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Based on review of policy/procedure, patient medical records, and staff interviews, the University of Iowa Hospital and Clinics (UIHC) failed to ensure that physician A (Practitioner #A) followed hospital EMTALA policies and procedures when a referring hospital requested transfer of a patient (Patient # 71) requiring the specialized capabilities available at UIHC. The UIHC identified an average of 200 burn patient visits per month.

Failure to accept a transfer from a referring hospital for a patient requiring the specialized capabilities of the UIHC could potentially delay the appropriate treatment for the patient.

Findings include:

1. Review of hospital policy titled "The Emergency Medical Treatment and Active Labor Act (EMTALA) As Amended", dated revised September 5, 2007, revealed "Acceptance of Transfers from Outside Facilities: Any physician with clinical privileges at the UIHC may accept such a transfer. A refusal to accept a transfer of a patient in an emergency medical condition and in need of specialized services available at the UIHC must be made by the on-call faculty physician of the service to which admission is sought pursuant to Paragraph II - H above. The decision will be communicated to the senior physician on duty in the ETC."

The policy also revealed "Services of Consulting (on-call) Physicians: Requests from a sending facility located within the boundaries of the United States to accept a transfer because the sending facility lacks specialized service(s) available at the UIHC will not be denied, unless UIHC does not have capacity to accept another patient. A determination that a specialty service does not have capacity to accept the transfer may be declared only by the on-call faculty physician of the specialty service unit for which admission is sought. If such a denial becomes necessary, the on-call faculty of the specialty service shall cooperate with the sending facility in seeking appropriate placement."

2. Review of patient # 71 ' s medical record revealed Hospital A (referring hospital) contacted the UIHC (located 72 miles away) on 1/13/2010 at 9:12 PM to arrange a transfer because they did not have the capability to care for patient # 71's burns (2nd degree burns, total body surface area 15 - 18%). According to the documentation on Hospital A's transfer form, Practitioner # A (on call physician for the UIHC burn care center) declined to accept the transfer because "they (UIHC) don't get reimbursed for IL (Illinois) patients." Further review of the transfer form revealed Hospital A contacted a second hospital (Hospital D, located 164 miles away) to arrange the transfer. According to the documentation, Hospital D accepted the transfer of patient # 71 at 9:34 PM.

3. During an interview on 1/21/10 at 11:20 AM, Practitioner # A acknowledged she refused to accept patient #71 in transfer to the UIHC on 1/13/10 for treatment of burns. Practitioner # A acknowledged she did not consult with the on call (faculty) attending physician regarding or prior to, refusing Hospital A's request to transfer patient #71.

4. During an interview on 1/21/10 at 10:10 AM, Practitioner # B stated there are not any burn patients the UIHC could not accept as long as they had the capacity. Practitioner # B acknowledged the UIHC had the capacity to care for another burn patient on 1/13/10.

5. During an interview on 1/27/10 at 1:00 PM, Practitioner # C acknowledged they were the (faculty) attending physician on call for the Burn Service on 1/13/10. Practitioner # C stated they had not received a call regarding the refusal to accept patient #71 in transfer to the UIHC on 1/13/10 for treatment of burns.

6. Review of the physician on call list for the UIHC revealed the hospital provided Burn Services on call and identified Practitioners #A and #C as the physicians on call for the Burn Service on 1/13/10.

Based on observation, document review, and staff interview, the UIHC administration failed to ensure staff placed appropriate signage in 1 of 1 waiting area (Emergency Trauma Center), and 3 of 3 treatment areas (Adult and Pediatric treatment areas, and triage/registration area). UIHC staff identified an average of 4,471 Emergency Treatment Center patient visits per month.

Failure to post signs informing patients of their rights could potentially cause patients to be uninformed of their right to receive emergency care, and not seek treatment at the hospital.

Findings include:

1. Observations during a tour of the Emergency Treatment Center (ETC) on 1/27/10 at 9:00 AM revealed:

a. A display case, running almost the full length of the wall, on the left side of the waiting area, away from where patients sit or register, contained a sign informing patients of their rights printed on a letter sized piece of paper. Staff had placed the sign in the lower left corner of the display case. Staff also had placed 6 wheelchairs in front of the display case, obscuring the visibility of the sign.

b. The adult treatment area lacked signs informing patients of their rights either in the examination rooms, or common areas.

c. The pediatric/fast track treatment area lacked signs informing patients of their rights either in the examination rooms, or common areas.

2. During an interview at the time of the tour, the Nurse Manager of the ETC stated the hospital used to have signs informing patients of their rights under EMTALA (the Emergency Medical Treatment and Labor Act) in every treatment room. However, the hospital had remodeled the ETC, and placed the signs back in the treatment rooms. The patients can find their rights either on the hospital's website, or in a brochure titled "Patients' Rights and Responsibilities". The Nurse Manager of the ETC also acknowledged the ETC staff had not ensured the brochure was easily visible in holding racks located in the waiting area.

3. Review of the brochure titled "Patient's Rights and Responsibilities", no revision date, revealed the brochure lacked the information on a patient's rights required under the EMTALA law.

