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Based on policy and procedure reviews, medical records reviews, hospital documentation reviews, audio review, staff and physician interviews, the hospital failed to comply with §489.24 as evidenced by the Dedicated Emergency Department (DED) physician failing to complete the physician certification closely to the time of the transfer and/or document the increased risks associated with the transfer to the individual and failing to accept a request for transfer of a patient with an emergency medical condition from a referring dedicated emergency department for specialized inpatient care when the receiving/recipient hospital had the capacity and capability to provide care of patients with an Emergency Medical Condition (EMC) .

The findings include:

1. ~ cross refer to 489.24(e)(1)(2) Risks and Benefits, Tag A2409.

2. ~ cross refer to 489.24(f) Recipient Hospital, Tag A2411.

Based on policy and procedure reviews, closed medical record reviews, staff and physician interviews the hospital's Dedicated Emergency Department (DED) failed to ensure an appropriate transfer by failing to: complete the physician certification closely to the time of the transfer and/or document the medical benefits reasonably expected at the time of transfer outweighed the increased risks associated with the transfer to individuals in 5 of 10 DED patients having an Emergency Medical Condition (EMC) that were transferred to another hospital (Patients #8, #33, #32, #21, #9) .

The Findings include:

Review of the hospital's current Medical Staff Rules and Regulations approved 08/12/2012 revealed "G. Transfer requirements:...Prior to any transfer of an individual who presented to the hospital with an emergency medical condition and whose condition remains unstable, the emergency physician, or when applicable, the on-call specialist physician, must examine and evaluate the person and certify in writing (see below), that , based upon reasonable risks and benefits to the patient and information available at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the individual's medical condition that may result from effecting the transfer...d. Patient consent and Refusal to Consent to Medically Indicated Transfer, The individual or legally responsible person will be advised orally or in writing, of the reasons for the transfer including its risks and benefits".

Review of the current hospital policy revised 03/12 "EMTALA COMPLIANCE, INCLUDING PATIENT TRANSFERS (EMERGENCY MEDICAL TREATMENT AND LABOR ACT) revealed "..(2) The physician certifies in writing that the expected benefits of the transfer outweigh the increased risks of transfer to the individual (and to the unborn child of a pregnant women). The physician must sign a certification. The XXX (name of the Health System) EMTALA Transfer Form serves as the certification of transfer as required by EMTALA..(b) A summary of the risks and benefits upon which the conclusion is based will be documented in the XXX EMTALA Transfer Form".

1. Medical record review of Patient # 8 revealed a 74 year old presenting to the DED on 05/25/2014 with a chief complaint of abdominal pain and heart burn after bowel resection surgery. Record review revealed the patient had bowel resection surgery on 04/16/2014. Record review revealed at 0127 the DED physician started a Medical Screening Exam (MSE). Record review revealed the physician's final impression was the patient had a suspected small bowel obstruction. Record review revealed the physician certified the patient for transfer to another hospital at 0315, however did not consult with surgery.

Review of the "EMTALA " form revealed the physician electronically signed the certification for transfer on 05/25/2014 at 0311. Further review revealed the physician signed (written) the certification for transfer at 0315. Record review revealed the patient left the DED for transfer at 0500 (one hour 45 minutes after certification completed). Record review revealed no further documentation of reassessment of the patient's condition, benefits related to transfer or risks of transfer. Review of the physician certification revealed the benefits of the transfer were documented "Benefits outweigh Risks of Transfer Medical Risks". Review of the documentation revealed the risks were documented "Worsening of condition or death if you stay here." Medical record review revealed there was no documentation of the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweighed the increased risks to the patient. Further record review revealed there was no documentation by the DED physician at the time of transfer.

