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Based documentation and interview, the hospital failed to comply with the requirements of 42 CFR 489.24 by failing to accept an emergency transfer of a patient requiring specialized care and failed to implement policies and procedures to ensure compliance with EMTALA (refer to data tag A-2411).

Findings:

1. The hospital which had a psychiatric service, failed to accept a patient from another hospital's emergency room which did not have this service (see A-2411).

2. The hospital failed to implement its own EMTALA policies and procedures by not referring a transfer request from another hospital emergency room to its transfer center. Furthermore, the hospital did not develop policies and procedures for the psychiatric service in regards to receiving inquiries for emergency transfer of patients to their service (see A-2411).

Based on documentation and interview, the hospital failed to accept a patient transfer in need of specialized services from another hospital's emergency room for one of 29 sampled patients (Patient 29). In addition, hospital staff failed to implement an EMTALA policy and procedure in regards to acceptance of patient transfers.

Findings:

1. On 1/2/12 at approximately 7:30 a.m. Hospital A made a request to Stanford Hospital to transfer Patient 29 from their emergency room with an acute mental disorder. The request was made because Hospital A did not have the capability to treat an acutely mentally ill patient in their emergency room and Stanford Hospital had the specialized service to treat the patient.

Patient 29's emergency record from Hospital A was reviewed on 1/26/12. The review indicated Patient 29 was brought to the hospital emergency room on 1/1/12 by the local police on a California Welfare and Institutions Code 5150 (72 hour hold for evaluation and treatment of a mental disorder) as danger to himself (patient) and gravely disabled. In addition to his behavior problems, the patient may have ingested an unknown substance prior to being picked up by the police. On arrival, the patient was assessed by the physician as delusional and acutely psychotic. The physician obtained a behavioral crises evaluation of Patient 29's mental status which confirmed the patient had delusional thoughts, had no means for food and shelter, and no local family members or friends. He was further assessed as gravely disabled and danger to himself. Patient 29 was medically cleared at 12:01 a.m. on 1/2/12 but needed acute psychiatric care.

An attempt was made to transfer the patient to Stanford Hospital on 1/2/12. According to Hospital A's emergency room Physician 1, who was interviewed on 1/24 and 1/26/12, Patient 29 was medically cleared for transfer and needed continued psychiatric evaluation and treatment. Physician 1 said he spoke with Physician 2 and was told, "It would not be in the patient's best interest" to have the patient transferred to Stanford. Physician 2 explained that the distance between the two hospitals (Hospital A and Stanford) would hamper their ability to acquire needed support services once the patient was discharged. Physician 1 stated Stanford clearly denied the request for transfer.

On 1/25/12 at 3:05 p.m., the on-call psychiatrist at Stanford was interviewed (Physician 2). Physician 2 stated she received a call from a social worker from another county wanting to refer a mentally ill patient to Stanford. She further stated it was difficult to get information about the patient from the social worker thus she had Patient 29's medical record faxed to her. After reviewing the "packet" which was faxed to her, she still was not clear regarding the patient's condition. Physician 2 said she needed to talk with Physician 1. Physician 1 called Physician 2 to discuss Patient 29's condition. After speaking with Physician 1, Physician 2 said she assessed the patient as not being stable enough for transfer. Physician 2 (a resident physician) met with her attending supervisor who agreed the patient was not stable enough to come, and denied the patient transfer. Physician 2 stated she made the assessment over the telephone without seeing the patient.

2. The hospital policy and procedure for EMTALA was reviewed on 1/24/12. The emergency transfer procedure indicated on page 2. "Transfers From Other Health Care Facilities," Admission and Transfer-In-Acceptance, 1. All transfer requests from other health care facilities (including external Emergency Departments) will be processed through the Transfer Center to ensure compliance with procedures and regulations for transfer. According to hospital administration staff, the request for transfer was not directed to the call center. Had the call been received by the transfer center, the dialog between the two physicians would have been recorded. Additionally, the EMTALA compliance policy indicated on page 13, I. 2. Documentation. Each individual department that is contacted to accept emergency transfers of individuals shall have policies and procedures for receiving inquiries from other hospitals, including documentation of calls, the names (if known) and conditions of the individuals attempted to be transferred, the outcomes of the calls and the reason if SHC/LPCH refuse to accept the transfer. The nurse manager for the psychiatric unit who was interviewed on 1/24/12 at 1:40 p.m. stated he did not have a policy and procedure for receiving emergency transfer inquiries. The hospital did present a "Resident" call log which indicated a transfer, from the county where Hospital A was located, was denied. No reason was given for the denial.

A review of the physician on-call list at Stanford Hospital Emergency Department revealed Physician 2 was on-call the day of the requested transfer (1/2/12). On 1/24/12 the psychiatric unit census was reviewed which indicated there were psychiatric beds available on 1/2/12. Thus the hospital had the capacity and the capability to care for Patient 29.