HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure the acceptance of the transfer was documented as required. (A-2409)

2. The Hospital failed to accept transfer of patients who needed specialized urology care based on the hospital's capacity/capability. (A-2411)

Based on document review and interview, it was determined that for 1 of 4 emergency room clinical records (Pt #10) reviewed for transfers, the hospital failed to ensure the acceptance of the transfer was documented as required.

Findings include:

1. On 02/11/2025, the hospital's policy titled, "EMTALA" (Revision Date 12/09/2024) was reviewed and indicated, "...D. Stabilization, Transfer, or Discharge. 1. Transfer or Discharge of a Patient: A physician or QMP (Qualified Medical Provider) may discharge or transfer a stable patient from the hospital to a recipient hospital for ongoing care... b) Recipient Hospital ... must confirm prior to Transfer that... has available space and agrees to accept the Transfer..."

2. On 02/10/2025, the clinical record for Pt #10 was reviewed. Pt #10 was seen in the emergency department (ED) on 09/10/2024 with a diagnosis of schizophrenia (mental disorder). Pt #10 was transferred to an outside hospital for inpatient psychiatric treatment. Pt.#10's clinical record lacked documentation that the recipient hospital accepted the transfer.

3. On 02/10/2025 at approximately 1:30 PM, an interview was conducted with the ED Nurse Manager (E #9). E#9 confirmed that the clinical record (Pt. #10) did not include a documentation of acceptance of the transfer.

Based on document review and interview, it was determined that for 3 of 6 (Pts. #1-#3) inbound transfer requests reviewed, the hospital failed to accept transfer of patients who needed specialized urology care based on the hospital's capacity/capability.

Findings include:

1. The hospital's (Hospital A's/Potential Recipient Hospital) policy titled, "EMTALA (Emergency Medical Treatment and Labor Act)" (effective 04/24/2023), was reviewed and required, " ...Individuals Transferred to [System Hospitals]: 1. If the Recipient Hospital has specialized capabilities that are not available at the transferring hospital, the Recipient Hospital will not refuse to accept the Transfer of an individual needing those capabilities if the hospital has the capacity to treat the individual ..."

2. The hospital's (Hospital A's) Medical Staff Bylaws (approved June/July 2022) was reviewed and required, " ...Compliance with Bylaws, Policies, and Laws/Regulations: As a condition of Medical Staff Membership, each Medical Staff Member agrees to strictly abide by: (a) these Bylaws, Medical Staff Policies, and all other rules, policies and procedures, guidelines, and other requirements of the Medical Staff, the Hospital ...including but not limited to [Hospital's] EMTALA policy ..."

3. Hospital A's Urology On-Call Assignments from September 2024-February 2025 was reviewed and indicated that there was urology coverage 24 hours a day, 7 days a week, without any gap in coverage and included the following:

- Urologist MD#4 was on-call on 10/06/2024 all weekend.
- Urologist MD#1 was on-call on 10/07/2024 from 7 AM to 5 PM.
- Urologist MD#3 was on-call on 11/11/2024 from 5 PM to 7 AM.

4. The Medical Staff files for Urologists (MD#1, MD#3, and MD#4) were reviewed on 02/11/2025. All urologists had current privileges (effective prior to October 2024) to admit and conduct urologic procedures, including procedures to breakdown/remove kidney stones. All files contained a signed acknowledgement that staff understood and would abide by the hospital's policies and bylaws.

5. Hospital A's inbound transfer logs from August 2024 to present were reviewed on 02/10/2025. The log included a transfer request for Pt. #1 on 10/07/2024 at 9:53 AM for a diagnosis of kidney stone on right side. The log indicated that the request was declined/canceled. Two other urology transfers were noted on 10/06/2024 (Pt. #2) and 11/11/2024 (Pt. #3). Both were declined as well.

