HospitalInspections.org

1. Based on medical record review(s), staff interview(s), review of the facility's policy and procedures the facility failed to ensure that the risks and benefits of the transfers were documented on the certification transfer form as stated in the facility's policy for 4 of 20 (#2, #14, #15 & #16) sampled medical records reviewed. Refer to findings in Tag A-2409.



2. Based on review of the facility's transfer logs, review of transfer center audio recordings, review of on-call schedules, staff interviews, and review of facility policies, the facility refused to accept from transferring hospitals within the boundaries of the United States an appropriate transfer of individuals who required such specialized capabilities and facilities because the receiving hospital had the capacity to treat two (2) (#17 and 18) of twenty (20) sampled medical records reviewed. Refer to findings in Tag A-2411.

2409
Based on medical record review(s), staff interview(s), review of the facility's policy and procedures the facility failed to ensure that the risks and benefits of the transfers were documented on the certification transfer form as stated in the facility's policy for 4 of 20 (#2, #14, #15 & #16) sampled medical records reviewed.

Findings include:

Medical record review revealed:

Patient #2 was transported to the facility's ER by ambulance on 4/11/15 at 11:39 AM with complaints of suicide attempt, overdose. Triage notes reveal that EMS stated patient took 11 Phentermine (an appetite suppressant) and 6 caffeine (pills) at midnight in a suicide attempt. After receiving stabilizing treatment, the patient was transferred in stable condition to View Point (psychiatric hospital) 4/11/15 at 8:36 PM. Review of the patient's transfer form and physician's notes revealed that it did not include the reason for transfer, MD certification, or risks and benefits of transfer.

Telephone interview with MD # 3 on 9/8/16 at 12:10 PM revealed that he/she had worked in the facility's ER for approximately six (6) years, and been trained in EMTALA, and was aware of the requirement to document Risks and Benefits. The MD did not recall the patient. He/she stated that the nurse sometimes completed the form and that he/she usually did document risks and benefits in the medical record.

Patient #14 was transported to the facility's ER by ambulance on 2/15/15 at 6:52 PM with complaints of Medical clearance/depressed. Triage notes reveal the patient was transferred from a Behavioral Health System Hospital (psych) for clearance. The patient was alert and oriented to person, place, and time; having visual hallucinations appeared sad and complained of a headache. The patient was transferred back to the Behavioral Health System Hospital on 2/16/15 at 1:54 AM with final diagnoses of UTI (urinary tract infection) and depression. Review of the patient's transfer form and physician's notes revealed that the risks and benefits of the transfer had not been documented.

Patient #15 was transported to the facility's ER by ambulance on 2/15/15 9:11 PM with complaints of epigastric pain (pain in the upper abdomen below the ribs). Triage notes reveal the patient's epigastric pain was relieved with Nitroglycerine (used to prevent or treat chest pain), and, the patient also complained of nausea and vomiting. After receiving stabilizing treatment, the patient was transferred to a (named) Medical Center on 2/16/15 at 3:16 AM. Review of the patient's transfer form and physician's notes revealed that the risks and benefits of the transfer had not been documented.

Telephone interviews with MD # 7 revealed:
On 9/8/2016 at 10:55 AM, the MD stated that he/she had worked in the facility's ER for eleven (11) years, and had been trained in EMTALA.

In a subsequent interview on 9/9/2016 at 8:20 AM, MD #7 stated that he/she had reviewed the medical records, and confirmed that it was his/her signature on the certification for transfer for patient #'s #14 and #15).

Regarding patient #14, the MD explained that the patient had been in a psychiatric facility for one (1) month, and found to be having worsening hallucinations. The ER MD had discovered the patient also had a urinary tract infection, which he/she treated, and had contacted the psychiatric facility to transfer the patient back there, which was a usual occurrence if there was no reason to keep the patient. The MD noted that he/she documented the need for transfer to another facility had been discussed, and the patient was aware.

Patient #16 was transported to the facility's ER by ambulance on 10/14/15 at 11:48 AM with a diagnosis of altered mental status. Triage notes revealed that the patient complained of an episode of syncope (dizziness) and an altered mental status. The patient had a history of seizures and noncompliance with medications. After receiving stabilizing treatment, the patient was transferred to another hospital on 10/14/15 at 4:27 PM via EMS. Review of the patient's transfer form and physician's notes revealed that the risks and benefits of the transfer had not been documented.

