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Based on interviews and record reviews, it was determined the facility failed to comply with 42 CFR 489.24(e)(1)-(2) in regard to an appropriate transfer for six patients (#10, #11, #12, #13, #14, and #19), in the selected sample of nine patients, who were transferred out of the facility. The facility failed to ensure the risks and benefits certification, completed by the physician, contained information that was specific to the condition of the patient upon transfer. Additionally, the facility failed to comply with 42 CFR 489.24(f) in regard to a recipient hospital's responsibilities for one patient (#1), in the selected sample of 20. The facility failed to accept a transfer, Patient #1, who required specialized services the facility offered and the facility had the capacity to treat.

Refer to A 2409 and A 2411.

Based on interviews and record reviews, it was determined the facility failed to ensure that during a transfer of a patient with an emergency medical condition, the physician's written certification contained a complete picture of the benefits to be expected from appropriate care at the receiving facility, the risks associated with the transfer, and that the risks and benefits certification was specific to the condition of the patient upon transfer, for six patients (#10, #11, #12, #13, #14, and #19), in the selected sample of nine patients transferred out of the facility.

Findings include:

Review of the facility's policy and procedure, "Emergency Medical Treatment and Active Labor Act (EMTALA) Treatment and Transfer Policy," revealed that during a transfer out of the facility the "physician and staff will explain the risks and benefits of the transfer and complete the Consent to Transfer and Documentation of Transfer Forms."

1. Review of Patient #10's emergency department (ED) record, for 06/15/11, revealed he/she was 10 years old and presented with a blood sugar "greater than 700." Review of the "Documentation of Transfer" form revealed the ED physician certified Patient #10 as having an emergency medical condition requiring transfer. Review of the "Consent to Transfer" form revealed the risks were "Time away from facility, decline in route, injury in route." The benefits included "Specialized higher level of care."

2. Review of Patient #11's emergency department (ED) record, for 06/19/11, revealed he/she was 11 months old and presented with a foreign body in their esophagus. Review of the "Documentation of Transfer" form revealed the ED physician certified Patient #11 as having an emergency medical condition requiring transfer. Review of the "Consent to Transfer" form revealed the risks were deterioration in condition, motor vehicle accident, and death. The benefits included a higher level of care and a specialist.

3. Review of Patient #12's emergency department (ED) record, for 06/19/11, revealed he/she was 1 month and 21 days old and presented with spitting up blood. Review of the Documentation of Transfer form revealed the ED physician certified Patient #12 as requiring transfer to a higher level of pediatric care. The physician failed to certify if Patient #12 had an emergency medical condition or not. Review of the "Consent to Transfer" form revealed the risks were motor vehicle accident and worsening of condition. The benefits included higher level of pediatric care.

4. Review of Patient #13's emergency department (ED) record, for 07/03/11, revealed he/she was 4 years and 11 months old and presented after being involved in a motor vehicle accident. Review of the "Documentation of Transfer" form revealed the ED physician certified Patient #13 as having an emergency medical condition requiring transfer. Review of the "Consent to Transfer" form revealed the risks were worsening of condition, accident, and death. The benefits included specialized treatment.

5. Review of Patient #14's emergency department (ED) record, for 07/04/11, revealed he/she was 2 years and 10 months old and presented after falling six feet from a ladder. Review of the "Documentation of Transfer" form revealed the ED physician certified Patient #14 as having an emergency medical condition requiring transfer. Review of the "Consent to Transfer" form revealed the risks were possible deterioration of the condition. The benefits included treatment by a pediatrics specialist at a trauma ED.

6. Review of Patient #19's emergency department (ED) record, for 04/12/11, revealed he/she was 18 days old and presented with "apnea and cyanosis". Review of the "Documentation of Transfer" form revealed the ED physician certified Patient #19 as having an emergency medical condition requiring transfer. Review of the "Consent to Transfer" form revealed the risks were worsening of condition, motor vehicle accident, and death. The benefits included specialized care.

Interviews with the Executive Vice President and the Chief Nursing Officer, on 08/11/11 at 11:30 AM, revealed the risk and benefits documented on Patients #10, #11, #12, #13, #14, and #19 were not specific or individualized to each patient's condition.

The facility failed to ensure the physician's certification for transfer was individualized for each patient and contained the risks and benefits specific to the condition of the patient.

Based on interviews and record reviews, it was determined the facility failed to ensure one patient (#1), in the selected sample of 20, was accepted from a referring hospital as a transfer, when the recipient hospital, which was a designated rural regional referral center, offered the specialized services that Patient #1 required and had the capacity to treat Patient #1.

