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Based on record review and staff and physician interviews it was determined the hospital failed to comply with Section 484.24(f). The hospital failed to accept a patient from a transferring hospital who potentially required the specialized services of the medical staff who was on call at the time of the request.

Emergency Department (ED) records and staff interview from the transferring hospital revealed Patient #1 presented to the transferring hospital on 05/18/17 at approximately 9:46 AM, with a laceration to the left forearm that resulted in arterial bleeding. A medical screening examination (MSE) determined the patient required the services of a vascular surgeon. Staff interviews and review of the specialty physician on-call log revealed the transferring hospital did not have a vascular surgeon available. The transferring hospital records revealed a request was made on 05/18/17 at approximately 10:54 AM, of the on-call vascular surgeon at Hospital B to accept Patient #1. Interviews with the ED staff at the transferring hospital and the vascular surgeon revealed this person refused to accept the transfer of Patient #1 related to past disputes between the vascular surgeon and the transferring hospital. After consultation with the Chief Medical Officer and CNO, the vascular surgeon agreed to accept Patient #1 and the transferring hospital was notified at approximately 12:48 PM. However, at that time the patient had already been transferred to another hospital who had agreed to accept the patient.

(Refer to A-2411)

Based on record reviews and staff interviews, it was determined the hospital failed to ensure an on-call specialty physician agreed to accept an appropriate transfer from a referring hospital of a patient who required specialized vascular services. This was found for one of 23 patients in the selected sample (Patient #1).

On 09/12/17 at 2:45 PM an interview with the Compliance Officer (CO) from Hospital A was conducted. The CO stated on 05/18/17 at approximately 9:46 AM Patient #1 presented to Hospital A's ED with a laceration injury to the left arm. Patient #1 received a MSE from a physician assistant (PA) and physician who noted arterial damage and determined the services of a vascular surgeon were required. As Hospital A had no vascular surgeon available, Hospital B's on-call vascular surgeon was contacted on 05/18/17 at approximately 10:54 AM. The vascular surgeon refused to accept the transfer of Patient #1 related to past disputes with Hospital A. Various telephone calls were made to Hospital B's administrative staff and at 12:48 PM Hospital A received a call from the CNO at Hospital B stating that the vascular surgeon had agreed to accept Patient #1. However, after the initial refusal by the surgeon to accept Patient #1, Hospital A contacted Hospital C who agreed to accept the patient. Patient #1 had been transferred to Hospital C on 05/18/17 at 12:20 PM.

On 09/11/17 at 3:12 PM, an interview was conducted with the vascular surgeon who was on call at Hospital B on 05/18/17. The surgeon stated sometime around midday on 05/18/17, he received a call that had been routed to him by his office. The caller identified themselves as a practitioner from the ED at Hospital A. The caller stated their ED had received a patient with a vascular injury to the arm and requested the surgeon accept the patient's transfer to Hospital B. The surgeon stated the call was confusing because such requests normally came through a transfer call center. The surgeon told the caller that Hospital A usually transferred such cases to hospitals out of state because of past disagreements between the surgeon and Hospital A. The surgeon informed the caller he would not accept the transfer unless the patient was at risk of serious injury. According to the surgeon, he was involved in a short procedure after the call took place. At the conclusion of the procedure, the Chief Medical Officer (CMO) and CNO were waiting to speak with him. After they explained to the surgeon that his/her refusal to accept the patient was a possible EMTALA violation, he agreed to accept the patient. He later learned the patient had been accepted at another hospital. The surgeon stated he had not received any formal EMTALA training.

An interview was conducted with the CMO on 09/13/17 at 8:50 AM. This person stated he accompanied the CNO at her request to discuss the transfer with the vascular surgeon. The CMO stated the vascular surgeon was located in the "special procedures" area performing a minor procedure. The CMO and CNO had to wait approximately 15-20 minutes for the surgeon to complete the procedure before speaking with him. In discussing the issue, the vascular surgeon questioned why he was obligated to accept the patient because Hospital A had a vascular surgeon on staff. When the CMO and CNO explained the vascular surgeon at hospital A was not available, the vascular surgeon agreed to accept the patient. The CMO stated new members of the medical staff receive EMTALA training as part of their orientation, but this was not part of an ongoing program.

A telephone interview was conducted on 09/12/17 at 2:55 PM, with the PA who was involved in the MSE of Patient #1 at Hospital A. The PA stated on 05/18/17 she examined the injury to Patient #1 and consulted with the ED physician and an orthopaedic surgeon. It was determined the patient required the services of a vascular surgeon and the only vascular surgeon on staff at Hospital A was not on-call. She contacted the on-call surgeon at Hospital B after having the unit secretary place the call. The surgeon stated it was an "inappropriate" call related to the surgeon being denied privileges at Hospital A by the administrator. The surgeon refused to accept the transfer on that basis.

Review of Hospital A medical records for Patient #1 revealed this person presented to the hospital on 05/18/17 at approximately 9:46 AM. The chief complaint was listed as "Vascular injury of left arm, initial encounter, laceration of left arm with complication, foreign body (FB) in soft tissue". ED physician notes on 05/18/17 at 11:34 AM, documented "pulsing blood loss" related to a vascular injury. The physician documented Patient #1 had "good" radial and ulnar pulses. On 05/08/17 at 11:30 AM, the PA documented the presence of a vascular injury and foreign body to the left arm. Bleeding was controlled with a pressure dressing. The PA documented that the general surgeon on-call (this was later determined to be an orthopaedic surgeon) was contacted and recommended the patient be transferred to a facility with a vascular surgeon. The PA documented the vascular surgeon at Hospital B was contacted but refused to accept the patient due to "political reasons". The PA documented Hospital C was contacted and agreed to accept the patient. Physician certification documented the patient's condition as stable at the time of transfer which was listed as 12:20 PM.

The medical records from Hospital C for Patient #1 were obtained and reviewed. The ED physician note for 05/18/17 at 2:00 PM, noted a 6 cm long by 3 cm wide by 3 cm deep laceration to the proximal dorsum of the left forearm with "scant arteriole bleeding". The record documented the services of a plastic surgeon was obtained. A history and physical and procedure note by the plastic surgeon documented a 2 cm glass shard was removed from Patient #1's left arm. The wound was then irrigated with normal saline and closed with surgical sutures. The patient was discharged home with antibiotic and narcotic prescriptions . There was no documentation of consultation with a vascular surgeon.

Review of medical staff bylaws for Hospital B revealed the section titled "Emergency Services". This section stated active medical staff were responsible for emergency call for their respective specialties. Physicians were responsible to respond within 30 minutes of being contacted in an emergency.