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Based on interview and record review, it was determined the facility failed to comply with Section 489.24(5)(3)(f). The facility failed to accept the transfer for one (1) patient, in the selected sample of twenty (20) patients (Patient #1), for further medical examination and treatment which was within the capabilities of the staff and the facilities available at the recipient Hospital (#2), to determine whether an unstable Emergency Medical Condition (EMC) existed.

Additionally, Hospital #2 failed to comply with Section 489.24(5)(3)(f), by refusing to provide further treatment for Patient #1 at the request of Hospital #1's Emergency Department (ED) Physician, patient's Primary Care Physician (PCP), and the request of Patient #1 and his/her family to ensure the patient's condition did not further deteriorate. On 04/07/18, Patient #1 presented to Hospital #1's ED with a complaint of sudden onset of severe pain in the lower abdominal region of the umbilicus, and he/she had a large hernia that has caused ongoing problems, which resulted in the patient becoming increasingly short of breath on this date. Patient #1 received a Medical Screening Examination (MSE) by Hospital #1's ED Physician, who also ordered a Computed Tomography (CT) scan without contrast of the abdomen, Complete Blood Count (CBC), and Comprehensive Metabolic Profile (CMP). Review of the CT scan indicated there was no evidence of an incarcerated hernia; however, evaluation of the soft tissue organs was limited without contrast. The ED Physician and the PCP requested for Patient #1 to be transferred to Hospital #2 for a surgical consultation; however, the recipient Hospital #2 failed to accept the appropriate transfer of Patient #1, which exhibited delay in examination and further medical treatment. It was determined Hospital #2 failed to meet the Federal Requirements of an EMTALA.

Refer to A-2408 and A-2411

Based on interview, record review, and review of Hospital #2's EMTALA policy, it was determined the hospital failed to accept an appropriate transfer for one (1) patient, in the selected sample of twenty (20) patients (Patient #1), with a delay in providing examination and treatment in an unstable emergency medical condition.

Patient #1 went to the Emergency Department (ED) of Hospital #1, on 04/07/18, for a complaint of severe pain in the lower abdominal region of the umbilicus. Patient #1 received a Medical Screening Examination (MSE) including a Computed Tomography (CT) scan of the abdomen. The ED Physician consulted with Patient #1's Primary Physician, and it was determined Patient #1 required further medical treatment to include a surgical consultation, which exceeded the capabilities of the referring hospital. Patient #1's Primary Physician requested he/she be transferred to Hospital #2. The ED Physician contacted the recipient Hospital #2, and spoke with the general surgeon on-call and informed him of Patient #1's condition and need of a surgical consultation. The recipient Hospital #2 refused to accept an appropriate transfer which delayed further medical treatment for Patient #1. The ED Physician at the transferring Hospital #1 was advised to contact Hospital #3. The referring Hospital ED Physician contacted the on-call surgeon at Hospital #3 and informed him of the need to transfer Patient #1, and the general surgeon on-call at Hospital #3 agreed to accept Patient #1.

The findings include:

Review of Hospital #2's policy, Emergency Medical Treatment And Labor Act (EMTALA), revised 01/19/17, revealed a hospital that has specialized capabilities or facilities 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. The hospital shall not delay the provisions of a medical screening examination, further treatment, or appropriated transfer of the individual to inquire about the individual's method of payment or insurance status.

Review of Patient #1's medical record from the transferring ED of Hospital #1 revealed, on 04/07/18 at approximately 3:21 PM, Patient #1 entered the ED for a complaint of severe pain in the lower abdominal region of the umbilicus. The patient revealed he/she had a large hernia which had caused ongoing problems, indicating the pain was of sudden onset and resulted in him/her becoming short of breath. Patient #1 received a Medical Screening Examination (MSE), and was also ordered a Computed Tomography (CT) scan without contrast of the abdomen, a Complete Blood Count (CBC), and a Comprehensive Metabolic Profile (CMP). Review of the CT scan indicated there was no evidence of an incarcerated hernia; however, evaluation of the soft tissue organs was limited without contrast.

