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Based on documentation review, staff interview and policy review, JFK Medical Center failed to comply with Requirement at §489.24. The hospital emergency service personnel failed to accept a patient on whose behalf a request was made to transfer the patient in to their facility, from another local hospital, for a higher level of care / service within JFK Medical Center ' s capabilities and capacity. This failure affected 1 of 22 sampled patients, Patient #7. See findings at A2411.

Based on documentation review, staff interview and policy review, the hospital emergency service personnel failed to accept a patient on whose behalf a request for transfer, for a higher level of emergency care and specialized neurological services within JFK Medical Center's capabilities, was made. This failure affected 1 of 22 sampled patients, Patient #7.

The findings include:

Review of the facility's administrative policy & procedure titled EMTALA - Florida Transfer Policy revealed Under Policy: " A hospital with specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units or with respect to rural areas, regional referral centers) shall accept from a transferring hospital an appropriate transfer of an individual with an EMC(Emergency Medical Condition) who requires specialized capabilities if the receiving hospital has the capacity to treat the individual. The transferring hospital must be within the boundaries of the United States. Under Policy 1. B. A transfer will be an appropriate transfer if: i. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual ' s health and, in the case of a woman in labor, the health of the unborn child; ii. The receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment ...iii. The transfer is effected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transfer. Under the same policy c. Higher Level of Care: i. A receiving hospital with specialized capabilities or facilities that are not available at the transferring hospital ...must accept an appropriate transfer of an individual with an EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual ...Under 2. Other Transfer Situations ...c. PreExisiting Transfer Agreements, Appropriate transfer agreements should be in place and in writing between the hospital ...Under 6. B. When a facility is a potential receiving facility, it has a duty to accept Medically Necessary Transfers regardless of whether Facility is the geographically closet hospital ... "

Review of the Medical Staff Rules and Regulations titled Emergency Services Under section F revealed, "Transfer upon Request by the Medically Unstable Patient or Legally Responsible Person Acting on the Individual ' s behalf ...Receiving or Recipient Hospital Responsibilities ...A Hospital that has specialized capabilities or facilities ...or is designated as a regional referral center, may not refuse to accept from a referring hospital an appropriate transfer of an individual requiring such specialized capabilities or facilities if the receiving or recipient hospital has the capacity to treat the individual ...Non-Discrimination, The hospital shall not refuse to accept an appropriate transfer of an individual with an emergency medical condition if the individual requires a specialized services ...available at the hospital, if the hospital has the space and personnel available necessary to treat the individual and the transferring facility does not have the specialized services needed ..."

Review of JFK Medical Center's State license and Emergency Department (ED) posted service capabilities revealed the facility offers the services of neurology and neurosurgery, which was requested for sampled patient #7 on 08/11/2014.

Review of the on-call specialty list for JFK Medical Center revealed a neurosurgeon is documented as being on call the day and night of 8/10/14 and 8/11/14.

There is a current transfer Agreement documented and in place for transfers to JFK Medical Center from the transferring facility (B).

2. Review of JFK Medical Center documentation related to Patient #7 revealed "There is no ED Clinical record for Patient #7 as the patient did not present to their ED, as a result of a refusal to accept the patient without specific stipulated test(s).

Review of the Emergency Transfer Log / Request for Transfer completed by the nursing supervisor revealed: 8/11/14, 0215 (2:15 AM), Emergency Room - Emergency Room transfer, Other - went to Facility C; the diagnosis documented is Possible Arteriovenous Malformation (AVM). Reason - Neurointervention; Under Patient Condition at Time of Transfer - Transfer Center (JFK Medical Center's) was told by charge at the transferring facility (Facility #B), facility B Neurosurgeon did not have the test capabilities; sent to Facility C; Administrator on Call for JFK Medical Center was notified; JFK Interventionalist told facility B ED doctor he wanted a CT Angio (angiogram) of patient #7's Brain.

Review of the ED record for Patient #7 from Facility B, the transferring hospital, revealed: the patent presented to the ED on 8/10/14 at 11:14 PM with complaint of dizziness, nausea / vomiting & generalized weakness; The patient was triaged at 11:27 PM; A Medical Screen Examination (MSE) was done at 11:33 PM & patient with Headache & increased blood pressure; A Computerized Tomography (CT) scan of the patient's head was completed on 8/11/14 at 00:40 AM. Facility B's ED physician documented diagnosis of Intracerebellar Bleed and possible Anteriovenous Malformation (AVM)/cerebellar. Review of the Transfer Form dated 8/11/14 revealed: diagnoses of Intracerebellar bleed, possible AVM for neurosurgical intervention, risks & benefits were explained; Receiving hospital: JFK Medical Center is documented on the Form and crossed off, and Facility-C is documented; The name of the received ED physician at JFK Medical Center was crossed off, and Facility-C 's neurosurgeon name is documented with facility-C's ED's physician name also documented. The patient is documented as transferred to Facility-C at 3:20 AM via Ambulance.

Review of the ED Record documentation for Patient #7 from Facility-C Hospital, which accepted Patient #7 revealed: Patient #7 presented to the ED on 8/11/14 and had a MSE performed on 8/11/14 with diagnosis of Intracerebral Hemorrhage. A Cerebral Angiogram was done.