Interview with MD # 8 on 9/9/2016 at 11:05 AM revealed that he/she had no recollection of the patient. After reviewing patient #16's medical record, the physician confirmed that neither the Transfer Form nor the physician notes contained Risks and Benefits of transferring the patient. The MD stated that the record did note that the transfer had been discussed, and the patient had agreed, and, he/she was certain that the risks and benefits would have been included in that discussion.

The Director of Clinical Informatics confirmed the absence of Risks and Benefits documentation in the medical records for patients' #'s 2, 14, 15 and 16.

Policy and Procedure review:

The facility's Policy and procedure titled Emergency Medical Treatment and Labor Act. Policy #: AMC-RL280, Effective Date: February 14, 2001, reviewed/Revision Date: August 2015 was reviewed. The policy revealed in part, "IV. POLICY: ... H ...b. With certification: The individual may be transferred ...if a physician or ...another qualified medical person in consultation with a physician has certified that the medical benefits expected from the transfer outweigh the risks." The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that the risks and benefits of the transfer were documented for patient #'s 2, 14. 15 and 16.

2. Based on review of the facility's transfer logs, review of transfer center audio recordings, review of on-call schedules, staff interviews, and review of facility policies, the facility refused to accept from transferring hospitals within the boundaries of the United States an appropriate transfer of individuals who required such specialized capabilities and facilities because the receiving hospital had the capacity to treat two (2) (#17 and 18) of twenty (20) sampled medical records reviewed. Refer to findings in Tag A-2411.

Findings include:

Review of the facility's transfer log for 4/11/2015 revealed that the transfer center received a request to transfer:
Patient #17, with the diagnosis of pancreatitis, from Hospital 'A' to Hospital 'B' (Wellstar Atlanta Medical Center) Internal Medicine services at 4:52 AM, with the disposition noted as "denied", "not medically necessary" - Insurance 'A'.

7/7/2015 Review of transfer center recording with the Market Compliance Officer and the Clinical Informatics Director, revealed the following conversation (as transcribed by the surveyor, some portions difficult to hear):
Telephone call to MD #9 (on call for internal medicine) Transfer center: (intro) I have a patient from xxxxx Hospital (A) with diagnosis of pancreatitis
MD #9: Why are you calling me? If the patient is sick enough to be in the hospital, then it is unsafe. Why are you sending the patient?
Transfer center: Insurance 'A', maybe?
MD #9: well, it doesn't matter if it's unsafe or not, so long as they get paid, huh? What's their name? Transfer center: (provides pt #17's name)
MD #9: (provides Pt. #17) name) with pancreatitis. And what am I supposed to do?
Transfer center: I can get you in touch with the sending physician, would you like to speak to him?
MD #9: Not particularly, I just need to know where the patient will be sent - to Hospital 'B'. to the ER? to the roof? where?
Transfer center: They didn't say, they usually connect you with the attending doctor, would you like to speak to him? I can grab our admin RN, and she can let you know what beds are available...
MD #9: (sighs) Just tell them to call me when the patient gets here. Transfer center: So you are accepting the patient?
MD #9: Yeah. Transfer center: Telemetry bed?
MD #9: Yeah. Transfer center: And you want to be called when they get there?
MD #9: Yeah. Transfer center: Will the patient be traveling by ground?
MD #9: How would I know? I don't know how they're sending the patient. The patient shouldn't be sent. That's an unsafe admission. I guess by ambulance. I guess you should know that, shouldn't you?
Transfer center: I'm just here at the Transfer Center and facilitate the transfer Dr. Would you like me to call xxxxxxx, the admin for you?
MD #9: That's okay if you want to, just make it quick. Transfer center: Okay, I will call him/her, I have her direct number. Just hold on for a minute.(admin RN answers and introduction made by the transfer center)
Admin RN: Good morning. What can I do for you?
MD #9: No, what can I do for you?
Transfer Center: (explains the transfer) admin RN: You don't want to be connected with the attending, correct?
MD #9: Just tell me what you want me to do. I'm supposed to be taking ER call and they told me to call this number, period.
Admin RN: So you're not Internal Medicine admission tonight?
MD #9: Yeah, I am. That's right. admin RN: Okay, that's why I'm calling you.
MD #9: Okay. What am I supposed to do?
Admin RN: There's a patient at xxxx hospital (A) with insurance they don't take and the patient is in the ER with pancreatitis and they want us to accept the patient here and since you're the Internal Medicine service here, you'll have to accept the patient. Well, you don't have to accept the patient, but that's why they are calling you.
MD #9: Well that's an unsafe admission. If the patient is sick enough to be transferred, I mean sick enough to be admitted to the hospital with pancreatitis, you know, it's a little, it's contrary to good medicine to move the patient around simply because they don't take the insurance. That's uh, but I know you all don't care about that, so what am I supposed to do?
Admin RN: You can either accept the patient; talk to the transferring MD over there, and let them explain what's going on over there. I barely, I only knew about this because the ER called me to take the patient and we have to go through the transfer line and get the internal medicine Dr on call to accept the patient. I can't accept the patient.
MD #9: Well I really don't want to do that. I don't, uh, if the patient is sick. Do you understand what I'm saying?
Admin RN: I understand what you're saying. I understand exactly what you're saying, but, I mean, you can either accept or deny for whatever reason you have.MD #9: Yeah, well, uh, this doctor, who is the doctor? Do you have the number for the ER?admin RN: I have the direct number for the emergency room, yes.
MD #9: What's the doctor's name?
Admin RN: Dr xxxxx. Would you like me to get him on the line for you?
MD #9: Okay admin RN: Alright just one minute. (phone call is made, ER transferring MD answers the phone)ER Dr: Transferring hospital. Can you hear me?
MD #9: Yeah, I hear you.
ER Dr: Well, I'm calling about a patient I have, (provides pt #17's name), a 55 years old. He/she came here with complaints of diabetes, abdominal pain, nausea and vomiting. He/she's been NPO for the last 3 days. You could tell he/she was miserable, his/her abdomen was distended and a little bit tender. We did a whole work up. His/her lipase was 1583; no known history of pancreatitis; not a heavy drinker. (provides lab values) elevated LFT; Alkaline phosphate 142; blood glucose 347; CT scan for lipase of 1583; ALP 133; AST 57; urine negative; white count normal. CT scan showed evidence of prominence in the bile duct and pancreatic duct and he/she will probably need an ERCP as an inpatient (endoscopic retrograde cholangiopancreatography- a procedure that uses a flexible scope and X-rays to look at the bile duct and the pancreatic duct). We've been giving him/her fluids and pain control.
MD #9: Why are you transferring the patient, because of insurance 'A'? No, I'm not going to take him/her. I'm not going to do that. This patient sounds sick, and you're going to transfer him/her just because of insurance?ER Dr: He/she looks better than he might sound.
MD #9: Yeah, no. I'm not going to take him/her.
ER Dr.: Alright that's fine. Thank you.
MD #9: Thank you.(call ends)

