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Based on record review and interview, the facility failed to comply with it's recipient hospital obligation by denying acceptance of a patient with an emergency medical condition that was referred from an Emergency Room for higher level of care that was not available at the sending hospital.

The facility denied the referral because the patient's insurance was out of network.

This failed practice had the potential for adverse outcome of the patient's emergency medical condition. Citing one patient named in a complaint, Patient #1.


Findings:

Patient #1

Review of complaint narrative revealed allegations that Hospital Q requested a transfer acceptance from Hospital G for Patient #1 seen in the Emergency Room (ER) at Hospital Q with significant Thrombocytopenia (low blood platelets)) requiring Hematology services and IgG (Immunoglobulin G) treatment which was not available at Hospital Q.

After an acceptance by the Hospitalist at Hospital G, Administration at Hospital G denied the transfer because the patient's health insurance was out of network.

During the survey, review of the transfer center recording at Hospital G revealed the following information:

Physician (A51), ER physician at Hospital Q, called the transfer center at Hospital G requesting services for Patient #1.

She spoke to Transfer Center Staff (B52) and gave her history that the patient was seen in the ER with significant Trombocytopenia, severe Chronic Obstructive Pulmonary Disease (COPD) exacerbation which did not respond to steroids, and since about October/November, the patient was out of the Promacta (medication to treat Thrombocytopenia) that was ordered for her.

Physician (A51) told staff (B52) that she consulted with the patient's Hematologist, Physician (D54), who requested hospitalization and treatment with IgG. However, Hospital Q did not have Hematology services nor IgG, so she is requesting transfer for the patient for a higher level of care and that the patient would benefit from a hospitalist service.

There was a discussion between Physician (A51) at Hospital Q and Physician (D53) Hospitalist at Hospital G who agreed to accept the patient for care.

The recording revealed that Physician (A52) called the transfer center at Hospital G to find out why the patient's transfer was denied after being accepted by Physician (E55) at their Hospital.

There was a discussion with Staff (H57) who introduced herself as the VP of Care Management with responsibility over the Transfer Center.

Staff (H57) told Physician (A51) that Hospital G gave her an opportunity to declare whether or not the patient was emergent or urgent and she declared the patient was urgent.

According to Staff (H57) that gave Hospital G the right to screen the patient both clinically and financially.

Physician (A51) asked her why did she deny the patient when her Hematologist, Physician (D54), who worked at Hospital G requested the patient be transferred there for a higher level of care.

Staff (H57) responded the physician might have seen Patient #1 as an outpatient, but the patient did not have a relationship with Hospital G.

Physician (A51) repeated that Patient #1 had a medical emergency condition, was not stabilized and required a higher level of care that was not available at Hospital Q.

Staff (H57) told the physician she did not declare the patient Emergent at the outset, she said the patient was Urgent, and EMTALA was very clear around this issue and, if the physician wants, she could discuss the rules with her. The physician declined stating she was well aware of EMTALA requirements.

Physician (A51) told Staff (H57) the patient had an emergency medical condition that required a higher level of care that hospital Q could not provide and she should not be denying the patient because of her insurance status.

Staff (H57) told Physician (A51) since she did not declare the patient emergent, she can deny the patient services.

Physician (A51) stated the question she was asked was not raised appropriately. The patient was not dying at the moment.

She stated emergent to her would be a patient requiring life flight/respirator, or pressers, and Patient #1 was not in that category, but she still had a medical emergency condition and was not stable to be discharged and require a higher level of care that Hospital G was able to provide.

Staff (H57) refused to take the patient, Physician (A51) told her she would file an EMTALA complaint against the hospital.

Review of the clinical record for Patient #1 revealed the 60 year old patient arrived at the ER at Hospital Q on 5/17/2017 at 12:23 PM with complaints of shortness of breath for 'awhile'. She stated she usually used an inhaler but was unable to fill her prescription.

Additional symptoms include cough. She had history of Congestive Heart Failure (CHF), asthma, ITP Diabetes, Coronary Artery Disease Hypertension and Atrial Fibrillation. Smokes half pack per day.

On examination the patient was alert and oriented to person, place and time. Blood Pressure 148/121, pulse 89 beats per minute, respiration 22 breaths per minutes, the patient weighed 265 lbs. Oxygenation 95% on room air. Abnormal ECG (Electrocardiogram). Wheezing and Tachypnea.

Laboratory Report for complete blood count (CBC) revealed Platelet Count of 5 (critically low). Reference Range on the lab report was 114-366 10g/L.

X-ray chest report: Borderline mild prominence of the cardiac silhouette with associated pulmonary vascular congestion and mild interstitial pulmonary edema which may relate to congestive heart failure or volume overload.

