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Based on document review and staff interview, the hospital, a regional referral center, failed to accept an appropriate transfer of a patient in an emergency medical condition, that Hospital A did not have the capabilities or capacity to care for (Patient #1) out of 43 medical records selected for review from January to February 2011; and failed to have a policy addressing their recipient hospital responsibilities.

Failure to develop and implement policies and procedures that delineated the regional referral center's responsibilities as a recipient hospital and failure to accept appropriate transfers within the capabilities of the hospital resulted in the delay of stabilizing treatment for Patient #1.

Findings include:

1. During an interview on 2/17/11 at 8:50 AM, in response to a request for a policy describing Ottumwa Regional Health Center's (ORHC) process for receiving appropriate transfers to their hospital, the Interim Director of Quality reported that ORHC did not have such a policy and it was up to the physician to determine if they felt comfortable accepting the patient.

2. During an interview on 2/17/11 at 11:50 AM, the Chief Nursing Officer (CNO) stated the decision for transferring patients "into their hospital" is "always determined" by the physician.

3. Review of the policy, "EMTALA transfer and Emergency Examinations," review date 9/10, showed the hospital staff had contemplated their EMTALA obligations regarding acceptance of appropriate transfers because the policy specified the type of receiving transfers in violation of EMTALA they would report. However, the policy failed to include ORHC's obligation as a regional referral center to accept appropriate transfers.

4. Review of Medical Staff Bylaws/Rules and Regulations, dated 6/8/10 revealed in part "...Care arrangements shall satisfy all applicable state and federal laws and regulations...."

5 During an interview on 2/15/11 at 9:30 AM Emergency Department (ED) Practitioner B, at Hospital A reported contacting Physician A (the on call internal medicine doctor at ORHC), to arrange the transfer of Patient #1, on 2/9/11, at 2:20 PM. Physician A said he did not feel comfortable caring for Patient #1 and declined the transfer.

6. During an interview on 2/15/11 at 4:00 PM, Physician A confirmed he was on call on 2/9/11. Physician A confirmed Hospital A had contacted him about 3-4 days ago, and requested acceptance of transfer for Patient #1 who required further stabilization beyond Hospital A's capabilities which included ICU monitoring and ventilator management. Physician A stated that he did not feel comfortable providing care to Patient # 1 and did not accept the patient.

7. Review of Hospital A's medical record revealed that after discussing the transfer with Physician A at ORHC and not receiving acceptance, Practitioner B contacted a second hospital and transferred Patient #1 where further care could be provided to treat his emergency. Refer to tag 2411 for further details.

Based on document review and staff interview, the hospital, a regional referral center, failed to accept an appropriate transfer of a patient in an emergency medical condition, that Hospital A did not have the capabilities or capacity to care for (Patient #1) out of 43 medical records selected for review from January to February 2011.

Failure to accept a patient in an unstable emergency medical condition resulted in the delay of treatment and specialized services for Patient #1.

Findings and hospital capabilities include:

1. Review of ORHC on-call schedule for 2/9/11 confirmed that Physician A was the on call hospitalist for Internal Medicine.

2. Review of daily census sheets for the Intensive Care Unit (ICU) at ORHC, dated 2/9/11 revealed an ICU bed was available. During an interview on 2/16/11, at 12:50 PM, the Interim Director of Quality confirmed the availability of an ICU bed on 2/9/11 and reported the ICU had 8 beds and an "overflow" area where staff could admit patients for a short period of time.

3. Review of Ventilator Patient Census sheets for January and February 2011 showed ORHC provided mechanical ventilation support to 2 patients during the month of February 2011.

4. Review of In-patient Seizures Census sheets for January and February 2011 showed ORHC provided care and services to 5 patients with seizure disorders during the month of January 2011.

5. During an interview on 2/17/11 at 11:50 AM, the Chief Nursing Officer (CNO) confirmed that the ICU at ORHC did have the capability to provide treatment and services for patients with ventilators and new onset seizures.

6. Review of policy, "ORHC Plan for Provision of Patient Care," dated 1/31/11 revealed in part "...Services include specialized intensive care services ...Technical-Respiratory services."

7. Review of policy, "ICU (Scope of Service)," review date 5/10, revealed in part "...The ICU's scope of service encompasses adult critical care ...The services provided by this unit include but are not limited to the care and treatment of the following conditions: ...Acute respiratory care including ventilation support."

8. Review of policy, "Provision of Patient Care," review date 12/10, revealed in part "...Major activities and services: Critical Care Services ICU."

9. Review of policy, "Adult Ventilation," review date 11/10, revealed in part "...Cardiopulmonary services are responsible for the proper operation and maintenance of...ventilators which are required when a patient is not able to breathe."

10. During an interview on 2/17/11 at 10:50 AM, Staff F, Director of Cardiopulmonary services stated the cardiopulmonary staff provided care and treatment to adult patients who required ventilation. Staff F reported that Internal Medicine Physicians would mange the patients' care with pulmonary consult if indicated.

11. During an interview on 2/17/11 at 11:00 AM, Staff A, Registered Nurse (RN) in the ICU reported the ICU at ORHC provided care and treatment to patients who required cardiac monitoring and patients with seizures and ventilators.

12. During an interview on 2/17/11 at 11:15 AM, Staff B, RN in the ICU reported physicians providing care to patients in the ICU included internal medicine physicians. Staff B further reported smaller area hospitals also transfer patients to ORHC. Staff B included Hospital A in the list of hospitals that would transfer patients to ORHC.

13. During an interview on 2/17/11 at 11:35 AM, the Interim Director of ICU reported the ICU provided care for patients with cardiac, respiratory, and neurological conditions including seizure and ventilator patients.

14. Review of Physician A's credential file, dated 9/17/09 showed he was board certified in Internal Medicine and had privileges that included cardiac monitoring.

15. Telephone interview with Emergency Department (ED) Practioner B at Hospital A (transferring hospital) on 2/15/11 at 9:30 AM confirmed Practioner B had contacted the on call internal medicine physician (Physician A) on 2/9/11 at 2:20 PM, requesting acceptance of an unstable emergency room patient who needed ICU services and ventilator management. Practitioner B confirmed Hospital A did not have an ICU services and that he contacted Physician A because Physician A's partner (Physician C) had previously seen and cared for Patient #1 at ORHC and Patient #1's family had requested transfer to ORHC.

Practioner B reported Physician A told him that he didn't know how to accept patients from outlying hospitals and for Practitioner B to contact the ED at ORHC to ask them how Physician A was suppose to accept a patient for transfer.

Practioner B stated while he was conversing with the ED physician at ORHC, Physician A contacted him by phone and told him he did not feel comfortable accepting Patient #1.

16. During an interview on 2/15/11 at 4:00 PM, Physician A confirmed he was on call on 2/9/11 and reported he was able to attend and provide care to critically ill patients, acute respiratory failure patients, and seizure patients. Physician A confirmed Practitioner B from Hospital A had contacted him 3-4 days ago requesting acceptance of an unstable emergency room patient who needed ICU services and ventilator management. Physician A stated he informed Practitioner B he did not feel comfortable accepting Patient #1 and declined the transfer.