Interview with the DED Medical Director on 07/10/2014 at 1730 revealed the certification of the benefits and risks for transfer should be signed within 30 minutes of the patient's departure per the hospital ' s standard of practice. The interview revealed the physician was to electronically sign the certification for transfer. The interview revealed if there was more than 30 minutes before the patient's departs the physician is to reassess the patient and sign (written) that the benefits expected outweigh the risks of transfer. The interview revealed there was two sections for the physician to document that the benefits outweigh the risks for transfer on the EMTALA form. The interview revealed one section is when the decision is made to transfer and one section when it is more than 30 minutes before the patient's departs the DED. The interview revealed the documentation section for the benefits and risk is a "drop down" in the electronic medical record that contains a list of predetermined examples of benefits and risks. The interview revealed the physician electronically chooses from the preselected list and documents the selection chosen and/or the physician can specifically individualize the risk and benefits to the patient based on the patient's condition. The interview revealed documentation for risks " death if you stay here" automatically populates on the transfer form as one of the selections. The interview revealed for the physician to document benefits and risk specifically to the patient's condition would require the physician to add the information to the electronic medical record.

2. Medical record review of Patient #33 revealed a 27 year old pregnant, 27 weeks gestation presenting to the DED on 07/15/2014 at 1448 with a chief complaint of neck swelling. Medical record review revealed Patient #33 had been seen the day before in the DED for pain in right molar. Record review revealed the patient was triaged at 1515 with a temperature of 100.6. Review of the MSE completed by the physician revealed "Patient's does report some difficulty opening her mouth and has not been able to keep today secondary to pain ...Right lower posterior molar is tender to palpation. There is significant swelling to the right submandibular area extending into the submental area ...Patient's exam is concerning for early Ludwig's angina (infection in the floor of the mouth may which block airway)". Further review of the MSE revealed the patient's was having trouble opening her mouth secondary to pain and was "not been able to tolerate any oral intake today...however is hungry". Review of the MSE revealed "Trachea is midline, tenderness to palpation over the superior anterior cervical chain...Large inflamed area mandibular space that is tender to light palpation, no fluctuant appreciated, poor dentation with cavity on the right inferior posterior molar, leukoplakia along the left buccal membranes is adhered to the mucosa". Review of the MSE revealed "Differentials for this patient presenting with worsening swelling in the jaw include submandibular abscess, pharyngeal abscess, and cellulite. Given this patient's poor dentition and exam, I am concerned about Ludwig's angina. She has not necessarily failed amoxicillin since she has not completed the course, however given the rapid growth of the infection, I believe she needs IV antibiotics initial course and to be monitored for potential airway compromise....Given intrauterine pregnancy, would hold off on exposure to radiation with CT scan". Record review revealed the patient's was administered Clindamycin intravenous (IV) and Morphine IV twice.
IV (intravenous) Clindamycin (antibiotic) and IV Morphine twice and "I was informed prior to discharge that the patient had rash develop at the IV site shortly after receiving IV morphine 2 mg, dose #2--she denied respiratory sx's (symptoms) and did not have pruritus anywhere else. She was given Benadryl 25 mg IV for local reaction". (Clindamycin is used to treat infections caused by bacteria. Morphine is used to treat moderate to severe pain. Benadryl is used to treat severe allergic reactions. Pruritus means itchy skin.)
Record review revealed the patient was transferred at 1905. Review of the written physician's certification revealed documentation of risk "Worsening of condition or death if you stay here". Record review revealed there was no documentation of the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweighed the increased risks to the patient. Additionally, documentation reveals that patient No. 33 who was at "risk of death" and of worsening breathing, was discharged/transported by "Private Car".

Interview with the DED Medical Director on 07/10/2014 at 1710 revealed the reason for transfer was for potential need for oral surgery. The interview revealed there was no further documentation for risk of the transfer. The interview revealed the documentation section for the benefits and risk is a "drop down" in the electronic medical record that contains a list of predetermined examples of benefits and risks. The interview revealed the physician electronically chooses from the preselected list and documents the selection chosen and/or the physician can specifically individualize the risk and benefits to the patient based on the patient's condition. The interview revealed there was no further documentation of risks for transfer for Patient #33.

