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Based on interviews, review of medical records from Facilities #1, #2, and #3, review of the facility's policy and procedure, intake audio recordings, bed census reports, and on call schedules, it was determined the facility failed to accept an appropriate transfer of an individual who required the specialized services (Cardiology), not provided by the transferring facility (Facility #2) and the receiving facility had the capacity to treat one (Patient #1) of 25 random sampled records reviewed. Refer to 42 CFR 489.24 (A2411).

Based on interviews, reviews of medical records from Facilities #1, #2, and #3, and review of the facility's policy and procedures, intake audio recordings, bed census reports and on call schedules, it was determined the facility failed to accept an appropriate transfer of an individual who required such specialized services (Cardiology), not provided by the transferring facility (Facility #2) or facilities and the receiving hospital (Facility #1-Pikeville Medical Center) had the capacity to treat 1 (Patient #1) of 25 random sampled medical records reviewed.

The findings include:

The facility's policy titled "EMTALA Duty to Accept" GUIDELINE #:8441-.0006 was reviewed. The policy revealed in part, "Purpose: To ensure that appropriate transfers are accepted by the hospital and medical staff on-call ...Policy: PMC (Pikeville Medical Center) shall accept any emergency transfer from another facility which meets the following conditions: 1. the individual being transferred has an emergency medical condition which requires treatment or services available at PMC, but not available at the transferring hospital; 2. PMC has the available space and qualified staff to treat the individual; 3.) an appropriate member of the medical staff with active admitting privileges has accepted the patient and agreed to accept.. Note: if the transferring hospital and physician do not have an identified accepting physician at PMC, the emergency Room medical director will facilitate communication with the appropriate on-call specialist."

The facility's policy titled "EMTALA- Transfer Process" Effective 07/16/10 Reference (Blank) specified in part, "Purpose: To ensure that a patient requesting or requiring a transfer for further medical care and follow-up is transferred appropriately ... DEFINITIONS: Capabilities refer to the hospital's physical space, equipment, supplies and services (e.g. trauma care, surgery, intensive care, pediatrics, obstetrics ...) ...The capabilities of the facility's staff mean the level of care the hospital's personnel can provide within the training and scope of their professional licenses. Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual. Capacity encompasses number and availability of qualified staff, beds, equipment, and the hospital's past practices of accommodating additional patients in excess of it occupancy limits. .. Emergency Medical Condition means: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain ...) such that the absence of immediate medical attention could reasonably be expected to result in (A) placing the health of the individual...in serious jeopardy."

A review of the facility's policy titled "Transfer Intake Process," not dated, revealed when a transferring hospital needed physician acceptance at the facility for the transfer of a patient, facility staff would utilize the call schedule to inquire with the physician on call to accept the patient. The policy further stated facility staff would connect the referring and receiving physician in a conference call to complete the transfer unless the on-call physician stated that the patient needed a higher level of care or service not offered at the facility.

A review of the medical record of Patient #1 from Facility #2 revealed the patient presented to the Emergency Department (ED) at Facility #2 on 10/12/14 at 6:05 PM with chest pain. According to the physician's clinical report, Patient #1's EKG was abnormal with an increased heart rate of 181 beats per minute and the patient's troponin level was elevated at 27.32 (normal troponin is less than 0.01. For patients who present with acute coronary symptoms, troponin values greater than or equal to 0.01 that continue to rise are indicative of cardiac injury.) Further review of the record revealed the ED physician from Facility #2 contacted Cardiologist #1 at Facility #1 on 10/12/14 at 7:20 PM to discuss the "patient's problems and lab results." Cardiologist #1 ordered medication changes to lower the patient's heart rate to less than 120 beats per minute prior to the transfer. Further review of Patient #1's physician clinical report from Facility #2 revealed the ED physician from Facility #2 spoke with Cardiologist #1 again at 8:20 PM to discuss Patient #1. The patient had a three to four second period of asystole (no heartbeat). Then the patient's blood pressure went down and the heart rate went up to greater than 40 beats per minute. According to the physician clinical report, Cardiologist #1 ordered cardioversion for Patient #1.