Telephone interview with MD #9 on 7/7/2015 at 4:30 PM revealed that the physician recalled the situation and stated that he/she was on call for internal medicine the day the transfer center called to transfer the patient. He/she explained that the sending hospital had a pattern of calling when the patient did not have insurance, and would try to push the patient (#17) a certain way. He/she further explained that the patient's clinical condition was not stable- the patient's enzymes were off, the patient was dehydrated, and did not sound well. He/she was vomiting, and not stable. MD #9 stated that he/she did not want to move the patient around just because of the insurance status. The Dr. continued on stating that it would benefit him/her to take the patient because he/she would get paid. He/she surmised that apparently, that hospital didn't take Insurance 'A', so they call to find someone else to take the patient, and that it would be okay if the patient was stable, but if the patient is unstable, he/she needs to stay where he/she is. The MD reiterated that he/she had spoken to the ER doctor, and, the patient didn't sound stable. MD #9 further stated that he/she had never been trained in EMTALA, and do not know what it was.

The hospital's Emergency Room Call schedule for April 2015 was reviewed. Review of the On-call schedule validated that on 2/11/2015 an Internal Medicine Physician was on call when the transferring hospital called Wellstar AMC requesting a transfer for Patient #17.

Review of the requested bed census report dated 4/11/2015, revealed the following units had beds available (Capacity): Medical Surgical Unit bed capacity was 31, the census was 24, beds available were 7; and the Medical Unit bed capacity was 22, the census was 15, and beds available were 7. The facility failed to accept from a referring hospital (B) Patient an appropriate transfer on 4/11/2015 Patient #17 who required such specialized services of the Internal Medicine Physician (Capability). The hospital also had capacity on 4/11/2015.

Review of the facility's transfer log for 2/17/2016 revealed that the transfer center received a request to transfer:
Patient #18, a fifty-one (51) year old patient with the diagnosis of pancreatitis and cholelithiasis, from Hospital ' C ' to Hospital ' B ' Atlanta Medical Center Internal Medicine services, with the disposition noted as "denied", "not medically necessary".

