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Based on review of the Medical Staff Bylaws/Rules and Regulations, medical records, facility policies and procedures, transfer log, and staff and physician interviews, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities and facilities if the receiving hospital has the capacity to treat the individual. This affected 1 of 21 sampled patients (#21). Refer to findings in tag A2411.

Based on review of the Medical Staff Bylaws/Rules and Regulations, medical record review, facility policies and procedures, transfer log, and staff and physician interviews, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital was accepted as an appropriate transfer who required the specialized capabilities and facilities if the receiving hospital has the capacity to treat the individual. This affected 1 of 21 sampled patients (#21).


Findings were:

Review of the patient's medical record (#21) from the transferring facility revealed the following information. The nurses notes indicated that the patient arrived at the transferring facility on 03/28/11 at 2:35 a.m. The physician noted that the patient's left eye lid was swollen shut and that fluid consistent with bloody tears was leaking from the eye, and that "Tissue appears to be protruding." The physician ordered a computerized tomography (specialized x-ray) of the left eye which revealed the bones on the floor of the eyeball were broken. The physician noted that the patient had a left eye globe rupture (occurs when the integrity of the outer membranes of the eye has been disrupted by blunt or penetrating trauma). The physician also noted that his/her facility did not have an ophthalmologist (physician who specializes in the treatment of eyes) on-call. Review of the section titled "Decision Making" revealed that the ED physician documented an attempt was made to call an acute care hospital to transfer patient #21 and the patient was refused acceptance. Further documentation by the ED physician revealed in part, "At this point over, 3 (three) hours had elapsed, and I felt we needed to find an accepting ophthalmologist elsewhere and contacted Dr.,____ (ophthalmologist) who is on call for North Fulton. He was contacted by the charge nurse and declined to speak with me or to accept the patient. I then contacted the emergency department at North Fulton, and they transferred us to the hospital coordinator, and when I spoke to her, she contacted, Dr____ (ophthalmologist) without having me speak to him. She state that Dr. ____ had refused the patient stating that he is not on call. I discussed with them that this is a transfer for a higher level of service, since we don't have an ophthalmologist on call at all, but she stated he declined the transfer." The hospital failed to accept an appropriate transfer (patient #21 on 3/28/2011) who required the hospital's specialized ophthalmology capability and capacity. The transferring nurse noted that the patient left the facility on 03/28/11 at 8:15 a.m. The recipient hospital medical record for patient #21 was reviewed. Review of the "Pre-Operative History and Physical" dated 3/28/11 revealed in part, "History of Present Illness: Pt (patient) fell early this am and on left orbit (eye) suffering instant loss of vision, (+) (positive of) pain." Review of the recipient hospital's Operative Report, dated 3/28/11 indicated that patient #21 was taken to surgery for an Exploratory orbitotomy (a surgical incision made into the orbit) and repair of open globe(eye) involving uveal contents posterior rectus muscle and repair of left upper lid laceration.
A review of the facility's transfer log and Emergency Room (ER) House Supervisor call log revealed that patient #21 was not listed on either log.

Review of facility policy entitled, "Transfer of Patients Into or Out of the Facility," revised 07/07, revealed that the policy was intended to provide guidelines when transferring patients to and from the facility in accordance with EMTALA. The policy indicated that all calls requesting transfer would be rerouted to the nursing supervisor and he/she would log the call and contact the appropriate attending. The policy indicated the facility accepted transfers from other facilities with the approval of an accepting physician in conjunction with the nursing supervisor and that an emergent ER to ER transfer required physician acceptance. Following coordination with the accepting physician, as appropriate, the transferring facility shall be notified of approval or denial. Emergent transfers were accepted when services could be provided and the physician was available.

Review of the facility's policy entitled, "EMTALA (Emergency Medical Treatment and Active Labor Act)", effective date 3/09 on pg 10 under I. Obligation to Accept Transfers indicated:

#1. To the extent that the Hospital has specialized capabilities (including capabilities available through the Hospital's on-call roster) or facilities, such as a burn unit, a shock-trauma unit or a neonatal intensive care unit, that are not available at the transferring facility, the Hospital shall accept appropriate transfers of an individual needing such specialized capabilities or facilities if the Hospital has the capacity to treat the individual.

