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Based upon review of hospital policies and procedures, Emergency Department Medical Records, Medical Staff Meeting Minutes and Peer Reviews, and physician and nursing staff interviews, the hospital failed to meet the EMTALA requirements as defined in 489.24 for failing to provide medical treatment for patient #6 who required hospital admission when the hospital had the capability and capacity to provide the necessary treatment. The hospital transferred patient #6 to another acute care hospital when the on-call physician refused to admit the patient.

Based upon review of 1 of 32 Emergency Department Records (#6), Medical Staff Meeting Minutes, Medical Staff Peer Reviews, Emergency Department On-Call Physician Schedule, and physician interview, the hospital failed to ensure that when the ED Physician contacted the on-call physician to provide further medical treatment, the on-call physician does not refuse when the hospital has the capability and capacity to treat the patient. The refusal of the on-call physician to provide further medical treatment resulted in the hospital transferring the patient to another acute care hospital. (Patient #6) Findings:

Review of the Emergency Department's On-Call Physician schedule revealed on 10/29/09, Internal Medicine Physician S8 was on-call for unassigned patient admissions.

Review of patient #6's Emergency Department (ED) record revealed on 10/29/09, the patient presented to the ED with the chief complaint of chest pain. The ED Physician S6 determined patient #6 required hospital admission; however, when the on-call physician, Internal Medicine Physician S8, was called, he refused to admit the patient. Physician S8 suggested to ED Physician S6 that he call the patient's primary care physician who was located at another hospital. When ED Physician S6 called patient #6's primary care physician, the on-call physician for that group told the ED Physician it would be an inappropriate transfer due to the fact the patient presented with chest pain, had past cardiac problems, and the transferring hospital was fully capable of admitting and treating the patient. When ED Physician S6 called the on-call Internal Medicine Physician S8 back the physician reiterated he would not admit the patient.

During an interview with ED physician S8 on 02/18/10, 7:05 PM, he confirmed Internal Medicine Physician S8 refused to admit patient #6 to the hospital and instructed him to call the patient's primary care physician for admission to another hospital.

Review of the Medical Staff Meeting Minutes and Medical Staff Peer Reviews for November and December 2009 and January 2010 revealed the Medical Staff identified Internal Medicine Physician S8 refused to admit patient #6 to the hospital; however, there failed to be further documentation the incident was acted upon. A letter sent to Internal Medicine Physician S8, dated 12/18/09, revealed the Peer Review Panel "identified this as an educational opportunity with no additional action required.".

Based upon review of 1 of 32 Emergency Department Records (#6), Medical Staff Meeting Minutes and Medical Staff Peer Reviews, Emergency Department On-Call Physician Schedule, EMTALA Policy and Guidelines, and staff and physician interviews, the hospital failed to provide on-going stabilizing treatment for patient #6 when she presented to the Emergency Department with the chief complaint of chest pain. The Emergency Department Physician transferred patient #6 to Hospital A for admission even though Willis Knighton Medical Center had the capacity and capability to admit and treat the patient. Findings:

On 10/29/09, patient #6 presented to the Emergency Department (ED) with the chief complaint of chest pain which radiated through to the back region and down the left arm. The patient was triaged by the Registered Nurse at 7:02 PM with the initial set of vital signs: Blood Pressure 179/78, pulse 67, respirations 16, Pulse Oximetry 99% on room air, and a temperature of 97.8. The patient was placed on a cardiac monitor which registered a normal sinus rhythm. The patient's past cardiac medical history was significant for dysrhythmia with ablation and Coronary Artery Disease with Stent Placement. The ED physician (S6) evaluated the patient and ordered laboratory tests and an Electrocardiogram (EKG). Physician S6 documented the laboratory tests and EKG results were all normal.

Continued review of patient #6's Emergency Department (ED) record revealed on 10/29/09, ED Physician S6 determined patient #6 required hospital admission for continued observation and treatment; however, when the on-call physician, Internal Medicine Physician S8, was called, he refused to admit the patient.

Review of the Emergency Department's On-Call Physician schedule revealed on 10/29/09, Internal Medicine Physician S8 was on-call for unassigned patient admissions.

Review of the documentation by ED physician S6 revealed the following:
10/29/09, 11:37 PM "ED course: Admission process as follows: D/W (Discussed With) (Internal Medicine Physician S8) who declines to admit as this is a (Hospital A) patient. Suggests I call (Hospital A). D/W (physician S7 on call at Hospital A) who also refuses to admit. Discussed again with (physician S8) who reiterates he will not admit."
10/30/09, 12:01 AM "ED course: Admission Course: D/W (physician S8) at this time who spoke with (physician S9). (physician S7) who is a fellow and (physician S9) agrees to admit after transfer."

