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Based on record review and interview the facility failed to ensure the emergency department on-call physician accepted a patient from a referring hospital that required specialized care. Citing 1 of 1 patient. (Patient #25).

Findings include:
Review of patient #25 medical record on 10/30/2013 at 11:45 am revealed the following:
Hospital A clinical report with discharge dated 8/25/2013 revealed patient arrived by private vehicle at 6:48 pm. History of current illness: Foreign body sensation in throat. This started today and is still present. It was gradual in onset and has been constant. Pain described as moderate. Patient states that around lunch time he was eating a piece of chicken and states that he felt it got lodged in throat. Patient states that he committed an attempt to get it out and believes he was able to expel all of the chicken he swallowed. Patient states that since he has not been able to swallow any food and cannot swallow his own secretions. History of similar symptoms.
Review of Systems: No fever, cough, difficulty breathing, chest pain or nausea. No diarrhea, abdominal pain, difficulty with urination, headache or skin rash. No vomiting. All systems otherwise negative, except as recorded above.
Past history: Thyroid disease, Hypercholesterolemia. Chronic back pain.
Surgeries: Back surgery and hernia repair.
Physical exam:
Appearance: alert. No acute distress
Vital signs: Within normal limits
ENT: Nose normal, Pharynx normal. (Pt. spitting up secretions).
Neck: Normal inspection. Trachea midline. Neck supple.
Respiratory: No respiratory distress. Breath sounds normal
Abdomen: Soft and non-tender. No organomegaly.
Neuro: Oriented x 3. No motor deficit. No sensory deficit.
Labs, X-ray, and EKG completed.
Progress and Procedures:
Course of Care: MD evaluation of blood oxygen level- patient is stable and nontoxic. Discussed Plan of Care (POC) with patient and family, who understands and agrees with POC.
IV started- normal saline initial 125 ml. Glucagon 1 mg IVP, Valium 5 mg IVP.
At 8:07 pm- Patient stable, but still spitting up his secretions. Glucagon 1 mg IVP. He thinks he is improving. Care to staff #31 at 8:45 pm.
At 10:40 pm- patient unable to handle fluids by mouth. Will transfer. Patient requesting Facility B transfer.
At 11:23 pm- Staff #32 from Facility B declined patient and states we don't have a surgeon to do EDG here.
At 11:25 pm- Spoke with staff #33, surgeon. He said he does not, has not ever done EGD's.
At 11:26 pm- Spoke with staff #32, GI on call at Facility B. States he is too busy and cannot come in to Facility B to see the patient if we transfer him there.
12:07 am- THR transfer line called our clerk and informed her that the on call GI doctor (staff #30) "refused to accept, see, consult or deal with the patient." And would not speak with me.
12:17 am- attempting to transfer to another THR facility.
12:22- Discussed case with staff #34 Presbyterian Hospital-Dallas (PHD) ED whom accepts patient in transfer.
Patient and family counseled in person regarding the patient's stable condition, test results and diagnosis. Old ED records reviewed.
Clinical Impression: Impacted esophageal foreign body.
Electronically signed by staff #31.

"Review of Hospital A emergency departments RN notes" revealed the following:
AT 11:41- attempting to arrange transportation to Facility B for GI. House supervisor at Facility B unable to come to phone, Will return call in 15 minutes.
Late entry- 11:04 pm -House supervisor at Facility B returned call and told unit clerk that this emergency department would have to call Facility B's on call GI (Staff #32).
11:14 pm - Staff #32 paged.
11:24 pm- Staff #32 states to unit clerk that ED should have our on call surgeon evaluate patient.
11:25 pm- Staff #32 called and spoke with staff #31.
11:31 pm- Staff #32 paged.
11:38 pm- Staff #32 informed staff #31, he is "too busy" to accept patient at this time and advised ED to call Presby Rockwall.
11:39 pm- Presby Rockwall called for transfer by unit clerk.
12:00 midnight- Staff #30 from Presby refused patient per the transfer line. No reason given.
12:15 am- Staff #34 accepted patient from Presby Dallas. Patient made aware of acceptance at PHD and that it will probably be several hours before ambulance will be available for transfer. Patient made comfortable.
Disposition/Discharge- Transported via stretcher by EMS. Report was given. Report included patient's care, treatment, medications, and condition. Transferred to PHD at 3:10 am.

