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Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR §489.24, Special Responsibilities of Medicare Hospitals in Emergency Cases as evidenced by:

1) Failing to ensure all patients who presented to the hospital's emergency department (ED) were provided on-going stabilizing treatment for an emergency medical condition. This deficient practice is evidenced by failing to provide stabilizing treatment for a fractured vertebra for 1 (#2) of 20 patients sampled when the hospital had the capacity and capability to treat the patient (see findings tag A-2407); and

2) Failing to provide documented evidence to indicate an appropriate transfer was provided for 1 (#2) of 20 patients who presented to the hospital's ED with an emergency medical condition. This failed practice was evidenced by Patient #2 being transferred to another facility when the transferring hospital had the capability and capacity to provide services (see findings tag A-2409).

Based on record review and interview, the hospital failed to ensure all patients who presented to the hospital's emergency department (ED) were provided on-going stabilizing treatment for an emergency medical condition. This deficient practice is evidenced by failing to provide further stabilizing treatment for a fractured vertebra for 1 (#2) of 20 patients sampled when the hospital had the capacity and capability to treat the patient.

Findings:

Review of the Hospital Policy titled Triage and Medical Screening Exam, Serial Code ADM-01, revealed in part:
2. An EMC (emergency medical condition) is a condition with acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) that without immediate attention could result in:
b. serious impairment to bodily function,
c. serious dysfunction of any bodily organ.
6. The hospital will provide, without discrimination, care for emergency medical conditions to individuals regardless of whether they are Financial Assistance Policy eligible. A medical screening examination and appropriate emergency services will be provided to any individual regardless of diagnosis, financial status, race, color, national origin, religion, age, gender or disability in accordance with 42 CFR 489.24 (d) (4) and (5).

Review of Patient #2's medical record revealed she had been accepted as an ED to ED transfer from Hospital "A"s emergency department on 11/17/16 at 8:51 p.m. because Hospital "A" did not have neurosurgery services available. Further review revealed Patient #2 was then transferred to Hospital "B" on 11/18/16 at 2:25 a.m.

Review of Patient #2's medical record revealed a MRI radiology report from Hospital "A" dated 11/17/16 at 3:59 p.m. revealed the following:
Clinical Indication: Back pain, bladder incontinence and lower extremity numbness status post recent fall.
Findings: There is an acute appearing anterior compression fracture of the T12 vertebral body with approximately 50% loss of vertebral body height and adjacent bone marrow edema. There is T12 vertebral body fracture retropulsion causing moderate central canal stenosis just below the T11-12 level contacting and mildly deforming the adjacent distal cord without evidence of cord edema.

Review of a progress note by S2PA (the on call neurosurgery PA) dated 11/17/16 at 10:00 p.m. revealed the following:
51 year old female status post fall on 11/1/16. Complains of immediate back pain and bladder incontinence started several days after. PCP sent her to the ER at Hospital "A" where lumber MRI was done showing T12 compression fracture with moderate canal stenosis.
Decreased sensation left 2nd/3rd toes, foley catheter
AIP: T12 compression fx
1) NSG recommendation is transfer pt to Hospital "B" for treatment.
2) pt refuses transfer due to family issues in Baton Rouge.
3) will order non custom TLSO brace.
4) Explained to pt that urinary incontinence can become permanent if she does not go to Hospital "B".

Review of Patient #2's Transfer Record revealed the reason for transfer was to a higher level of care. Further review revealed the following statements: You are being transferred to another facility that has a particular service that you need for continued stabilization of your condition. We are currently unable to offer those services at this facility. The specialty service that you require is ortho-spinal.

Review of Patient #2's nurses notes dated 11/17/16 revealed an entry by S3RN at
10:45 p.m.: Notified charge nurse S4RN of suspected EMTALA violation. Pt states, "They are transferring me because of my Medicaid, they told me so".
10:45: Was told by charge nurse S4RN, "We do this all of the time, don't worry about it".
10:45: Called neuro to verify this, spoke with PA who confirmed that she told the patient, "We are sending you to Hospital "B" because of your Medicaid.

In a phone interview on 4/11/17 at 10:30 a.m. with Patient #2, she said she was embarrassed when S2PA told her they would not operate on her at Our Lady of the Lake Regional Medical Center because she was a Medicaid patient. Patient #2 said after she refused the transfer to Hospital "B", S3PA told her if she did not go to Hospital "B" she could be paralyzed so she changed her mind. Patient #2 said after she arrived at Hospital "B", she was admitted to the ICU and had spine surgery within 4 hours.

