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Based on review of policies and procedures and hospital documents and interviews with hospital staff, the hospital failed to adopt and enforce a policy concerning recipient hospital responsibilities. Eleven (#'s 21, 23, 25, 26, 27, 28, 29, 30, 31, 32 & 33) of fourteen (#'s 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 & 33) requests for transfer from a requesting hospital documented on the admission/transfer log were refused without a valid reason when the hospital had the capacity and capability.

Findings:

1. The hospital has not developed policies that comply with the requirements for 42 CFR 489.20 and 489.24.

2. After review of the policies provided concerning EMTALA (Emergency Medical Treatment and Labor Act) and medical staff bylaws and rules and regulations, the hospital did not have a written policy concerning recipient hospital responsibilities.

3. Hospital Staff B, Staff E and Staff C stated on 05/01/13 in the morning and the afternoon that the procedure when a request for transfer comes in, the phone operator directs the call to the house supervisor who takes the information, then calls the hospitalist on duty to relay the information. The hospitalist makes the decision whether or not to accept the patient solely on the information relayed by the House Supervisor. Unless requested by the requesting physician there was seldom physician to physician communication. The hospital does not have a policy and procedure for the process the hospital uses for requests from hospitals requesting transfers. The admission/transfer log documented that if ER to ER communication occurred then the patients were accepted.

4. Patient # 23 presented to the requesting emergency department (ER) on 04/25/2013 sometime between 0400 am and 0700 am via EMS that was enroute to Hospital J from Patient # 23's home. The ambulance diverted to Hospital K, a 25 bed critical access hospital, because the paramedic had misread the EKG (electrocardiogram) as a STEMI (ST Segment Element Myocardial Infarction). According to the requesting hospital ER physician the patient on exam had a pacemaker and his EKG was consistent with a V-Paced rhythm. The patient complained of chest pain and was treated with standard therapy. The patient was noted to become hypotensive any time preload was reduced, making treatment difficult, however the patient was stabilized and prepared for transfer. At that time the patient was normotensive and stable according to the requesting hospital ER physician. The patient and his wife both requested to be transferred to Hospital J where his PCP (primary care physician) was. According to the requesting physician the patient was a complex cardiac patient with aortic stenosis and a pacemaker and possibly would need evaluation by cardiology and possible ICU (intensive care unit). This type of care is not available at Hospital K, a critical access hospital, and the hospital does not have ICU capability or a cath lab.

The requesting ED physician called Hospital J and talked with the house supervisor who believed that Hospital J could accommodate this patient and would discuss with the on call hospitalist. The ED physician at the requesting hospital received a call saying that Doctor E was refusing to accept the patient. No reason was given. The ED physician told the house supervisor that the patient was enroute to Hospital J via EMS where his primary care physician was and needed the specialized services that Hospital J was able to provide and Hospital K could not. The House Supervisor stated she would have Dr. E call me. The requesting physician received a call from Dr. E refusing acceptance of the patient even after the reasons for the patient to be transferred to a higher level of care were stated.

The patient was subsequently transferred to Hospital L. The patient was accepted by Dr H, a cardiologist at Hospital L.

5. The specialty on-call sheets for 04/25/2013 show the receiving hospital had cardiology and internal medicine oncall coverage.

6. Patient # 25, a 15 year old, was refused according to the admission/transfer log because she was a 15 year old. The hospitalist on duty was resident trained in pediatrics and had pediatric privileges at Hospital J. The referring diagnoses were possible appendicitis/cholecystitis. Surgeon who was consulted felt it should be a medical admit, but Dr. E didn't want to accept due to patient being 15 years old. No other reason was documented.

7. Patient # 21 according to the admission/transfer log with a referring diagnoses of abdominal pain was declined with the reason "not accepting for pain control." No other reason was documented.

8. Patient # 26 according to the admission/transfer log with a referring diagnoses of chest pain from a critical access hospital approximately thirty miles away was declined with the reason "did not meet criteria for admission, suggested they consult one of our cardiologist as an op (out patient)." No other reason was documented.