"Review of Transfer Center-Transfer Order" dated 8/25/2013 revealed the following:
Referring facility: Hospital A
Patient: Patient #25
Transfer reason: HLOC
Consult notes:
8/26/2013 12:03 am-Per staff #30 he does not want to accept patient and does not want to consult and refuse to do doc to doc with staff #31.
8/26/2013 12:06 am- Staff #30 did not give reason for declining patient and hung up telephone.
8/26/2013 12:07 am- Informed clerk at Hospital A that GI doc declined patient, clerk to call PLC back with another facility to transfer to.
8/26/2013 12:16 am- Doc to doc completed with staff #31 at Hospital A and staff #34 at Texas Health Presbyterian-Dallas.
8/26/2013 12:20 am- Admin approval by staff #35 at 12:15 am. Telephone number for report 214-345-7885. Patient transport by ground EMS. Information provided to clerk at Hospital A.
8/26/2013 4:10 am- MRN and Acct# added
8/26/2013 4:12 am- Informed clerk at Hospital A of patient's arrival to Texas Health Presbyterian-Dallas.
Targeted Physicians: Physician name/on call
Staff #30, GI Physician Type- Declining Decision Date/Time: 8/26/2013 at 12:02 am
Staff #34, ED Physician Type- Accepting Decision Date/Time: 8/26/2013 at 12:15 am.

"Review of Documentation from Texas Health Presbyterian-Rockwall" on 10/30/2013 at 1:00 pm in the conference room revealed the following:

"Review of Tracking Tool for Incoming Hospital Transfers:"
Date: 8/26/2013 Time: 12:00 midnight From Facility: Hospital A
Caller: ED Nurse Title: RN Phone Number: 888/782/8233
Patient Name: patient #26 Age: 48 Sex: Male Diagnosis: Obstruction in airway
Reason for Transfer: HLOC- GI Services
Higher Level of Care: Yes Mode of Transportation: EMS
Attending Physician: Staff #31 Accepting Physician: Staff #30
Administrator on call: Staff #1
House Supervisor: Staff #36
*staff #30 declined, no reason given, hung up on transfer line.

Interview with ED Physician at Hospital A dated 10/29/2013 at 4:40 pm per phone revealed the following:

"When the patient presented to our emergency room we had no GI coverage for that evening, our GI doctor was out of town. The patient had a history of food bolus and needed to be scoped. The patient requested to be sent to Facility B, so I called and attempted to send patient there. I was informed by GI physician on-call at Facility B that he was too busy to see the patient and would not accept transfer. The patient had seen staff #30 in the past so I called Presbyterian-Rockwall and attempted to send patient there for endoscopy to remove food bolus. I was informed by the clerk that staff #30 refused to accept the transfer and refused to talk to me concerning the matter. I was not surprised by this. So, we sent the patient to Presbyterian-Dallas for care".

Interview with VP Quality/Risk/Regulatory at Texas Presbyterian-Rockwall on 10/30/2013 at 10:00 am in the conference room revealed the following:

"Any time in the past when we've had a question of an EMTALA violation I've been proactive with the issue and began my own investigation. I've contacted CMS with concerns and requested assistance in the past. EMTALA can sometimes be a difficult issue, and assistance is needed to make it clear and understandable. The MD involved was interviewed and the allegations were shared with him. He was also advised of his responsibilities as a representative of this facility. He more or less advised us that he was an independent physician and could refuse a patient, and again we advised of his responsibility as a representative of this facility. We requested the transcript from the transfer line and pulled medical staff rules and regulations and clarified again his responsibility. I also spoke with CNO at Hospital A to arrange a meeting to discuss any problems with the process that might exist. She more or less told me if we didn't want transfers from their facility, no more would be sent. We just wanted to sit down to try and figure the issues out. The next step was to educate all supervisors in facility to follow the chain of command if a problem occurred. If someone had been notified of the refusal steps could've been taken to prevent what happened."

