HospitalInspections.org

Based on hospital policy and procedure review, review of Rapid Access logs, and staff interview the hospital failed to accept a transfer of a patient with an emergency medical condition that required specialized capabilities when the hospital had the capability and capacity to accept the transfer.

Findings:

1. On February 1, 2016 at 9:00 a.m., surveyors reviewed a hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)." The policy documented, "...{name of hospital omitted} serves as a receiving hospital for other hospitals to send a patient with specialized capabilities or facilities. {name of hospital omitted} may not refuse to accept an appropriate transfer of an individual with an emergency medical condition who requires those specialized capabilities..."

2. On February 1, 2016 at 9:45 a.m., the Chief Nursing Officer (CNO) told surveyors the hospital utilized a Rapid Access call center for calls from other facilities for incoming transfers. The CNO told surveyors that a Registered Nurse (RN) was who would take the calls at Rapid Access.

3. On February 1, 2016 at 2:15 p.m., the CNO told surveyors that the hospital also participated in a regional trauma plan called TReC (trauma referral center). the CNO told surveyors that the hospital took trauma call for level II trauma and rotated the call with three other metro hospitals.

4. On February 1, 2016 at 3:00 p.m., surveyors requested and reviewed the Rapid Access transfer call log. The Rapid Access transfer log documented on January 5, 2016 at 4:51 p.m. the Rapid Access center received a call from an outside transferring hospital. The log documented the patient's (#5) diagnosis as ICH (intracranial hemorrhage) status post fall. The log documented the physician on call for neurology service referred the call to TReC for Level II. The director of performance improvement verified that the call was transferred to TReC for level II. The director of performance improvement told surveyors the call was transferred to TReC because the hospital was not on call for level II that day.

5. On February 1, 2016 at 3:30 p.m., surveyors reviewed the physician call schedule for the day of January 5, 2016. The call schedule documented a neurologist was on call that day, a neurologist was on back up call that day and a neurosurgeon was on call that day.

6. On February 2, 2016 at 9:35 a.m., surveyors interviewed the neurologist who was on call the day of January 5, 2016. The neurologist told surveyors the hospital was not on call for level II trauma on that day and the system has been that all trauma calls are referred to TReC for appropriate placement of the patients. The neurologist told surveyors that if the patient with the medical emergency condition of ICH had presented to the hospital on that day he would have accepted the patient.