3. Medical record review of Patient #32 revealed a 17 year old, presenting to the DED on 05/01/2014 at 1510 with a chief complaint of snake bite to left hand. Medical record review revealed the patient was triaged at 1520, urgent (ESI Emergency Severity Index) with blood pressure of 155/105 and pulse 125. (Normal Systolic Blood Pressure (first number) is less than 120 mm Hg, normal Diastolic Blood Pressure (second number) is less than 80 mm Hg. Normal heart rate for adults ranges from 60 to 100 beats a minute.)
Review of the MSE revealed the patient had severe pain with "left dorsal hand with significant swelling to mid forearm". Record review revealed the patient was administered antivenom. (Antivenom is a biological product used in the treatment of toxic bites.) Record review revealed "Snake bite. Copperhead (venomous snake). Significant local reaction Antivenom given. Continues w/ (with) significant pain. No signs of compartment syndrome at this time". Record review revealed the patient was transferred for services not available at the hospital. Review of the written physician's certification for transfer at 1933 revealed documentation for the risk of transfer "Worsening of condition or death if you stay here". Record review revealed the patient was transferred at 2010. Record review revealed no further documentation of the risks for transfer.

Interview with the DED Medical Director on 07/10/2014 at 1730 revealed there are two sections for the physician to document that the benefits outweigh the risks for transfer on the EMTALA form. The interview revealed the documentation section for the benefits and risk is a "drop down" in the electronic medical record that contains a list of predetermined examples of benefits and risks. The interview revealed the physician electronically chooses from the preselected list and documents the selection chosen and/or the physician can specifically individualize the risk and benefits to the patient based on the patient's condition. The interview revealed for risks "death if you stay here" automatically populates on the transfer form as one of the selections. The interview revealed for the physician to document benefits and risk specifically to the patient's condition would require the physician to add the information to the electronic medical record.

4. Medical record review of Patient #21 revealed a 2 year old, presenting to the DED on 06/23/2014 at 2038 with a chief complaint of " child choked " on unknown object and crying. Medical record review revealed the patient was triaged at 2047, pulse 150, respirations 36. Review of the chest X-ray at 2055 revealed "Rounded radiopaque foreign body measuring 2.6 cm (centimeters) is noted within the upper esophagus just below hypopharynx". Review of the MSE revealed "X-ray reveals what appears to be a coin in the proximal portion of his esophagus just below the hypopharynx. ..be transferred to the ER...to see pediatric surgery to have this foreign body removed...went by ambulance in case he develops any airway compromise and should he vomit the coin up". Record review revealed the patient was transferred for pediatric surgery that was not available at the hospital. Review of the written physician's certification for transfer at 2234 revealed documentation for the risk of transfer "Worsening of condition or death if you stay here There is always a risk of traffic delay/accident resulting in condition deterioration. " Record review revealed the patient was transferred at 2301. Record review revealed no further documentation of the risks for transfer.

Interview with the DED Medical Director on 07/10/2014 at 1730 revealed there are two sections for the physician to document that the benefits outweigh the risks for transfer on the EMTALA form. The interview revealed the documentation section for the benefits and risk is a "drop down" in the electronic medical record that contains a list of predetermined examples of benefits and risks. The interview revealed the physician electronically chooses from the preselected list and documents the selection chosen and/or the physician can specifically individualize the risk and benefits to the patient based on the patient's condition. The interview revealed for risks "death if you stay here" automatically populates on the transfer form as one of the selections. The interview revealed for the physician to document benefits and risk specifically to the patient's condition would require the physician to add the information to the electronic medical record.

5. Medical record review of Patient #9 revealed a 24 year old, presenting to the DED on 04/25/2014 at 1806 with a chief complaint motor vehicle crash, trauma and altered mental status. Medical record review revealed documentation by the physician the patient had a comminuted right maxillary fracture with some associated free air, gluteal hematoma and multiple fractures dislocations of the right ankle/foot, however the patient was not evaluated by trauma surgery. Record review revealed documentation by the physician the patient would be transferred for a higher level of care for trauma services not available at the hospital. There was evidence that the facility had extensive surgical services even in the area of trauma critical care as well as extensive orthopedic services and plastic reconstruction and trauma surgery was on call. Review of the written physician's certification for transfer at 2009 revealed documentation for the risk of transfer "Worsening of condition or death if you stay here". Record review revealed the patient was transferred at 2020. Record review revealed no further documentation of the risks or reasons for transfer.

