HospitalInspections.org

Based on interview, review of OHSU Transfer Center audio recordings, review of Transfer Center documentation of a request from another hospital to transfer a patient to OHSU for specialty services (Patient 21), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure compliance in the following areas:
*On-call physician responsibilities.
*Recipient hospital responsibilities.


Findings include:

1. Regarding on-call physician responsibilities refer to the findings identified under Tag A2404, 489.20 (r) and CFR 489.24(j).

2. Regarding recipient hospital responsibilities refer to the findings identified under Tag A2411, CFR 489.24(f).

Based on interview, review of OHSU Transfer Center audio recordings, review of Transfer Center documentation of a request from another hospital to transfer a patient to OHSU for specialty services (Patient 21), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce its EMTALA policies and procedures to ensure its on-call physicians fulfilled their on-call duties, to accept patients for whom the hospital had capability and capacity to treat.

Findings include:

1. Refer to the findings identified under Tag A2411, CFR 489.24(f) that reflects on-call hand surgeon Physician A refused to accept Patient 21 from another hospital's ED. OHSU had capability and capacity to treat Patient 21.

Based on interviews, review of OHSU Transfer Center audio recordings, review of Transfer Center documentation of a request from another hospital to transfer a patient to OHSU for specialty services (Patient 21), and review of hospital policies and procedures and other documents, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure its compliance with recipient hospital responsibilities to accept patients from referring hospital EDs for further examination and stabilizing treatment for whom it had capability and capacity to treat.

Findings include:

1. A document provided to reflect the hospital's scope of services included an OHSU website with a section titled "Hand and Wrist Services OHSU/Orthopaedics and Rehabilitation." The document reflected that OHSU had capability for surgical hand specialty services where it reflected "Hand and wrist treatments...OHSU's team of doctors and surgeons are specialty trained to treat hand and wrist injuries and conditions such as carpal tunnel, ganglion cysts, fractures and more."

2. During interview with the AIO on 01/09/2019 at 1730 he/she stated the hospital's scope of services included surgical hand specialty services that were provided by orthopedic and plastic surgeons.

3. The policy and procedure titled "Emergency Medical Treatment and Active Labor Act Obligations," dated as effective 01/29/2018 was reviewed. It stipulated:
* "...OHSU Healthcare must...Accept appropriate transfers of individuals with emergency medical conditions from other facilities if OHSU has specialized capabilities and capacity to treat such individuals not available at the transferring hospital."

4. The policy and procedure titled "Inter-Hospital Transfers of Adult and Pediatric Patient Transfers," dated as effective 10/18/2018 was reviewed. It stipulated:
* "When OHSU is not 'at capacity' the following transfers will be accepted...All transfers from emergency departments at other facilities that meet EMTALA requirements of an emergency medical condition for whom OHSU has the capability to provide needed care."

5. The policy and procedure titled "EMTALA On-Call Policy," dated as effective 06/14/2018 was reviewed. It stipulated:
* "The purpose of this policy is to set forth OHSU Healthcare's on-call requirements to comply with the Emergency Management (sic) Treatment & Active Labor Act ('EMTALA')."
* "This policy applies to any OHSU Healthcare workforce member who has a role in fulfilling the on-call responsibilities set forth in this policy."
* "OHSU Healthcare complies with EMTALA's requirements to have adequate on-call coverage to care for patients who have come to the Emergency Department for treatment of what may be an emergency medical condition or who may need to be transferred from another hospital's emergency department to OHSU's Emergency Department to be treated for an emergency medical condition."
* "OHSU Healthcare shall maintain a list of Professional Staff members who are on-call for the specialty and sub-specialty medical services that it offers."
* "A Clinical Service Chief may allow Professional Staff members in his or her clinical service/department to participate in elective procedures while on-call as well as simultaneous call as long as the Clinical Service Chief establishes backup coverage in the event the on-call Professional Staff member is unavailable."
* "...The on-call physician is not allowed to discriminate against or refuse to provide care because of the patient's ability to pay, immigration status, race, ethnicity, sex, sexual orientation, gender identity, disability, religion, or insurance coverage."
* "...On-Call: a Professional Staff member who is on-call has the following responsibilities...availability, at least by telephone, for his or her scheduled 'on-call' period...respond to Emergency Department personnel within the timeframe described in this policy...when requested, arrive in the Emergency Department within the timeframe described in this policy...provide specialty care services as needed to any individual who comes to the Emergency Department either as an initial presentation or upon transfer from another facility."