6. Hospital A's Daily Hospital Resources Availability Tracking records from August 2024 to 02/10/2025 were reviewed and included the following:

- 10/06/2024 at 7:14 AM: 8 ICU (intensive care unit) beds, 24 medical/surgical beds, and 2 OR (operating rooms) were available.
- 10/07/2024 at 7:17 AM: 8 ICU beds, 26 medical/surgical beds, and 2 OR were available.
- 11/11/2024 at 7:14 AM: 19 ICU (intensive care unit) beds, 15 medical/surgical beds, and 2 OR were available.

7. Hospital A's Transfer Center Intake Info [Information] for Pt. #1 was reviewed on 02/10/2025 and included, "Received: 10/07/2024 9:53 AM ... Referring Location: ED [Emergency Department] ...0.8 [centimeter] stone right distal right ureteral with severe hydronephrosis [swelling of kidney] ... Priority: High ... Reason for Transfer: HLOC [higher lever of care]/Service not available ...[Hospital B] does not have Urology this week ..." The record included the following timeline:

- 10/07/2024 at 10:16 AM: Physician approval was completed by an accepting physician [Hospitalist MD#2].
- 10/07/2024 at 11:54 AM: "Call from [MD#1], declined the pt stating that the Facility [Hospital B] has Urology Service, thus declining the case."
- 10/07/2024 at 1:03 PM: "Declined Transfer, Reason: Service Unavailable"
- 10/07/2024 at 1:09 PM: "Call from [MD#1]. Conferenced with [Referring Provider Z#1]. [MD#1] stated that [MD#1] is not employee of [Hospital A], so [MD#1] has the right to decline. [MD#1] is available for Major cases only."
- The record did not include any documentation indicating the hospital did not have the capacity (beds) or capability to accept the transfer.

8. The Transferring Hospital (Hospital B's) record for Pt. #1 was reviewed and indicated that after several attempts to transfer Pt. #1 were not successful, Hospital B's attending urologist (who was out of of the country at the time) was reached and had instructed to admit Pt. #1 under observation status with plan for urologist to come for intervention on 10/08/2024. Pt. #1 was admitted under observation status at Hospital B on 10/07/2024 at 3:37 PM and Pt. #1 had a right uteroscopy with laser lithotripsy [procedure to breakup kidney stones]; stone manipulation; and ureteral stent insertion procedure completed in the operating room on 10/08/2024. Pt. #1 was discharged to home on 10/09/2024.

9. Hospital A's Transfer Center Intake Info for Pt. #2 was reviewed on 02/10/2025 and included, "Received: 10/06/2024 11:00 AM ... Referring Location: ED [at Hospital B] ... Diagnosis: ureteral stone with hydronephrosis ... [Pt. #2] was in ER [Emergency Room] yesterday with right sided flank pain. 0.3 cm right ureteral stone-discharged home. Came back today hypotensive [low blood pressure], tachycardic [elevated heart rate], believe [Pt. #2] is septic (generalized infection) from the stone ... Priority: High ... Reason for Transfer: higher level of care ... no urology attending at [referring facility] today ... " The record indicated that Urologist (MD#4) was called on 10/06/2024 at 11:48 AM regarding the transfer request. A note on 10/06/2024 at 12:07 PM included, "[MD#4] called PCC [transfer center] back. Stated [MD#4] did not want to hear this case. [MD#4] will not take transfers or consult with any doctors. Will decline." The reason for the declined transfer was documented as "Provider declined." The record did not include any documentation indicating the hospital did not have the capacity (beds) or capability to accept the transfer. Disposition of the patient is unknown.