Interview with the DED Medical Director on 07/10/2014 at 1730 revealed there are two sections for the physician to document that the benefits outweigh the risks for transfer on the EMTALA form. The interview revealed the documentation section for the benefits and risk is a "drop down" in the electronic medical record that contains a list of predetermined examples of benefits and risks. The interview revealed the physician electronically chooses from the preselected list and documents the selection chosen and/or the physician can specifically individualize the risk and benefits to the patient based on the patient's condition. The interview revealed for risks "death if you stay here" automatically populates on the transfer form as one of the selections. The interview revealed for the physician to document benefits and risk specifically to the patient's condition would require the physician to add the information to the electronic medical record.

Based on policy review, staff and physician interviews, audio documentation review and hospital document review the hospital failed to accept a request for transfer of a patient with an Emergency Medical Condition (EMC) from a referring Dedicated Emergency Department (DED) for specialized inpatient care when the receiving/recipient hospital had the capacity and capability to provide care for 1 of 1 sampled intake calls reviewed. (Patient #37)

The Findings include:

Review of the hospital's current Medical Staff Rules and Regulations approved 08/12/2012 revealed H. Transfers to XXX (name of Health System) Facilities: Hospital Responsibilities: 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 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".

Review of the current hospital policy revised 03/12 "EMTALA COMPLIANCE, INCLUDING PATIENT TRANSFERS (EMERGENCY MEDICAL TREATMENT AND LABOR ACT) revealed "VI. Receiving Transfers from Outside Facilities. A. Receiving Transfers. Medicare-participating hospital that has specialized capabilities or facilities (including burn units, shock trauma units, neonatal intensive care units, or [with respect to rural areas] regional referral centers) may not refuse to accept an appropriate transfer of an individual who needs such specialized capabilities or facilities if the receiving hospital has the capacity and capabilities to treat the individual. 1. A receiving facility cannot condition acceptance of the transfer on use of a specific mode of transportation or transportation service. 2. A receiving facility should not unreasonably delay in treating a transferred individual".

Interview on 07/09/2014 at 1025 with the Administrator on call 04/03/2014 revealed she received a call from Physician #2 (DED physician at Hospital B, transferring hospital) at approximately 0300 to 0400 04/03/2014. The Interview revealed Physician #2 wanted to share concerns about a critical care physician and the physician had "refused" to accept a patient for transfer from Hospital B. The interview revealed the main concern was that Physician #1 (receiving physician at Hospital A, recipient hospital) wanted the patient intubated (to place a tube into the patient's airway to administer oxygen) for transport and Physician #2 was with the patient and did not see the need to intubate the patient for transport. The interview revealed she communicated with the House Supervisor to find out what had occurred. The interview revealed she was told by the House Supervisor that the hospital did not have any critical care beds available for any patient (when Physician #2 requested the ICU transfer on Patient #37). The interview revealed she had a second conversation with the House Supervisor and was again informed the Hospital did not have any available critical care beds. The interview revealed the next morning she discussed the situation with the Chief Medical Officer, the Administrative staff and the Medical Director of the ICU (Intensive Care Unit).