6. "The undated "OHSU Triage Guidelines & Practice Goals" reflected "EMTALA...Hospitals must keep a list of on-call physicians who can perform emergency treatment to stabilize individuals who seek care on (sic) the emergency department...Any on-call physician who fails to respond in a reasonable time, or refuses to provide care to a patient, can be subject to liability...Hospitals with specialized capabilities or facilities...will be required to accept appropriate transfers of those individuals who need those services from hospitals that do not have such services..."

7. The OHSU medical staff roster titled "OHSU Good Standing Roster," dated 12/28/2018 reflected that hand on-call surgeon Physician A had been on staff at OHSU since 08/30/2007, was "Active" status, and Physician A's "Department/Section" was "Orthopedics and Rehabilitation."

8. The "Hand On-Call Calendar" for December 2018, "Last updated: 1/9/19," reflected Physician A was scheduled on-call for specialty hand surgery services on 12/17/2018.

9. During an interview on 01/08/2019 at 1530 with hospital staff that included the CIO and AIO, the following information was provided:
* They were aware of a potential EMTALA violation on 12/17/2018 whereby a patient presented to PNMC ED with a gunshot wound to the hand.
* PNMC requested transfer of the patient to OHSU for treatment of the hand injury.
* PNMC initially talked to OHSU ED physician, Physician B and requested to transfer the patient to OHSU. Physician B stated he/she could accept the patient but PNMC needed to talk to the physician who was on-call for hand surgery first.
* PNMC called and spoke to OHSU on-call hand surgeon Physician A two times about the patient. Physician A did not accept the patient and instead instructed PNMC to call PSVMC to see if they could take the patient.
* The CIO stated that Physician A took the position that the patient should be transferred to PSVMC.

