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Based on document review and staff interview, the hospital, a regional referral center, failed to follow their hospital's policies including "Transfer of Patients" and "EMTALA Transfer and Emergency Examinations". The hospital failed to accept an appropriate transfer for 1 (of 1) patients (Patient #26) with an emergency medical condition from Hospital A, a critical access hospital when the hospital had the capability and capacity to accept the patient.

The patient was placed on a ventilator to assist with breathing in Hospital A's Emergency Department but the critical access hospital did not have an Intensive Care Unit (ICU). Hospital A lacked the capability and capacity to care for a patient requiring a ventilator. A Hospital A physician contacted Mary Greeley Medical Center (MCMG) to arrange an appropriate transfer for Patient #26 and a MCMG physician agreed to accept the patient. Later, the House Manager, a registered nurse (RN) on duty at MCMG contacted Hospital A and refused the transfer.

Failure to accept an appropriate transfer within the capabilities of the hospital resulted in the delay of the patient's transfer to a different acute care hospital by air ambulance. This caused an unnecessary delay in providing the critical care treatment that Patient #26 needed.

Findings include:

1. Review of the undated policy, "Transfer of Patients", revealed the following in part, ..."Transfers to Medical Center Emergency Department (ED): The ED physician on duty will have responsibility for accepting patients in transfer when contacted directly by phone by the transferring physician, if the nature of the medical problem is emergent...prior to accepting a patient in transfer, the ED physician will verify bed availability, ensure adequate staffing resources and notify the consulting physician..."

Review of the policy, "ED Ambulance Bypass/Diversion Policy," review date 10/12, revealed in part, ..."To provide guidelines for implementing diversion of patient being transported by ambulance to Marcy Greeley Medical Center (MGMC) due to the lack of resources to ensure safe patient care...diversion status status will be requested after the hospital has exhausted all internal resources to meet the current patient load, including any necessary call-backs of staff, expedited discharges, opening of "virtual beds", and similar mechanisms to address the patient load.

2. During an interview on 3/4/14 at 11:00 AM, Staff F, Director of Quality Management, stated the decision for transferring patients to their hospital is determined by the physician after consulting with house managers to ascertain bed availability. During an interview on 3/4/14 at 11:30 AM, Staff F, stated on 1/21/14 to 1/22/14 the hospital was on open status, they were not diverting patients due to lack of resources to ensure safe patient care and there were 4 beds available on the ICU unit. Additionally, Staff F stated they had the capabilities and capacity to admit and provide services to intubated patients (insertion of a tube into the larynx for entrance of air into the patients lungs) that required mechanical ventilation and adequate staffing.

3. During an interview on 3/5/14 at 10:50 AM, Staff D, Registered Nurse (RN)/Director of ICU stated there were 4 beds available on the ICU on 1/21/14 to 1/22/14 and sufficient staffing to provide critical care and services to intubated patients and mechanical ventilation.

4. Review of the policy, "EMTALA Transfer and Emergency Examinations" dated 1/11, documented the hospital's EMTALA obligations regarding appropriate transfers. The policy specified the type of receiving transfers in violation of EMTALA that they would report. However, the policy failed to include MGMC's obligation to accept appropriate transfers.

5. During an interview on 2/3/14 at 1:25 PM, the Director of Maternal Child Services acknowledged the EMTALA policy failed to include MGMC's obligation to accept appropriate transfers and stated the decision for transferring patients into their hospital is determined by the physician.

During an interview on 2/3/14 at 2:50 PM, Staff A, RN/Obstetrical (OB) Clinical Supervisor stated the hospital "is obligated" to accept patients into their hospital if they had the capacity and capabilities to provide care. Additionally, Staff A stated there were several options afforded all nursing staff to consider if there were sudden increases in patient census and complexity of patient care including but not limited to contacting the house manager so he/she could phone for additional nursing staff, calling nursing staff who are "on call" for backup. Staff A stated her opinion that administration encouraged autonomy of all nurses and house managers in determining if they needed additional nursing staff they were able to make the "call" when necessary without fear of reprimand.

6. Review of the Bylaws of the Medical Staff, dated 2013, revealed in part, ..."Transfers to Medical Center ED...the ED physician on duty will have responsibility for accepting patient in transfer when contacted directly by phone by the transferring physician, if the nature of the medical problem is emergent...Prior to accepting a patient in transfer, the ED physician will verify bed availability, ensure adequate staffing resources and notify the consulting physician."