10. The Transferring Hospital (Hospital B) record for Pt. #2 was reviewed and indicated that Pt. #2 presented to Hospital B's ED on 10/06/2024 at 8:30 AM with diagnoses of septic shock, urinary tract infection, nephrolithiasis, and right ureteral stone. ED physician progress notes included the following:
- 10/06/2024 at 8:41 AM: "[Pt. #2] comes from home after fall. Patient was seen yesterday for renal colic with 0.3 cm distal right ureteral stone without signs of infections. [Pt. #2] was feeling well at that time, had normal renal function, and desired to discharge home ... Today [Pt. #2] is acutely weaker than was day prior leading to fall ... presents tachycardic with soft blood pressures. Highest concern for septic stone ..."
- 10/06/2024 at 10:30 AM: "Unfortunately today there is no urology attending on-call. Spoke on the phone with on-call urology resident, who recommended transfer to center with a urologist on staff. Spoke with patient's daughter at beside who agreed to transfer to [Hospital A]. I spoke on the phone with [Hospital A] transfer RN [registered nurse], shortly after who will speak to the urologist at [Hospital A] ..."
- 10/06/2024 at 12:28 PM: "[Hospital A] transfer center called to inform me patient was rejected by urologist at [Hospital A] ..."
- 10/06/2024 at 3:30 PM: "Spoke on the phone with urology resident, who was able to get in touch with surgeon who will be traveling from Rockford for patient's procedure ... will be at [Hospital B] around 4:30 PM with plans to take patient to OR [operating room] [for cystoscopy with ureteral stent]
- The record indicated that Pt. #2 was admitted to the ICU [intensive care unit] on 10/06/2024 for further management of septic shock and was discharged on 10/09/2024.

11. Hospital A's Transfer Center Intake Info for Pt. #3 was reviewed on 02/10/2025 and included, "Received: 11/11/2024 4:24 PM ... Referring Location: ED [at Hospital C] ... Diagnosis: Urethral stone left with hydroureteronephrosis ... Priority: High ... Reason for Transfer: Higher level of care ... Level of care request: Med Surg [Medical-Surgical] ..." The record indicated that Urologist (MD#3) was called on 11/11/2024 at 4:46 PM regarding the transfer request. A note on 11/11/2024 at 5:20 PM included, "Call from [MD#3], declined the case. No reason given." The reason for the declined transfer was documented as "Service Unavailable." The record did not include any documentation indicating the hospital did not have the capacity (beds) or capability to accept the transfer. Disposition of the patient is unknown.

12. The Transferring Hospital (Hospital C) record for Pt. #3 was reviewed and indicated that Pt. #3 was transferred to Hospital D (Receiving Hospital) on 11/12/2024 at 9:40 AM.

13. The Recipient Hospital (Hospital D) record for Pt. #3 was reviewed and indicated that Pt. #3 was admitted to Hospital D on 11/12/2024 for kidney stones. The Discharge Summary, dated 11/13/2024, included "[Pt. #3] presented with left flank pain and found to have 7 mm obstructive stone with upstream left hydronephrosis and underwent a cystoscopy, and ureter stent placement on 11/12/2024 with [urology]." The patient was discharged home on 11/13/2024.

14. A telephone interview was conducted with Transfer Center (Patient Command Center/PCC) Registered Nurse (E#3) on 02/10/2025, at approximately 3:00 PM. E#3 stated that both Hospitalist (admitting physician) and Specialist for consult need to accept incoming transfers. E#3 stated that most of the time transfers are declined because the hospital is at capacity. E#3 stated that if a transfer is declined due to no beds, the reason would be documented as "Hospital Capacity" and if the transfer is declined because the physician is not able to take on another patient, they will document the reason as "Physician Capacity." E#3 stated that if the accepting/consulting physician does not give a reason for declining or the reason is not due to capability, E#3 documents the reason as "Service Unavailable." E#3 stated that urology is available on-call 24/7 and E#3 will reach out to the on-call physician via the hospital's messaging system (Perfect Serve). E#3 stated that sometimes the hospital may be on a transfer pause, which means that management has decided to put a hold on inbound transfers if the hospital is reaching capacity. E#3 stated that it would be noted in the record if a transfer pause was in place. E#3 did not recall the conversation between the doctors regarding Pt. #1 on 10/07/2024.

