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Based on clinical record review, policy review, Transfer Center transcript audio review and staff interview, it was determined, the facility failed to adopt and enforce policy and procedures to ensure compliance with the EMTALA requirements at 42 CFR 489.24 as evidenced by failure to timely accept an appropriate transfer. The facility had the capacity and capability to accept the patient and provide stabilization treatment. This failure affected 1 of 23 sampled patients (Patient #1).


The findings include:


Based on clinical record review, audio transcript review and interviews conducted on 12/20/22 and 12/21/22, the facility failed to timely accept an appropriate transfer, who required specialized services available at the facility. The failure affected 1 of 23 sampled patients (Patient #1) as detailed in citation A 2411.

Based on record review, policy review, audio transcript review and interviews, it was determined, the facility failed to timely accept an appropriate transfer (Patient #1), of 23 sampled patients who required specialized services that were available at the receiving facility.


The findings include:


Clinical record review conducted on 12/20/22 and 12/21/22 revealed Patient #1 was a victim of a drive by shooting and arrived at Facility B (Referring Facility) for emergency care on 11/24/22. Further review of the record revealed the ED physician documented at 8:08 P.M., the patient visit diagnoses were gunshot wound to the head, Subdural Hematoma (type of bleed inside the head), depressed skull fracture, and fracture of the knee. Review of the physical examination, revealed in part, "General Appearance: Awake and Alert cooperative, no distress, O(oriented) x3 ...head normal cephalic entry wound left post auricular (behind left ear) scalp no powder burns, no obvious exit wound, although there is great amount of blood.

Facility B contacted the Transfer Center (TC) for the receiving facility, HCA Florida Lawnwood Hospital, a trauma center, requesting acceptance to transfer Patient #1. Clinical record review of Patient #1 conducted on 12/20/22-12/23/22 indicates Patient #1 was transferred from Facility B to facility C on 11/24/22 at 9:38 PM.


The section of the Physician's note titled "Disposition" was reviewed. The referring ED physician documented the initial call was placed to Hospital A (Lawnwood Regional Medical Center-Hospital A) regarding the other living patient in this 3-patient shooting. We were working 3 traumas patients at once ...The accepting physician at Hospital A had accepted the first patient (Chest GSW) ...and an aircraft was in bound to transport this patient (Pt.#1).We had this patient (second patient) and I advised the accepting physician at Hospital A of our second patient (this patient) and his injuries (I described GSW to head with GSC 15 and nl (normal) neurologic exam (examination) with GSW to knee with good perfusion ...( I had done a head to toe primary survey). And I specifically recall describing the normal lungs/abdomen/remaining extremities. The receiving MD at hospital A interrupted me and ...that I needed to perform a primary survey and call me back. I at one point told him there was an entry wound with and no exit wound and shortly after this he told me something to the effect, that there might be no injury and therefore no reason to be sent to him. He declined to accept. ... the conversation ended ...and I immediately called Hospital C's Trauma Center and patient (#1) was accepted ...as a trauma alert."

Facility C, Medical Screening Exam dated 11/24/22 at 10:25 PM documents 18-year-old presented as trauma alert for gunshot wound to the head and the knee. The patient is awake and alert, grazing type of ballistic injury to the left parietal scalp. Ballistic wound to the right knee. Glasgow Coma Scale 15, and admitted to trauma for gunshot wound to the knee.
Trauma History & Physical dated 11/24/22 at 11:27 PM documents the patient is a gunshot victim to the head and knee, airway intact, hemodynamic is stable, alert, and oriented and reportedly he drove himself to the transferring hospital.
Discharge summary dated 11/28/22 documents the patient had no surgical interventions. The CT brain revealed stable traumatic sequelae with small contusion left temporal lobe. The X-ray Left knee revealed small avulsion fracture left patella. Patient #1 was discharged home with a knee immobilizer and instructions to follow up with neurology and orthopedic services.

Review of the Transfer Center audio and transcript of the calls placed on 11/24/22 at 7:12 PM and 7:16 PM, revealed the transferring Emergency Department (ED) physician wanted to present Patient #1's case to the trauma surgeon on call. The surgeon was not aware the call involved multiple patients and the ED physician did not have all requested information readily available. The audio revealed back-and-forth discussions, the trauma surgeon requested further screening and stabilization prior to transfer. The transferring ED provider seemed to agree to this during the call and subsequently transferred the patient to another trauma center (Facility C). When HCA Florida Lawnwood Hospital followed up on the transfer request, Facility B advised to cancel the request as Patient #1 was being transferred to Facility C.