7. During an interview on 2/26/14 at 9:30 AM, ED Physician D, at Hospital A reported contacting Physician A (the on call internal medicine doctor at MGMC), to arrange the transfer of Patient #26 on 1/22/14 at approximately 1:31 AM. Physician D said Patient #26 arrived to Hospital A on 1/21/14 at 10:43 PM with complaints of increased cough and chest pain and he determined the patient had an allergic reaction that required prophylactic intubation. Physician D stated the patient needed ENT (Ear-Nose-Throat) specialty services and ventilation management, services that Hospital A did not have.

Physician D said he called MGMC and spoke with [Physician A] who was an internal medicine physician. He accepted the patient and Hospital A prepared the patient for ambulance transport. Physician D stated the patient was on the ambulance cot and was being moved towards the ambulance garage when he received the "strangest" phone call from the house manager at MGMC [Staff B, RN]. Physician D said it was about 20 minutes after he spoke with Physician A. Staff B stated they could not accept the patient, since they didn't have the ICU staff to take care of an intubated patient that required mechanical ventilation. Physician D asked the house supervisor if they were on diversion, and she said they did not need to be on diversion. Physician D said after the call he called another ED physician, a female, (Physician B) at MGMC and asked her if they were on diversion and she said they were not. Physician D stated he made arrangements with the next closest facility and Patient #26 had to be transferred by helicopter.

During a follow up interview on 3/3/14 at 1:00 PM, Physician D said in his opinion it is not within a nurses scope of practice to determine whether to refuse a transfer and whether or not a patient should be admitted to a hospital. Physician D stated delays in obtaining specialty services for Patient #26 resulted in the patient having to be transferred by air ambulance and delays in critical treatment.

8. During an interview on 3/4/14 at 2:10 PM, ED Physician B confirmed she was working in the ED overnight on 1/21/14. Physician B confirmed a male physician, she stated she did not recall his name, at Hospital A had contacted her approximately 1 month ago to inform her [Staff B] contacted him and said there were no beds available for accepting a intubated patient to their ICU and he asked if they were on diversion. Physician B said she vaguely recalled the conversation with Physician D and did not remember wether they were on diversion that night. Physician B stated she was familiar with EMTALA and if an outlying hospital requested transfer of a critically ill patient to their hospital a physician would be responsible for accepting or denying admission.

9. During an interview on 3/5/14 at 12:00 PM, ED Physician A confirmed he was on-call overnight on 1/21/14. Physician A confirmed Physician D at Hospital A had contacted him approximately 1 month ago, to request acceptance of transfer for an intubated patient who required further stabilization beyond Hospital A's capabilities including ICU monitoring and ventilator management. Physician A stated he accepted the transfer and then contacted Staff B. Physician A stated Staff B explained to him that they did not have adequate staffing on the ICU to provide care to the patient and that she would call Hospital A and tell them. Physician A acknowledged he failed to verify bed availability and adequate staffing resources prior to accepting Patient #26 and it was his responsibility to contact Physician D after being told they did not have adequate staffing on the ICU.

Based on document review and staff interview, the hospital, a regional referral center, failed to accept an appropriate transfer for 1 (of 1) patient with an emergency medical condition from Hospital A, a critical access hospital (Patient #26).

The patient was placed on a ventilator to assist with breathing in Hospital A's Emergency Department but the critical access hospital did not have an Intensive Care Unit (ICU). Hospital A lacked the capability and capacity to care for a patient requiring a ventilator. The Hospital A physician contacted Mary Greeley Medical Center (MGMC) to arrange an appropriate transfer for Patient #26 and a MGMC physician agreed to accept the patient. Later, the House Manager, a registered nurse (RN) on duty at MGMC contacted Hospital A and refused the transfer.

Failure to accept an appropriate transfer within the capabilities of the hospital resulted in the delay of the patient's transfer to a different acute care hospital by air ambulance. This caused an unnecessary delay in providing the critical care treatment that Patient #26 needed.

Findings include:

1. Review of Patient #26's medical record from Hospital A revealed the patient arrived to Hospital A on 1/21/14 at 10:43 PM complaining of a deep cough for the past 4 days and chest pain when coughing. Diagnoses listed on the past medical history including but not limited to: asthma, chronic cough, chronic bronchitis and chronic obstructive pulmonary disease (COPD).