10. An audio recording of a call between PNMC ED PA and OHSU on-call hand surgeon Physician A was recorded on 12/17/2018 beginning at 1443 and was 4 minutes and 7 seconds in duration. During play of the audio recording the following was heard:
* OHSU Transfer Center staff connected PNMC ED PA and OHSU Physician A: "[unintelligible]"
OHSU Physician A: "Hello."
PNMC ED PA: "Hello. Hi."
OHSU Physician A: "Hi, this is [Physician A], yeah."
PNMC ED PA: "Hi."
OHSU Physician A: "What's up?"
PNMC ED PA: "Um, so I have a 49-year-old [male/female] named [Patient 21] who is, um, has a history of hypertension and has a gunshot wound to [his/her] left hand, um."
OHSU Physician A: "Okay."
PNMC ED PA: "[He/she's] right, [he/she's] right handed. [He/she] was cleaning [his/her] nine-millimeter gun about an hour ago and shot [his/her] hand. And [he/she] has..."
OHSU Physician A: "Okay."
PNMC ED PA: "...um, one...four-centimeter laceration on the lateral aspect of [his/her], um, like fifth...metacarpal area extending..."
OHSU Physician A: "Okay."
PNMC ED PA: "...to the pinky with um, a exposed tendon there, um."
OHSU Physician A: "Okay."
PNMC ED PA: "And then [he/she] has another wound that's kind of like a mangled wound to [his/her], um, volar aspect of..."
OHSU Physician A: "Uh huh."
PNMC ED PA: "...[his/her] fourth and fifth metacarpal, um, distal metacarpal region. [He/she] can't move [his/her] pinky at all. [He/she] can feel [his/her] pinky. Um, the x-ray looks like [his/her] finger exploded with bony fragments everywhere in the proximal phalanx."
OHSU Physician A: "Uh hmm."
PNMC ED PA: "Um nothing is, you know, pulsatile. The bleeding is controlled with pressure."
OHSU Physician A: "[He/she's] got good vasculary?"
PNMC ED PA: "Yeah, [he/she] can, [he/she] does have good capillary refill and can feel me touch [him/her], but obviously can't, uh, move."
OHSU Physician A: "Okay."
PNMC ED PA: "I mean, yeah, the tendon is lacerated so..."
OHSU Physician A: "Okay."
PNMC ED PA: "...um, I'm going to send [him/her] over to the ER, um, at OHSU and..."
OHSU Physician A: "Where is [he/she] coming from?"
PNMC ED PA: "I talked to [OHSU ED Physician B] who said [he/she] would be..."
OHSU Physician A: "Wait, wait, where is [he/she] coming from? Where are you guys at?"
PNMC ED PA: "[He/she's] coming from Newberg, from Providence Newberg."
OHSU Physician A: "Okay [unintelligible] Um, why would, why would you not send [him/her] to a Providence facility?"
PNMC ED PA: "Um, our hand surgeon here doesn't take gunshot wounds, so we send to OHSU."
OHSU Physician A: "No, that's not okay. There's no way. Your, your hand surgeon has to take gunshot wounds. Why? That makes no sense at all. Do you want to get [him/her] on the phone with me and I will have a conversation with [him/her] and maybe we will talk about why [he/she] doesn't take gunshot wounds?"
PNMC ED PA: "Well...So, I mean, we've been through this before with, with, our hand surgeon, [Physician C]..."
OHSU Physician A: "Yeah."
PNMC ED PA: "...who doesn't come here to Newberg, Um."
OHSU Physician A: "Um, uh, yeah, I mean [he/she] can send [the patient] to, to Saint Vincent's but that's not an appropriate response from somebody, from somebody who's on-call for hand surgery. Um, It's not an emergency, it's not dysvascular right? Yes, it needs a surgery. There's no reason why [he/she] shouldn't be able to take that. And if [he/she] has a problem with it, then [he/she] needs to get a hold of me and contact me personally as to why I need to handle something that [he/she's] qualified to operate on."
PNMC ED PA: "Okay, well, I can get in touch with [him/her]."
OHSU Physician A: "Yeah."
PNMC ED PA: "And then what is your name, how do you spell your name?"
OHSU Physician A: "My name is, first name is [first name], last name is [last name], and I would be happy to have a conversation with [Physician C] on the phone and [he/she] can explain to me why [he/she] can't handle this."
PNMC ED PA: "Okay, and how do you spell your last name?"
OHSU Physician A: "Sure, it's [last name spelled out]."
PNMC ED PA: "Sorry what, sorry what?"
OHSU Physician A: "Sure, [last name spelled out]."
PNMC ED PA: "[last name spelled out] I, okay."
OHSU Physician A: "Yeah. Sorry I, you know, I don't mean to be a stickler, but we get this all the time."
PNMC ED PA: "Uh huh."
OHSU Physician A: "I'm happy to receive a lot of consults but when..."
PNMC ED PA: "Yeah."
OHSU Physician A: "...but when there's somebody on call who's perfectly capable of doing it and they tell you that they don't handle gunshot wounds to the hand then maybe we have to have a conversation with the medical board about what [his/her] licensing is."
PNMC ED PA: "Okay."
OHSU Physician A: "That's not reasonable. Yeah."
PNMC ED PA: "Okay, well I will, I will."
OHSU Physician A: "Have [Physician C] reach out to me if [he/she's] not willing to do it."
PNMC ED PA: "Okay."
OHSU Physician A: "Thanks."
PNMC ED PA: "Uh, alright, thank you. Bye."
End of call, length 04:07