Further review of patient #6's ED record revealed a form titled "Transfer Form #1", dated 10/30/09, 12:30 AM, revealed: Part A. Patient Condition, #4. "Patient/Family requests transfer" was check marked and documented to the side "Dr. transfer". Part C of the Transfer Form was titled "Physician Certification" and revealed the statement "I have examined the patient and explained the following risks and benefits of being transferred/refusing transfer to the patient". Also in Part C was an area for the ED Physician to identify, in writing, the Risks and Benefits of Transfer; however, these areas were left blank. The ED Physician (S6) identified by check mark the Risk "Worsening of condition or death if patient stays here" and check marked "Obtain level of care not available at this facility" as a benefit of transfer. On page 2 of the Transfer Form, patient #6 signed that she consented to the transfer to Hospital A on 10/30/09, 12:30 AM.

An interview with ED Physician S6, on 02/18/10, 7:05 PM, revealed Physician S8 suggested to ED Physician S6 that he call the patient's primary care physician who was located at another hospital (Hospital A). When ED Physician S6 called patient #6's primary care physician, the on-call physician for that group told the ED Physician it would be an inappropriate transfer due to the fact the patient presented with chest pain, had past cardiac problems, and the transferring hospital was fully capable of admitting and treating the patient. When ED Physician S6 called the on-call Internal Medicine Physician S8 back the physician reiterated he would not admit the patient. ED physician S6 confirmed Internal Medicine Physician S8 refused to admit patient #6 to the hospital and instructed him to call the patient's primary care physician for admission to Hospital A.

Review of the Medical Staff Meeting Minutes and Medical Staff Peer Reviews for November and December 2009 and January 2010 revealed the Medical Staff identified Internal Medicine Physician S8 refused to admit patient #6 to the hospital.

Interview with ED Physician S6 on 02/18/10, 7:05 PM, revealed when questioned about the reasons for transferring patient #6 to Hospital A, physician S6 stated that when the on-call physician S8 was initially contacted to admit the patient to the hospital, physician S8 told him that since the patient's primary care physician was located at Hospital A, that is where the patient should be transferred to and admitted. When asked about the statements check marked for risks and benefits of transfer, ED Physician S6 stated the the risk of the patient's condition worsening if they stayed was marked in error. The benefit of obtaining level of care not available at this facility was check marked because the patient's primary care physician was not on staff at the hospital and the patient needed to be admitted. ED Physician S6 confirmed the hospital had the capacity and capability to care for patient #6.

ED Physician S6 was further interviewed regarding on-call physician S8's refusal to accept patient #6 for admission. ED Physician S6 stated that physician S8 told him that since the patient's primary care physician only admitted to Hospital A, that was where the patient needed to be admitted. When ED Physician S6 was asked if patient #6 requested to be transferred to Hospital A, ED Physician S6 replied "no".

Review of policy titled "EMTALA Policy and Guidelines" revealed Part III., B. If it is determined that the individual has an emergency medical condition, that the individual shall be either: 1. Given further medical examination and treatment, within the capabilities of the staff and that facility, necessary stabilized their condition, unless the individual, or person acting on the individual's behalf, refuses to consent to further examination and treatment... G. Generally individuals will be transferred for the following reasons: 1. The patient or the patient's legal representative requests the transfer, in writing, after being informed of the hospital's obligations under EMTALA and the risk of transfer; 2. The facility is not the most appropriate for treating certain types of individuals or the facility does not offer the specialty needed by the individual...

Interview conducted by telephone, 02/15/10, 1:45 PM, with patient #6 confirmed she did not request to be transferred to Hospital A. Continued interview revealed she had been informed by a physician (she could not remember his name) that she needed to be admitted to the hospital but physician S8 would not admit her because she had a primary care physician located at Hospital A. Patient #6 further stated she could not understand why she had to be transferred to Hospital A especially since the areas around this hospital had sustained damages from tornados earlier in the evening.

Interview with the Director of Patient Care Services on 02/22/10 revealed the hospital (transferring hospital) provided the same services as the receiving hospital, Hospital A. The Director of Patient Care Services further confirmed the hospital had the capability and capacity to care for patient #6.

Based upon review of 1 of 32 Emergency Department Medical Records (#6), EMTALA Policy and Guidelines, and physician and nursing staff interviews, the hospital failed to provide medical treatment for patient #6's emergency medical condition by failing to admit the patient to the hospital when the hospital had the capability and capacity to treat the patient. The hospital transferred the patient to another acute care hospital when the patient did not request the transfer. Findings:

On 10/29/09, patient #6 presented to the Emergency Department (ED) with the chief complaint of chest pain which radiated through to the back region and down the left arm. The patient was triaged by the Registered Nurse at 7:02 PM with the initial set of vital signs: Blood Pressure 179/78, pulse 67, respirations 16, Pulse Oximetry 99% on room air, and a temperature of 97.8. The patient was placed on a cardiac monitor with registered a normal sinus rhythm. The patient's past cardiac medical history was significant for dysrhythmia with ablation and Coronary Artery Disease with Stent Placement. The ED physician (S6) evaluated the patient and ordered laboratory tests and an Electrocardiogram (EKG).

Review of the documentation by ED physician S6 revealed the following:
10/29/09, 11:37 PM "ED course: Admission process as follows: D/W (Discussed With) (Internal Medicine Physician S8) who declines to admit as this is a (Hospital A) patient. Suggests I call (Hospital A). D/W (physician S7 on call at Hospital A) who also refuses to admit. Discussed again with (physician S8) who reiterates he will not admit."
10/30/09, 12:01 AM "ED course: Admission Course: D/W (physician S8) at this time who spoke with (physician S9). (physician S7) who is a fellow and (physician S9) agrees to admit after transfer."

