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Based on a review of documentation and interview, the facility failed to ensure that a participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual.

Findings included:

Patient #1 presented to Hospital A on 09/22/16 with right shoulder and elbow pain, which an x-ray of the right elbow showed a complete dislocation of the radial head at the elbow. At Hospital A a reduction of the radius was completed, a post-reduction x-ray was taken, which indicated dislocation of the medial condyle of the right humerus.

The emergency room physician at Hospital A recommended a transfer to a higher level of care. Hospital A then contacted Hospital B (Odessa Regional Medical Center) regarding transfer of Patient #1 for care by an orthopedic surgeon. Nursing notes state that staff member #1 (Hospital A Emergency Department physician) spoke to the house supervisor over the telephone. A note at 10:28 pm states "[staff member #4 from ORMC] called, notified about pt [#1] status, verbalized he was declining patient, [staff member #4 from ORMC] on phone with [staff member #1], [Staff member #1] verbalized to call transfer center."

After the transfer was declined by ORMC, patient #1 was transferred directly from Hospital A to Hospital C in another town with a pediatric orthopedist available.

Odessa Regional Medical Center (ORMC) declined the transfer of Patient #1 on 09/22/16. ORMC had an orthopedic surgeon on-call for 09/22/16 and 09/23/16 (Staff member #4) .
* A review of the on-call schedule for September & October 2016 revealed that staff member #4 was on call for orthopedics on 09/22/16 and 09/23/16, when the patient's injury occurred.
* Review of the credentialing file for staff member #4 revealed current licensure, privileging and appointment. Staff member #4 received provisional appointment to the facility's medical staff on 08/23/16, to expire on 07/31/17.

Delineation of clinical privileges and procedures for staff member #4 revealed privileging including (but not limited to) the following:
-Adult and pediatric orthopaedic disorders, diagnosis and management of
-Athletic and recreational injuries, evaluation, management of
-Nerve injuries, management of
-Neurovascular impairment, diagnosis and care - both operative and nonoperative
-Pediatric trauma
-Shoulder and elbow conditions, assessment and management of
-Soft tissue wounds, management of
-Tendon and ligament injuries, management of
-Urgent and emergent orthopaedic problems, treatment evaluation
-Fracture/dislocation reduction techniques
-Ligament reconstruction
-Sports medicine
-Tendons and nerves, repair

In an interview on 10/04/16 staff member #4 was asked if they were aware of the nature of the patient #1's injury. Staff #4 replied, "the ER physician (at Hospital A) could not describe properly what he had. I didn't have his X-ray report...he [Hospital A physican] didn't read the report to me. The kid should have been transferred here and been evaluated by the ER first. When I tried to tell him [MD at Hospital A] that, he behaved belligerently. If he (Hospital A physician) was not comfortable taking care of the case he should not have started it. He should have transferred him then. (Hospital C) had the pediatric orthopedic. I gave the prerogative to him to just send it to (Hospital C) because they're equal distance. This ER physician could not adequately tell me what was wrong with this kid other than that he had dislocated his elbow, so I had been told. I don't feel comfortable saying 'send the patient here.' He should have called the ER doctor here and have him transferred. He was going outside the protocol ... He (the patient) ended up going to [Hospital C] which was probably better for him in the long run. To this day I still don't know exactly what injury the patient had."

Staff #4 reviewed the radiology reports from Hospital A and stated, "Had he (Hospital A physican) read this to me 'suspected epicondyle', I would have told him to send him to (Hospital C). We do some pediatric orth here, we do it when we feel capable. Fractures of elbow we often transfer up to (Hospital C). This kid, if he had come here I would have transferred him up to (Hospital C). He had open growth plates and injury to those plates ...I don't know what I would do next time. I don't want to have to give care I don't feel comfortable providing ....pediatric patients don't skeletally mature until 15-16. They have 6 or 7 open growth plates in elbow and he can be deformed. Plate injuries in children most often go to (Hospital C). If it's not a growth plate issue I will treat it. With a growth plate injury, they need a specialist to follow them out to treat any issues or deformity. The privilege forms are often vague at best. My partners do the same thing, often times. The closest one is (Hospital C). I have the cell phone number for the pediatric orthopedic surgeon up there. It's a big gray area with pediatric fractures."

Staff member #4 was privileged to address pediatric trauma and management of pediatric orthopedic disorders. ORMC had specialized capabilities available and refused the transfer of Patient #1 from Hospital A. No reason for denying the transfer of Patient #1 from Hospital A to ORMC for specialized care within it's capacity was documented.




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