In an interview on 4/12/17 at 7:35 a.m. with S5MD, he said he was an ED physician at the hospital and he was working the night Patient #2 had been transferred from Hospital "A". He said Hospital "A" did not have neurosurgery capacity. S5MD said they accepted Patient #2 because they had neurosurgery on call. He said S2PA came to the ED for neurosurgery on call and assessed Patient #2. He said S2PA indicated the patient needed further care and said it would be easier for her to go to Hospital "B". S5MD verified S6Neuro was capable of doing the type of surgery Patient #2 required.

In an interview on 4/12/17 at 7:55 a.m. with S6Neuro, he said he was the neurosurgeon on call for the hospital on 11/17/16. He said Patient #2 was transferred from Hospital "A" because she had a compression fracture and they did not have neuro coverage. S6Neuro said Patient #2 needed surgery for her injury. S6Neuro said he has a relationship with Hospital "B" and the environment was good for large cases. He said Patient #2's surgery would require a group of people to coordinate. He said it is good for the residents in training at Hospital "B". He said coordinating with other services at Our Lady of the Lake Regional Medical Center was complex because they had to coordinate the vascular service and the equipment company in the middle of the night and schedule the OR time. S6Neuro also verified he had the capability to do the surgery here at the hospital and had done the type of surgery she needed in the past.

In an interview on 4/12/17 at 8:36 a.m. with S2PA, she said she worked for a neurosurgical group. S2PA said she was taking call with S6Neuro on 11/17/16. She said Patient #2 had been transferred from Hospital "A" because they did not have neurosurgery services. S2PA said she was consulted for neurosurgery and Patient #2 needed to have surgery, a lumbar fusion and a brace. S2PA said S6Neuro reviewed Patient #2's radiology films and asked her to transfer Patient #2 to Hospital "B". She said Patient #2 did not want to be transferred. S2PA said she told Patient #2 she would be transferred because she was stable and the group did not accept Medicaid patients for non-emergent cases. She said emergent was life or death and Patient #2 was not at risk of dying.

In an interview on 4/12/17 at 9:10 a.m. with S7MD, he said he was working in the ED on the night of 11/17/16. S7MD said he accepted Patient #2 because the hospital had neurosurgery available and Hospital "A" did not. S7MD said the hospital had the capability and capacity to treat Patient #2. S7MD said he did not know why Patient #2 was transferred.

In an interview on 4/12/17 at 9:55 a.m. with S3RN, he said he was working the night of 11/17/16 in the ED. He said Patient #2 had a T12 compression fracture. He said Patient #2 told him the S2PA told her she was being transferred because she was a Medicaid patient. He said he told the charge nurse S4RN. S3RN said he called S2PA and she confirmed that the patient was being transferred because she was a Medicaid patient. S3RN said he was not sure if transferring a patient because they were a Medicaid patient would be an appropriate transfer or not.

Based on record review and interviews, the hospital failed to provide documented evidence to indicate an appropriate transfer was provided for 1 (#2) of 20 patients who presented to the hospital's ED with an emergency medical condition. This failed practice was evidenced by Patient #2 being transferred to another facility when the transferring hospital had the capability and capacity to provide services.

Findings:

Review of the Hospital Policies titled Patient Transfer revealed in part:
2. If medical treatment has been provided within available capabilities and it is determined to be in the best interest of the patient to transfer to another facility, the following process will be followed.
a. Patient condition will be stabilized to the point that within reasonable medical probability, no material deterioration will occur during or as the result of transfer.
b. The patient or person acting on the patient's behalf will be informed by the physician of the hospital's obligations under the OBRA/COBRA regulations, medical benefits associated with the transfer and risks if the transfer does not occur.

Review of Patient #2's medical record revealed she had been accepted as an ED to ED transfer from Hospital "A"s emergency department on 11/17/16 at 8:51 p.m. because Hospital "A" did not have neurosurgery services available. Further review revealed Patient #2 was then transferred to Hospital "B" on 11/18/16 at 2:25 a.m.

Review of Patient #2's medical record revealed a MRI radiology report from Hospital "A" dated 11/17/16 at 3:59 p.m. revealed the following:
Clinical Indication: Back pain, bladder incontinence and lower extremity numbness status post recent fall.
Findings: There is an acute appearing anterior compression fracture of the T12 vertebral body with approximately 50% loss of vertebral body height and adjacent bone marrow edema. There is T12 vertebral body fracture retropulsion causing moderate central canal stenosis just below the T11-12 level contacting and mildly deforming the adjacent distal cord without evidence of cord edema.