Further review of Patient #1's medical record from Facility #2 revealed on 10/12/14 at 8:35 PM, the ED physician contacted Facility #3 to discuss Patient #1's "problems and test results." The Cardiologist at Facility #3 accepted the patient for transfer to Facility #3, which was approximately 104 miles from Facility #2.

A review of a "Patient Intake Form" from Facility #1 dated 10/12/14 at 6:58 PM revealed Facility #2 contacted the facility regarding the transfer of Patient #1 due to chest pain, acute Myocardial Infarction (heart attack), and a heart rate in the 150's. According to the patient intake form, Cardiologist #1 wanted the patient's heart rate to be in the 110's to 120's prior to transferring the patient. Further review of the intake form revealed Facility #2 called again at 8:17 PM because the patient had four seconds of asystole and for 15 seconds the patient's heart rate was in the 30's and was currently in the 160's. Cardiologist #1 instructed Facility #2 to "cardiovert (Cardioversion is a medical procedure done to restore a normal heart rhythm for people who have certain types of abnormal heartbeats. Cardioversion is most often done by sending electric shocks to the heart through electrodes placed on the chest and occasionally using only medications to restore the heart's rhythm.) [Patient #1] before transfer."

A review of the intake audio recordings from Facility #1 on 10/12/14 regarding Patient #1 was conducted on 11/20/14 at 2:20 PM. The audio recording revealed there were 14 phone calls placed between Facility #1 and Facility #2 when Facility #2 was attempting to transfer Patient #1. Cardiologist #1 spoke with the ED physician from Facility #2 on two different occasions, both times making recommendations for treatment and transfer, but putting conditions on the transfer stating "I would like the patient to have a lower heart rate, rate of between 110-120 before transfer." Further review of the audio recordings revealed on 10/12/14 at 8:17 PM, a nurse from Facility #2 contacted a Registered Nurse (RN) from Facility #1 (RN #1) and stated, "If you don't want to take the patient then I'll find someone else who will. The patient needs to go somewhere before [Patient#1] crashes and dies." Further review revealed RN #1 then contacted Cardiologist #1 and informed him, "The patient kind of crashed on them, a little bit." Cardiologist #1 stated, "They need to cardiovert the patient." At 9:04 PM Facility #2 informed Facility #1 that Patient #1 had been transferred to Facility #3.

Medical record review revealed Facility #3 admitted Patient #1 on 10/12/14 at approximately 11:34 PM. A review of the discharge summary revealed Facility #3 diagnosed Patient #1 with pneumonia, urinary tract infection, and "NSTEMI" (NSTEMI is a type of heart attack) with a troponin level greater than 27. Further review of the discharge summary revealed the patient also had a heart catheterization with stent placement and received a pacemaker.

An interview with Cardiologist #1 on 11/20/14 at 3:00 PM revealed he did not recall specifics of the case with Patient #1 but he did recall the scenario. Cardiologist #1 stated that Patient #1 was at Facility #2 with a heart rate of 170-180 and he tried to help the ED physician at Facility #2 by walking the physician through ACLS (Advanced Cardiac Life Support) protocol. He stated that with Patient #1's symptomology after medication, he recommended the patient be cardioverted. Cardiologist #1 stated that he was not delaying transfer. He stated he was attempting stabilization prior to transport to Facility #1. Cardiologist #1 was unaware of the numerous phone calls between Facility #1 and Facility #2 to attempt to arrange transfer for Patient #1.

Pikeville Medical Center failed to ensure that their policy and procedure "Duty to Accept" was followed as evidenced by failing to ensure that on 10/12/2014 Patient #1 was accepted from the transferring hospital (Facility #2) and medical staff and the medical staff on-call (Cardiology).

Patient #1 required Cardiology services on 10/12/14 that was available at Facility #1, but not available at Facility #2.

