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Based on policy and procedure review, medical record review and interview, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements. See A2411 for details.

Based on policy and procedure review, medical record review, and interview, it was determined the facility failed to accept an appropriate transfer for one of one (#1) patient requiring urology services not offered by the transferring facility. By not accepting Patient #1 the facility delayed the urology treatment needed for Patient #1. The failed practice had the likelihood to affect any patient needing urology services provided by the facility. Findings follow:

A. Review of Policy and Procedures of the Baxter Health Medical Center, "EMTALA Guidelines for Emergency Department Services," revised 07/11, showed. "Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual. Capacity includes the space and equipment capacity of hospital as well as the medical and hospital staff available to treat the individual."

B. Review of Policy and Procedures of the Baxter Health Medical Center, "Transfers to Hospital," revised 07/11, showed "Hospital, or the On-Call Physician, may not refuse to accept an appropriate transfer of an individual who requires specialized capabilities of facilities that Hospital offers so long as Hospital has the capacity to treat the individual. Requests for transfer should be directed to an Emergency Department Physician or an On-Call Physician on duty at the time of the request. If there is any doubt, the Emergency Department Physician shall consult with the On-Call Physician regarding the On-Call Physician's privileges or ability to perform the services needed by the patient. Requests to accept incoming transfer patients should be approved and received by (blank). The hospital shall not refuse to accept the transfer of an individual for emergency care if the individual requires the hospital's specialized care unless the hospital lacks the capacity, or the individual is in an ambulance en route to the hospital unless the hospital is on diversionary status."

C. Review of Policy and Procedures of the Baxter Health Medical Center, "EMTALA Guidelines for Emergency Department Services," revised 07/11, showed. "On-Call Physicians, an on-call physician specialty list including all specialties privileged at this facility and listing physicians by name will be openly posted in the Emergency Department and a record of all on-call lists shall be maintained in for five years."

D. During an interview on 02/15/24 at 1:45 PM, the Director of the ED (Emergency Department) confirmed the findings in A to C.

E. Review of Patient #1's Clinical record from the transferring facility ED showed the following:
1) Admission date was 01/01/24.
2) Provider Note dated 01/01/24 at 11:51 AM, by Physician #2 showed "History of present illness: Presents to emergency room with complaint of swollen painful left testicle. In early November patient had a hydrocele removed. He stated shortly after that trouble expenditure a couple courses of antibiotics and is continuing to increase in size and discomfort has not had any fever, sweats, or chills, he is diabetic. He has been able to urinate without difficulty, no dysuria, urgency, or frequency. Additionally, patient has a small portion of the incision along the scrotal raphe that is opened up. He is intermittently, has had some oozing and slight blood from it, is not actively bleeding now."
3) A Radiology Impressions note, dated 01/01/24 at 10:56 AM, showed, "Scrotum ultrasound Impression, Large complex peritesticular left scrotal cystic structure measuring up to 6.6 cm (centimeters) suggestive of hematoma."
4) A Medical Decision-making note, dated 01/01/24 at 11:51 PM, showed, "6 cm hematoma, possible abscess in the left scrotum. Concerned he has been treated several times with antibiotics, Bay area partially treated abscess with his history of diabetes, he may develop foreign years (fournier) gangrene. Think this may require early intervention. Will transfer to (Named) Medical Center for urology consultation and treatment. We did try to call Baxter Regional Medical Center, they told us they had no urology on-call and could not accept the transfer."

F. On 02/14/24 at 3:00 PM the "Doctors Call List from Dispatch," on-call schedule for 01/01/24 was reviewed and showed, "Urology See special note below." The comments section showed Physician # 3 was on-call for urology and listed phone contact number for Physician # 3.

G. On 02/14/24 at 3:30 PM the Chief Nursing officer (CNO) was asked what the "Only takes call for (facility initials) meant that was documented on the Urology section of the "Doctors call list from Dispatch," and if Physician # 3 was on-call for 01/01/24? She stated, "That was a mistake, Physician # 3 was on call."

H. On 02/15/24 at 10:01 AM, the House Supervisor on duty on 01/01/24 was interviewed by phone. She was asked to explain the role of the House Supervisor in an ED to ED transfer and if she contacted Physician # 3 (listed on Doctors Call List) on 01/01/24 concerning transfer of patient # 1? She stated, "The Doctors call list from Dispatch tells us who to call, I don't know who that Physician (Physician #3) is. We haven't had an on-call for Urology in a long time. The urologist (Urology Group) takes calls for patients in our hospital only. I do remember getting a call from transferring hospital, not the date or anything specific. They asked if we had Urology on-call and I told them Urology only takes calls for patients at our facility. Physician # 1 (ED Physician) was on duty, he talked to them too."

I. On 02/15/24 at 12:05 PM the CNO stated, "I checked with Dispatch, we had a couple of calls on 01/01/24 that asked if we had urology coverage. One was from the transferring facility at 12:02 PM and the other was from a family member at 12:28 PM. "We did have coverage, they weren't contacted." Review of the audio file provided showed two dispatch employees told the callers that Urology only takes calls for patients in our facility.

J. On 02/15/24 at 1:40 PM Physician # 1 was interviewed and asked what the process for ED to ED transfers were? He stated, "If we get a call, I communicate with the House Supervisor, to determine if we have coverage and available space. I also look at the Dispatch on call list. Physician # 1 was asked if he remembered getting a call for an ED to ED transfer for Urology? Physician # 1 stated, "I do remember getting a call from (transferring facility), they asked if we had Urology coverage and I told them we did not."

K. On 02/15/24 at 3:00 PM the CNO provided a letter dated 10/03/24 that showed, "Dear (Physician # 3), Thank you for agreeing to provide locum tenens coverage for urology for the following dates: Friday 12/29/23 at 5:00 PM, through Tuesday 01/02/24 at 7:00 AM."