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Based on reviews of medical records, policies and procedures, Medical Staff Rules and regulations, transfer logs, non-acceptance logs, Daily On Call assignments, clinical privileges (urology), bed census, and interviews the facility failed to accept from a referring hospital an appropriate transfer of an individual who required such specialized capabilities (Urologist) or facilities, the hospital also had the capacity to treat 1 (#21) of 20 sampled patients. The hospital also failed to have an effective Policy and procedure in place that addresses appropriate transfers from transferring/receiving hospitals; as this has the potential to affect other emergency department to emergency department EMTALA transfers.


Cross- Refer to A2411 for details

Based on reviews of medical records, policies and procedures, Medical Staff Rules and regulations, transfer logs, non-acceptance logs, Daily On Call assignments, clinical privileges (urology), bed census, and interviews the facility failed to accept from a referring hospital an appropriate transfer of an individual who required such specialized capabilities (Urologist) or facilities, the hospital also had the capacity to treat 1 (#21) of 20 sampled patients. The hospital also failed to have an effective Policy and procedure in place that addresses appropriate transfers from transferring/receiving hospitals as this has the potential to affect other emergency department to emergency department EMTALA transfers.
The findings are:

The medical record from the transferring hospital was reviewed. Review of the medical record revealed that patient #21 was an elderly male that presented to the emergency department (ED) on 4/28/2014, triaged at 3:37 p.m., with a chief complaint of " Hematuria (blood in urine). " A review of the section titled " History of Present illness " revealed in part, " patient states he is a little sore in his abdomen ...Location suprapubic ...modifying factors: worsened with movement ...Associated symptoms: abdominal pain ... Past History: Cardiovascular: Hypertension ...Genitourinary: Enlarged prostate- Prostate Cancer : Endocrine: Diabetes Type 2 ... Review of Systems: Genitourinary: Hematuria gross (gross-Blood in the urine that can be seen in the naked eye) ... Physical Exam (examination) .. . Male genitals ...bleeding, bloody drainage noted from foley catheter (foley catheter is a flexible tube that is often passed through the urethra and into the bladder). Bleeding from around cath (catheter) site. " The results of the CT scan of the abdomen and the pelvis dated 4/28/2014 was reviewed. The results revealed in part, " Impression: Complex 3 cm (centimeters) left renal mass worrisome for renal cell carcinoma (cancer); Large 9 cm bladder mass representing possible neoplasm (tumor is an abnormal mass of tissues as a result of abnormal growth); Hemorrhagic clot (blood clot); Large prostate gland. " Further documentation by the ED physician revealed in part, " ED physician discussed care with Urologist (not on call at referring hospital) who has apparently seen before states he is no longer caring for this patient (#21) ... Spoke with Albany Urology ( Urologist on call at Phoebe Putney Memorial Hospital), feels Physician ( who previously took care of patient ) Should take care of pt (#21) ...Case again reviewed with Urologist(who previously took care of patient) ...recommendation for irrigating bladder ...Receiving hospital called again .. .Will help with patient care will transfer to receiving hospital. " Further review of the medical record indicated that patient #21 departed from the transferring hospital's ED on 4/29/2014 at 2:08 a.m., and was appropriately transferred to a receiving hospital.

The medical record for patient #21 from the receiving hospital was reviewed. Documentation by the ED physician on the "History and Physical" indicated that patient #21 presented to the receiving hospital on April 29, 2014 at 5:29 a.m. The section titled "History of Present illness " specified in part, " ... pt's (patient's) home foley cath was removed. They were unable to re-introduce the foley cath for the pt. ... Urology consult Dr. (Urologist at receiving Hospital) was called and pt. was transferred to Receiving Hospital (hospital Name) for evaluation and management ... Review of Systems Genitourinary: Hematuria ... Impression and plan ...Hematuria, bladder mass with possible hemorrhage renal mass and anemia ...Plan: Admit, npo (nothing to eat or drink by mouth), Intravenous fluids. Review of the Operative Report dated April 29, 2014 revealed that patient #21's pre-operative diagnoses were " Gross hematuria with apparent clot urinary retention, bilateral hydronephrosis (is the swelling of a kidney due to build of urine. It happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction), possible bladder tumor, clot urinary retention. " The surgical procedures performed in part were, TURBT(Transurethral resection of the bladder tumor is a procedure used to diagnose bladder cancer and remove any unusual growths or tumors on your bladder wall), Large; left JJ stent(A urethral stent, is a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney); TURP(Transurethral resection of the Prostate is a type of prostate surgery done to relieve moderate to severe urinary symptoms caused by enlarged prostate).

