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Based on review of medical records, policy and procedures, staff interviews, it was determined that the facility failed to provide an appropriate transfer when one (P#1) of 20 sampled patients was transferred from the Emergency Department (ED) to another facility and the transferring facility had the capacity and capabilities to provide care to P#1.

Additionally, 13 medical records reviewed revealed patients were transferred to another facility and the medical record failed to reveal a signed physician certification form.

Findings included:

Cross Refer to A-2409.

Based on a review of medical records, staff interviews, and facility policies, it was determined that the facility failed to appropriately transfer one (P#1) of 20 sampled patients. Patient (P#1), who was 11 weeks pregnant presented to the Emergency Department (ED) on 7/31/24 with complaints of abdominal pain, nausea, chest pain, and tachycardia and the ED provider determined that the patient required treatment. The ED provider transferred P#1 to another acute care facility when an accepting physician was not located at the facility.

In addition, review of medical records for 13 patients transferred failed to include a signed physician certification form with an explanation of the risks and benefits documented.

Findings Included:

A review of P#1's ED record revealed that she arrived on 7/31/24 at 3:05 p.m. for complaints of abdominal pain, nausea, vomiting, and chest pain. P#1 reported that she was 11 weeks pregnant. Continued review of the record revealed that P#1 had been in the ED six (6) days earlier on 7/25/24 with complaints of nausea and vomiting.

Continued review of the record revealed that P#1 was seen by ED Medical Doctor (MD) BB at 3:19 p.m. A review of 'History of Present Illness' that P#1 presented with right upper quadrant abdominal pain that started one (1) day ago, P#1 reported nausea and vomiting, chest pain, and tachycardia (fast heart rate over 100 beats per minute) episodes. P#1 denied shortness of breath, fever or back pain. P#1 had a history of pregnancy and was seen in the ED six days prior and diagnosed with cholelithiasis (gallbladder inflammation). Physician orders included laboratory tests, ultrasound of abdomen, intravenous fluids, and medications for pain and nausea.

A review of the abdominal ultrasound report at 4:45 p.m. revealed findings consistent with acute cholecystitis. A follow up abdominal MRI revealed normal findings with no evidence of choledocholithiasis (presence of stones in the bile duct). A review of MD BB 'Notes' at 6:18 p.m. revealed that P#1 was evaluated and treated for an emergency medical condition. A bedside ultrasound showed good fetal movement and fetal heart rate of 154 beats per minute. P#1 likely presenting with biliary pathology. Gastroenterology was consulted. Laboratory results showed urinary tract infection.

Continued review revealed that MD BB "had multiple phone conversation consultations with the hospitalist, general surgery and OB/GYN fortunately, unable to admit patient here or in Brunswick and we will transfer Jacksonville Memorial and that this may be an EMTALA at the end of the day I have to take care of the patient." A review of the 'Impression and Plan' revealed a diagnosis of acute upper quadrant abdominal pain, acute worsening transaminitis (elevated liver enzymes), concern for cholecystitis (inflammation of the gallbladder), pregnancy and acute tachycardia.

A review of "Calls-Consults" revealed the following:

At 6:43 p.m., MD BB spoke with MD DD, a surgeon. MD DD recommended that if OB admitted P#1 and she was not a high risk, MD DD would evaluate the patient.

At 6:50 p.m., MD BB consulted with MD CC, OB/GYN, who declined the admission.

At 6:58 p.m., MD BB spoke with MD FF, who declined admission.

At 7:10 p.m., MD BB spoke with MD DD, who declined the admission.

At 8:37 p.m., MD BB contacted the Medical Director, MD GG, who would speak with the Chief of Staff, MD HH.

At 9:17 p.m., MD BB consulted with MD EE, a hospitalist, who declined the admission.

At 9:17 p.m., MD BB called a surgeon at another facility who agreed to accept the patient but stated 'that this could be an EMTALA violation'.