9/8/2016 Review of transfer center recording revealed the following conversation (as transcribed by the surveyor):

9/8/2016 Review of transfer center recording revealed the following conversation (as transcribed by the surveyor, some portions difficult to hear):
Conversation #1
Transfer Center - Atlanta Medical Center, you are on a recorded line,
this is Transfer Center, how may I help you?
Hospital C ED Physician - Hey Transfer Center, this is Hospital C (transferring Hospital) ED Physician,
calling you from Name of Transferring Hospital (Hospital C).. I have
a patient I would like to transfer. We have no beds and do not expect any
empty beds today.
Transfer Center - Alright, let me get a new one opened, so you do not have to repeat too much to me here, ok?
Hospital C ED Physician - Ok, Ok
Transfer Center - And you are trying to go to Atlanta Medical
Center Main Campus, correct?
Hospital C ED Physician - Yes.
Transfer Center - And you are calling from Hospital C?
Hospital C ED Physician - Correct.
Transfer Center - Hospital C ..., new name?
Hospital C ED Physician - Hospital C in (a city in), GA.
Transfer Center - And what's you requesting service?
Hospital C ED Physician - Hospitalist.
Transfer Center - And where is the patient currently located at
your facility?
Hospital C ED Physician - In Emergency Room number 4.
Transfer Center - And doctor, your name again?
Hospital C ED Physician - (spells out his/her name)
Transfer Center - And a good call back number?
Hospital C ED Physician - (gives phone number)
Transfer Center - Patients last name?
Hospital C ED Physician - Patient #18 last name
Transfer Center - First name?
Hospital C ED Physician - Patient #18 first name
Transfer Center - Date of birth?
Hospital C ED Physician - Patient #18 date of birth
Transfer Center - Any flu like symptoms?
Hospital C ED Physician - No
Transfer Center - Any foreign travel in the last 3 weeks?
Hospital C ED Physician - No
Transfer Center - Diagnosis?
Hospital C ED Physician - Acute Pancreatitis and Cholelithiasis without Cholecystitis.
Transfer Center - Acute Pancreatitis and Cholecystitis?
Hospital C ED Physician - No, no, no Cholelithiasis, no Cholecystitis. Gallbladder stones
and acute Pancreatitis.
Transfer Center - And their not a Department of Corrections
Patient, correct?
Hospital C ED Physician - Say that again?
Transfer Center - Are they a Department of Corrections patient?
Hospital C ED Physician - What does it mean?
Transfer Center - Are they coming from a jail?
Hospital C ED Physician - No
Transfer Center - OK
Hospital C ED Physician - I was like, ok, nobody ask me this question.
Transfer Center - Is the referral, a emergency medical condition at this time?
Hospital C ED Physician - Yes
Transfer Center - Does your facility have the capabilities to care for the patient?
Hospital C ED Physician - We have no beds.
Transfer Center - Ok, hold on one moment for me. The request is
not traumatic, is it?
Hospital C ED Physician - No
Transfer Center - Will they need an ICU bed?
Hospital C ED Physician - No
Transfer Center - Is this an emergent request or a non-emergent, just looking for a higher level
of care?
Hospital C ED Physician - Higher level of care, we have no beds. I would like to admit
the patient here and I spoke with my facility, they not expect we have four surgical patients and we have no beds and they not expect to have a bed.
Transfer Center - Perfect, can I go ahead and get a face sheet
and a H&P sent over to us?
Hospital C ED Physician - Wow, this is new. H&P? So, I'm not going to speak to a
physician?
Transfer Center - You will, but, I need case manager for this
approval.
Hospital C ED Physician - ok
Since its non-emergent and we are looking for a higher level of care.
Hospital C ED Physician - What if I say it is emergent, then you don't need an H&P?
Transfer Center - Hold on, let me go back and find out. Nope, then I just need a face sheet.
Hospital C ED Physician - Ok, lets just do emergent then.
Transfer Center - Alright, the fax number over here is (Fax number given) and I will go ahead and page internal medicine and I will give you a call right back.
Hospital C ED Physician - Thank you.
Transfer Center - Thank you
Hospital C ED Physician - Bye Bye
Transfer Center - Bye