Findings include:

Review of the facility's policy "Emergency Medical Treatment and Active Labor Act (EMTALA) Treatment and Transfer Policy," revealed the purpose of the policy was "to ensure that treatment/transfer of patients is appropriate and complies with EMTALA regulations."

A review of the credentialing file, of Physician #1, revealed he signed acknowledgement of reviewing the information the facility provided regarding EMTALA on 02/29/08 and on 03/01/10. The information included a letter written by an attorney of the facility. The letter included the following: "It is a requirement that hospital facilities with a higher level of care must accept patients who may have an emergency medical condition and need to be transferred from facilities which have lower level of care or lack of specialty care physicians. Failure of a hospital facility or an on-call medical staff specialty physician to accept a transfer patient under circumstances which otherwise meet the requirements of EMTALA is a direct violation of EMTALA." Additional information provided was "Physicians' Guide to EMTALA" included "On-call physicians who, as part of their routine responsibilities, are charged with the duty to accept patients transferred from other facilities, may not refuse any unstable transfers as long as their hospital has the capability and capacity to provide treatment." Review of the credentialing file, of Physician #3, revealed he signed acknowledgement of the same information on 11/17/08 and on 11/18/10.

A review of the facility's physician on-call schedule revealed a pediatrician (Physician #1) was on-call to provide care for the emergency department on 08/06/11.

A review of the transferring hospital's on-call schedule revealed there had not been any pediatric on-call services since April 1, 2011. An interview with the transferring hospital's Director of Quality Assurance (QA), on 08/11/11 at 11:15 AM, revealed there had been a change in the facility's bylaws in December 2010 and physicians that were considered "Courtesy staff members" were not required to take call. Most of the pediatricians changed their status to "Courtesy," therefore not having to take call. The other pediatricians had been on staff more than 20 years and they were not required to take call. The Director of QA stated this action caused the facility to no longer have pediatric on-call services.

Interview with the Chief Nursing Officer of the recipient hospital, on 08/10/11 at 10:30 AM, revealed the facility was a designated rural regional referral center.

A review of the emergency department (ED) medical record of Patient #1, from the transferring hospital revealed he/she was six years old and presented to the ED, on 08/06/11 at 6:22 PM, with the complaint of "abscess on the left calf, not getting better, seen last night." Blood work revealed Patient #1's white blood count was elevated at 17.2 (normal 4.8 - 10.8). Documentation by Physician #2 (ED Physician at the transferring hospital) on the "EMTALA Memorandum of Transfer" form revealed the medical condition and diagnosis was cellulitis and abscess to the right leg with failed outpatient treatment. Physician #2 certified Patient #1 to be stable for transfer. Further documentation by Physician #2 revealed Physician #1 (on-call Pediatrician at the recipient hospital) and Physician #3 (ED Physician at the recipient hospital) refused to accept Patient #1 as a transfer. Patient #1 was transferred to an out of state hospital by ambulance.

Interview with Physician #2 (ED Physician at the transferring hospital), on 08/10/11 at 11:35 AM, revealed Patient #1 presented to the ED, on 08/05/11, with a developing abscess to the left lower leg. Patient #1 was treated and discharged on 08/05/11. On 08/06/11, Patient #1 returned to the ED with increased redness and pain to the left lower leg. Patient #1 was given an initial dose of intravenous (IV) antibiotic (Tobramycin), but required further inpatient treatment. Physician #2 stated Patient #1 had an emergency medical condition and needed admission to a hospital with pediatric services. Physician #2's facility did not have any pediatric services on-call, therefore they needed to transfer Patient #1. Physician #2 called the other local hospital's ED and spoke with Physician #3 (ED Physician at the recipient hospital). Physician #3 told Physician #2 they had on-call pediatric services available. Physician #1 (pediatrician on-call at the recipient hospital) was paged and returned the call to the transferring hospital ED. Physician #1 did not talk with Physician #2 (ED Physician at the transferring hospital) when he called, but he spoke with the secretary. Physician #1 informed the secretary that he was not on call for the transferring hospital. Physician #2 (ED Physician at the transferring hospital) called Physician #3 (ED Physician at the recipient hospital) and explained Physician #1 was refusing the transfer. Physician #3 stated he would have Physician #1 call directly to Physician #2. Physician #1 (on-call Pediatrician at the recipient hospital) called Physician #2 and stated he was not on call for the transferring hospital and that the transferring hospital had their own pediatricians on staff. Physician #2 explained they no longer had pediatricians on-call for unestablished pediatric patients. Physician #2 stated that Physician #1 said "If you have political problems it is not my job to solve these problems." Physician #2 informed Physician #1 that he thought this was an EMTALA violation. Physician #2 spoke with Physician #3 (ED Physician at the recipient hospital) and informed him of the refusal by Physician #1. Physician #3 stated he would have to refuse the transfer since the pediatrician on-call was refusing. Physician #2 stated he informed Physician #3 that he thought this was an EMTALA violation. Patient #1 was transferred out of state for inpatient care. Physician #2 stated the transfer process was delayed due to the refusal of the transfer by Physicians #1 and #3.