Interview with Physician #1 on 07/09/2014 at 0920 revealed he was a staff physician for Hospital A's Critical Care Associates on call for in house coverage. The interview revealed on 04/03/2014 he was on call. The interview revealed he had a patient expired in an ICU bed and when he received the request call for transfer from Physician #2 he thought he had an available ICU bed. The interview revealed he found out after the conversation with Physician #2 that another patient had been admitted to the ICU bed and he was not aware of this. The interview revealed the Physician Call Line (PCL) accepts the initial calls for transfers and the PCL knows the capability of the hospital resources. The interview revealed the issue of transporting a patient with BiPAP had been for a "long time". (Bilevel positive airway pressure (BiPAP) is used during noninvasive positive pressure ventilation.) The interview revealed Physician #1's group of physician had decided it was not a safe way to transport a patient on BiPAP. The interview revealed intubation was the only safe way to send a patient. The interview revealed the "key words" used by Physician # 2 that made him request intubation for the patient for transport were "PCO2 of 84 and rapid new onset of Atrial Fibrillation". The interview revealed it was a "standard of practice" for intubation in this circumstance but physician #2 was resistant to the idea of intubation. The interview revealed he thought he offered a bed and services but felt the patient needed to be intubated 'because of decompensation quickly and safer for the patient" during transport. The interview revealed after the call with Physician #2 he talked with the House Supervisor and was told Physician #2 had complained but there was no bed available for any patient at that time. The interview revealed if he had accepted the patient Physician #2 would have had to be called back to make him aware there was o bed available. The interview revealed this event had been discussed with the Administrative System Officials, the system Critical Care physicians, the Chief Medical Officer of Hospital A and Hospital A's Medical Director of Critical Care. The interview revealed after these discussion the request for intubation for transport for the patient was consistent with "standard of practice".

Review of audio documentation (recorded conversations received by Hospital A's Physician's Call Line) revealed a conversation between Physician #1 (receiving physician at Hospital A, recipient hospital with specialized capabilities) and Physician #2, (referring DED physician at Hospital B, transferring hospital) on 04/03/2014. Further review of the audio revealed the following:

~Physician #2 " sorry to bother you Dr. (name of physician #1). I have a patient here with COPD, ARF, 75 year old guy, generally healthy otherwise just some cholesterol and COPD inhalers, that's all the meds he was on. Recently new to the area and came in with severely distress diminish breath sounds with a little bit of wheezes. ABG PACO2@ 84, put him on BiPAP and got some neb, he also came in with a HR 160 with new onset atrial fibrillation flutter with a variable block. So he's on a couple of boluses of Cardizem and on a Cardizem drip, that's holding with a rate control of atrial flutter in the 80's no issue, we have no ICU beds, he currently on BiPAP, Cardizem drip for rapid afib"
~Physician #1 "the problem is he is on BiPAP and that is not a safe way to transport someone to another hospital. So if he needed to be intubated then I will be glad to accept him, but in term of the ambulance with BiPAP mask is not something I typically do"
~Physician #2 "Yeah, I mean he doesn't look like somebody I would tube at this point I guess we could re-draw his ABG and see where he is"
~Physician #1 "Yeah, we have a bed and if he needed to be intubated then I would be happy to accept him, but to put the patient on the ambulance on BiPAP mask and run a risk of having intubation on route 85, you see where I am going with that"
~Physician #2 "Yeah, if his PACO2 improved, well I don't know, I guess I have to see if we will be able to admit him here just the Cardizem drip on a simple O2 or not. Well I will re-evaluate the situation..."
~Physician #1 "ok give me a call if..."
~Physician #2 " I'm not a guy that I would prophylactically intubate for transport I think would put him more..."
~Physician #1 Yeah, I mean certainly a problem, I got a call from the ED with people on BiPAP and the question is what do you do. The best answer usually is to keep him there and if they needed to be intubated-intubate them, if they don't- just find a bed unfortunately he is on the BiPAP "
~Physician #2 " ok, honestly, I haven't have this this issue before I guess is a refusal if he is not intubated that what you were saying"
~Physician #1 " you've never have this happen before"
~Physician #2 "no"
~Physician #1 " all I can say is that I ' m not saying that everybody in our group would use it. It's a fair standard of recommendation that ' s all I can say"
~Physician #2 "Yeah, I understand that I mean if I explain the risk to the patient and that is part of the informed consent for a transfer explain the risk of travel with BiPAP that could deteriorate requiring intubation which could fail result of that, that is the risk that I'm explaining to him but this is the guy that had , he has a very lot of problem initially refusing of transfer because his wife wasn't here and we have no bed, can't admit him here so I'm not going to talk him into intubation so he can go"
~Physician #1 " well, I don't know what to say other than I have already said"
~Physician #2 " well I need on record is this a refusal for transfer or not because if it's refusing for transport than it's an issue I'm going to have to take with the administration and I have to figure something else to do with this guy"
~Physician #1 " well, I mean I'm not the only..."
~Physician #2 "...I'm not feeling comfort incubating for transport and I understand your apprehension about transport with BiPAP but I feel it's safe enough way to transport him"
~Physician #1 " I don't..."
~Physician #2 "and I feel ok taking myself so you have a service that we need and I'm asking you for that and so I need to hear whether you are refusing to accept him or not"
~Physician #1 " you know I'm trying my best to be nice and cordial to you and you make it's very difficult..."
~Physician #2 " ...I am too and this is why I tried not to raise my voice and trying to be logical to you as well..."
~Physician #1 "I have nothing to say other than I have already said to you and we can go around this and if you don't like my recommendation or you don't like what I'm saying you can circle around and you can find another hospital where someone says things that you like(...unable to hear) and I'm really sorry"
~Physician #2 "the patient had requested you hospital and you have a bed, so I need to know if you I mean I could send him there and if he gets there and you refused to take him it's an issue"
~Physician#1 " you can write down whatever you like. That's fine, you can have administration or quality you can do whatever you like...this is entirely up to you want to do"
~Physician #2 " I want to send the patient and I think he will do fine with transport...but you ' re going to turn him away when he gets there so...I will talk with the patient about the risk if he thinks it's risky as well, doesn't want to go there because of (unable to hear) then I will find something else to do but..."
~Physician #1 " you know I have never had an ER physician behaving like this that's all I can say"
~Physician #2 "again I have never had a situation where I'm running around trying to find a place for a patient that needed the ICU so we are in the same --(unable to hear) tonight and I don't think I was being rude and I'm cornering you and I am, I am absolutely cornering you because I need this patient to have a place to go and our stupid law said that I need to know that you're going to accept the transfer or you're going to refuse the transfer"
~Physician #1 " all right, write down refusing"
~Physician #2 " ok"
~Physician #1 " thank you"
~Physician #2 " operator, are you there"
~ Operator " I am"
~Physician #2 " ok, I don't know if you needed to send to your administration for..."
~Operator " ... the call can be reviewed. Yes it's on the recorded line and it can pull for review"
~Physician #2 " ok"
~Operator " ok"