Further review of patient #6's ED record revealed a form titled "Transfer Form #1", dated 10/30/09, 12:30 AM, revealed: Part A. Patient Condition, #4. "Patient/Family requests transfer" was check marked and documented to the side "Dr. transfer". Part C of the Transfer Form was titled "Physician Certification" and revealed the statement "I have examined the patient and explained the following risks and benefits of being transferred/refusing transfer to the patient". Also in Part C was an area for the ED Physician to identify, in writing, the Risks and Benefits of Transfer; however, these areas were left blank. The ED Physician (S6) identified by check mark the Risk "Worsening of condition or death if patient stays here" and check marked "Obtain level of care not available at this facility" as a benefit of transfer. On page 2 of the Transfer Form, patient #6 signed that she consented to the transfer to Hospital A on 10/30/09, 12:30 AM.

Interview with ED Physician S6 on 02/18/10, 7:05 PM, revealed when questioned about the reasons for transferring patient #6 to Hospital A, S6 stated that when the on-call physician S8 was initially contacted to admit the patient to the hospital, physician S8 told him that since the patient's primary care physician was located at Hospital A, that is were the patient should be transferred and admitted to. When asked about the statements check marked for risks and benefits of transfer, ED Physician S6 stated the the risk of the patient's condition worsening if they stayed was marked in error. The benefit of obtaining level of care not available at this facility was check marked because the patient's primary care physician was not on staff at the hospital and the patient needed to be admitted to the hospital, the level of care, admission was not available.

ED Physician S6 was further interviewed regarding on-call physician S8's refusal to accept patient #6 for admission. ED Physician S6 stated that physician S8 told him that since the patient's primary care physician only admitted to Hospital A, that was where the patient needed to be admitted. When asked about physician S7, the on-call physician for the patient's primary care physician group, and his refusal to accept patient #6 for transfer to Hospital A, ED Physician S6 stated that physician S7 told him that since patient #6 was in a hospital that was fully capable of handling the patient and there had been tornados in the surrounding areas that damaged business and homes of where Hospital A was located, it would be inappropriate to transfer the patient. ED Physician S6 stated he then called on-call physician S8 back, told him was physician S6 said, and that physician S8 again stated he would not admit the patient and that the patient needed to be transferred to Hospital A and admitted by her primary care physician. After a few minutes, ED Physician S6 stated he received a telephone call from patient #6's primary care physician S9 who told him he would accept the transfer and admit the patient to Hospital A. When asked if patient #6 requested to be transferred to Hospital A, ED Physician S6 replied "no".

On 02/22/10, 12:20 PM, a telephone interview was conducted with Hospital A's on-call physician S7. When asked about his refusal to accept patient #6, he stated when he initially received the call from ED Physician S6, he was told patient #6 presented to the ED at Willis Knighton Pierremont Health Care with the complaint of chest pain and needed to be transferred to Hospital A for admission to her primary care physician. Physician S7 stated when he asked ED Physician S6 if the patient was requesting the transfer, he was told "no". Physician S7 stated he explained to ED Physician S6 that since tornados had hit the area around Hospital A and damaged homes and business, and since Willis Knighton Pierremont was fully capable of admitting and treating patient #6, it would be an inappropriate transfer. Physician S7 further stated that he instructed the ED Physician S6 to again call the on-call physician (S8) for the patient admission. After awhile, physician S7 stated he received a phone call from physician S9 who told him he had accepted the transfer and admission of patient #6 to Hospital A.

On 02/15/10, 1:45 PM, a telephone interview was conducted with patient #6. When asked about the events of her stay in the ED at Willis Knighton Health Center, patient #6 stated earlier in the day of 10/29/09, she began having chest pain during the day which worsened so she went to the ED. Since she had heart problems, she was scared she was having a heart attack. When asked if she requested to be transferred to Hospital A, patient #6 replied "no" and that she had been informed by a physician (could not remember his name) that she needed to be admitted to the hospital but that physician S8 would not admit her because she had a primary care physician located at Hospital A. Patient #6 further stated she could not understand why she had to be transferred to Hospital A especially since there had been tornados had damaged the area earlier in the evening.

Review of policy titled "EMTALA Policy and Guidelines" revealed Part III., B. If it is determined that the individual has an emergency medical condition, that the individual shall be either: 1. Given further medical examination and treatment, within the capabilities of the staff and that facility, necessary stabilized their condition, unless the individual, or person acting on the individual's behalf, refuses to consent to further examination and treatment...G. Generally individuals will be transferred for the following reasons: 1. The patient or the patient's legal representative requests the transfer, in writing, after being informed of the hospital's obligations under EMTALA and the risk of transfer; 2. The facility is not the most appropriate for treating certain types of individuals or the facility does not offer the specialty needed by the individual...

Interview with the Director of Patient Care Services on 02/22/10 revealed Willis Knighton Pierremont Health Center provided the same services as Hospital A.