P#1 was discharged on 7/31/24 at 9:40 p.m. via ambulance transport to another facility.

A review of the facility's policy titled, "EMTALA - Medical Screening Examination and Stabilization Policy," (no policy number, last reviewed 11/1/21) revealed that the purpose of the policy is that when an individual comes to the dedicated emergency department (DED). A request is made on his or her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition (EMC) and appropriate medical screening examination (MSE) within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed by an individual qualified to perform such examination to determine whether an EMC exists.

Continued review revealed that if an EMC is determined to exist, the individual will be provided necessary stabilizing treatment within the capacity and capability of the facility or an appropriate transfer as required by EMTALA.

A review of the facility's policy titled, "EMTALA - Provision of On-Call Coverage", (no policy number, last reviewed 7/28/21), revealed that the purpose of the policy was to establish guidelines for the facility, including a specialty facility and its personnel to be prospectively aware of which physicians, including specialists and sub-specialists, are available to provide additional medical evaluation and treatment necessary to stabilize individuals with emergency medical conditions.

A review of the policy "Admission from Emergency Care Center", (no policy number, last reviewed on 3/10/23.) The purpose was to provide guidelines for the admission of patients from the Emergency Care Center to in-house units at either Campus.
2. In-House Units:

1. Med/Surg-primary medical/surgical/gynecology diagnosis ICU-critical cardiac/medical diagnosis
2. Maternity-primary obstetrics

A further review of the policy lists the following procedure:

A. General In-House Units:

1. The ECC physician consults with the primary medical provider or on-call physician to obtain the patient's acceptance of their service.
2. Attending physician, admitting diagnosis, date, and time are documented on the Chart.

E. Obstetrics

a. If the patient is greater than or equal to 20 weeks gestational age, send to Miriam and Hugh Nunnally Maternity Care Center for evaluation by the primary gynecologist or their designee.

b. If the patient is less than 20 weeks gestational age, proceed as any other general in- house admission.


A review of the facility's "EMTALA-Transfer Policy" (no policy, last reviewed 4/20/2021)The purpose of this policy is to establish guidelines for either accepting an appropriate transfer from another facility or providing an appropriate transfer to another facility for an individual with an emergency medical condition (EMC) who requests or requires a transfer for further medical care and follow-up to a receiving facility as required by EMTALA, 42 U.S.C., Section 1395 and all Federal regulations and interpretative guidelines promulgated there under.

It is the responsibility of the leadership team, Patient Care Services, Risk Management, Quality, and Medical Staff to ensure compliance with this policy and procedure and that all requirements are met.

2. A transfer will be appropriate if:

a. 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.

3. Higher Level of Care:

A higher level of care should generally be the primary reason to transfer an individual with an EMC that has not been stabilized. The following are examples of higher levels of care:

a. A receiving hospital with specialized capabilities or facilities that are not available at the health system (including, but not limited to, burn units, shock-trauma units, neonatal intensive care units or regional referral centers) must accept and appropriate transfer of an individual with and EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual.

The Chief Medical Officer (CMO) MD HH was interviewed by phone on 8/14/24 at 9:30 a.m. MD HH explained that physicians on the "on-call list" are expected to discuss patients with the ED MD and come to the facility to see the patient when the ED MD requests a patient to be seen. If a physician declines to see the patient, the ED MD can contact CMO HH, who will then call the on-call MD to discuss the case and why they declined to see or admit a patient referred to them by the ED MD.

CMO HH explained that the general rule is that the OB/GYN does not admit pregnant women with a medical issue under 20 weeks gestation. He further explained that the hospitalist would generally admit pregnant patients with a medical diagnosis unrelated to pregnancy under 20 weeks gestation and they would then consult an OB/GYN to see the patient in the facility. CMO HH explained that if the pregnant woman had a surgical diagnosis, the on-call surgeon, was contacted to assess and/or admit the patient to the facility, and the OB/GYN MD will be consulted.