Review of the facility policy entitled, " External Transfers and Bed Assignment " , no review, no date, revealed that the process for the Central Intake and Assessment (CIA), would include that after 11:00 p.m. the Emergency Center Care Manager (ECCM) would receive external patient transfer calls. The ECCM would facilitate a multi-way call utilizing the TRACE (phone recording tracking system), the participants on the call would include the transferring physician, the accepting physician, and the ECCM. The section of the policy titled " Procedure " specified in part, " A. After 7:00 a.m. -11:00 p.m. (Central Intake Assessment) Process: states in part, . . " Accepting physician converses with the sending physician and determines the need for urgent transfer. If the accepting physician does accept the transfer, the process ends, and the CIA personnel records the information in the " Transfer Not Accepted Log " . V. If the EC Care manager does not agree that the transfer is urgent, he/she documents this appropriately in the transfer log. This procedure failed to address the acceptance of appropriate EMTALA transfers from transferring/referring hospitals. As this Policy and Procedure delayed treatment of patient #21 on 4/28/2014. According to the " Emergency Medical Treatment and Labor Act statute codified at 1867 of the Social Security Act (the Act) the accompanying regulations in 42CFR 489.24 ....489.24 (f) Recipient Hospital Responsibilities A participating hospital that has specialized capabilities or facilities may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. "

Review of the facility " Non-Acceptance Transfer Log " , dated 4/29/14 at 11:00 p.m. revealed patient #21 was identified on the log with an On - call Urologist was listed and the emergency room (ER) physician of the transferring facility. Continued review of the Log revealed the 'Action Taken/Reason not accepted' was the On-Call Urologist did not accept because patient #21, did not need a higher level of care that could not be provided at the transferring facility, Urological services are available closer to the transferring facility than Phoebe Putney Memorial Hospital, Urological care was available at the transferring facility, patient #21 was not stable enough for transfer, and other. The transfer log was reviewed. The transfer log verified that on 4/29/2014 at 11:p.m., the " non Accepting physician at PPMH (Phoebe Memorial Hospital) for patient #21 was the Urologist Physician on call (on 4/28/2014) at PPMH.


Review of the Medical Staff Rules and Regulations, dated February 1992, under #2.2-2 revealed members of the medical staff with delineated privileges to attend on -call patients according to the on- call schedule to the applicable department or division.



The hospital's "Daily On call assignment " sheet for April 28, 2014 was reviewed. Review of this sheet revealed that Physician On-call was the Urologist (A urologist is a physician who has specialized knowledge and skill regarding problems of the male and female urinary tract and the male reproductive organs) was on call for April 28, 2014, when a request was made to transfer patient #21 on April 28, 2014. Review of the Credential files dated 10/01/2013 for the on-call Urologist, revealed appropriate licensure and credentialing. Summarily, the On call physician had met the requirements of the Medical Staff Bylaws/ Rules and Regulations. Additionally, the On Call Urologist was properly credentialed and had been granted privileges to provide Urology care. Further review indicated Core privileges to treat and provide surgical procedures for urology patients had also been granted. The hospital had the capability to provide urological services to Patient #21 on April 28, 2014.


The Bed census report for the SICU (Surgical Intensive Care Unit) and the Medical -Surgical units for Phoebe Putney Memorial Hospital dated 4/28/2014 were reviewed. According to the report the SICU had a bed capacity of 14. On 4/28/2014 the SICU had 1 (one) bed available. The hospital's medical units on 3A and 3B combined had a bed capacity of 48 beds, 11 beds available. The hospital's surgical units on 6A and 6B combined had a bed capacity of 38, 16 beds were available on these units. The hospital's medical units on 8A and 8B combined had a bed capacity if 47, 11 beds were available. On 4/28/2014 PPMH had the capacity to care for patient #21 on 4/28/2014.



Interview on 05/27/14 at 11:00 a.m. with the Central Intake and Assessment (CIA) manager revealed that the CIA center normal operations were from 7:00 a.m. until 11:00 p.m. Monday through Friday. After the CIA center closes calls were transferred to the ECCM. The CIA manager revealed that a "Requesting Transfer Log " and a schedule of the specialty physician on -call list are maintained. The CIA manager revealed that the TRACE system was not working at the time (4/28/2014)and the conversation concerning patient #21 was not recorded. The CIA manager revealed the following sequence of events related to patient #21, the transferring physician, the On-Call Urologist at Phoebe Putney Memorial Hospital, and the ECCM were connected on the multi system phone line. The information recorded by the ECCM included who the ECCM had contacted, action taken with the date, time of the occurrence and the identity of who created the entry in the log. The CIA continued to reveal in relationship to patient #21, the action taken, the On-Call Urologist did not accept patient #21, a higher level of care was not needed, Urological services were available closer to the transferring facility and Urological services are available at referring facility. The hospital failed to have an effective Policy and Procedure that addresses appropriate EMTALA transfers when a request is made from a transferring hospital after the transferring physician has determined that an emergency medical condition existed for patient #21 on 4/28/2013.

Interview on 05/28/14 12:15 p.m. with the On-Call Urologist revealed per the Non Acceptance Log dated 4/28/2014, receiving a call from the transferring facility related to patient #21's condition however this was not an acute problem for patient #21, who was having some urological bleeding through a indwelling catheter, but was not in any acute distress. The On-Call Urologist stated that patient #21 had a long history with a Urologist from the transferring facility, however was informed that patient #21, Urologist no longer wanted to treat patient #21, even though he was on- call physician at the transferring facility. The On-Call Urologist continued to reveal that the transferring facility appeared to be irritated with the situation and stated that the situation would be handled. The On-Call Urologist explained to the transferring facility to call back if patient #21 could not receive care at the transferring facility. The facility failed to accept from a referring/transferring hospital an appropriate transfer of Patient #21 on 4/28/2014, who required the hospital's specialized capability a credentialed Urologist, and the hospital had capacity to treat this patient who had an emergency medical condition.