While in the ER, the patient was treated with Albuterol Nebulizer and Solu-Medrol 125 mg/2mL injection 125 mg.

Labs notable for profound thrombocytopenia. Patient with h/o chronic ITP (Idiopathic Thrombocytopenia Purpura).

Spoke with her Hematologist, Physician (D54), who stated the patient did not see a hematologist since August and her recurrent thrombocytopenia is likely the result of not taking Promacta. She has not been responsive to steroids in the past.

Although I have given her Solumedrol here for her COPD exacerbation. She may benefit from IgG which is not available to us.

Emergency Room diagnosis Thrombocytopenia, COPD exacerbation and Dyspnea.

The patient prefers to reestablish care with Physician (D54), who practices out of Hospital G.

At 3:15 PM spoke to Physician (E55) about patient transfer, and she accepts to Hospital G.

Disposition:

Patient #1 has been evaluated by me and should be transferred from the Emergency Department to Hospital G due to need for hematology. Patient has established care with hematologist at Hospital G.

4:30 PM

Staff (B52) at Hospital G reports Administrative Denial. I spoke with Staff (H57), VP of Care Management, who tells me that this patient's transfer is not emergent, and they do not take her insurance.

I told her that the patient requires stabilization further than we are capable of here in Hospital Q, and that her specialist requests transfer to their facility. She continues to deny acceptance.

4:54 PM Patient has requested Hospital (Y) as her next choice of hospital. Hospitalist at that hospital accepts transfer. (The Surveyor verified the transfer acceptance with Hospital Y).

Review of documents from Hospital G:

Review of Hospital G's Transfer Center Workflow, dated 5/4/17, revealed the following:

Receive transfer request

Collect information

Transfer clinically appropriate? If no, contact VP, CM or AOV.

If Yes..

Document patient status: emergent vs urgent If Urgent:

IS patient in sending facility ER

If Yes..

Fax transfer request categories form to referring facility

Get transfer request categories form from sending facility

If status is urgent: collect patient's face sheet, H&P, and insurance information.
Issue with insurance contact VP or CM (Care Manager), or AOC (Administrator on call), proceed as directed.

Transfer Request Categories (check one category only).

Review of the transfer request document from Hospital G revealed the following information:

There were three listed categories, Emergent, Urgent and Elective.

Emergent:

The patient has a condition manifesting itself by acute symptoms of sufficient severity such that without immediate medical/surgical attention is reasonably expected to result in:

Death of the patient/or unborn child; Serious impairment of a bodily function placing the health of the patient or the patient's unborn child in serious jeopardy; and or Serious dysfunction of or loss of limb or organ;

And the facility at which the patient is currently being treated does not have a bed, specialist needed for the condition, the ability to provide care for this condition; Or the on-call physician at the facility has refused or failed to accept the patient for services.

Urgent:

The patient is in need of inpatient hospital services and is reasonably stable, but is in need of specialty care or an intervention that is not available at the facility where the patient is currently located.

The patient needs a specialist and this specialty is not available at the current facility.

The patient needs an intervention and this procedure is not available at the current facility.

Policy:

Emergency Transfer Policy dated January 2016 (Hospital G):

'When a patient is in an Emergency Room and is called in as a medical emergency, the PFR/PFC (Patient Flow Representative/Patient Flow Coordinator) shall certify the transfer status by faxing the Transfer Center Categories (TCC) form to the referring hospital for completion.

Upon Receipt of the initial call, the FPR/PFC shall process the transfer immediately and request the referring hospital/physician to return the TCC via fax immediately.
Emergent transfer time starts at time call is received from referring facility regardless of receipt of TCC form.

If the TCC form received from the referring facility with status other than emergent, the PFR/PFC will call referring physician to confirm request status.
In compliance with EMTALA, a patient that has a true emergency medical condition shall not be delayed or denied due to financial status".

Medical Staff Bylaws (Hospital G):

Review of Medical Staff Bylaws Rules and Regulations amended July 2016 revealed the following information:

Transfers from other hospitals dated January 2016 (Hospital G):

"All requests to accept a transfer from another hospital or health care facility shall be referred to the Hospital Transfer Center.

An On-Call Practitioner must accept the transfer of a patient with an Emergency Medical Condition in another hospital's emergency department if the other hospital does not have the needed emergency services and the On-Call Practitioner and the Hospital have the capacity and capability to provide the needed emergency services (see Health Systems policy for further detail)".

Review of Hospital Transfer Policy for Hospital G dated January 2016 revealed the following information:

'BSLMC (Hospital G) shall not refuse to accept an appropriate transfer of an individual who requires specialized capabilities or facilities that are available at BSLMC provided BSLMC has the capacity to treat the individual; and
such treatment is not available at the transferring facility.