CMO HH recalled being called by Medical Director GG about P#1. He recalled that P#1 was considered high risk obstetrical patient due to increased white blood count (WBC), elevated bilirubin (a yellow pigment in bile that if high in blood tests could indicate gallbladder issues), and tachycardia. CMO MD HH explained that they do not have the services at the facility to care for high-risk Obstetrical (OB) patients. CMO HH recalled that there had been questions about P#1 being septic and possibly needed surgery. MD HH was under the impression that P#1 was high-risk and there was concern about the fetus.

An interview was conducted on 8/14/24 at 9:45 a.m. in classroom A with the Surgeon and Vice Chief of Staff (MD) DD. MD DD verified that he was the surgeon on-call when P#1 was in the ED. MD DD explained that the facility was limited by the services it provides as a small facility. MD DD explained that there was not a gastroenterologist (GI) or cardiologist on-call on evenings or weekends. The facility had a sister facility that provided these services, which was about one-half hour away. MD DD believed P#1 may have needed an Endoscopic Retrograde Cholangiopancreatography (ERCP - procedure that combines endscopy and X-ray imaging to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas), which could only be done at the sister facility.

A phone interview was conducted on 8/14/24 at 10:30 a.m. with Hospitalist (MD) EE. MD EE did not recall P#1, although he reviewed the chart, he stated that if he had been contacted, he would not have admitted her under their service because he believed P#1 was a surgical case and not medical due to the cholelithiasis diagnosis. MD EE stated that if the nausea was related to hydration or the urinary tract infection (UTI), he could have admitted; however, there was concern that she was only 18 years old and eleven (11) weeks pregnant.

An interview was conducted in Classroom A on 8/14/24 at 11:00 a.m. with Obstetrics/Gynecology (OB/GYN) (MD) CC. MD CC was on call the day P#1 presented to the ED. MD CC recalled that P#1 had been in the ED earlier and that her liver function tests (LFT) and bilirubin were elevated on the return visit. Therefore, the medical issues were not pregnancy related. MD CC stated it was her understanding that the surgeon wanted P#1 seen by gastroenterology (GI). Therefore, since it was not pregnancy-related, she would not be the MD to admit the patient. MD CC explained that she did not feel she was the appropriate MD to admit P#1 because there was something more going on besides the pregnancy. MD CC said she would have been willing to follow the patient as a consultant.

A phone interview was conducted on 8/14/24 at 1:00 p.m. with the surgeon (MD) FF. MD FF had been the on-call surgeon at the sister facility the day P# 1 presented to the ED on 7/31/24. MD FF recalled that MD BB, contacted him about transferring P#1 to the sister facility. MD FF did not believe that P# 1 needed to be transferred to the sister facility and felt that the facility could handle the case from his standpoint. He was aware that P#1 was 18 years old and 11 weeks pregnant with an increased bilirubin; but that P#1 did not need a higher level of care.

MD FF explained that the facility could have admitted and observed P#1 and repeat the laboratory tests in the morning to see if there was a stone in the bile duct. He did not understand why the facility would not admit and observe P#1 at the facility. He stated that gastroenterology (GI) generally did not perform ERCPs for pregnant patients with gallstones. MD FF did not feel the bilirubin level at 3.0 was that high. He was aware that P#1 had been in the ED six (6) days earlier for hydration. MD FF did not consider P#1 high-risk but said that there was an issue with MDs being concerned about caring for pregnant patients.

A phone interview was conducted on 8/14/24 at 1:30 p.m. with the Emergency Room Medical Director (MD) GG. MD GG stated that he relied on the ED physicians to make decisions about consults and admissions. He believed that when an ED physician consulted an on-call MD, the level of willingness varied between this facility and the sister facility. They are trying to work on the "culture" between the facilities. MD GG further explained that the hospitalists often handle the medical admissions at the sister facility, where they will consult the other specialists. MD GG said that this facility could do this.

