HospitalInspections.org

Based on review of medical records, policies/procedures and staff interviews, it was determined that the hospital failed to comply with the provider agreement as defined in ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The findings were:

Refer to findings for Tag A 2411 - Recipient Hospital Responsibilities:
The facility failed to accept a burn patient for transfer from another facility that stated they did not have the capability to care for the patient's burns, even though the contacted facility had a bed available to accept a burn patient, was substantiated. The facility failed to comply with applicable CMS/EMTALA regulations related to the requirements of a facility receiving a request to accept a transfer of an emergency/obstetric patient from another facility that stated they lacked the capability and/or capacity to stabilize and treat the patient's emergency medical condition.

Based on tours/observations, staff/physician interviews and review of facility documents, the facility failed to accept a burn patient for transfer from another facility that stated they did not have the capability to care for the patient's burns, even though the contacted facility had a bed available to accept a burn patient, was substantiated. The facility failed to comply with applicable CMS/EMTALA regulations related to the requirements of a facility receiving a request to accept a transfer of an emergency/obstetric patient from another facility that stated they lacked the capability and/or capacity to stabilize and treat the patient's emergency medical condition.

Findings:

The facility failed to comply with the EMTALA requirements of the receiving facility to accept a patient in need of a higher level of specialized care, even though the hospital had the capability and capacity to accept the patient at the time they refused the transfer. The failure created an unnecessary delay in the patient accessing specialized burn unit care.


Observations, interviews and record reviews revealed that a physician responsible for accepting transfers for the trauma and burn unit of the facility that night declined to accept the patient, even though the facility had a bed available on their burn unit. The physician questioned the appropriateness of the patient's described burns for a burn unit and questioned the referring physicians' judgement that they were unable to adequately treat the patient's burns in the referring hospital. They physician refused the patient transfer a second time during a subsequent telephone call when a different physician from the treatment team made a second attempt to get the hospital to reconsider accepting the patient for the burn unit. The patient was transferred about an hour later to a burn unit in an adjacent state that accepted the patient for treatment.

a. Review of the (Referring Hospital Name) medical record for the patient referenced in the complaint:
Review of the medical record revealed the following, in part:
Time of arrival in ED at (name of referring hospital): 11/2/12 at 19:51 (5:51 p.m.).
"HPI
(Name of the patient) was a (young adult patient) who was transported to the emergency department after being ejected from his/her SUV in a motor vehicle accident. Patient swerved to miss an on coming vehicle, was unrestrained, was ejected from the vehicle and the vehicle landed on top of him/her. S/he did not lose consciousness during the accident. S/he denies neck pain. S/he denies any numbness or weakness of her extremities. S/he complains of severe pelvic pain and back pain. The vehicle had to be jacked up to extricate (name of the patient).
PHYSICAL EXAM
Constitutional: This is an alert, oriented, (young adult patient ) fully immobilized on a long spine board head and neck immobilized in hard cervical collar bolsters and tape. Lower extremities are elevated on several pillows.
Back: Although not initially examined, on return from CT patient was intubated, then log rolled off the spine board. S/he had an approximately 6% full-thickness burn of his/her left upper back and the posterior aspect of his/her left shoulder. Diffused abrasions over his/her left hip and buttocks. Superficial second degree burns of her right posterior thigh and the left lower leg.
Extremities: Severe pain about the pelvis with any movement of lower extremities.
MUSCULOSKELETAL: No obvious deformity. Tenderness on AP and Lateral pelvic compression.
RADIOLOGY/PROCEDURES
CT of chest: T 7 and T 8 endplate fractures on the left, multiple transverse process fractures thoracic spine, left posterior 8th rib fracture, anterior pneumonitis. CT of the abdomen with contrast: Grade 2-3 liver laceration with perihepatic fluid, bilateral sacral fractures, diastases left SI joint, bilateral pubic rami fractures, left pubic body fracture, right superior and inferior rami fractures, small pelvic hematomas.
ED COURSE & MEDICAL DECISION MAKING
Patient was initially treated with IV Dilaudid and Zofran, but remained terribly uncomfortable. S/he did develop significant tachycardia and was given a 1 L fluid bolus. His/her pulse slowed from about 160 to 130. Blood pressure remained stable.
On return from CT, I consulted with trauma surgeon on call. On (trauma surgeon)'s arrival in the emergency department, patient was intubated, log rolled from the spine board, his/her back examined and Foley catheter placed. (Trauma surgeon) attempted to arrange transfer to (possible receiving hospital) because of the patient's significant burns. Burn Center however would not accept patient in transfer. Our plastic surgeon was uncomfortable caring for patient burns here at (referring hospital) without a burn unit. I attempted a 2nd time to transfer patient to (potential receiving hospital) without success and then arranged for transfer to (out-of-state hospital that accepted the patient). Patient has been accepted by (name of receiving ED physician) in the emergency department at (out-of-state hospital that accepted the patient. I also discussed patient with (receiving burn specialist), who was on call for the burn unit.