15. A telephone interview was conducted with Urologist (MD#3) on 02/10/2025, at approximately 3:30 PM. MD#3 stated that MD#3 is not employed directly by the hospital and that MD#3 just has privileges to work and see patients at the hospital. MD#3 stated that the hospital does not pay MD#3 directly. MD#3 stated that MD#3 is privileged to perform basic urology care and procedures including treatment of kidney stones. MD#3 stated that besides seeing patients on consult, MD#3 does take in-house calls in cases of emergencies. MD#3 stated that in general they would have to be available within 1 hour. MD#3 stated when they are on-call, they may receive calls from the transfer center regarding a transfer request. MD#3 stated that they give them basic information and ask if we are available to accept the transfer. MD#3 stated that whether urology would be available or if the transfer is appropriate for our hospital is considered when deciding to accept a transfer. Regarding reasons to decline a transfer, MD#3 stated, "We are not under any obligation to accept transfers. I'm not going to discuss that point any further. I would have to get attorneys involved. I'm under no obligation to give a reason to decline a transfer."

16. A telephone interview was conducted with Urologist (MD#4) on 02/11/2025, at approximately 11:00 AM. MD#4 stated MD#4 is part of the active medical staff and has privileges to consult and perform urological core services. MD#4 stated that MD#4's role is to act as a consulting physician for patients admitted to the Hospital. MD#4 stated that MD#4's privileges cover the patients at this hospital and not other hospitals. MD#4 stated that MD#4 may receive calls about transfer requests and stated that acceptance of transfers depend on MD#4's availability, if the case is within MD#4's scope of practice, and/or if the transfer is reasonable and the patient needs to be transferred. When asked about whether there is a discussion regarding each transfer case, MD#4 stated that MD#4 would need a lawyer present to discuss the topic of accepting transfers any further and stated that MD#4 would not speak about any specific cases without counsel. MD#4 did not provide an answer in regard to the hospital's responsibility in accepting transfers under EMTALA, except for stating that that was a question for the hospital's administration.

17. An interview was conducted with the Chief Medical Officer (MD#6) on 02/11/2025, at approximately 11:40 AM. MD#6 stated that they are a Level I Trauma Center and are required to have emergency coverage for various specialties 24 hours a day, 7 days a week. MD#6 stated that both Affiliate and Active Medical Staff can be included on the on-call schedule and should respond within 30 minutes. MD#6 stated that the on-call staff may also be reached for requests for incoming transfers from other hospitals. MD#6 stated that the expectation for the specialty/on-call providers is to engage in discussion about the case and make a determination if they are capable and have the capacity to accept the patient. MD#1 stated that the decision to accept a transfer should be based on bed availability and whether the provider can or can't take the case based on the information presented, and not on whether the physician wants or does not want to accept the transfer.

18. A telephone interview was conducted with Urologist (MD#1) on 02/11/2025, at approximately 3:00 PM. MD#1 stated that MD#1 has 3 main patient populations to care for at the hospital which include: 1) Patients that belong to MD#1's private practice; 2) Inpatients with urologic consult; and 3) Emergency Room/Trauma patients. MD#1 stated that if there is a request from another outside hospital, they will receive a message from the transfer center (PCC) to call them back. MD#1 stated that when they are on-call, they may not be in-house at the time. MD#1 stated that they explain the case and what are the problems and ask us if we can accept the transfer or not. MD#1 stated that MD#1 considers whether MD#1 has the capacity to accept the transfer without interfering with the other three groups of patients mentioned earlier. MD#1 stated that MD#1 has to consider whether taking on the transfer case will take a lot of MD#1's time and energy and could possibly compromise care to MD#1's other patients. MD#1 stated that there is only one person in their department on-call at any given time 24/7 and they have very little reserve which can be taxing and a very stressful responsibility for even just one hospital. MD#1 stated that factors such as where the patient is coming from, who is working at the hospital, the available beds, and how MD#1 will be paid for services are not within MD#1's control or consideration when deciding to accept a transfer. MD#1 did recall the conversation regarding Pt. #1's transfer and stated, "I was very disturbed and upset by the ER doctor because they threatened to report me for EMTALA... I very vividly remember that I was still in the office seeing patients [at a clinic offsite from the hospital], they [transfer center] said they wanted to transfer a patient. I said I don't have the capacity, and in this case, I mentioned that they do have a urologists [at their hospital]. There was some back and forth and they said their urologist was on vacation... The discussion got heated and I don't recall specifically thereafter... I wasn't able to abandon my patients and I couldn't head over to the hospital."