Review of a progress note by S2PA (the on call neurologist's PA) dated 11/17/16 at 10:00 p.m. revealed the following:
51 year old female status post fall on 11/1/16. Complains of immediate back pain and bladder incontinence started several days after. PCP sent her to the ER at Hospital "A" where lumber MRI was done showing T12 compression fracture with moderate canal stenosis.
Decreased sensation left 2nd/3rd toes , foley catheter
AIP: T12 compression fx
1) NSG recommendation is transfer pt to Hospital "B" for treatment.
2) pt refuses transfer due to family issues in Baton Rouge.
3) will order non custom TLSO brace.
4) Explained to pt that urinary incontinence can become permanent if she does not go to Hospital "B".

Review of Patient #2's Transfer Record revealed the reason for transfer was to a higher level of care. Further review revealed the follwing statements: You are being transferred to another facility that has a particular service that you need for continued stabilization of your condition. We are currently unable to offer those services at this facility. The specialty service that you require is ortho-spinal.

Review of Patient #2's nurses notes dated 11/17/16 revealed an entry by S3RN at
10:45 p.m.: Notified charge nurse S4RN of suspected EMTALA violation. Pt states, "They are transferring me because of my Medicaid, they told me so".
10:45: Was told by charge nurse S4RN, "We do this all of the time, don't worry about it".
10:45: Called neuro to verify this, spoke with PA who confirmed that she told the patient, "We are sending you to Hospital "B" because of your Medicaid.

In a phone interview on 4/11/17 at 10:30 a.m. with Patient #2, she said she was embarrassed when S2PA told her they would not operate on her at Our Lady of the Lake Regional Medical Center because she was a Medicaid patient. Patient #2 said after she refused the transfer to Hospital "B", S3PA told her if she did not go to Hospital "B" she could be paralyzed so she changed her mind. Patient #2 said after she arrived at Hospital "B", she was admitted to the ICU and had spine surgery within 4 hours.

In an interview on 4/12/17 at 7:35 a.m. with S5MD, he said he was an ED physician at the hospital and he was working the night Patient #2 had been transferred from Hospital "A". He said Hospital "A" did not have neurosurgery capacity. S5MD said they accepted Patient #2 because they had neurosurgery on call. He said S2PA came to the ED for neurosurgery on call and assessed Patient #2. He said S2PA indicated the patient needed further care and said it would be easier for her to go to Hospital "B". S5MD verified S6Neuro was capable of doing the type of surgery Patient #2 required.

In an interview on 4/12/17 at 7:55 a.m. with S6Neuro, he said he was the neurosurgeon on call for the hospital on 11/17/16. He said Patient #2 was transferred from Hospital "A" because she had a compression fracture and they did not have neuro coverage. S6Neuro said Patient #2 needed surgery for her injury. S6Neuro said he has a relationship with Hospital "B" and the environment was good for large cases. He said Patient #2's surgery would require a group of people to coordinate. He said it is good for the residents in training at Hospital "B". He said coordinating with other services at Our Lady of the Lake Regional Medical Center was complex because they had to coordinate the vascular service and the equipment company in the middle of the night and schedule the OR time. S6Neuro also verified he had the capability to do the surgery here at the hospital and had done the type of surgery she needed in the past.

In an interview on 4/12/17 at 8:36 a.m. with S2PA, she said she worked for a neurosurgical group. S2PA said she was taking call with S6Neuro on 11/17/16. She said Patient #2 had been transferred from Hospital "A" because they did not have neurosurgery services. S2PA said she was consulted for neurosurgery and Patient #2 needed to have surgery, a lumbar fusion and a brace. S2PA said S6Neuro reviewed Patient #2's radiology films and asked her to transfer Patient #2 to Hospital "B". She said Patient #2 did not want to be transferred. S2PA said she told Patient #2 she would be transferred because she was stable and the group did not accept Medicaid patients for non-emergent cases. She said emergent was life or death and Patient #2 was not at risk of dying.

In an interview on 4/12/17 at 9:10 a.m. with S7MD, he said he was working in the ED on the night of 11/17/16. S7MD said he accepted Patient #2 because the hospital had neurosurgery available and Hospital "A" did not. S7MD said the hospital had the capability and capacity to treat Patient #2. S7MD said he did not know why Patient #2 was transferred.

In an interview on 4/12/17 at 9:55 a.m. with S3RN, he said he was working the night of 11/17/16 in the ED. He said Patient #2 had a T12 compression fracture. He said Patient #2 told him the S2PA told her she was being transferred because she was a Medicaid patient. He said he told the charge nurse S4RN. S3RN said he called S2PA and she confirmed that the patient was being transferred because she was a Medicaid patient. S3RN said he was not sure if transferring a patient because they were a Medicaid patient would be an appropriate transfer or not.