Consultation Notes: (Trauma physician at referring hospital)
Trauma consult note, patient seen at the request of (referring ED physician).
History of Present Illness: (Name of patient) is a (young adult) with a chief complaint of back and ;pelvic pain. Patient is a (young adult) post ejection from a car after being unrestrained and swerving to avoid a car that ran a stop sign. The vehicle came to rest on top of the patient and after extrication s/he was transported to SMH ED. Patient denied loss of consciousness.
Physical Exam:
Back exam - 7% full thickness burn injury to the left upper back and shoulder. Also has severe abrasions to the left hip and some minimal midline tenderness.
Extremities - 2nd and 3rd degree burn to posterior right leg approximately 4% TBSA. Also with multiple abrasions.
Skin - abrasion(s) Diffusely
Assessment/Plan:
Patient is a (young adult) post ejection after MVC.
Injuries:
7% TBSA 3rd degree burn left back and shoulder
6% TBSA severe abrasion left hip
4% TBSA posterior right thigh 2nd degree burns
Bilateral Pubic Rami fx
Bilateral Sacral FX with SI disassociation
T 7/8 Endplate Fx
Transverse process Fx's, T-spine
Liver Laceration Grade 2
Anterior Pneumomediastinum

Patient alert, but intubated during evaluation for comfort as we assessed the burns. Burn injuries exceed our ability at (referring hospital) to care for, I consulted (name of plastic surgeon), Plastic Surgeon on the phone and we felt transfer to a burn/ trauma center would be in the patient's best interest. Patient has been accepted by (out-of-state hospital that accepted the patient). ."

PHYSICIAN ASSESSMENT AND CERTIFICATION (Transfer Form)
Provider Certification
I have examined the patient and explained the following risks and benefits of being transferred/refusing transfer to the patient:
"We do not have a burn unit at (referring hospital) to care for your burn"

Transport Medical Record - (Referring hospital air transport team
"Reason for Transport (Medical necessity determination)
Sending: Level of care required which is not available at patient's location.
Receiving: Needed Specialist available at receiving facility: Burn Specialist.
Patient Medical History
Chief Complaint: Patient unable to effectively communicate, sedated and on ventilator. Patient was involved in a rollover MVA where s/he was ejected and entrapped under the exhaust causing 3rd degree burns to his/her posterior left chest and right posterior leg, as well as multiple fractures and soft tissue injuries.
Primary Symptom: Burns
Other Symptoms: Fracture
Incident: (Location of accident) Motor vehicle incident. Patient was a driver of/in an auto which rolled over. Patient was thrown from vehicle. Unknown loss of consciousness. Extrication required.
History of Present Illness/Injury
Called to (referring hospital) to transport (young adult patient) to (out-of-state hospital that accepted the patient). The patient was involved in a vehicle rollover accident where she was ejected and entrapped under part of the vehicle and required prolonged extrication.
Per the sending RN the patient had been awake and alert prior to the intubation and had been moving all her extremities. Unknown whether she lost consciousness at the time of the accident. The sending physician reported to have intubated her for pain control. Her burns on left posterior shoulder have been covered with moist dressings and she had warm blankets on her. Family was at the bedside and was given her belongings prior to her departure.
Event Log
11/2 23:00 Flight Team present to (referring hospital) ED to rendezvous with patient. Sending physician unable to find accepting physician at (potential receiving hospital that refused the patient). Team standing by while accepting physician and facility arranged.
11/3 00:30 Patient Condition Update - Patient will be sent to (out-of-state hospital that accepted the patient). Transfer paperwork given to flight team. Team received report from Nurse and Physician. Patient placed on transport ventilator.
11/3 02:50 Patient Condition Update - Patient care transferred to 15+ member trauma team in ED. Brief report given to team. Copy of transfer paperwork and written flight record left with ED staff."