Review of systems revealed the patient's respiratory system positive for cough and stridor (an abnormally high pitched sound when an airway is obstructed, heard on breathing in air and can be heard without a stethoscope). The patient had a history of anaphylaxis (a serious allergic reaction that is rapid in onset and may cause death typically causes a number of symptoms including but not limited to swelling of the throat).

A Computed Tomography (CT) scan revealed minimal swelling to the right glossoepiglotic fold (folds where the tongue meets the throat) and minimal effacement of the right vallecula (area just behind the tongue next to the throat).

Physician D determined critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following condition: potential failure of airway from obstruction and the patient was intubated (placing a tube in the patient's throat to keep the airway open). The patient's respiratory status improved after intubation. Medical Diagnoses and Management options revealed diagnoses including but not limited to stridor.

Physician D documented the following in part, ..."I do believe she will need to be admitted at an institution that has Ears -Nose and Throat (ENT)...1:15 AM (1/22/14) patient back from CT and states she feels like her throat is tighter...CT shows narrowing...1:31 AM [Physician A] of Ames paged...2:11 AM, Physician A accepted to ICU...2:15 AM [Staff B] of Ames called back and refused patient transfer. ...General comments included: 2:15 AM nurse house supervisor [Staff B] who states that he/she will not accept the patient because she does not have the staff; I asked her if Mary Greeley was on diversion and she said no. I then called the ER and discussed with ED doctor who stated she knew of no diversion."

The patient transferred by air ambulance to another acute care hospital at 2:37 AM for higher level of care services. Review of transfer refusal section revealed, name of refusing facility - Mary Greeley, Ames, Iowa (MGMC); Contact person and credentials, [Staff B] house supervisor refused patient.

Review of Iowa EMS report dated 1/22/14 at 3:44 AM revealed the following in part, ..."patient requires rapid smooth transport to a facility with ICU services which is not available at [Hospital A]. Patient is potentially unstable and extended time of ground transport could be detrimental to the patient...patient has had a worsening cough...she was intubated after significant worsening of her shortness of breath and significant anxiety."

Patient #26 tolerated the air transport well and was admitted to the routing hospital and subsequently treated and discharged from the hospital on 1/25/14 in stable condition.

2. During an interview on 2/26/14 at 9:30 AM, ED Physician D, at Hospital A reported contacting Physician A (the on call internal medicine doctor at MGMC), to arrange the transfer of Patient #26 on 1/22/14 at approximately 1:31 AM. Physician D said he called MGMC and spoke with [Physician A] who was an internal medicine physician. He accepted the patient and Hospital A prepared the patient for ambulance transport. Physician D stated the patient was on the ambulance cot and was being moved towards the ambulance garage when he received the "strangest" phone call from the house manager at MGMC [Staff B, RN]. Physician D said it was about 20 minutes after he spoken with [Physician A], and she told him they could not accept the patient, because they didn't have enough nurses in the ICU to provide care to additional patients. Physician D asked the house manager if they were on diversion and she said no, they did not need to be on diversion. Physician D said after the call he called another ED physician at MGMC [Physician B] and asked her if they were on diversion and she said they were not. Physician D stated he made arrangements with the next closest facility and Patient #26 had to be transferred by helicopter.

During a follow up interview on 3/3/14 at 1:00 PM, Physician D reported believing it is not within a nurses scope of practice to determine whether or not a patient should be admitted to a hospital. Physician D stated delays in obtaining specialty services for Patient #26 resulted in the patient having to be transferred by air ambulance and caused delays in critical treatment potentially causing death.

3. Review of the MGMC on-call sheet for 1/21/14 confirmed that Physician A was the on call hospitalist for Internal Medicine and Physician B was the ED overnight physician.

During an interview on 3/4/14 at 2:10 PM, ED Physician B confirmed she was working in the ED overnight on 1/21/14. Physician B confirmed Physician D at Hospital A had contacted her approximately 1 month ago to inform her [Staff B] contacted him and said there were no beds available for accepting Patient #26 and he asked if they were on diversion. Physician B said she vaguely recalled the conversation with Physician D and did not remember whether they were on diversion that night. Physician B stated she was familiar with EMTALA rules and knew if an outlying hospital requested transfer of a critically ill patient to their hospital a physician would be responsible for accepting or denying admission.

