HospitalInspections.org

Based on interview and record reviews it was determined the facility failed to comply with 489.24 as evidenced by a failure of the facility to accept the transfer of Patient#21from a facility they had a transfer agreement with and failed to coordinate their response regarding Patient #21, who had a previous medical history with the facility.

Based on document review, medical record review, and interview, the hospital failed to accept the transfer of 1 of 2 (Patient #21) patients reviewed that involved a request for transfer to the facility. Hospital #2, who had a Transfer Agreement with Hospital #1, a Critical Access Hospital, failed to coordinate their response regarding patient #21, who had a previous medical relationship with Hospital #2. Hospital #2 is a tertiary care center that offers Obstetrics and Cardiology services.

The findings included:

1. Review of the Rules and Regulations of the Medical Staff for Hospital #2 adopted 12/1/09 revealed on pages 28 and 30 under the heading of Emergency Services, "Each physician shall cover services in his/her specialty or in the field in which he/she has privileges, except in an emergency situation ... Each patient who is transferred from another acute care facility/Emergency Department to [Hospital #2] shall be directly admitted unless (1) the physician at [Hospital #2] who has accepted the patient makes a direct verbal request that the Emergency Department examine the patient upon his/her arrival; or (2) the condition of the patient has become an emergency during transfer."

2. Review of the EMTALA GUIDELINES policy for Hospital #2 last reviewed 6/9/10 revealed, "This policy specifically applies to the Emergency Department and Labor & Delivery Department of the hospital ... EMTALA obligations include: To accept appropriate transfers of individuals with emergency medical conditions if [Hospital #2] has specialized capabilities not available at the transferring hospital ... policy applies to all emergency Department staff members, all Labor & Delivery Department staff members, and all Medical Staff members who are performing Emergency Department/Labor & Delivery Department 'on call' responsibilities pursuant to [Hospital #2] Medical Staff Bylaws."

3. Review of the Transfer Agreement between Hospital #1 and Hospital #2 revealed, "...to facilitate the continuity of care and timely transfer of patients and records from [Hospital #1] to [Hospital #2] in the event that a patient ' s physician determines a transfer is medically necessary ... agree as follows: 1. Transfer of Patients. Whenever a patient's attending physician determines that it is medically necessary to transfer the patient from [Hospital #1] to [Hospital #2], [Hospital #2] agrees to accept and admit the patient as promptly as possible, provided admission requirements are met and bed space to accommodate the patient is available. Such transfers shall be made in accordance with normal policies and procedures of [Hospital #2], as well as federal and state laws and regulations."

4. Review of the facility's Internet website revealed, "March 29, 2010 [Hospital #2] NAMED ONE OF THE NATION'S 100 TOP HOSPITALS ...is the largest hospital between [name of city in Tennessee] and [name of city in Alabama] offering a vast array of specialty services, including a Cancer Center, Heart Center, Neonatal Intensive Care Unit, Women's Center and Wound Center. In addition, the medical center offers critical care ... has a medical staff of more than 185 physicians. From a comprehensive interventional and surgical heart program with chest pain center accreditation to a neonatal intensive care and cancer center, the medical center offers a wide range of advanced services ... OB/GYN Services ... fourth floor centralizes our labor/delivery, nursery, neonatal intensive care, and obstetrics units ... Heart Services ... provides a comprehensive array of cardiac services ... From interventional procedures to our partnership with [a facility name] to provide cardiothoracic surgery, we have a highly skilled and experienced team ..."

5. Review of the Emergency Department (ED) medical record from Hospital #1, a 25 bed Critical Access Hospital, for Patient #21, revealed the patient was seen in that ED on 9/11/10.
The record contained a form from a drug treatment center stating Patient #21 was being referred to Hospital #1 for chest pain, irregular heart beat and hurting in her stomach.
Page 1 of the Emergency Department Record titled Primary Nurse Assessment documented the patient was triaged at 1810 with the chief complaint as upper abdominal pain, low abdominal pain since last PM, anxious, and cough. Additional information documented on the page included, valve problem, smokes 1/2 pack cigarettes daily, heart arrhythmia, drug abuse but clean for 9 months, Gravada 3 Para 2 and 5 1/2 months pregnant. B/P 128/80, pulse 106 and irregular, respirations 18, temperature 97.2, oxygen saturation 96%, no acute distress. The patient was triaged as "Urgent."