3. The ED manager at JFK Medical Center said on 10/02/2014 at approximately 9:00 AM: All transfers go through the Transfer Centers; ED physician makes a determination based on patient needs; patient transfers-in go through the Transfer Center; the call goes directly to the ED physician (with transferring physician on the line), and then to the nursing supervisor, the nursing supervisor would accept the patient based on facility capacity; ED physician accepts from a physician stand point. Normally the process is pretty quick; ED physician would let the nursing supervisor know giving details of the patient coming in. It is the same process on all shifts.

Interview with a Nursing supervisor (7a-7pm) on 10/02/2014 at 9:50 AM revealed:
Transfer-in calls from any ED to ED are documented; Right now for ED patient transfers in, we receive a call from the HCA Transfer Center saying that the ED-physician has accepted a patient from another ED, and the Supervisors are given the patient's name and reason for required transfer. The call is not received until the ED physician has accepted the patient. She agreed JFK Medical Center offers neurology & neurosurgery.

Interview with the Ethics & Compliance Officer on 10/02/2014 at 10:18 AM revealed a self reported incident in which JFK Medical Center newly hired ED doctor may not have been fully informed of their facility process fro transfers. A transferring facility (Facility B) had alleged their CT scan was down and had some question as to whether the MRI/MRA (Magnetic resonance imaging/angiogram) could be done by them (facility B) at nighttime or if a team was not available. ED Physician said we could not accept the patient (#7) without the MRI/A. The compliance officer said the ED physician should have accepted the patient anyway. The patient (#7) was transferred to another facility for pending or possible pre-stroke to rule stroke, by facility B.
She said it is JFK Medical Center's process to accept any patient for neurology or neurosurgery. The new ED physician engaged other physicians in the ED & the on-call neurologist in making the decision whether to accept the patient instead of just accepting the patient. She said the on-call physician/specialist should not have been contacted until the patient was accepted and enroute to JFK Medical Center.
She also said: The transferring ED called the transfer center, which in turn contacted our facility ED doctor for ED-ED conversation. Normally the Transfer center would notify the nursing supervisor also, it was determined this was not done so the ED physician did not have the additional input/knowledge of the nursing supervisor.

The Transferring facility's (facility B) ED doctor was told the patient needed a CTA (Computed Tomography Angiogram) prior to being accepted for transfer; Facility-B had said they could not do the CTA but wanted to transfer the patient to a higher level of care. The Compliance Officer said our ED physician should have accepted whether an Agreement was signed or not.

The Compliance Officer agreed the time frame from the initial call from the Transfer Center to accepting patient #7, was approximately 2 hours, when it should not be more than 20 minutes. The nursing supervisory was not notified by the Transfer Center initially per protocol, and when she became involved (2:15 AM) and called the transferring hospital (facility B) back, Patient #7 was already being sent to another facility (C) for higher level of care. The Compliance Officer said the ED physician was relatively new but should have accepted patient without calling the specialty on-call or engaging other physicians prior to accepting the patient. The Compliance Officer said, JFK Medical Center had the capability and the capacity to accept Patient #7.


Review of the Timeline of Transfer Call for 8/11/14 revealed: 1:25 AM - connected with referring doctor; 2:10 AM - administrator (JFK) notified; 2:05 AM - nursing supervisor notified of transfer request; 3:04 AM - nursing supervisor advised the transfer to JFK was canceled. It was determined from listening to the audio-tape of the transfer call that Physician-A said "need to discuss with our neurosurgeon before accepting" and will get back to Facility-B; there were several calls placed; the nursing supervisor was notified by the Transfer Center of the delay in accepting Patient #7; JFK Medical Center ED-physician called Facility-B saying if Patient has just intracranial bleed, that you can handle, will not accept; If an AVM that you can't handle, will accept patient. JFK Medical Center was notified Patient #7 was transferred to Facility-C, after 2 hours delay in accepting the patient.

Review of documentation provided by the Compliance Officer revealed Physician #A told the Medical Director at JFK Medical Center that he was notified of the request to transfer Patient #7 in at approximately 1:13 AM, and that the patient has complaints of headache, dizziness, and vomiting, was neurologically intact, alert & oriented; that subsequently was found to be intraparenchymal bleed; Facility-B stated their Radiologist said, bleed was possibly due to AVM and recommended MRA; was told it was discussed with Facility-B's neurosurgeon who said they do not treat AVMs and the patient needs to be transferred to higher level of care for MRA. Physician A was told facility B does not do MRAs at night; JFK Medical Center's ED physician discussed the concerns with the neurosurgeon on call and it could not be determined, based on the current scan at Facility-B, if the patient had AVM. JFK Medical Center's neurosurgery team was notified; Shortly after this, the Transfer Center station called and said the ED physician had a duty to accept the patient; the ED physician then told the Transfer Center he would accept the patient but needed the neurosurgeon involved and on board because if patient arrives and decompensates, they need to be on board for definitive therapy. After discussion with the neurosurgeon, the ED physician called Facility-B to accept the patient, after CTA was completed. Later, approximately 2 hours, the Transfer Center called back and stated Facility-C has accepted the patient.