4. During an interview on 3/5/14 at 12:00 PM, Internal Medicine Physician A confirmed he was on call overnight on 1/21/14. Physician A confirmed [Physician D], at Hospital A, had contacted him approximately 1 month ago, to request acceptance of transfer for a intubated patient who required further stabilization beyond Hospital A's capabilities including ICU monitoring and ventilator management. Physician A stated he accepted the transfer and then contacted the house supervisor [Staff B]. Physician A stated the house supervisor explained to him that they did not have adequate staffing on the ICU to provide care to a transfer patient and she would call Hospital A and tell them. Physician A acknowledged he had failed to verify bed availability and adequate staffing resources prior to accepting the patient from Hospital A and it was his responsibility to contact the physician at Hospital A to accept of refuse admission of the patient.

Review of Physician A's credential file revealed the physician received EMTALA training in December of 2012.

5. Review of MGMC's house managers schedules confirmed that Staff B, RN was the over night house manager on 1/21/14.

During an interview on 3/4/14 at 2:55 PM, Staff B confirmed Physician A contacted her at approximately 2:00 AM on 1/22/14 to request an ICU bed for a patient being transferred to their hospital from Hospital A. Staff B stated she told Physician A they did not have adequate staffing on the unit to provide care safely to another patient. After the phone call, she called Hospital A and told [Physician D] that they were declining admission of the patient. Staff B denied she contacted the ICU at the time of the request to ascertain what their census, availability of beds and patient acuity and admitted she "should have." Staff B said, Physician A asked if they were on diversion and she told him no, they didn't have to be. Staff B acknowledged she failed to follow policies for EMTALA, managing staff patient flow throughout the hospital and ICU scope of service. Staff B stated she spoke with [Physician A] after refusing to admit the patient from Hospital A to ICU and he admitted it was his responsibility to contact the physician at Hospital A. Prior to conclusion of the interview, Staff B stated Physician D called their hospital, after speaking with her, and asked what her name was and if she was a house manager.

Review of personnel files revealed Staff B received EMTALA training on 2/20/13.

6. Review of MGMC Nursing Schedules revealed there were a total of 5 Registered Nurses (RN) and 1 Patient Care Tech (PCT) working on the oversight shift on 1/21/14 on the Intensive Care Unit (ICU). Review of patient census sheets for 1/21/14 through 1/22/14 revealed there were 6 patients in the ICU.

During an interview on 3/4/14 at 11:30 AM, Staff F, Director of Quality Management, stated the hospital staff's the ICU for 10 beds and they have 12 physical beds available for patients at all times.

During an interview on 3/5/14 at 10:50 AM, Staff D, RN/ICU Director confirmed the documentation on the patient census sheets. Staff D stated there were 4 beds available and they were capable of providing mechanical ventilation support to 6 patients. Staff D stated, in her opinion, the patients in the ICU on 1/21/14 through 1/22/14 were stable; and they had the resources and capacity to safely admit patients to their unit. Staff D said options afforded, if necessary, for new admission on 1/22/14 AM including but not limited to; reallocating patients to different nursing units, reassigning a medical telemetry nurse to ICU, calling additional staff, or reassigning patients. Prior to conclusion of the interview, Staff D stated that none of the 6 ICU patients that evening required 1 on 1 nursing care. There were 5 registered nurses working in the ICU during that time.

7. Review of policy "Managing Patient Flow" review, dated 8/13, revealed the following in part, "define methods to...facilitate patient flow...the medical center is considered to have limited capacity when the following conditions exist: ICU: 1 bed available...the house supervisor has the authority to identify and request alternate holding areas to be utilized with appropriate patient care...all units are expected to contribute to staffing needs...ED physicians will be asked to assist with prioritization of patients."

During an interview on 3/4/14 at 11:30 AM, at the time of policy review, Staff F stated the policy was applicable throughout all patient units in the hospital.

8. Review of policy "ICU Scope of Service" dated 7/11, revealed the following in part, ..."The purpose of the ICU is to provide quality critical care to patients who are critically ill...Areas of nurse expertise...will be focused on critical care medical and/or surgical diagnoses, which include the following:...respiratory emergencies...The staff standards in the ICU are based on an average daily census of 7 patients. The ICU staffing matrix is utilized to determine the numbers of staff based on census.

Nurse: Patient ratios are:
7-3 shift: 1 nurse to 2 patients
3-11 shift: 1 nurse to 2 patients
11-7 shift: 1 nurse to 2 patients

The usual staffing patterns for ICU:7-3 shift: 3-4 RN's and 1-2 PCT's
3-11 shift: 3-4 RN's and 1 PCT
11-7 shift: 3-4 RN's

9. Review of policy "Scope of Cardiopulmonary Department" dated 7/13, revealed the following in part, ..."Respiratory Care practitioners play an important role in the care of critically ill patients requiring mechanical ventilatory support...the cardiopulmonary services department is staffed 24 hours a day, seven days a week to provide services...core staffing...on weekends...4 therapists on evening shift, and 2 therapists on night shift...critical care: ventilatory support - adult."

