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Based on interview and document review, the hospital failed to ensure compliance with requirements at 42 CFR 489.24, as evidenced by the deficient practice cited at 42 CFR 489.24 (a) and (c).

Hospital #2 failed to accept a patient for transfer from hospital #1. The pateint had an emergecny medical condition and required additional services from a urologist.

Based on documentation and interviews, hospital #2 failed to ensure that each patient with an emergency medical condition who required and requested transfer was accepted, in one of twenty-one patients reviewed. The patient presented at hospital #1's ED with a complaint of left testicular pain, tenderness and swelling that resulted from a scrotum injury that occurred two days prior. It was determined that the patient likely had a left testicular rupture and should be seen by a urologist. The hospital staff determined that the patient had an emergency medical condition, but hospital #1 did not have a urologist on staff. Hospital #1 requested to transfer the patient to hospital #2 for treatment, but hospital #2 refused to accept the patient's transfer. The patient was transferred to another hospital, (one hundred miles away), by private vehicle, for further care. Findings include:

Patient #1's 11/18/14 ED record (5:09 p.m. admission) from hospital #1 indicated the patient arrived at the ED with a complaint of left testicular pain, tenderness and swelling that resulted from a scrotum injury that occurred two days prior while the patient was playing basketball. It was determined that the patient likely had a left testicular rupture. The patient initially received Motrin for pain at the ED and continued to complain of increased pain and received Morphine 4 mg. per IV. Hospital #1 did not have a urologist on staff, and it was determined that the patient's condition needed to be evaluated by a urologist. Hospital #1 contacted hospital #2 and requested a transfer to hospital #2's urology service. Hospital #2 did not accept the transfer of the patient to hospital #2's urology service. Hospital #1 then contacted hospital #3 and requested a transfer of the patient to hospital #3. Hospital #3 accepted the transfer, and the patient was transferred to hospital #3, by private vehicle, at 8:47 p.m.

An 11/18/14 patient intake form from hospital #2 was reviewed. The form was completed by nurse (G) in response to physician (H's) request for consultation and transfer of the patient from hospital #1 to hospital #2 for treatment of a ruptured testicle. The form indicated that physician (F), the on-call urologist, was paged related to the request for transfer of the patient to hospital #2. The form indicated the patient's transfer met the EMTALA criteria related to transfers, but physician (F) refused the transfer. The form did not provide a reason for the refusal of the transfer.

Review of patient #1's 11/18/14 ED record (11:04 p.m. admission) from hospital #3 indicated the patient was evaluated by a urologist related to a left testicular injury following his arrival at the ED. The patient was sent to surgery for a left scrotal exploration and partial left orchiectomy and left orchidopathy. The surgery revealed that the left testicle was fractured and that 80% of the testicle was necrotic. The patient was discharged from hospital #3 on 11/19/14 @ 4:06 p.m. with a follow-up appointment scheduled for three weeks from the date of surgery .

When interviewed by phone on 12/10/14 at 8:00 a.m., physician (H) told the SA investigator that he provided care to the patient on 11/18/14 when the patient arrived at hospital #1 with a testicular rupture. Hospital #1 did not have a urologist on staff, and the extent of the patient's injury needed to be evaluated by a urologist and further treatment determined by the urologist. Physician (H) requested to transfer the patient to hospital #2 for further treatment, but hospital #2 refused to accept the transfer. Physician (H) did not speak with physician (F), the on-call urologist at hospital #2. Physician (H) stated he has transferred patients to hospital #2 in the past but not to the urology service. Physician (H) stated that according to EMTALA regulations, hospital #2 should have accepted the transfer from hospital #1.

When interviewed by phone on 12/8/14 at 3:00 p.m., nurse (G) told the SA investigator that he received a call on 11/18/14 from hospital #1 and a request to transfer the patient to hospital #2 for care. He stated he paged physician (F) about the patient and the request for transfer to hospital #2. Physician (F) refused the transfer and requested that the local clinic's urologist be contacted related to taking the patient's case.

When interviewed by phone on 12/8/14 at 9:00 a.m., physician (F) told the SA investigator that he was the on-call urologist at hospital #2 on 11/18/14. He stated hospital #2 has accepted many transfers from hospital #1 in the past. On 11/18/14 hospital #1's ED contacted hospital #2 and requested to transfer a patient with symptoms of a ruptured left testicle to hospital #2. Physician (F) stated he did not accept the transfer to hospital #2 because he does not have privileges at hospital #1. He referred the patient to the local clinic for care because he thought the clinic's urologist provided on-call services to patients who received care at hospital #1. He stated he has received re-education related to EMTALA regulations since the incident and realizes he should have accepted the transfer of the patient from hospital #1. He stated he will know how to handle this type of situation in the future.