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Based on a letter of self report, interviews, and document review the facility failed to ensure that the receiving facility had agreed to accept the transfer of the identified patient (Patient) prior to initiating the transfer process. When the patient arrived at the receiving facility, the receiving facility had no idea that the patient was being transferred. The failure of the facility to obtain prior agreement for the transfer greatly increased the risk that (a) the receiving facility did not have available space, (b) the receiving facility did not have qualified personnel available for the treatment of the patient, or (c) the receiving facility might not be able to provide appropriate medical treatment. The findings are:

A. On 04/26/13 the facility's multi-hospital management group sent a certified letter to CMS-Dallas and the New Mexico State Agency making a self-report of a possible EMTALA violation that had occurred at the facility at 05:02 on April 19, 2013. The self-report states that a 69-year-old female (Patient) who had recently had a gastric bypass surgery presented at the facility's Emergency Department complaining of abdominal pain. The Emergency Department registered the Patient, did triage and performed a CAT scan. The CAT scan revealed a small bowel obstruction. The Emergency Department physician, Physician #1, contacted the Patient's surgeon who performed the gastric bypass, Physician #2, and advised him of the Patient's condition. Physician #2, who was in Albuquerque at the time, told Physician #1 that he wanted the Patient transferred to a facility in El Paso, TX, where he would provide treatment. The Patient agreed to the transfer and signed an EMTALA Transfer Request Form. The facility's Emergency Department arranged for a ground ambulance transfer. When the ED nurse attempted to contact the receiving facility to obtain the receiving hospital's acceptance of the Patient, she was unable to reach anyone at the facility. Three attempts to reach the receiving facility were made but none was successful. The nursing staff finally decided to send the Patient without the confirmation from the receiving facility that the receiving facility would accept the Patient. This decision was made based on the accepting physician's instructions.

Later on 05/02/13 the House Supervisor of the receiving facility contacted the facility House Supervisor and stated that she felt the unauthorized transfer was an EMTALA violation since the transferring facility had never contacted the receiving facility about transferring the Patient.

Based on the comments about EMTALA violation from the receiving facility House Supervisor, the legal department of the multiple hospital management group sent the self-report letter to CMS Regional Office - Dallas and the NM State Agency.

B. Following the entrance conference, the Medical Director reviewed the patient's medical record with the surveyors. She confirmed that the patient had a gastric bypass performed at the receiving facility in El Paso, TX on 04/04/13. The patient presented at 05:02 am on 04/19/13 complaining of abdominal pain. Based on a CT scan a small bowel obstruction was diagnosed. The Medical Director confirmed that the small bowel obstruction would constitute an emergency condition.

C. Physician #1, facility Emergency Dept physician, was interviewed at 3:00 pm. Physician #1 stated that he determined from the CT scan that there was a small bowel obstruction. Physician #1 contacted Physician #2, the surgeon who performed the gastric bypass operation on 04/04/13. As Physician #2, who was in Albuquerque at the time, did not have privileges at the facility, he told Physician #1 that he wanted the patient transferred to the receiving facility in El Paso,TX. Physician #1 stated that he had the impression that Physician #2 would notify his partner at the receiving facility that the patient was being transferred. Physician #1 stated that during their conversation, Physician #2 did not discuss notifying the receiving facility. After speaking with Physician #2, Physician #1 told RN#1 that the patient would be transferred.

D. On 05/10/13 at 8:30 am, during telephonic interview, Medical Assistant #1, who was acting as an ER clerk during that shift stated, "My understanding was that I was asked by Physician #1 to call the number at the receiving facility. I asked for Physician #2 and was told that he was in Albuquerque. Physician #2 called back and spoke with Physician #1. It was determined that the patient would be transported to El Paso. I was the unit secretary that day -- normally an ER tech. Physician #1 said he was told by Physician #2 that Physician #2 would make all the arrangements, to include contacting the receiving facility and letting them know of the transfer. Later ground ambulance staff was told on arrival in El Paso that the patient was not expected. Later on, the care coordinator at the receiving facility told me that Physician #2 had forgotten to call the facility or call anyone else. We didn't know that Physician #2 had not contacted the hospital."

E. On 05/10/13 at 8:55 am, during a telephonic interview, RN #1 stated, "Physician #1 told me that Physician #2 said that the patient had to go to El Paso due to complications from her bariatric surgery. Medical Assistant #1 gave me a phone number. No one answered. I left a message and told them I have a patient to be transported to their facility. I tried again 15 minutes later and made a third call, leaving my information. I sent the patient's chart with the ambulance. Physician #1 told me that Physician #2 was making all the arrangements. My charge nurse, after the first call, told me to call back. Normally we call report before the patient departs. I thought it was OK that Physician #2 was going to make the arrangements for the transfer."

F. On 05/10/13 at 9:15 am during interview, the complainant, counsel for the multiple hospital management group , stated, "I put in the EMTALA report. I am a staff attorney. I got a call from the [transferring] facility telling me that they might have a problem with a transfer and that they were told that a person at the receiving facility said that they were going to file an EMTALA complaint. The [transferring] facility didn't think there was a problem because they had a receiving physician and the docs had spoken to each other. We tried to err on the side of caution by filing the EMTALA complaint report. I feel that we had an accepting physician and that the physician was the representative of the facility. In my review of EMTALA, there is not a definite regulation that would cover this unusual situation."

G. On 05/10/13 at 9:25 am Physician #2 stated that he spoke with Physician #1 at the facility's Emergency Department and that
the patient needed to be transferred to the receiving facility. He said that he didn't contact the receiving facility about the transfer.

H. On 05/09/13 at 3:43 pm during interview, the Medical Director verified that portions of the EMTALA transfer form pertaining to the patient were not properly completed. There was no documentation that the receiving facility had accepted the patient.

I. On 05/09/13 a review of 21 medical records of patients who had been transferred outside the facility's system revealed that 5 of 21 medical records did not have documentation of acceptance by the receiving facility.

The case was reviewed by a CMS physician consultant. It was determined that the ground transportation was not an appropriate mode of transportation given the patient's emergency medical condition and the length of travel time (5 hours). The patient should have been more appropriately transported by air which would have taken only one hour. The use of ground transportation increased the risk of deterioration of the patient's condition and resources would not have been available to appropriately treat the patient.

The findings are:

A. On 04/19/13 the Emergency Department physician, Physician #1, contacted the Patient's surgeon who performed the gastric bypass, Physician #2, and advised him of the Patient's condition. Physician #2, who was in Albuquerque at the time, told Physician #1 that he wanted the Patient transferred to a facility in El Paso, TX, where he would provide treatment. The Patient agreed to the transfer and signed an EMTALA Transfer Request Form. The facility's Emergency Department arranged for a ground ambulance transfer.