Interview with ED Physician (#4), on 04/26/18 at 10:10 AM, revealed Patient #1 complained of abdominal pain that was "so intense" it caused the patient to be short of breath. The ED's Physician (#4) stated, "During the physical exam, I was really concerned because the patient was guarded of the abdomen, especially at the peri-umbilical area. Patient #1's history revealed he/she had a previous surgery to repair an umbilical hernia with mesh, and my concern was a possible bowel obstruction. I contacted the patient's Primary Care Physician (Physician #3), reviewed the case with him, and he specifically requested for Patient #1 to be referred for a surgical consultation at Hospital #2. Patient #1 had previously been treated at Hospital #2, and it was the choice of the patient and his/her family to be transferred there. I made contact with the general surgeon on-call at Hospital #2 at approximately 7:30 PM. I explained my concern about Patient #1's condition, treatment received here at Hospital #1, contact made with Physician #3, and the need to transfer the patient to Hospital #2 for a surgical consult; however, after I gave Patient #1's name, the surgeon on-call was well versed with Patient #1's history. He (Physician #2) informed me Patient #1's surgery (hernia surgery with mesh) was done by a former surgeon at Hospital #3, and advised me to get in touch with that Doctor, that he would not accept the patient". Physician #4 revealed the on-call center at Hospital #3 was contacted, and he was connected to the on-call surgeon, discussed Patient #1's condition with Physician #5, who agreed to accept Patient #1 for consult and evaluation.

Interview with Physician (#3) at Hospital #1, on 04/25/18 at 9:35 AM, revealed he was Patient #1's Primary Care Physician (PCP). Interview revealed he was contacted by Physician #4, on 04/07/18, and informed the patient was in the ED of Hospital #1 for complaints of intense abdominal pain. Interview revealed Patient #1 was having more abdominal pain than normal and after consulting with Physician #4 felt the pain was a new onset due to the severity. Physician #3 stated, "I requested the patient be transferred to Hospital #2 for surgical consultation. The patient had been treated at Hospital #2 previously, and they (Hospital #2) would be familiar with the history of the patient. My concern was the patient may have a bowel obstruction or strangulated hernia, just based on the sudden onset of severe pain. This was new for him/her, and the patient needed to be at a hospital in the event surgical intervention was required".

Interview with Physician #2 at Hospital #2, on 04/25/18 at 12:30 PM, revealed he received a call from the ED Physician at Hospital #1, on 04/07/18, requesting to transfer Patient #1. Interview revealed Patient #1 had a hernia repair which was done by a retired Surgeon at Hospital #3. Physician #2 stated, "although the Primary Surgeon involved was retired, the surgical group he was affiliated with at Hospital #3 would be familiar with the patient care needs". Interview revealed Physician #2 did not feel transfer was an emergent situation and wanted to ensure Patient #1 was followed under affiliation of the Primary Surgeon's group for continuity of care; therefore, Physician #2 did not accept the transfer.

Interview with Physician #5 (Hospital #3) by phone, on 04/25/18 at 10:32 AM, revealed he was the Surgeon on-call 04/07/18. Interview revealed, at approximately 7:00 PM on 04/07/18, he was contacted by Physician #4 who informed him of Patient #1's condition and requested to transfer Patient #1 to Hospital #3. Further interview revealed Physician #5 was concerned Patient #1 had a strangulated hernia and/or possible bowel obstruction; therefore, he agreed to accept the patient. Physician #5 stated, "I thought Patient #1 may be having an emergency medical condition and may require emergency surgery".

Based on interview, record review, and review of Hospital #2's EMTALA policy, it was determined the hospital failed to accept an appropriate transfer for one (1) patient, in the selected sample of twenty (20) patients (Patient #1).

On 04/07/18, Patient #1 went to the Emergency Department (ED) of Hospital #1 for a complaint of severe pain in the lower abdominal region of the umbilicus. Patient #1 received a Medical Screening Examination (MSE) including a Computed Tomography (CT) scan of the abdomen. The ED Physician consulted with Patient #1's Primary Physician, and it was determined Patient #1 required further medical treatment to include a surgical consultation, which exceeded the capabilities of the referring hospital. Patient #1's Primary Physician requested he/she be transferred to Hospital #2. The ED Physician contacted the recipient Hospital #2, spoke with the general surgeon on-call and informed him of Patient #1's condition and need of a surgical consultation. The recipient Hospital #2 refused to accept an appropriate transfer. The ED Physician at the transferring Hospital #1 was advised to contact Hospital #3. The referring Hospital ED Physician contacted the on-call surgeon at Hospital #3 and informed him of the need to transfer Patient #1, and the general surgeon on-call at Hospital #3 agreed to accept Patient #1.

The findings include:

Review of Hospital #2's EMTALA policy, "Duty Of Receiving Hospital To Accept Transfers", revised 01/19/17, revealed a hospital that has specialized capabilities or facilities 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.