Interview with Chief Medical Officer at Texas Presbyrerian-Rockwall on 10/30/2013 at 11:40 am in the conference room revealed the following:

"I don't typically reach out, staff #1 usually does out-reach. This was one time I reached out in the question of an EMTALA allegation and I spoke with CEO at Facility B. In the past we have done a teleconference with any problems we had with other facilities. We find it's better to address issues as they occur and be proactive in solving issues. We are a transparent facility and want to remain that way, our patients welfare are our main concern. We have had a few problems with transfers in the past. When the incident occurred we immediately started the process to see what actually happened. We requested the transcript from the transfer line and interviewed staff in the emergency department. In our meeting with staff #30, it was made clear what his responsibilities were as an on-call physician with our facility. I reviewed all of the transfers from Hospital A during the past year when patients are sent here when staff not available. All general surgeons at Hospital A are credentialed with full endoscopy privileges. I just find it odd that a level III Trauma Center has to send patients to our facility with no trauma rating for our ED. We have made attempts to sit down with Hospital A to work out any problems in the process concerning patient transfers, and we have addressed the physician involved."

Interview with staff #1 on 10/30/2013 at 2:00 pm confirmed the findings.

Based on record review and interview the facility failed to ensure the emergency department on-call physician accepted a patient from a referring hospital that required specialized care. Citing 1 of 1 patient. (Patient #25).

Findings include:
Review of patient #25 medical record on 10/30/2013 at 11:45 am revealed the following:
Hospital A clinical report with discharge dated 8/25/2013 revealed patient arrived by private vehicle at 6:48 pm. History of current illness: Foreign body sensation in throat. This started today and is still present. It was gradual in onset and has been constant. Pain described as moderate. Patient states that around lunch time he was eating a piece of chicken and states that he felt it got lodged in throat. Patient states that he committed an attempt to get it out and believes he was able to expel all of the chicken he swallowed. Patient states that since he has not been able to swallow any food and cannot swallow his own secretions. History of similar symptoms.
Review of Systems: No fever, cough, difficulty breathing, chest pain or nausea. No diarrhea, abdominal pain, difficulty with urination, headache or skin rash. No vomiting. All systems otherwise negative, except as recorded above.
Past history: Thyroid disease, Hypercholesterolemia. Chronic back pain.
Surgeries: Back surgery and hernia repair.
Physical exam:
Appearance: alert. No acute distress
Vital signs: Within normal limits
ENT: Nose normal, Pharynx normal. (Pt. spitting up secretions).
Neck: Normal inspection. Trachea midline. Neck supple.
Respiratory: No respiratory distress. Breath sounds normal
Abdomen: Soft and non-tender. No organomegaly.
Neuro: Oriented x 3. No motor deficit. No sensory deficit.
Labs, X-ray, and EKG completed.
Progress and Procedures:
Course of Care: MD evaluation of blood oxygen level- patient is stable and nontoxic. Discussed Plan of Care (POC) with patient and family, who understands and agrees with POC.
IV started- normal saline initial 125 ml. Glucagon 1 mg IVP, Valium 5 mg IVP.
At 8:07 pm- Patient stable, but still spitting up his secretions. Glucagon 1 mg IVP. He thinks he is improving. Care to staff #31 at 8:45 pm.
At 10:40 pm- patient unable to handle fluids by mouth. Will transfer. Patient requesting Facility B transfer.
At 11:23 pm- Staff #32 from Facility B declined patient and states we don't have a surgeon to do EDG here.
At 11:25 pm- Spoke with staff #33, surgeon. He said he does not, has not ever done EGD's.
At 11:26 pm- Spoke with staff #32, GI on call at Facility B. States he is too busy and cannot come in to Facility B to see the patient if we transfer him there.
12:07 am- THR transfer line called our clerk and informed her that the on call GI doctor (staff #30) "refused to accept, see, consult or deal with the patient." And would not speak with me.
12:17 am- attempting to transfer to another THR facility.
12:22- Discussed case with staff #34 Presbyterian Hospital-Dallas (PHD) ED whom accepts patient in transfer.
Patient and family counseled in person regarding the patient's stable condition, test results and diagnosis. Old ED records reviewed.
Clinical Impression: Impacted esophageal foreign body.
Electronically signed by staff #31.

