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Based on observation, record review and interview the facility failed to ensure compliance with EMTALA Regulations 489.20 and 489.24 in that the facility failed to appropriately transfer 1 of 20 patients (Pt. #1) and post EMTALA signs. Failure to appropriately transfer and post signs has the potential to affect all patients presenting in an emergency.


See findings:

The hospital failed to post signs. See A2402.

The hospital failed to appropriately transfer. See A 2409.

Based on observations of 5 of 6 areas within the emergency department (entrance, triage, and exam rooms #1, 8 & 16), and interview with staff (A, B, C), the hospital failed to have appropriate signage informing patients of their rights. This has the potential to affect all current and potential patients seeking emergency services.

Findings include:

During tour of the ED on 07/02/14 at 10:30 AM, which included observations of the entrance, a triage area, and 3 examination rooms, it was noted there was no EMTALA signage. CAO "A", EMS supervisor "B", and ED Manager "C" were informed of the requirements. When asked about other languages spoken by the population in the area, A,B and C stated there were many Spanish speaking migrant workers in the surrounding area. The only EMTALA signs posted were in the registration/waiting room area and were in English only.

Based on record review and interview the transferring hospital failed to ensure that a qualified physician would accept pt. #1 before transfer. 1 of 20 patients was inappropriately transferred (pt. #1). This has the potential to affect all patients seeking emergency services.

Findings include:

The hospital policy on EMTALA reviewed on 07/01/2014 at 2:00 PM entitled;"EMTALA"Transfer of the Patient to Other Institution" dated 06/2013 states;

- "Physician-to-physician contact must be established at the receiving institution and there must be an accepting physician at the receiving facility prior to the patient being transported."


Based on record review of pt. #1 on 07/01/14 at 1:30 PM, presentation to the Emergency Department (ED) occurred on 06/23/14 at 5:11 PM. Pt. #1 arrived by ambulance with complaints of sharp, tearing abdominal pain according to EMS documentation.

ED physician D documented the following history of present illness in pt. #1's record; "The patient presents with abdominal pain. This 57-year-old white male patient with a past medical history of obesity, hypertension, and congestive heart failure presents with the acute onset of severe abdominal pain described as tearing and associated with a sudden enlargement in his abdominal girth, obvious to him and his daughter. His daughter states that he has not been compliant with his blood pressure medications, the onset was just prior to arrival. The course/duration of symptoms is worsening. The character of symptoms is sharp. The location of pain at present is diffuse. Radiating pain: none. Exacerbating factors consist of changing position. The relieving factor is none. Therapy today: none. Risk factors consist of hypertension, age and obesity associated symptoms: none."

A differential diagnosis of "abdominal pain, bowel obstruction, bowel perforation, urinary tract infection, abdominal aortic aneurysm (AAA), appendicitis." was made.

According to D's note dated 06/23/14, pt. #1 was transferred to another hospital at 5:49 PM.

Pt. #1's medical record contained a completed physician certification for transfer which was signed by physician D on 06/23/14 at 5:33 PM and indicated that the receiving facility's physician had been notified by the receiving facility's RN/House Supervisor.

Per interview by phone with ED physician D on 07/02/14 at 11:05 AM, D recalled pt. #1 came in with excruciating abdominal pain and as D suspected an AAA, D immediately ordered helicopter transport. D stated that he asked the unit secretary (E) to contact the receiving hospital to find an accepting physician. D got the message from E that the receiving hospital nurse supervisor would accept patient #1. Directly before patient #1 was to be transported an ultra-sound was done which indicated there was no aneurysm, D stated he decided to send pt. #1 despite this finding as the helicopter was waiting. D stated that the receiving physician would normally be contacted directly but was not in this case. Once pt. #1 was under way in the helicopter, D was able to speak to the receiving hospital's physician. The receiving hospital's physician told D there was no vascular surgeon available."

Per interview with Unit Secretary (US) E on 07/01/14 at 2:30 PM in the administration boardroom it is E's responsibility to facilitate the transfer. E stated that the house supervisor at the receiving hospital was contacted and the go ahead was given to send pt. #1. E stated physician D was told about the contact with the house supervisor and the approval for transfer. E stated it is expected that the receiving physician would call the sending physician before the transfer is initiated."

Per interview with the receiving hospital's House Supervisor F on 07/07/14 at 11:30 AM the sending hospital called on 06/23/14 and told them they had a patient (#1) who had an unstable AAA. Before F was able to find a physician to accept the transfer of pt. #1 transportation by air was initiated. F stated that the sending hospital was not told to send the patient and no physician to physician contact occurred before the transfer.

Minutes from a 06/26/14 Emergency Medicine/Urgent Care Meeting at the sending hospital indicated the following; "(ED physician D) discussed a transfer of a patient which occurred yesterday, to (the receiving hospital). His concern was not having contacted an accepting physician prior to the patient's transfer. In regards to the patient in question, he states he was told by the ED Unit Secretary, who spoke to the Nursing Supervisor at (the receiving hospital) to 'send the patient.' However, during the ensuing transfer no physician-to-physician contact was made until the transfer was already in progress. (D) states that he accepts responsibility for not having spoken with an accepting physician prior to the patient's transfer. (D) stated that he spoke to the Emergency Physician on duty at (the receiving hospital)...once the patient was in air transfer."