11. An audio recording of a second call between PNMC ED PA and OHSU Physician A was recorded on 12/17/2018 beginning at 1716 and was 3 minutes and 24 seconds in duration. During play of the audio recording the following was heard:
* OHSU Transfer Center staff connected PNMC ED PA and OHSU Physician A and says "Direct Call is connected..."
PNMC ED PA: "Hello."
OHSU Physician A: "Hi there."
PNMC ED PA: "Hi, so after a long [unintelligible]..."
OHSU Physician A: "This is [Physician A]."
PNMC ED PA: "Yeah, so I talked to you before about this patient [Patient 21] [unintelligible]."
OHSU Physician A: "Uh huh."
PNMC ED PA: "Yeah."
OHSU Physician A: "Yeah."
PNMC ED PA: "So, umm, I eventually found out after talking to Providence and finding out that we don't have any capabilities of taking [him/her], that [he/she] is a Kaiser patient. So then I talked to [Physician I], who is on-call for Kaiser, umm..."
OHSU Physician A: "Uh huh."
PNMC ED PA: "...and it took them a long time to tell me to send [him/her] to OHSU, like I had originally wanted to do, so um..."
OHSU Physician A: "Yeah."
PNMC ED PA: "I'm going to..."
OHSU Physician A: "Well, so here's, here's the problem with all of this, and I know you guys get stuck in the middle but not a single one of those reasons, um, is a reason to send this patient, uh, when there's, there's [unintelligible] you know, and this is, this is the problem that we run into. We're full. We're totally full, we can't even, we can't even get our elective cases done. We have no space because everybody keeps wanting to send these types of patients to us instead of doing them where they are appropriate. The [patient] doesn't need an emergency surgery. [He/she] doesn't need an emergency reconstructive surgery. [He/she] needs a wash-out. Anybody can do a wash-out. They can send [him/her] to me to do a reconstructive surgery if [he/she] needs it. I can't even get my elective surgeries done today, I'm still waiting around to get an, get a operating room. We're on hold for all kinds of stuff."
PNMC ED PA: "Right and [Physician C]..."
OHSU Physician A: "That's the problem with [unintelligible]."
PNMC ED PA: "...said that [he/she] was in the OR when I talked to [him/her], and so [he/she] couldn't do it today so umm."
OHSU Physician A: "Yes, yes [he/she] can."
PNMC ED PA: "Well."
OHSU Physician A: "Why? Why can't [he/she]?"
PNMC ED PA: "Well now."
OHSU Physician A: "[He/she's] on call for hand."
PNMC ED PA: "[He/she's] a Kaiser patient, so Kaiser insurance, um, so now..."
OHSU Physician A: "That, that means nothing. That means nothing to me, [he/she] can certainly get transferred within the Providence system. There is zero reason why [Physician C] couldn't do the, do the operation after [he/she's] finished tonight which is the same thing that I would do, because I'm still operating. So, unless [he/she] wants to get on the phone with me after [he/she's] done and explain to me why [he/she's] not capable of taking this patient to the operating room later tonight like every other person on-call, I am not going to accept the transfer. It's not appropriate. It's not an emergency, and it's not my, it's not my responsibility to handle things that [he/she] can do on [his/her] call."
PNMC ED PA: "Okay."
OHSU Physician A: "So, I'm, I'm sorry to sort of get hard line like that but that's the only way that we're going to get this issue settled. [Physician C] has to do it, or [he/she] has to communicate to me why [he/she] can't possibly do it, why [he/she's] not capable of doing this operation after [he/she's] finished tonight."
PNMC ED PA: "Okay."
OHSU Physician A: "That's, that's what I'm doing. I'm, I'm waiting for my last operation to go, and then guess what? I would be doing that operation in the middle of the night, too."
PNMC ED PA: "Right."
OHSU Physician A: "[He/she] can do that."
PNMC ED PA: "Okay. Alright."
OHSU Physician A: "[He/she's] just not willing to and if [he/she's] not willing to, then [he/she] needs to call me."
PNMC ED PA: "Okay."
OHSU Physician A: "Yeah."
PNMC ED PA: "Alright, thank you."
OHSU Physician A: "And again, I'm so so sorry that you're stuck in the middle of this and I know that's not fair to you."
PNMC ED PA: (laughing)
OHSU Physician A: "But I can't accept that transfer because that's not appropriate, we're already stacked to the gills."
PNMC ED PA: "Okay, gotcha. Alright."
OHSU Physician A: "Yeah."
PNMC ED PA: "Thank you."
OHSU Physician A: "Sorry."
PNMC ED PA: "Bye."
End of call, length 03:24

12. Review of the untitled electronic Transfer Center intake document dated 12/17/2018 related to PNMC's request to transfer Patient 21 to the hospital for specialty hand surgery services contained spaces for specified information. It reflected:
* "Referring Facility...Providence Newberg"
* "Received: 12/17/2018 2:00PM"
* "Request Type ED Transfer"
* "Referred by [PNMC ED PA]"
* "ED to ED...Expected on 12/17/2018"
* "Transfer Reason: Higher Level Of Care"
* "Diagnosis: GSW to hand"
* "Level of Care: Emergency Dept"
* "Transportation Information"
* "Service Provider: -----"
* "Contact Number: -----"
* "Transport Dispatched: -----"
* "Patient Picked Up: -----"
* "Patient Arrived: -----"
* "Timeline of Canceled request for [Patient 21]"
* "12/17 1716...[PNMC ED PA] connected with [Physician A], Per [Physician A] (hand) pt is not appropriate for transfer..."
* "12/17 2252...Request Canceled...Reason: Consult Only - No Transfer Required."