Review of Patient #1's medical record from the transferring ED of Hospital #1 revealed, on 04/07/18 at approximately 3:21 PM, the Patient entered the ED for a complaint of severe pain in the lower abdominal region of the umbilicus. The patient revealed he/she had a large hernia which had caused ongoing problems indicating the pain was of sudden onset and resulted in him/her becoming short of breath. Patient #1 received a Medical Screening Examination (MSE), who also ordered a Computed Tomography (CT) scan without contrast of the abdomen, a Complete Blood Count (CBC), and a Comprehensive Metabolic Profile (CMP). Review of the CT scan indicated there was no evidence of an incarcerated hernia; however, evaluation of the soft tissue organs was limited without contrast.

Interview with ED Physician (#4), on 04/26/18 at 10:10 AM, revealed Patient #1 complained of abdominal pain that was "so intense" it caused the Patient to be short of breath. The ED's Physician (#4) stated, "During the physical exam, I was really concerned because the Patient was guarded of the abdomen, especially at the peri-umbilical area. Patient #1's history revealed he/she had a previous surgery to repair an umbilical hernia with mesh, and my concern was a possible bowel obstruction. I contacted the Patient's Primary Care Physician (Physician #3), reviewed the case with him, and he specifically requested for Patient #1 to be referred for a surgical consultation at Hospital #2. Patient #1 had previously been treated at Hospital #2, and it was the choice of the patient and his/her family to be transferred there. I made contact with the general surgeon on-call at Hospital #2 at approximately 7:30 PM. I explained my concern of Patient #1's condition, treatment received here at Hospital #1, contact made with Physician #3, and the need to transfer the patient there (Hospital #2) for a surgical consult; however, after I gave Patient #1's name, the surgeon on-call was well versed with Patient #1's history. He (Physician #2) informed me Patient #1's surgery (hernia surgery with mesh) was done by a former surgeon at Hospital #3, and advised me to get in touch with that Doctor, that he would not accept the Patient". Physician #4 revealed the on-call center at Hospital #3 was contacted, and he was connected to the on-call surgeon, discussed Patient #1's condition with Physician #5, who agreed to accept Patient #1 for consult and evaluation.

Interview with Physician #3 at Hospital #1, on 04/25/18 at 9:35 AM, revealed he was Patient #1's Primary Care Physician (PCP). Interview revealed he was contacted by Physician #4, on 04/07/18, and informed the patient was in the ED of Hospital #1 for complaints of intense abdominal pain. Interview revealed Patient #1 was having more abdominal pain than normal and after consulting with Physician #4 felt the pain was a new onset due to the severity. Physician #3 stated, "I requested the patient be transferred to Hospital #2 for surgical consultation. The patient had been treated at Hospital #2 previously, and they (Hospital #2) would be familiar with the history of the patient. My concern was the patient may have a bowel obstruction or strangulated hernia, just based on the sudden onset of severe pain. This was new for him/her, and the patient needed to be at a hospital in the event surgical intervention was required".

Interview with Physician #2 at Hospital #2, on 04/25/18 at 12:30 PM, revealed he received a call from the ED Physician at Hospital #1, on 04/07/18, requesting to transfer Patient #1. Interview revealed Patient #1 had a hernia repair which was done by a retired Surgeon at Hospital #3. Physician #2 stated, "although the Primary Surgeon involved was retired, the surgical group he was affiliated with at Hospital #3 would be familiar with the patient care needs". Interview revealed Physician #2 did not feel transfer was an emergent situation and wanted to ensure Patient #1 was followed under affiliation of the Primary Surgeon's group for continuity of care; therefore, Physician #2 did not accept the transfer.

Interview with Physician #5 (Hospital #3) by phone, on 04/25/18 at 10:32 AM, revealed he was the Surgeon on-call 04/07/18. Interview revealed, at approximately 7:00 PM on 04/07/18, he was contacted by Physician #4 who informed him of Patient #1's condition and requested to transfer Patient #1 to Hospital #3. Further interview revealed Physician #5 was concerned Patient #1 had a strangulated hernia and/or possible bowel obstruction; therefore, he agreed to accept the patient. Physician #5 stated, "I thought Patient #1 may be having an emergency medical condition and may require emergency surgery".

The medical records from Hospital #3 for Patient #1 were obtained and reviewed. Review of the Physician Discharge Summary by Physician #5, dated 04/10/18 at 11:26 AM, revealed Patient #1 resided at a long-term care facility. On the day of admission, 04/07/18, Patient #1 complained of severe abdominal pain and was taken to Hospital #1's ED for evaluation. The Physician (#4) there felt the Patient may have had a recurrent umbilical hernia and requested transfer to a higher level of care. There was a palpable mesh in the abdominal wall at the level of the umbilicus, but no evidence of a recurrent hernia. Review of the CT scan from Hospital #1 confirmed the finding and no other acute findings were noted in the abdomen. A note was made that this was chronic and stable.