#2. The following personnel or categories of personnel are authorized to accept or reject transfers from another hospital on behalf North Fulton Regional Hospital: House Supervisors and the attending physician who will be admitting the patient. Personnel who accept or reject another facility's request for transfer should record the request, the response to the request, and the basis for any denial of such a request in a patient transfer log. The log should be maintained in the House Supervisor's office in order to document the appropriateness of any transfers that were refused by either the house supervisor or the attending physician.

#3 All Hospital medical staff and employees, in particular those that work in a Dedicated Emergency Department, and who believe that the Hospital received an inappropriate transfer in violation of the law, shall report the incident to the Hospital Compliance Officer (HCO) or designee, as soon as possible for investigation. If, based on the investigation, the HCO or designee determines that an inappropriate transfer has occurred: the HCO or designee shall report the transfer to federal or the state survey agency.

Further review of the policy indicated that all employees are expected to be familiar with the basic procedures and responsibilities created by this policy. Employees who fail to comply with the policy will be subject to appropriate disciplinary action pursuant to all applicable policies and procedures up to and including termination. Such disciplinary action may also include modification of compensation, including any merit or discretionary compensation awards.

Review of the Medical Staff Rules & Regulations, updated May 2010, revealed in Section R 14 #16 revealed that a specialist coverage will be provided by medical staff members in accordance with an established roster or on-call system as required by the hospital and/or medical staff policies. When a transportable patient requires medical staff consultation/treatment which is not available, the patient will be transferred to an appropriate facility as soon as possible, subject to compliance with the hospitals' transfer protocol, and subject to having first obtained acceptance by that facility through a physician or other qualified health care provider. The Medical Staff Members were responsible for following appropriate policies and procedures for in-house and inter-facility transfers. Section 4.4 revealed that the emergency call was for 24 hours and that the specific starting and ending times were to be determined by the facility. The medical staff member's name that appeared on the Emergency Department (ED) on-call roster was to be responsible for patients in the ED requiring their services.

Further review of the Medical Staff Rules & Regulations revealed in Section R 14, #23, that the period for being the Emergency Department on-call physician was for twenty-four (24) consecutive hours, beginning at 7:00 a.m. and ending at 7:00 a.m. the following day. During this period, the on-call physician is expected to be available by telephone (respond within 30 minutes), be available to serve as consultant in his/her appropriate field, to come to the ED when requested by the ED physician (or designee), and be responsible for the disposition of any patient who was accepted in transfer to North Fulton Hospital by such physician.

During interview #1 on 9/21/11 at 10:45 a.m. in the conference room, The Director of Quality Improvement stated that in the past, calls requesting a transfer were only being tracked if the call was made directly to the emergency department. There was no method of tracking calls that were made to other departments or individuals. The Director explained that when the request for this transfer occurred, it may not have been communicated to the emergency room and/or the emergency room physician. The facility had started working on a one call system whereby all the transfer calls for high risk specialties would be implemented through a new system that started in April 2011.

During interview #2 at 2:05 p.m. on 09/21/11 in the ED, the Nurse Director (ND) of the ED stated that calls that were received requesting transfer to the facility were addressed by the House Supervisor or the attending emergency room physician. The director explained that most transferred patients were admitted directly to the floor or surgery.

During interview #6 on 9/21/11 at 2.30 p.m. in the conference, the Chef Executive Officer (CEO) explained he/she was not aware of a patient that was denied transfer to the facility and vaguely remembered having talked to a physician concerning the incident. The CEO explained that facilities sometimes try to call the specialist directly but that the protocol was for the outside hospital requesting transfer to go through the House supervisor and/or the ED physician. The CEO stated those calls were documented but any call coming outside the normal protocol was not documented. The CEO explained that if he/she was aware of any patient that was denied transfer or was dumped, he/she would have reported it. The CEO stated he/she was not sure if all physicians were trained in EMTALA. The ED physician group was a contracted agency. The CEO stated the physicians were required to respond to on-call request within 30 minutes. The CEO reported that he/she had not been aware of any problems with on-call physicians responding to requests to see a patient.