An interview was conducted with the Assistant Medical Director of Facility #1's ED on 11/20/14 at 4:06 PM. The Assistant Medical Director stated that he had been an ED physician for eight years and would consider it a delay in treatment if it took 14 phone calls and one and a half hours to get the receiving facility to agree to take a patient. Continued interview revealed, "If it took that much work and time to transfer a patient, you would just find another facility to take your patient."

An interview with the Chief Nursing Officer (CNO) of Facility #1 on 11/20/14 at 4:30 PM revealed she had reviewed the audio tapes of the phone calls regarding the attempted transfer of Patient #1 and was not happy with the number of phone calls and the time it took to facilitate the transfer of Patient #1. The CNO stated she was going to re-educate the staff in the intake center regarding the facilitation of transfers from other facilities.

An interview was conducted with the ED physician from Facility #2 on 11/21/14 at 4:00 PM who stated he was working at Facility #2 on 10/12/14 when Patient #1 presented to the ED seeking medical treatment for chest pain and atrial fibrillation. Physician #1 stated the EMTALA allegation was reported to authorities because several calls were made to conduct a transfer of Patient #1 but Cardiologist #1 kept stating he wanted the patient's heart rate at 120 or lower. It was the ED physician's professional opinion that the patient could not wait any longer and the recommendation to cardiovert with atrial fibrillation "would have killed the patient." Continued interview revealed the ED physician from Facility #2 contacted Facility #3 one time and was able to transfer Patient #1 to Facility #3.

An interview was conducted with Patient #1's family member on 11/25/14 at 12:10 PM. Patient #1's family member stated that Patient #1 had a heart attack at Facility #2 and the ED physician from Facility #2 did everything he could to help the patient, but Facility #1 would not accept Patient #1. The family member stated that Facility #1 wanted the ED physician from Facility #2 to do different things/try different methods and Patient #1 just did not have the time. The family member stated that Patient #1 kept crashing and needed to get out of Facility #2.

An interview with the cardiologist from Facility #3 on 11/26/14 at 10:45 AM revealed he was the on-call cardiologist when Patient #1 was admitted to Facility #3. The Cardiologist stated the patient was immediately taken to the heart catheterization lab upon arrival and required a stent and a pacemaker. The cardiologist stated that he believed 14 phone calls to transfer one patient was "excessive." He stated he would have only called twice and then would have looked for another accepting hospital.

The hospital's "Cardiology On-Call Schedule - October 2014" was reviewed. The on-call schedule verified that Facility #1 had a Cardiologist (Cardiologist #1) on call on 10/12/2014. The facility had Cardiac capabilities and/or facilities on 10/12/14 to provide the specialty care that Patient #1 needed on 10/12/14.

Facility #1's midnight census report for 10/12/14 was reviewed. The hospital has 261 licensed beds. Review of the bed census midnight report dated 10/12/14 revealed that on 10/12/14 the hospital had 80 vacant beds. The facility had the capacity to provide further treatment and evaluation for Patient #1 on 10/12/14 for his emergent cardiac condition that was not available at Facility #2.

Patient #1 presented to Facility #2 with chest pain and was diagnosed with a heart arrhythmia and heart attack, which required specialized cardiology services that were not provided by Facility #2. Facility #2 contacted the facility (Facility #1), which is approximately 44 miles from Facility #2, in an attempt to transfer the patient for cardiology services; however, the facility placed conditions on the transfer, requiring Patient #1 to have a heart rate of 110-120 beats per minute prior to transfer. After making fourteen (14) phone calls to Facility #1 and attempting to stabilize Patient #1 for approximately 97 minutes, Facility #2 arranged for Patient #1 to be transferred to Facility #3, approximately 103 miles away, who accepted the patient immediately. The facility failed to ensure that their "Transfer Process" was followed as evidenced by failing to ensure that when the request was made from Facility #2 for a patient (Patient #1) who required transfer on 10/12/14 for further medical care was transferred appropriately to Facility #1. Because of his emergent cardiac medical condition that manifested itself by acute symptoms (chest pains & cardiac arrhythmias) of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing patient #1's health in serious jeopardy.