Interview with Physician #1, on 08/10/11 at 11:55 AM, that he was on-call for pediatric services for the recipient facility on 08/06/11. She stated he was paged to the transferring hospital's ED, on 08/06/11, and answered the page. He was told by ED staff that they needed orders to admit Patient #1. Initially, he thought they wanted Physician #1 to admit Patient #1 to their facility and he responded "I do not have admitting privileges at your hospital and cannot give orders." Physician #1 instructed the facility to get one of their pediatricians to admit Patient #1. Physician #1 later spoke with Physician #3 (ED Physician at the recipient hospital) and was asked to call and speak directly with Physician #2 (ED Physician at the transferring hospital). Physician #1 called and spoke with Physician #2. Physician #2 informed Physician #1 that they did not have any pediatricians on-call to accept Patient #1. Physician #1 stated "that sounded like an internal problem." Physician #1 did not accept Patient #1 as a transfer, but informed Physician #2 that if Patient #1 "showed up" in the ED he would evaluate him/her and admit if necessary. Physician #1 stated he had the ability to treat a child with cellulitis.

Interview with Physician #3, on 08/10/11 at 2:10 PM, revealed he was the ED Physician at the recipient hospital on 08/06/11. He stated he was notified by Physician #2 (ED Physician at the transferring facility) that he had a six year-old child with cellulites that needed to be admitted to a pediatrician's services for inpatient care. Physician #2 informed him that they did not have any on-call pediatricians. Physician #3 informed Physician #2 that Physician #1 was the pediatrician on-call. Physician #3 stated that was the routine way the ED handled a transfer; they assisted in facilitating the transfer and allowed the specialty physician to talk with the transferring physician. After several calls were made between the physicians Physician #1 did not accept Patient #1 as a transfer. Physician #3 stated that Physician #1 said that the transferring facility had pediatricians and they could admit Patient #1. Physician #3 stated he informed Physician #1 that the transferring facility no longer had pediatricians on-call. Physician #3 stated he did not refuse Patient #1, he was following the system in place by facilitating the transfer through the specialty physician.

Review of a written statement, by the House Supervisor at the transferring facility, revealed the following events took place on 08/06/11: Physician #1 refused to accept Patient #1 as a direct admission at 9:40 PM. Physician #3 refused to accept Patient #1 as an ED to ED transfer at 9:45 PM. Physician #1 called Physician #2 at 10:20 PM and again refused to accept Patient #1. Physician #2 informed Physician #1 that this would be treated as an EMTALA violation. Physician #2 called another facility out of state and Patient #1 was transferred to that ED. Additionally, the House Supervisor received a call from the House Supervisor at the local recipient hospital stating that the Administrative staff had decided they were not going to accept Patient #1 as a transfer, but if they wanted to discharge Patient #1 and tell them to come to the ED, that would be ok.

Interview with the Executive Vice President at the recipient hospital, on 08/10/11 at 4:00 PM, revealed, that on 08/06/11, the facility had the specialty service of Pediatrics on-call and the facility had the capacity to treat Patient #1.

Interview with Patient #1's mother, on 08/09/11 at 4:00 PM, revealed, that on 08/06/11, Patient #1 needed to be admitted to a hospital that could provide pediatric inpatient care due to Patient #1 needing IV antibiotics. She stated the hospital she presented to did not have pediatric services on-call. Patient #1 was not an established patient with a pediatrician, therefore, Patient #1 needed to be transferred to a hospital with pediatricians on-call. The hospital she had taken Patient #1 to attempted to transfer Patient #1 to another local facility, that had pediatricians on-call, but they refused the transfer. Patient #1 had to be transferred out of state to a hospital with pediatricians on-call. After arriving at the out of state hospital, Patient #1 required incision and drainage of the area on his/her leg. She stated the physician "drew off two and one-half tablespoons of fluid." Patient #1 had "cellulitis with methicillin resistant staphylococcus aureus (MRSA). Patient #1 was discharged home on 08/09/11.

The facility failed to ensure the specialty physicians on-call followed the information provided to them in the letter from the facility attorney and the "Physicians' Guide to EMTALA," resulting in Patient #1 being refused at the recipient facility, which was a designated rural regional referral center, that offered the specialized services Patient #1 required and the facility had the capacity to treat Patient #1. Additionally, it resulted in the transferring hospital having to seek care for Patient #1 elsewhere.