The lower portion of page 2 of the Emergency Department Record documented, "Transfer... Condition Improved... Discharge Pain 0 [zero]... Discharged Via Stretcher... ER Level 4." That page was signed by Physician #1. Discharge time was documented as 2218.
The Emergency Physician Record documented the patient was seen at 1900. The History of Present Illness section of the form documented the patient was 5 1/2 months pregnant and was sent from a drug treatment center for chest pain and irregular heartbeat, had a past medical history of heart arrhythmia and a cholecystectomy. She was taking no medications. Systems review documented she experienced fever, chills, nasal congestion, and cough for 2 weeks, had dyspnea on exertion, positive for shortness of breath, had had nausea, heartburn, esophageal reflux and flank pain. An EKG revealed a sinus rhythm with frequent premature ventricular complexes in a pattern of bigeminy, and had right atrial enlargement. A chest x-ray showed no evidence of acute cardiopulmonary disease. The cardiac profile was normal. A urine drug screen tested positive for cannabinoids. Physician #1 listed the following under clinical impression: chest pain, ventricular bigeminy, GERD, abdominal pain, UTI, high risk pregnancy. Physician #1 documented he had spoken by telephone with Physician #2, the cardiologist on call at Hospital #2, and with Physician #3 the obstetrician the patient had seen at Hospital #2. Documentation revealed Physician #2 had said she would "go on consult," and Physician #3 had recommended referring the patient to a maternal fetal group in another city. Handwritten along the side of page 2 of the form was, "Transfer to [Hospital #3]." Handwritten along the bottom of the same page was, "[Physician #4] refuses to accept transfer to [Hospital #2]." A Transfer Information Form was present in the record that documented the patient would be transferred to Hospital #3 by ambulance to Physician #5 as the receiving physician. The reason for transfer was documented as Inability to Provide Service.
There was no evidence in the record to indicate the patient was admitted to the Hospital 1 as an inpatient or moved from the ED prior to transfer to Hospital #3. It could not be determined if the patient had been declared stable by the physician prior to request for transfer to Hospital #2 or the actual transfer to Hospital #3 as it was not documented in the record.

During an interview on 10/4/10, the Chief Nursing Officer and Hospital Administrator for Hospital #1 stated the patient needed to be transferred because she was a high risk pregnancy and Hospital #1 did not admit OB patients, and they do not have a cardiologist available on a regular basis.

During a telephone interview on 10/8/10, Physician #1 stated Patient #21 was in stable condition when he called Hospital #2 to ask about transferring her there. Physician #1 stated his intent was for her to be a direct admission to Hospital #2 because they had the means to monitor a high risk OB patient there, and they did not have the means to monitor a high risk OB patient at Hospital #1 When the hospitalist, Physician #4, at Hospital #2 refused to accept the patient, Physician #1 stated he spoke with an obstetrician at Hospital #3 who was on call for a maternal fetal group that Physician #3 had recommended and that the obstetrician agreed to accept the patient.

6. Review of an Emergency Medical Services ambulance run report documented on 9/11/10 Patient #21 was transported non-emergency mode from Hospital #1 to Hospital #3.

7. Review of Hospital #3's Obstetrical Emergency Department (OBER) record documented Patient #21 arrived on 9/11/10 at 2339. Triage level was not checked. EKG and a urinalysis were ordered. A verbal order by Physician #5 timed 0045, which would have been on 9/12/10, documented, "Admit to [Physician #6] inpt [inpatient] in tower." The Obstetrical Medical Screening Exam form documented the patient was seen by Physician #5 at 0021 and transferred to room #4308 at 0115. The Discharge Summary electronically signed by Physician #6 on 9/14/10 at 0706 revealed the patient was discharged on 9/13/10.