Based on review of medical records, hospital documents and other documents supplied to the surveyors, and interviews with hospital staff, the hospital failed to accept, from a referring hospital, an appropriate transfer of an individual who required the specialized capabilities and facilities of the hospital. On the date and time of the proposed transfer for one patient (Patient # 23), the hospital had the capability and capacity to treat the individual. Eleven (#'s 21, 23, 25, 26, 27, 28, 29, 30, 31, 32 & 33) of fourteen (#'s 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 & 33) requests for transfer/admission to the receiving hospital documented on the transfer/admission log from December 25, 2012 through April 29, 2013 were declined without a valid reason that the hospital did not have either the capacity or the capability to provide the specialized capabilities and facilities needed.

Findings:

1. Patient # 23 presented to the requesting emergency department (ER) on 04/25/2013 sometime between 0400 am and 0700 am via EMS that was enroute to Hospital J from Patient # 23's home. The ambulance diverted to Hospital K, a 25 bed critical access hospital, because the paramedic had misread the EKG (electrocardiogram) as a STEMI (ST Segment Element Myocardial Infarction). According to the requesting hospital ER physician the patient on exam had a pacemaker and his EKG was consistent with a V-Paced rhythm. The patient complained of chest pain and was treated with standard therapy. The patient was noted to become hypotensive any time preload was reduced, making treatment difficult, however the patient was stabilized and prepared for transfer. At that time the patient was normotensive and stable according to the requesting hospital ER physician. The patient and his wife both requested to be transferred to Hospital J where his PCP (primary care physician) was. According to the requesting physician the patient was a complex cardiac patient with aortic stenosis and a pacemaker and possibly would need evaluation by cardiology and possible ICU (intensive care unit). This type of care is not available at Hospital K and the hospital does not have ICU capability or a cath lab.

The requesting ED physician called Hospital J and talked with the house supervisor who believed that Hospital J could accommodate this patient and would discuss with the on call hospitalist. The ED physician at the requesting hospital received a call saying that Doctor E was refusing to accept the patient. No reason was given. The ED physician told the house supervisor that the patient was enroute to Hospital J via EMS where his primary care physician was and needed the specialized services that Hospital J was able to provide and Hospital K could not. The House Supervisor stated she would have Dr. E call me. The requesting physician received a call from Dr. E refusing acceptance of the patient even after the reasons for the patient to be transferred to a higher level of care were stated.

The patient was subsequently transferred to Hospital L. The patient was accepted by Dr H, a cardiologist at Hospital L.

2. The specialty on-call sheets for 04/25/2013 show the receiving hospital had cardiology and internal medicine on call coverage

3. According to Staff B, on the date and time of the requested transfer, the receiving hospital was not on divert. The divert log was requested, but the hospital never provided a log for review during the survey. The House Supervisor on duty during this time of 04/25/13 period stated on 05/01/13 that the hospital had ICU and telemetry beds available when the requesting hospital called.

4. On the morning of 05/01/2013, Staff C confirmed that usually requests for transfer from other hospitals were directed through the hospital's house supervisor to the hospitalist on call who made the decision whether to accept a transfer or not. According to the hospital's admission/transfer log an entry with Patient # 23's name which had no date, but a time of 0540, a request for transfer was received from another hospital. The admission/transfer log documented the referring diagnosis was "aorta stenosis". Under "comments by the accepting physician" the following was documented: "(Dr E) first refused then accepted but patient had already been transferred to (Hospital L) Hospital." The requested/needed service was cardiology and intensive care. The log documented the request was "declined".

5. The receiving hospital's Admission/Transfer log documented several instances where other hospitals had requested transfers into Hospital J, but were refused.

Patient # 25, a 15 year old, was refused according to the log because she was a 15 year old. The hospitalist on duty was resident trained in pediatrics and had pediatric privileges at Hospital J. The referring diagnoses were possible appendicitis/cholecystitis. Surgeon felt it should be a medical admit, but Dr. E didn't want to accept due to patient being 15 years old. No other reason was documented.

Patient # 21 with a referring diagnoses of abdominal pain was declined with the reason "not accepting for pain control." No other reason was documented.

Patient # 26 with a referring diagnoses of chest pain from a critical access hospital approximately thirty miles away was declined with the reason "did not meet criteria for admission, suggested they consult one of our cardiologist as an op (out patient)."

6. Staff B stated on 05/01/13 in the afternoon that there was no review by the hospital of transferred patients or patients that the hospital had refused to accept as a transfer.

7. An interview with Dr E on 05/01/13 and Staff I confirmed that Hospital J did not accept Patient # 23 as a transfer.