Review of the hospital "Call Detail" documentation revealed Call ID 197591 received on 04/03/2014 " Referring Location, Name of Hospital B; Referring Physician, name of Physician #2, Receiving Location, Name of Hospital A; Pt last (patient last name); Pt first (first name of patient); Diagnosis, respiratory failure new onset afib--on BiPAP, out of beds request ICU or IMC; Requested Specialty, Critical Care/MICU; AGE/GROUP, Adult; Pt DOB (Patient date of Birth), 4/23/1938; Pt sex, Male".

Review of Hospital A's PCL "Call Data revealed on 04/03/2014 at 0254 a call was received in the PCL (Physician Call Line) from Physician #2 to Physician #1. Further review revealed Diagnosis "respiratory failure new onset afib--on BiPAP, out of beds request ICU or IMC". Review revealed the reason for transfer "per name of Physician #1 needed to be intubated for transfer". At 0258 documentation in the PCL revealed "76 year old male--respiratory failure and new onset afib. Pt (patient) is new to the area. No remarkable past medical history. Per Dr. (name of Physician #2) pt comes in distress. Pt is on bi pap and is on a Cardizem drip, there are no ICU beds at (name of Hospital B). Per (name of Physician #1) BiPAP would not be a safe means of transport so if the Pt is intubated they have a bed and will be happy to accept. Per (name of Physician #2) he does not believe the Pt needs to be intubated and wants Dr. (name of Physician #1) to say this is a refusal. Dr. (Physician #1) declined to accept the Pt if on BiPAP for transport".

NC00096658