The transfer intake documentation reflected the reason the transfer request was canceled was "Consult Only - No Transfer Required." However, that documentation was not accurate as Physician A refused to accept the patient in transfer, no medical "consult" was provided, and Patient 21 still required transfer to a hospital with hand surgery capabilities.

13. A written summary of the request for transfer of Patient 21 dated 12/28/2018 was reviewed and primarily contained excerpts from the recorded Transfer Center calls related to Patient 21. The summary also included the following narrative:
* "Call received...on 12/18/18 stating that [Physician A] refused request for patient transfer with no adequate reason given, simply stating patient should remain with Providence system."
* "12/24/18...OHSU physician stated [he/she] would accept after talking to [Physician C] re: the reason [he/she] could not take care of patient. [Physician C] never called. [Physician A] also cited capacity concerns. OHSU was very full but not on diver (sic) for ED patients."
"...Kaiser...eventually accepted the patient."

14. Review of an email from the CMTO to the CIO dated 01/09/2019 at 1612 reflected the hospital had capacity on 12/17/2018 where it reflected "Here is the AOD report with hospital capacity information for 12/17/18. Shows adult acute care was at 99%, which is where the patient would have been admitted." An attachment to the email titled "Administrator on Duty Report to Administration" dated "Monday, December 17, 2018" reflected "Hospital Occupancy Totals...Adult Acute Care...99%"

15. During an interview on 01/09/2019 at 1600 the CIO confirmed that the hospital had capability for specialty hand surgical services and capacity on 12/17/2018 when PNMC requested to transfer Patient 21 to the hospital.

16. During an interview with Physician A, the OHSU on-call hand surgeon on 01/09/2019 at 1325 he/she provided the following information:
* Physician A stated he/she had worked at the hospital for 11 years as an orthopedic surgeon specializing in hand surgery.
* Physician A stated he/she had on-call responsibilities that included responding to calls related to hand injuries. He/she stated his/her EMTALA obligation when on-call was to accept a patient from another hospital ED if the ED provider requested to transfer the patient. He/she stated "If they don't feel they have the ability to care for the patient then the transfer happens."
* Physician A stated he/she was on-call for hand services when he/she received a phone call in the mid afternoon from a PNMC ED provider about Patient 21.
* Physician A stated the PNMC ED provider "presented a case of a [male/female] with a GSW" to the hand.
* Physician A stated the PNMC ED provider requested to transfer the patient to OHSU for treatment of the hand injuries.
* Physician A stated he/she asked the PNMC ED provider if he/she had reached out to any Providence providers. Physician A stated he/she asked the PNMC ED provider why he/she was not sending the patient to "your provider."
* Physician A stated he/she told the PNMC ED provider that Providence should be able to take the case and if the Providence provider, Physician C, "can't handle it, [he/she] should call me."
* Physician A was asked if he/she accepted the patient for transfer after receiving the call from PNMC. Physician A stated "No."
* Physician A stated he/she was on-call for hand services when he/she received a second phone call about Patient 21 from the PNMC ED provider "a couple hours after the first call" at approximately 1700.
* Physician A stated the PNMC ED provider "wanted me to accept the patient for transfer."
* Physician A stated the PNMC ED provider stated that Physician C wouldn't take the patient and that Physician C was in the OR.
* Physician A stated he/she told the PNMC ED provider he/she would not accept the patient unless Physician C called him/her to say why he/she would not accept the patient.
* Physician A stated as far as he/she knew OHSU had capability and capacity when PNMC requested to transfer the patient.
* Physician A was asked if he/she accepted the patient for transfer after receiving the second call from PNMC. Physician A stated "No."

17. During an interview on 01/10/2019 at 1400 the AIO confirmed that Patient 21 never came to the hospital on 12/17/2018 after PNMC requested to transfer the patient for specialty hand services.

18. During an interview on 01/10/2019 at 1405 the CIO stated he/she had no documentation that reflected Physician A had received EMTALA training.

19. Training records for Physician A titled "Transcript Report" dated 01/10/2019 were reviewed. The records reflected training for the time period of 01/01/2017 through 01/10/2019. The training records contained no EMTALA training. This was confirmed during an interview with the CIO on 01/10/2019 at 1745.