During telephone interview #5 on 9/21/11 at 2:25 p.m., the Ophthalmologist explained he/she was the only ophthalmologist on-call and had received a call in the middle of the night from a female staff from another hospital. The female staff was requesting to transfer a patient with ophthalmology needs. The ophthalmologist stated he/she asked the caller why their facility's ophthalmologist,who was on-call, had not seen the patient and was told that the ophthalmologist had refused to see the patient. The caller had not given a clear reason for why the other ophthalmologist had denied coming to see the patient. The ophthalmologist stated that he/she explained to the female staff at the other facility that they had a on-call ophthalmologist that should see the patient and that he/she would not accept the patient. The ophthalmologist stated he/she never talked to the requesting facility's ophthalmologist to find out the reason he/she did not come and see the patient. The receiving ophthalmologist stated he/she did not accept the transfer patient because the requesting facility had an ophthalmologist on-call who should have seen the patient. The ophthalmologist stated after he/she received the call he/she did not notify the emergency room physician or the house supervisor or explain to the female caller that he/she needed to go through the emergency room physician to request a transfer. The ophthalmologist stated that he/she had spoken to the CEO a couple of days later and expressed that he/she felt the patient was being dumped on the facility. The ophthalmologist also reported that he/she had not received EMTALA training from the facility.

Review of the ophthalmologist (#5) credential file confirmed that there was no evidence of EMTALA training.

During interview (#7) on 9/21/11 at 2:45 p.m. in the conference room, the House Supervisor stated that the facility used contracted physicians. The supervisor stated the ophthalmology service used by the facility would be notified by an emergency room physician and/or attending. Calls that went directly to the ophthalmologist were not tracked. The supervisor confirmed that the process of accepting a transfer patient was that a requesting facility call the facility's ED and that the House supervisor and/or attending, notified the specialty. The supervisor stated, in this case, it was possible that outside sources had called the specialist (ophthalmologist) direct number. The supervisor stated he/she was not familiar with the request for the patient to transfer from another facility and was denied transfer. The supervisor had reviewed the transfer log and had not seen any request for transfer of the patient.

Based on review of the Medical Staff Bylaws/Rules and Regulations, medical records, facility policies and procedures, transfer log, and staff and physician interviews, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities and facilities if the receiving hospital has the capacity to treat the individual. This affected 1 of 21 sampled patients (#21). Refer to findings in tag A2411.

Based on review of the Medical Staff Bylaws/Rules and Regulations, medical record review, facility policies and procedures, transfer log, and staff and physician interviews, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital was accepted as an appropriate transfer who required the specialized capabilities and facilities if the receiving hospital has the capacity to treat the individual. This affected 1 of 21 sampled patients (#21).


Findings were:

Review of the patient's medical record (#21) from the transferring facility revealed the following information. The nurses notes indicated that the patient arrived at the transferring facility on 03/28/11 at 2:35 a.m. The physician noted that the patient's left eye lid was swollen shut and that fluid consistent with bloody tears was leaking from the eye, and that "Tissue appears to be protruding." The physician ordered a computerized tomography (specialized x-ray) of the left eye which revealed the bones on the floor of the eyeball were broken. The physician noted that the patient had a left eye globe rupture (occurs when the integrity of the outer membranes of the eye has been disrupted by blunt or penetrating trauma). The physician also noted that his/her facility did not have an ophthalmologist (physician who specializes in the treatment of eyes) on-call. Review of the section titled "Decision Making" revealed that the ED physician documented an attempt was made to call an acute care hospital to transfer patient #21 and the patient was refused acceptance. Further documentation by the ED physician revealed in part, "At this point over, 3 (three) hours had elapsed, and I felt we needed to find an accepting ophthalmologist elsewhere and contacted Dr.,____ (ophthalmologist) who is on call for North Fulton. He was contacted by the charge nurse and declined to speak with me or to accept the patient. I then contacted the emergency department at North Fulton, and they transferred us to the hospital coordinator, and when I spoke to her, she contacted, Dr____ (ophthalmologist) without having me speak to him. She state that Dr. ____ had refused the patient stating that he is not on call. I discussed with them that this is a transfer for a higher level of service, since we don't have an ophthalmologist on call at all, but she stated he declined the transfer." The hospital failed to accept an appropriate transfer (patient #21 on 3/28/2011) who required the hospital's specialized ophthalmology capability and capacity. The transferring nurse noted that the patient left the facility on 03/28/11 at 8:15 a.m. The recipient hospital medical record for patient #21 was reviewed. Review of the "Pre-Operative History and Physical" dated 3/28/11 revealed in part, "History of Present Illness: Pt (patient) fell early this am and on left orbit (eye) suffering instant loss of vision, (+) (positive of) pain." Review of the recipient hospital's Operative Report, dated 3/28/11 indicated that patient #21 was taken to surgery for an Exploratory orbitotomy (a surgical incision made into the orbit) and repair of open globe(eye) involving uveal contents posterior rectus muscle and repair of left upper lid laceration.
A review of the facility's transfer log and Emergency Room (ER) House Supervisor call log revealed that patient #21 was not listed on either log.