During a telephone interview on 10/4/10 at 12:35 PM, Physician #5 stated he received a telephone call from Physician #1 at Hospital #1 stating he had a patient that needed to be transferred. Physician #1 had told him he had spoken with Physician #3 at Hospital #2 and he had said he wanted to take the patient, but the hospitalist and cardiologist had both refused. Physician #6 stated he told Physician #1 he was not going to refuse to take the patient, but, that he thought this was an EMTALA. Physician #5 said he then called Physician #4, the hospitalist at Hospital #2, and was told by Physician #4 that he would not admit Patient #21 because they (Hospital #2) did not have the services/resources at to admit/treat this patient. Physician #5 stated he told Physician #4 he thought Hospital #2 could provide better care there since her cardiologist and obstetrician were both at Hospital #2 and they had access to her medical record. When Physician #4 again stated they did not have the resources to see this patient, so he would not admit her, Physician #5 said he told him he thought this was an EMTALA violation. During the interview, Physician #5 stated Hospital #2 was a large hospital, he felt sure they had a large OB department and that they advertise they are a cardiac center and perform open heart surgery, so he could not understand why they were not able to take the patient.

8. An on site visit made to Hospital #2 revealed there was no medical record for Patient #21 dated 9/11/10.

During an interview on 10/5/10 at 11:30 AM, Physician #4 stated that when Physician #1 called him the night of 9/11/10, he recalled Physician #1 stating he had a patient in the ED at Hospital #1 that was having chest pain and abdominal pain. Later in the conservation, Physician #1 added that the patient was 5 ? months pregnant and had a heart condition. Physician #1 had stated he had already spoken with Physician #2 who was willing to see the patient in consult if Physician #4 would admit her. Physician #4 stated he told Physician #1 he was not going to accept the patient without more information and asked if the patient was in labor. Physician #4 stated he then called Physician #2 and they discussed the patient. Physician #2 was unsure about admitting the patient. Physician #4 stated he told Physician #1 that he should be talking to Physician #3 since he was the obstetrician. Physician #4 said it was not clear to him if the patient was in labor, but Physician #1 had told him she was in sustained bigeminy. Physician #4 stated he Physician #1 that he did not admit high risk pregnant women with heart problems and told Physician #1 that the patient needed to go to a hospital that had the capability to do both maternal and fetal monitoring at the same time. He stated at Hospital #2 they do not have the capability to do that. During the interview, Physician #4 stated his specialty is Internal Medicine and he is not comfortable with admitting pregnant women with arrhythmias. He said even though he could have gotten a cardiac and OB consult, he was still ultimately responsible for her care and since she was a high risk pregnant patient with heart problems it was out of his realm of practice.

During a telephone interview on 10/5/10 at 11:55 AM, Physician #3 stated Physician #1 did not call to ask him to admit the patient, but to find out where he could send her. Physician #1 had already spoken with Physician #2 (the cardiologist) and she agreed to consult but Physician #4, (the hospitalist) would have to admit her. Physician #4 had refused to admit her because she was a high risk OB patient and needed to go to another city's hospital. Physician #3 stated he gave Physician #1 the name of a Maternal Fetal Group at Hospital #3 where he could refer the patient. Physician #3 stated he then called one of the Maternal Fetal Group physicians and gave her a report on the patient. Physician #3 stated that based on the report Physician #1 gave him, he did not think the patient was having an obstetrical problem but was having a cardiac problem.

During an interview on 10/5/10 at 2:15 PM, Physician #2 stated she had received a call from Physician #1 saying he had a pregnant patient having abdominal pain as her chief complaint. He reported she was very anxious and not having any real shortness of breath. The patient had told him she had congenital heart problems and mentioned she had seen a physician in group practice with Physician #2 in the past. Physician #2 stated, based on what Physician #1 had told her, she did not think this was a cardiac problem and she did not admit or treat high risk pregnancies. She said she did tell Physician #1 she would consult if Physician #4 admitted the patient.

During an interview on 10/6/10 at 1:00 PM, the Director of Risk Management for Hospital #2 stated when a physician in an outlying hospital needs to transfer a patient, it is best if they call and first speak with the ED physician. Surveyor telephonic interview revealed that neither of the 2 ED physicians remembered receiving a call from Physician #1 the night of 9/11/10 about Patient #21.

During a telephone interview on 10/7/10 at 4:40 PM, the Nurse Manager of Labor and Delivery for Hospital #2 stated in CCU they do not have the capability to monitor fetal heart tones continuously but stated a trained OB nurse could be sent to CCU with portable equipment to monitor periodically if need be.