4. During an interview on 1/27/10 at 10:55, the Program Assistant - Joint Commission from the Joint Office for Compliance stated the hospital does not have a policy explicitly addressing signage requirements under the EMTALA law. Instead, the general policy ("The Emergency Medical Treatment and Active Labor Act (EMTALA) as Amended) addresses the signage requirements.

5. Review of the policy "The Emergency Medical Treatment and Active Labor Act (EMTALA) As Amended", revised 9/5/07, revealed the policy did not address the signage requirements under the EMTALA law.

Based on medical record review, and staff interviews, the University of Iowa Hospital & Clinics (UIHC) failed to accept a patient (Patient # 71) in transfer from a referring hospital that required the specialized capabilities available at UIHC. The hospital identified an average of 200 burn patient visits per month.

Failure to accept a patient in transfer from a referring hospital requiring the specialized capabilities available at the UIHC could potentially delay the appropriate treatment.

Findings include:

1. Review of Hospital A's (referring hospital) medical record revealed patient #71 had, 2nd degree burns over 15 - 18% total body surface area. Hospital A staff documented contact with Practitioner # A at UIHC and that Practitioner # A stated they (UIHC) don't get reimbursed for (out of state) patients. Hospital A then transferred patient #71 to Hospital D (another hospital) for treatment of burns, a service not available at Hospital A.

2. During an interview on 1/21/10 at 11:20 AM, Practitioner # B acknowledged Practitioner # A refused to accept patient #71 in transfer to the UIHC on 1/13/10 for treatment of burns. Practitioner # B acknowledged that Practitioner # A is capable of accepting transfers but must contact the (faculty) attending staff physician who is the one with authority to refuse to accept another hospital's transfer request if the UIHC does not have capacity.

3. During an interview on 1/21/10 at 10:10 AM, Practitioner # B stated there are not any burn patients the UIHC could not accept as long as the hospital had the capacity. Practitioner # B acknowledged the UIHC had the capacity to care for another burn patient on 1/13/10.

4. During an interview on 1/27/10 at 1:00 PM, Practitioner # C acknowledged they were the (faculty) attending staff physician on call for the Burn Service on 1/13/10. Practitioner #C stated that they were not contacted about patient # 71 or asked by Practitioner # A whether to deny Hospital A's transfer request.

5. Review of the physician on-call list for the UIHC revealed the hospital provided Burn Services on call and identified Practitioners # A and # C as physicians on call for the Burn Service on 1/13/10.

Based on review of policy/procedure, patient medical records, and staff interviews, the University of Iowa Hospital and Clinics (UIHC) failed to ensure that physician A (Practitioner #A) followed hospital EMTALA policies and procedures when a referring hospital requested transfer of a patient (Patient # 71) requiring the specialized capabilities available at UIHC. The UIHC identified an average of 200 burn patient visits per month.

Failure to accept a transfer from a referring hospital for a patient requiring the specialized capabilities of the UIHC could potentially delay the appropriate treatment for the patient.

Findings include:

1. Review of hospital policy titled "The Emergency Medical Treatment and Active Labor Act (EMTALA) As Amended", dated revised September 5, 2007, revealed "Acceptance of Transfers from Outside Facilities: Any physician with clinical privileges at the UIHC may accept such a transfer. A refusal to accept a transfer of a patient in an emergency medical condition and in need of specialized services available at the UIHC must be made by the on-call faculty physician of the service to which admission is sought pursuant to Paragraph II - H above. The decision will be communicated to the senior physician on duty in the ETC."

The policy also revealed "Services of Consulting (on-call) Physicians: Requests from a sending facility located within the boundaries of the United States to accept a transfer because the sending facility lacks specialized service(s) available at the UIHC will not be denied, unless UIHC does not have capacity to accept another patient. A determination that a specialty service does not have capacity to accept the transfer may be declared only by the on-call faculty physician of the specialty service unit for which admission is sought. If such a denial becomes necessary, the on-call faculty of the specialty service shall cooperate with the sending facility in seeking appropriate placement."

2. Review of patient # 71 ' s medical record revealed Hospital A (referring hospital) contacted the UIHC (located 72 miles away) on 1/13/2010 at 9:12 PM to arrange a transfer because they did not have the capability to care for patient # 71's burns (2nd degree burns, total body surface area 15 - 18%). According to the documentation on Hospital A's transfer form, Practitioner # A (on call physician for the UIHC burn care center) declined to accept the transfer because "they (UIHC) don't get reimbursed for IL (Illinois) patients." Further review of the transfer form revealed Hospital A contacted a second hospital (Hospital D, located 164 miles away) to arrange the transfer. According to the documentation, Hospital D accepted the transfer of patient # 71 at 9:34 PM.

3. During an interview on 1/21/10 at 11:20 AM, Practitioner # A acknowledged she refused to accept patient #71 in transfer to the UIHC on 1/13/10 for treatment of burns. Practitioner # A acknowledged she did not consult with the on call (faculty) attending physician regarding or prior to, refusing Hospital A's request to transfer patient #71.