During an interview on 3/5/14 at 10:50 AM, Staff E, RN/Executive Director for In-patient Services confirmed the ICU did have the capability to provide services for intubated patients with ventilators on 1/22/14. Staff E stated after reviewing all of the information she concluded the patients on the ICU were relatively stable that night and in her opinion they had beds available to admit an intubated patient from Hospital A. Additionally, Staff E stated physicians are responsible for accepting or denying admissions of patients to their hospital and it would be inappropriate for a house supervisor to refuse a transfer from an outlying hospital. Staff E confirmed that this was hospital policy and essential to ensure continuity of care to the patient.

10. Additional interviews conducted throughout the investigation revealed:

a. During an interview on 3/3/14 at 1:25 PM, Staff G, RN/Clinical Resource Nurse for the OB unit, stated nursing staff throughout the hospital received education on the hospital's policy for staffing guidelines. And at any time if they felt necessary if there were a sudden influx of patients to the hospital, they could activate the "Red Phone" list. It essentially serves as a guideline for activating a call list for nursing and administrative staff if necessary to meet the needs of patients safely. Staff G explained postings of the red phone list are located throughout the hospital at the nurse's stations and the list provided step by step guidance to nursing staff on the procedures necessary if they determined additional staff were required to meet the needs of patient's safely.

b. During an interview on 3/3/14 at 2:00 PM, Staff A, RN/Clinical Supervisor for the OB unit confirmed all staff received education on the hospital's EMTALA policy annually. Staff A stated if the hospital had the capabilities to provide care and services to patients transferred to their facility then they would be triaged, seen by a provider and admitted for treatment. Staff A said if they determined additional nursing staff were required the charge nurse would make phone calls to see if they could get additional nursing or PCT staff. Staff A stated the hospital's policy for staffing is based on the acuity of the patient and in her opinion, administrative staff were supportive if the charge nurse activated the calling system for additional staff, encourage autonomy of their decision to increase staffing levels if necessary, and staff would not be reprimanded if they decided to do so.

c. During an interview on 3/4/14 at 2:40 PM, ED Physician E stated any physician with privileges at their hospital may accept or deny the care of a transferred patient to their facility. Physician E said the decision to refuse care can not be based on a shortage of nurses and if a patient required a higher level of care and they had a bed they would have to accept them. Physician E said in his 7 years of being an ED physician at MGMC he was only aware of one time when they had experienced an ambulance diversion and that this occurred a couple of years ago.

d. During an interview on 3/4/14 at 4:05 PM, Physician C, Director of Cardiology services confirmed the ICU provided care and services to non-surgical cardiac patients including intubated patients. Physician C stated that a physician with expertise would have the scope of practice to accept or decline patients for admission to their hospital. Additionally, a nurse would not have the authority to make a decision to admit or deny transfer to their hospital from an outlying hospital.

e. During an interview on 3/5/14 at 10:00 AM, Staff C, RN/Interim Director of ED acknowledged the EMTALA policy failed to included MGMC's obligation to accept appropriate transfers. Staff C stated that although in his opinion ED staff understand the EMTALA rules however they may not have a clear understanding of the transfer aspect of the policy e.g.; the responsibilities of receiving patients from other hospitals (transfers into the hospital). Staff C said that only providers and/or physicians can accept or refuse transfers of patients from another hospital to their hospital because they have the scope and practice to make the determination.

f. During an interview on 3/5/14 at 11:50 AM, Staff F, RN/Director of Quality Management confirmed house managers are responsible for determining bed availability, adequate staffing and the capacity to provide care to patient's that may need to be transferred to their hospital from an outlying hospital, and communicating this information to the provider. Staff F emphasized house managers cannot accept or decline patient admissions and/or transfers, that this determination should be based on a provider's medical expertise. At the conclusion of the interview, Staff F acknowledged the hospital failed to follow policy and procedure on 1/22/14 when they denied admission to a patient from Hospital A. Staff F confirmed the hospital was not on diversion status, there were beds available on the ICU for admission of an intubated patient, and [Staff B] failed to follow hospital policies when she denied the request for transfer.