b. Review of the facility (hospital that refused the patient)policy/procedure entitled "Medical Screening Examinations, Stabilizing Treatment and Appropriate Transfers (EMTALA)":

Review of the facility policy/procedure entitled "Medical Screening Examinations, Stabilizing Treatment and Appropriate Transfers (EMTALA)" revealed the following, in part:
"Description: The purpose of this policy is to define the obligations of (hospital that refused the patient) to provide appropriate medical screening examinations, to provide stabilizing medical care to those persons who present with an emergency medical condition, and to provide appropriate transfer in compliance with the Emergency Medical Treatment and Active Labor Act ('EMTALA').
Accountability: The Medical Director of Emergency Services, the Vice President of Ambulatory Services and the Vice President of Clinical Affairs are responsible for ensuring that (hospital that refused the patient) provides 'emergency services and care' (as defined in this policy within the capabilities of its facilities and staff to any individual who comes to (hospital that refused the patient) and requests emergency services, `examination or treatment, or for who emergency services, examination, or treatment is requested. All employees and staff are accountable to know and comply with EMTALA.
H. (Hospital that refused the patient)'s Responsibility to Accept Transfers
1. (hospital that refused the patient), due to its specialized capabilities and facilities (such as burn, trauma, and neonatal care). is legally obligated and will not refuse to accept an appropriate transfer of any individual with an unstabilized EMC who requires such specialized capabilities or facilities."

c. Interviews with the Director of ED and Trauma Services, ED Manager and the Executive Director of Chairman of Cardiac and Vascular Services/Chairman of EMTALA Committee on 01/17/13 and 01/23/13:


On 1/17/13, at 1 p.m., interviews were conducted with the Director of ED/Trauma and ED Manager. The Director of ED/Trauma also worked with hospital managers re: bed placement and works with the Access Center (the contact center for bed control/transfers). The interviews revealed the following information:

Director of ED/Trauma became aware of the alleged EMTALA violation approximately 45 days after the incident while attending a trauma network meeting. A transfer refusal was reported to them by (referring hospital).

S/he learned that a burn patient in the ED in (referring hospital) had been refused a transfer admission to the burn unit at (out-of-state hospital that accepted the patient) on the night of 11/2/12. S/he provided the following information about the incident:

On 11/2/12 a (young adult patient) was involved in a MVA. The patient, (pt name), BD (pt's birthday) was unbelted in his/her SUV when s/he attempted to avoid a car that ran a light. S/he was ejected from the SUV and the car rolled on top of him/her. S/he sustained fractures and 3rd degree burns to his/her back, shoulder and his/her upper leg. In (referring hospital) s/he was assessed by the ED physician (name of physician), Trauma MD (name of physician) and a plastic surgeon who determined the patient needed to be transferred to the burn unit at (hospital that refused the patient). Apparently the Trauma physician (name of the physician that refused the patient) refused to accept the patient and no reason was given. The patient was then transferred to another hospital out-of-state for burn care.

After being notified of the incident the Access Center tapes were reviewed and (name of physician) (President of the Medical Staff) and (name of physician) (VP of Clinical Services) were notified, about 15 days after (Director of ED/Trauma) was informed (which was 45 days after the incident) and the tapes were reviewed by them. "Unfavorable behavior" was identified. (Physician that refused patient) was counseled by the medical staff (Chief Medical Officer and President of the Medical Staff).

(Director of ED/Trauma) stated that they had beds in the burn unit on 11/2/12 and could have taken the patient. S/he said " We always have beds available on the burn unit." S/he stated that the head of the burn unit had been going to the other hospitals promoting the burn unit and encouraging patient referrals to the unit. S/he stated that it was his/her understanding under American Burn Association standards, that 3rd degree full thickness burns were appropriate for a burn unit admission. S/he stated that s/he was concerned about the transfer refusal. S/he stated that they were reviewing the Access Center process and staff since becoming aware of this incident. S/he stated they had made the decision to to reorganize the Access Center and make sure that transfer refusals were tracked. S/he wanted to ensure that there were clinical staff involved that were knowledgeable about EMTALA regulations that could appeal a transfer refusal at the time to an administrator on call if the Access Staff had a concern that an EMTALA violation might be occurring or was unable to convey that information successfully to the the physician refusing the transfer. S/he also stressed the need for more EMTALA training of Access Center staff and providers taking transfer calls.