"Review of Hospital A emergency departments RN notes" revealed the following:
AT 11:41- attempting to arrange transportation to Facility B for GI. House supervisor at Facility B unable to come to phone, Will return call in 15 minutes.
Late entry- 11:04 pm -House supervisor at Facility B returned call and told unit clerk that this emergency department would have to call Facility B's on call GI (Staff #32).
11:14 pm - Staff #32 paged.
11:24 pm- Staff #32 states to unit clerk that ED should have our on call surgeon evaluate patient.
11:25 pm- Staff #32 called and spoke with staff #31.
11:31 pm- Staff #32 paged.
11:38 pm- Staff #32 informed staff #31, he is "too busy" to accept patient at this time and advised ED to call Presby Rockwall.
11:39 pm- Presby Rockwall called for transfer by unit clerk.
12:00 midnight- Staff #30 from Presby refused patient per the transfer line. No reason given.
12:15 am- Staff #34 accepted patient from Presby Dallas. Patient made aware of acceptance at PHD and that it will probably be several hours before ambulance will be available for transfer. Patient made comfortable.
Disposition/Discharge- Transported via stretcher by EMS. Report was given. Report included patient's care, treatment, medications, and condition. Transferred to PHD at 3:10 am.

"Review of Transfer Center-Transfer Order" dated 8/25/2013 revealed the following:
Referring facility: Hospital A
Patient: Patient #25
Transfer reason: HLOC
Consult notes:
8/26/2013 12:03 am-Per staff #30 he does not want to accept patient and does not want to consult and refuse to do doc to doc with staff #31.
8/26/2013 12:06 am- Staff #30 did not give reason for declining patient and hung up telephone.
8/26/2013 12:07 am- Informed clerk at Hospital A that GI doc declined patient, clerk to call PLC back with another facility to transfer to.
8/26/2013 12:16 am- Doc to doc completed with staff #31 at Hospital A and staff #34 at Texas Health Presbyterian-Dallas.
8/26/2013 12:20 am- Admin approval by staff #35 at 12:15 am. Telephone number for report 214-345-7885. Patient transport by ground EMS. Information provided to clerk at Hospital A.
8/26/2013 4:10 am- MRN and Acct# added
8/26/2013 4:12 am- Informed clerk at Hospital A of patient's arrival to Texas Health Presbyterian-Dallas.
Targeted Physicians: Physician name/on call
Staff #30, GI Physician Type- Declining Decision Date/Time: 8/26/2013 at 12:02 am
Staff #34, ED Physician Type- Accepting Decision Date/Time: 8/26/2013 at 12:15 am.

"Review of Documentation from Texas Health Presbyterian-Rockwall" on 10/30/2013 at 1:00 pm in the conference room revealed the following:

"Review of Tracking Tool for Incoming Hospital Transfers:"
Date: 8/26/2013 Time: 12:00 midnight From Facility: Hospital A
Caller: ED Nurse Title: RN Phone Number: 888/782/8233
Patient Name: patient #26 Age: 48 Sex: Male Diagnosis: Obstruction in airway
Reason for Transfer: HLOC- GI Services
Higher Level of Care: Yes Mode of Transportation: EMS
Attending Physician: Staff #31 Accepting Physician: Staff #30
Administrator on call: Staff #1
House Supervisor: Staff #36
*staff #30 declined, no reason given, hung up on transfer line.

Interview with ED Physician at Hospital A dated 10/29/2013 at 4:40 pm per phone revealed the following:

"When the patient presented to our emergency room we had no GI coverage for that evening, our GI doctor was out of town. The patient had a history of food bolus and needed to be scoped. The patient requested to be sent to Facility B, so I called and attempted to send patient there. I was informed by GI physician on-call at Facility B that he was too busy to see the patient and would not accept transfer. The patient had seen staff #30 in the past so I called Presbyterian-Rockwall and attempted to send patient there for endoscopy to remove food bolus. I was informed by the clerk that staff #30 refused to accept the transfer and refused to talk to me concerning the matter. I was not surprised by this. So, we sent the patient to Presbyterian-Dallas for care".

Interview with VP Quality/Risk/Regulatory at Texas Presbyterian-Rockwall on 10/30/2013 at 10:00 am in the conference room revealed the following:

"Any time in the past when we've had a question of an EMTALA violation I've been proactive with the issue and began my own investigation. I've contacted CMS with concerns and requested assistance in the past. EMTALA can sometimes be a difficult issue, and assistance is needed to make it clear and understandable. The MD involved was interviewed and the allegations were shared with him. He was also advised of his responsibilities as a representative of this facility. He more or less advised us that he was an independent physician and could refuse a patient, and again we advised of his responsib