Review of facility policy entitled, "Transfer of Patients Into or Out of the Facility," revised 07/07, revealed that the policy was intended to provide guidelines when transferring patients to and from the facility in accordance with EMTALA. The policy indicated that all calls requesting transfer would be rerouted to the nursing supervisor and he/she would log the call and contact the appropriate attending. The policy indicated the facility accepted transfers from other facilities with the approval of an accepting physician in conjunction with the nursing supervisor and that an emergent ER to ER transfer required physician acceptance. Following coordination with the accepting physician, as appropriate, the transferring facility shall be notified of approval or denial. Emergent transfers were accepted when services could be provided and the physician was available.

Review of the facility's policy entitled, "EMTALA (Emergency Medical Treatment and Active Labor Act)", effective date 3/09 on pg 10 under I. Obligation to Accept Transfers indicated:

#1. To the extent that the Hospital has specialized capabilities (including capabilities available through the Hospital's on-call roster) or facilities, such as a burn unit, a shock-trauma unit or a neonatal intensive care unit, that are not available at the transferring facility, the Hospital shall accept appropriate transfers of an individual needing such specialized capabilities or facilities if the Hospital has the capacity to treat the individual.

#2. The following personnel or categories of personnel are authorized to accept or reject transfers from another hospital on behalf North Fulton Regional Hospital: House Supervisors and the attending physician who will be admitting the patient. Personnel who accept or reject another facility's request for transfer should record the request, the response to the request, and the basis for any denial of such a request in a patient transfer log. The log should be maintained in the House Supervisor's office in order to document the appropriateness of any transfers that were refused by either the house supervisor or the attending physician.

#3 All Hospital medical staff and employees, in particular those that work in a Dedicated Emergency Department, and who believe that the Hospital received an inappropriate transfer in violation of the law, shall report the incident to the Hospital Compliance Officer (HCO) or designee, as soon as possible for investigation. If, based on the investigation, the HCO or designee determines that an inappropriate transfer has occurred: the HCO or designee shall report the transfer to federal or the state survey agency.

Further review of the policy indicated that all employees are expected to be familiar with the basic procedures and responsibilities created by this policy. Employees who fail to comply with the policy will be subject to appropriate disciplinary action pursuant to all applicable policies and procedures up to and including termination. Such disciplinary action may also include modification of compensation, including any merit or discretionary compensation awards.

Review of the Medical Staff Rules & Regulations, updated May 2010, revealed in Section R 14 #16 revealed that a specialist coverage will be provided by medical staff members in accordance with an established roster or on-call system as required by the hospital and/or medical staff policies. When a transportable patient requires medical staff consultation/treatment which is not available, the patient will be transferred to an appropriate facility as soon as possible, subject to compliance with the hospitals' transfer protocol, and subject to having first obtained acceptance by that facility through a physician or other qualified health care provider. The Medical Staff Members were responsible for following appropriate policies and procedures for in-house and inter-facility transfers. Section 4.4 revealed that the emergency call was for 24 hours and that the specific starting and ending times were to be determined by the facility. The medical staff member's name that appeared on the Emergency Department (ED) on-call roster was to be responsible for patients in the ED requiring their services.

Further review of the Medical Staff Rules & Regulations revealed in Section R 14, #23, that the period for being the Emergency Department on-call physician was for twenty-four (24) consecutive hours, beginning at 7:00 a.m. and ending at 7:00 a.m. the following day. During this period, the on-call physician is expected to be available by telephone (respond within 30 minutes), be available to serve as consultant in his/her appropriate field, to come to the ED when requested by the ED physician (or de