Conversation #2
Transfer Center - Atlanta Medical Center, you are on a recorded line, this is transfer center, how may I help you?
Physician #4 - Hey, this is Physician #4
Transfer Center - Hey Physician #4, thanks for giving me a call back. We have a transfer request from Hospital C, on a fifty-one year old male
with Acute Pancreatitis and Cholelithcytis. Would you like his/her name and date of birth or can I connect you with the sending?
Physician #4 - Why are they sending him/her?
Transfer Center - Because they have no beds. He/she said they are not anticipating to have beds for days.
Physician #4 - What's the insurance?
Transfer Center - Hold on, I was just pulling that up. They are self-pay.
Physician #4 - yea, well I'm not going to be able to take that patient.
Transfer Center - Ok, should I just put on, and the reason you are not going to take?
Physician #4 - Because it's nothing to do with the higher level of care. That's just, they don't have a bed, that's bull. They don't even know how many people are going to be discharged today. That's not a real reason.
Transfer Center - Ok, I will let them know.
Physician #4 - Alright, Thanks
Transfer Center - Thank you

Conversation #3
Dial tone, phone ringing
Hospital C ED - Emergency Department, may I help you?
Transfer Center - Hey Piedmont ED, this is Transfer Center, over here at the AMC transfer center. Is Hospital C ED Physician around?
Hospital C ED - one second, hey Hospital C ED Physician (placed on hold)
Hospital C ED Physician - Hello, this is Hospital C ED Physician
Transfer Center - Hello, this is Transfer Center, over here at the AMC transfer center. I'm calling to let you know that I have spoken to administration and they are denying the patient.
Hospital C ED Physician - Why?
Transfer Center - I explained to him/her what was going on with the Acute Pancreatitis, Cholelithcytis, gall stones and all of that and he/she said, so, why are they transferring. I said, lack of beds at this time. And he/she said no, they don't know what their discharges will be, they can keep the patient.
Hospital C ED Physician - That's why I'm calling you, because I know what my discharges are going to be, I have four people coming out of OR and we have no beds. That's why I'm calling you.
Transfer Center - And I explained to him/her that you wouldn't have beds for days, is what you said.
Hospital C ED Physician - Correct. Alright, I'm going to call other hospital. What else can I do? I've been calling already. You are the fourth hospital I am calling.
Transfer Center - I'm sorry doctor.
Hospital C ED Physician - I transfer patient to Tennessee, then they are going to complain about this denial. Thank you
Transfer Center - Thank you



The hospital's Emergency Room Call schedule for February 2016 was reviewed. Review of the On-call schedule validated that on 2/17/2016 an Internal Medicine Physician was on call when the transferring hospital called Wellstar AMC requesting a transfer for Patient #18.


Review of the requested bed census report dated 2/17/2016, revealed the following units had beds available (Capacity): Medical Surgical Unit bed capacity was 31, the census was 28, beds available were 3; and the Medical Unit bed capacity was 22, the census was 21, and bed available was 1. The facility failed to accept from a referring hospital (B) Patient an appropriate transfer on 2/17/2016 Patient #18 who required such specialized services of the Internal Medicine Physician (Capability). The hospital also had capacity on 2/17/2016.


Telephone interview with MD #4 on 9/8/2016 at 10:15 AM revealed that he/she had been on call for the facility for the past sixteen (16) years, and admitted eight (8) to thirteen (13) patients monthly. MD #4 stated that he/she had become aware of EMTALA requirements approximately one (1) year ago, had attended a couple of meetings in the past two (2) or three (3) months, and now understood.
The MD explained that the Transfer Center contacted the MD on call for the service requested, not the ER MD, and that he/she was on call for Internal Medicine (IM) Services. The physician had no recollection of the transfer request for patient #18.


Interview with the ER Medical Director in the conference room on 7/7/2015 at 5:21 p.m. revealed that all MDs should be aware of EMTALA. He/she stated that the hospital is in the process of training all on-call physicians on EMTALA and that he/she had spoken to on-call physicians in the past regarding EMTALA regulations. The MD stated that someone in administration reviews the transfer log daily. The medical director added that he/she had not been made aware of any denied transfers.


Review of facility policy #AMC-RI.280, EMTALA, effective date February 14, 2001, current reviewed/revision date August 2015, III. Procedure I. Obligation to Accept Transfers, revealed that to the extent that the Hospital has specialized capabilities (including capabilities available through the Hospital's on-call roster) or facilities, such as a shock-trauma unit or a neonatal intensive care unit, that are not available at the transferring facility, the Hospital shall accept appropriate transfers of an individual needing such specialized capabilities or facilities if the Hospital has the capacity to treat the individual.