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Based on a review of audio recordings, medical records, policies, and staff interviews, the Hospital failed to follow the Emergency Medical Treatment and Labor Act (EMTALA) requirements, when on 5/10/25, despite having the capability and capacity, the Hospital refused a transfer request for patient #1 (see tag A2411).

Based on a review of audio recordings, medical records, policies, and staff interviews, the Hospital failed to follow the Emergency Medical Treatment and Labor Act (EMTALA) requirements, when on 5/10/25, despite having the capability and capacity, the Hospital refused a transfer request for Patient #1, who had a small bowel obstruction and history of Crohn ' s Disease along with a suspected biliary malignancy, from a rural Critical Access Hospital (CAH) that did not have Gastroenterology Services or a working operating room due a mechanical failure of equipment.

Findings include:

Review of the Hospital's Policy titled, Examination, Treatment and Transfer of Patients to other Facilities, dated 1/23/20, indicated the Hospital would, within its capabilities, provide, without discrimination, an appropriate medication screening exam to any individual who was seeking emergency medical care or who is being transferred in an unstable condition. The Policy defined capability as the physical space, equipment, supplies, and specialized services (such as surgery, psychiatry, obstetrics, intensive care, pediatrics, and trauma), including ancillary services available at the Hospital. The Policy further indicated that if the Hospital was believed to have violated any of the EMTALA regulations, the event should be reported to the Chairman of the Emergency Medicine Department for immediate review.

Review of the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS), dated 5/12/25, included a report alleging that on 5/10/25, a rural CAH Emergency Department (ED) Physican contacted the Hospital to transfer Patient #1, who had a small bowel obstruction and history of Crohn's Disease, along with a suspected biliary malignancy, as the Hospital did not have Gastroenterology Services to complete an evaluation or a functioning operating room due to an equipment failure. The Report alleged the Hospital declined to accept Patient #1 because he/she did not need surgery emergently.

Review of DPH's HCFRS, dated 5/15/25, included a report from the Hospital self reporting an EMTALA violation involving a transfer request for Patient #1 on 5/10/25. The Report indicated that two surgeons spoke with the transferring Hospital ED Physician regarding Patient #1's case and although there was no identified need for surgery, Patient #1 could transfer to the Hospital for a full work up by internal medicine. The Report indicated the internal medicine group received incomplete information reported internally when a Hospitalist #1 refused Patient #1's transfer request by the CAH.

On 5/21/25, the Senior Director of Regulatory Affairs provided a review of audio recordings of the Hospitals Transfer Center phone conversations on 5/10/25, between Hospital staff members and the CAH staff members, who requested the transfer of Patient #1. The audio revealed the following:

- 2:39 P.M.: The transferring Hospital's ED Physician told staff (a General Surgeon and a Patient Placement Nurse Manager) that the CAH did not have the capability and capacity to care for Patient #1 and they requested transfer according to the EMTALA requirements as they are the closest.

- 3:19 P.M.: The CAH's ED Physician told staff (a Colorectal Surgeon and a Patient Placement Nurse Manager) that Patient #1 needed a more extensive work up and she was happy to speak with internal medicine as the CAH was unable to admit Patient #1 who needs further evaluation, and possibly treatment and/or surgery.

- 4:07 P.M.: A Patient Placement Nurse told the CAH ED Physician that she spoke with the internal medicine group, who declined the transfer of Patient #1. The CAH ED Physician said she felt like the decline of Patient #1's transfer was inappropriate as they were a Critical Access Hospital and did not have the staff (specialists or surgeons) or a working operating room to treat Patient #1 who had a complicated medical condition and needed a further medical workup.

During an interview on 5/21/25 at 12:30 P.M., Hospitalist #1 said he refused the transfer request for Patient #1 on 5/10/25. Hospitalist #2 said he was not made aware that the CAH was unable to provide a gastrointestinal evaluation; additionally, he was unaware of the lesions found on a computed tomography (CT) scan when considering accepting Patient #1's transfer request. Hospitalist # 2 said that if he would have known that additional information, he would have accepted the transfer request and admitted Patient #1 to internal medicine for further GI evaluation.

During an interview on 5/20/25 at 1:05 P.M., The Senior Director of Patient Safety and the Senior Director of Regulatory Affairs said the Hospital completed an Internal Investigation and identified an EMTALA violation 5/10/25; additionally, staff did not follow Hospital Policy when they failed to internally escalate the reported EMATALA concerns made by the CAH ED Physician during Patient #1's transfer request conversations. They said the Hospital had developed but not implemented system wide corrective actions in response to the event.