospital #2 after the initial referral to Hospital #1 was refused. Physician #2 reported that a patient was referred to Hospital #3 from Hospital #2 with a diagnosis of Testicular Torsion. Physician #2 reported that Hospital #2 was referring the patient because their hospital did not have a urologist on call to treat the patient. According to Physician #2, Hospital #3 had accepted and treated the patient. Physician #2 stated that Hospital #3 eventually learned that Hospital #2 had initially contacted the Emergency Department at Hospital #1 and was told by hospital personnel that Hospital #1 would accept the patient and that the on-call urologist at Hospital #1 would be contacted. However, Hospital #2 reported that the physician in Hospital #1's Emergency Department telephoned Hospital #2 and reported that the on-call urologist for Hospital #1 had refused to accept the patient from Hospital #2 and then, a request for transfer of the patient was initiated with Hospital #3 and the patient was accepted. Physician #2 stated that Hospital #3 did request and receive the call schedule from the transferring hospital, Hospital #2 that validated the transferring hospital, Hospital #2 did not have a urologist on call to treat patient #33 on 9/22/09.

On 3/09/10 at 1435, a telephone interview was conducted with the urologist identified as the on-call Urologist for Hospital #1 on 9/21/09. The Urologist stated that he/she recalled receiving a telephone call from a hospital regarding a patient with testicular torsion in September 2009. The Urologist stated that the referring hospital, Hospital #2 had three Urologists on staff and they (Hospital #2) should use their own staff for call. The Urologist on call for Hospital #1 reported that he/she was not on-call for the referring hospital, Hospital #2.