MD GG recalled speaking with MD BB about P#1 when MD BB was getting "push-back" from the on-call physicians. MD BB believed that P#1 needed to be admitted because she was high-risk and agreed to the referral to the outside facility and "let it play out." MD GG explained that he expected the facility to be able to handle P#1 but that the on-call physicians would not admit her, so the transfer was necessary for P#1 care. MD GG made MD HH aware of the situation.

During an interview on 8/14/24 at 2:43 p.m. in the conference room, Compliance Officer (CO) II explained that he was the individual who self-reported the potential Emergency Medical Treatment and Labor Act (EMTALA) violation on the Centers for Medicare and Medicaid Services (CMS) website. CO II recalled that he was first informed of the potential violation when a Risk Manager heard about it and reported it to CO II.

CO II recalled that he began an investigation immediately which included reviewing the chart, interviewing individuals involved, and reviewing the policies regarding EMTALA. CO II recalled that at the end of the investigation, he felt that the facility had the capacity to admit the patient for further evaluation even though the patient did get a medical screening examination and a stabilization treatment. CO II said that the transfer may not have been appropriate. CO II said that after reporting the potential EMTALA violation, he has been coordinating with the executive medical staff and realizing areas for opportunities for improved physician communication and how to handle appropriate admissions and transfers. CO II said that meetings are being scheduled and that education will soon be dispersed to all physicians once they are available.

An interview was conducted in the facility's classroom A on 8/14/24 at 2:00 p.m. with Emergency Room (MD) BB, who cared for P#1 on 7/31/24. MD BB recalled that P#1 presented with pregnancy, tachycardia, right upper quadrant pain, elevated liver function tests, biliary pathology, and hyperemesis (persistent nausea and vomiting that may occur during pregnancy). He felt that something more was going on than just the pregnancy and ordered the ultrasound, labs, fluids, anti-emetics (medication used to prevent nausea and vomiting). He did the Magnetic Resonance Cholangiopancreatography (MRCP) (medical imaging used to visualize biliary and pancreatic ducts) to make sure P#1 did not have choledocholithiasis and the test results were negative.

MD BB remembered discussing the case with the on-call surgeon twice, thinking P #1 might be surgical. He explained that MD DD wanted the OB/GYN MD to admit P#1 because she was pregnant. MD BB explained that it was the "perfect storm" where it was possibly surgical. The hospitalist doesn't generally touch pregnant patients, and the OB/GYN MD generally doesn't see patients under 20 weeks. It's the facility's culture, which is different from his experience at other facilities. MD BB explained that this situation would not have occurred if P#1 had presented to the sister facility. Generally, the OB/GYN and surgeons at the sister facility would have admitted the patient.

MD BB remembered speaking to MD FF, the surgeon at the sister facility. MD FF told MD BB that he felt they could handle the case at their facility, which is why MD FF refused the transfer. MD BB explained that he could not hold P#1 for observation because he was the only MD in the ER. If something serious came in, he could not adequately oversee P#1's care, and that was why he wanted her admitted. He was concerned that more was going on due to her tachycardia and laboratory test and felt she could not be safely discharged.

MD BB stated that when the on-call physicians refused to admit, he called MD GG, who then called CMO HH. CMO HH advised that P#1 be transferred elsewhere. MD BB stated that he shared his concerns about a possible EMTALA violation with MD GG.

A review of 13 medical records (P#1, P#3, P#4, P#5, P#6, P#8, P#10, P#12, P#13, P#15, P#16, P#17, and P#18) failed to reveal a signed physician certification for transfer.

During an interview on 8/14/24 at 10:25 a.m. in the conference room, Emergency Room (ER) Manager (ERM) JJ said that when patients are transferred, they are given a general ER packet for transfer. ERM JJ said that the ER did not use the same transfer packet that is used in the Labor and Delivery or Obstetrics (OB) unit which contained a Physician Certification for Transfer Form. ERM JJ said that he was not sure why the ER did not use the form and said that this may be something they should include as well.