4. During an interview on 1/21/10 at 10:10 AM, Practitioner # B stated there are not any burn patients the UIHC could not accept as long as they had the capacity. Practitioner # B acknowledged the UIHC had the capacity to care for another burn patient on 1/13/10.

5. During an interview on 1/27/10 at 1:00 PM, Practitioner # C acknowledged they were the (faculty) attending physician on call for the Burn Service on 1/13/10. Practitioner # C stated they had not received a call regarding the refusal to accept patient #71 in transfer to the UIHC on 1/13/10 for treatment of burns.

6. Review of the physician on call list for the UIHC revealed the hospital provided Burn Services on call and identified Practitioners #A and #C as the physicians on call for the Burn Service on 1/13/10.

Based on observation, document review, and staff interview, the UIHC administration failed to ensure staff placed appropriate signage in 1 of 1 waiting area (Emergency Trauma Center), and 3 of 3 treatment areas (Adult and Pediatric treatment areas, and triage/registration area). UIHC staff identified an average of 4,471 Emergency Treatment Center patient visits per month.

Failure to post signs informing patients of their rights could potentially cause patients to be uninformed of their right to receive emergency care, and not seek treatment at the hospital.

Findings include:

1. Observations during a tour of the Emergency Treatment Center (ETC) on 1/27/10 at 9:00 AM revealed:

a. A display case, running almost the full length of the wall, on the left side of the waiting area, away from where patients sit or register, contained a sign informing patients of their rights printed on a letter sized piece of paper. Staff had placed the sign in the lower left corner of the display case. Staff also had placed 6 wheelchairs in front of the display case, obscuring the visibility of the sign.

b. The adult treatment area lacked signs informing patients of their rights either in the examination rooms, or common areas.

c. The pediatric/fast track treatment area lacked signs informing patients of their rights either in the examination rooms, or common areas.

2. During an interview at the time of the tour, the Nurse Manager of the ETC stated the hospital used to have signs informing patients of their rights under EMTALA (the Emergency Medical Treatment and Labor Act) in every treatment room. However, the hospital had remodeled the ETC, and placed the signs back in the treatment rooms. The patients can find their rights either on the hospital's website, or in a brochure titled "Patients' Rights and Responsibilities". The Nurse Manager of the ETC also acknowledged the ETC staff had not ensured the brochure was easily visible in holding racks located in the waiting area.

3. Review of the brochure titled "Patient's Rights and Responsibilities", no revision date, revealed the brochure lacked the information on a patient's rights required under the EMTALA law.

4. During an interview on 1/27/10 at 10:55, the Program Assistant - Joint Commission from the Joint Office for Compliance stated the hospital does not have a policy explicitly addressing signage requirements under the EMTALA law. Instead, the general policy ("The Emergency Medical Treatment and Active Labor Act (EMTALA) as Amended) addresses the signage requirements.

5. Review of the policy "The Emergency Medical Treatment and Active Labor Act (EMTALA) As Amended", revised 9/5/07, revealed the policy did not address the signage requirements under the EMTALA law.

Based on medical record review, and staff interviews, the University of Iowa Hospital & Clinics (UIHC) failed to accept a patient (Patient # 71) in transfer from a referring hospital that required the specialized capabilities available at UIHC. The hospital identified an average of 200 burn patient visits per month.

Failure to accept a patient in transfer from a referring hospital requiring the specialized capabilities available at the UIHC could potentially delay the appropriate treatment.

Findings include:

1. Review of Hospital A's (referring hospital) medical record revealed patient #71 had, 2nd degree burns over 15 - 18% total body surface area. Hospital A staff documented contact with Practitioner # A at UIHC and that Practitioner # A stated they (UIHC) don't get reimbursed for (out of state) patients. Hospital A then transferred patient #71 to Hospital D (another hospital) for treatment of burns, a service not available at Hospital A.

2. During an interview on 1/21/10 at 11:20 AM, Practitioner # B acknowledged Practitioner # A refused to accept patient #71 in transfer to the UIHC on 1/13/10 for treatment of burns. Practitioner # B acknowledged that Practitioner # A is capable of accepting transfers but must contact the (faculty) attending staff physician who is the one with authority to refuse to accept another hospital's transfer request if the UIHC does not have capacity.

3. During an interview on 1/21/10 at 10:10 AM, Practitioner # B stated there are not any burn patients the UIHC could not accept as long as the hospital had the capacity. Practitioner # B acknowledged the UIHC had the capacity to care for another burn patient on 1/13/10.

4. During an interview on 1/27/10 at 1:00 PM, Practitioner # C acknowledged they were the (faculty) attending staff physician on call for the Burn Service on 1/13/10. Practitioner #C stated that they were not contacted about patient # 71 or asked by Practitioner # A whether to deny Hospital A's transfer request.

5. Review of the physician on-call list for the UIHC revealed the hospital provided Burn Services on call and identified Practitioners # A and # C as physicians on call for the Burn Service on 1/13/10.