During a subsequent interview with (Director of ED/Trauma and Executive Director of Chairman of Cardiac and Vascular Services/Chairman of EMTALA Committee) on 11/23/13, they reiterated their concerns about how the transfer request had been handled and discussed the plans to put monitoring and training in place to prevent a similar refusal in the future. They confirmed that when a referring physician had made a decision that the hospital was unable to care for the patient and a higher level of specialized care was required, that the referring physician did not need to defend that judgement to the accepting physician in order to get permission for a transfer. They stated that interaction was only appropriate if the sending physician was unsure of the need for transfer and was requesting consultation, which was not the case in this instance.

d. Review of American Burn Association referral criteria:

Review of information obtained on on the website for the American Burn Association revealed the following , in part:
"Burn Center Referral Criteria
Burn injuries that should be referred to a burn center include:
3. Third degree burns in any age group."

e. Interview on with (physician who refused transfer of patient) and(President of the Medical Staff, who had recently reviewed the case with (physician who had refused the patient):

An interview was conducted on 1/22/13 at 9 a.m. with physician who refused the transfer and the president of the medical staff. During the interview, (physician that refused patient)d described the calls and explained his/her rationale for refusing the transfer. S/he stressed that the burns described sounded like abrasions/"road rash" secondary to MVA and ejection from the car. S/he stated that no thermal source for burns was described. S/he felt that the burns were injuries that the physicians at (referring hospital) should have been able to care for. When asked if s/he had been counseled about this situation or given directions about how to handle transfers differently in the future, s/he stated that s/he would" ask more questions and get more information."

(Physician who refused transfer) stated that later that night (into early 11/3/12), s/he received another call from (referring hospital) about a different burn patient that had been burned by flames on his/her stove. S/he state s/he accepted that patient because they described thermal burns that were appropriate for the burn unit.
(Note: The tape of that phone call is contained on the CD with the other Access Center calls about the refused patient). The second burn patient, was placed in the sample as sample patient #21 and summary portions of his/her record were obtained and are part of the complaint investigation file.)

(Physician that refused the transfer) was asked if s/he had received any EMTALA training and s/he stated that s/he could not remember when or if s/he had received any training, but had looked at the regulations after this case was brought to his/her attention by (the President of the Medical Staff and Chief Medical Officer).
(President of the Medical Staff) was asked about the role of the physician being called to accept a transfer. S/he stated that s/he felt it was appropriate to have a conversation with the physician requesting the transfer to determine whether the other hospital did have the ability to take care of the patient, rather than resorting to a transfer. S/he was asked if the physicians in the tapes sounded like they were unsure of their decision, assessment of the patient's needs and their capability to take care of the patient, or if they were requesting a consultation to make that decision. S/he stated that the physicians sounded certain of their decisions and did not appear to be requesting a consultation about whether or not they could care for the patient at (referring hospital). (President of the Medical Staff) was also asked about EMTALA training for physicians, particularly those who were taking calls from ED's about accepting transfers under EMTALA regulations. S/he stated that s/he was not aware of any EMTALA training requirements for providers.

f. Review of the audio recordings of the phone calls by the (referring hospital) physicians to the Access Center at (hospital that refused the patient) requesting a transfer on 11/02/12:

The tape of Access Center call on 11/2/12 regarding Patient in the complaint) was played on 1/17/13 during the 1 p.m. interview with (Director of ED/Trauma and ED Manager):
(NOTE: A complete copy of all of the phone calls is available in the complaint investigation file on a CD.)

The initial review of 01/17/13 and a second review with (Director of ED/Trauma and Executive Director of Chairman of Cardiac and Vascular Services/Chairman of EMTALA Committee) a second time on 1/23/13 after the survey team had interview (the physician that refused the patient) on 1/22/13. The second review confirmed that the referring physicians did state that they had exceeded their ability to care for the patient and were requesting a transfer to the burn unit. The providers described third degree burns that were full-thickness burns, in addition to 2nd degree burns and abrasions. (Name of physician that refused the patient) did not clearly ask for the source of the burns (i.e. thermal heat source) that he had stated to the surveyors was the basis for his decision to decline the transfer, thinking the burns were abrasion burns.