A phone interview conducted with the Transfer Center, Assistant Vice President (AVP) of Patient Logistic and Director of Clinical Operations, on 12/21/22 at 10:08 AM revealed the process when someone calls the transfer center to request acceptance for a transfer. The staff handles one patient at a time, as they need to separate cases, obtain demographics and medical records. It is possible to handle multiple requests simultaneously, but is more difficult, is like registering two people at the same time. The AVP explained the case involving Patient #1, Facility B was requesting acceptance for two patients. Facility B was made aware of the recommendation to have someone else to call the second case to expedite the intake, but it doesn't seem they followed the request. The surgeon was not aware the facility was requesting acceptance for two patients. The surveyor asked to clarify why the TC agent posed the question "are you not accepting the patient", and the Director of Clinical Operations explained it was done to ensure if there was a denial that the agent would follow protocol and escalate the request to the AOC (Administrator On Call).

Interview with The Trauma Surgeon conducted on 12/21/22 at 11:41 AM, revealed his recollection of the events regarding Patient #1. The Transfer Center (TC) called to transfer a patient in; he was having a hard time hearing; the audio was poor. The ED physician from the receiving facility got on the phone and presented the case of a female with gunshot wound. The patient was accepted. After finishing the case, the ED MD proceeded to provide information on another patient. He was not aware of the second case. The Surgeon explained the facility is a trauma center, they accept every patient, yes he was asking questions and in his mind he was trying to figure out what the transferring facility had done so far, so he could be prepared for the patients and prioritize care. The Surgeon confirmed the facility had the capacity and capability of treating both patients, (Patient #1 and #2). He did not refuse the transfer, he recalls that the ED physician was supposed to call back with additional information, but never did, instead the patient was sent someplace else. When they are expecting multiple trauma victims, they need to prioritize and ask qualifying questions. A lot of the time the questions are to triage on his head, not to question the transferring facility capabilities. Some facilities are able to do more than others. The trauma surgeon clarified he was asking regarding the primary survey, just to ascertain the patient's condition. The surgeon stated he is aware unstable patients can be transferred; the facility gets them frequently. The intent was to prioritize care, minimize wasting time and the patient had penetrating trauma, so the more information he had the better, to see who he may need on hand to treat the case. Again, the questions were asked to evaluate the injury pattern, level of stability and to be prepared for the patient on arrival. The questions are to help the patient, and expedite the care, not to critique the physician. The hospital can handle multiple victims, the goal is to be prepared and prioritize care.

Facility C, Medical Screening Exam dated 11/24/22 at 10:25 PM documents 18-year-old presented as trauma alert for gunshot wound to the head and the knee. The patient is awake and alert, grazing type of ballistic injury to the left parietal scalp. Ballistic wound to the right knee. Glasgow Coma Scale 15, and admitted to trauma for gunshot wound to the knee.
Trauma History & Physical dated 11/24/22 at 11:27 PM documents the patient is a gunshot victim to the head and knee, airway intact, hemodynamic is stable, alert, and oriented and reportedly he drove himself to the transferring hospital.
Discharge summary dated 11/28/22 documents the patient had no surgical interventions. The CT brain revealed stable traumatic sequelae with small contusion left temporal lobe. The X-ray Left knee revealed small avulsion fracture left patella. Patient #1 was discharged home with a knee immobilizer and instructions to follow up with neurology and orthopedic services.

Facility policy titled "EMTALA Transfer Policies" last reviewed 10/21/2 documents:
Recipient Hospital Responsibilities.
a. A participating hospital that has specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units, dedicated behavioral health units, or regional referral centers in rural areas) may not refuse to accept an appropriate transfer from a transferring hospital within the boundaries of the United States, of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual.
b. The requirement to accept an appropriate EMTALA transfer applies to any Medicare participating hospital with specialized capabilities, regardless of whether the hospital has a DED.

Based on the review, it was determined the facility failed to accept Patient #1 in a timely manner. The facility had the capacity and capability to treat and stabilize Patient #1 on 11/24/2022.