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Based on observation, interview, and record review, the hospital failed to comply with the provisions of 42 CFR 489.24 for one of 20 sampled patients (Patient 1) who was brought to the hospital's ED by paramedic ambulance, seeking emergency medical treatment as evidenced by:

The hospital failed to appropriately transfer Patient 1 to another acute care hospital (Hospital B) for further stabilizing of the patient's emergency medical condition when the hospital did not obtain the acceptance from Hospital B prior to the transfer and did not send a copy of the patient's medical record at the time of transfer or as soon as possible afterwards. In addition, there was no physician's documentation to show the medical benefits outweighed the risks to the patient from the transfer. Cross reference to A2409.

Based on interview and document review the hospital failed to appropriately transfer one of 20 sampled patients (Patient 1) to another acute care hospital for further stabilizing treatment of the patient's emergency medical condition. Patient 1 was brought to the hospital's ED due to bleeding from a right arm laceration. The hospital did not obtain the acceptance, including the name of the accepting physician from Hospital B prior to the transfer and did not send a copy of the patient's medical record at the time of transfer or as soon as possible afterwards. In addition, there was no physician documentation to show the medical benefits outweighed the risks to the patient from the transfer. These failures created the risk of poor health outcomes to the patients.

Findings:

On 7/17/17, Hospital B reported to the Department an alleged EMTALA violation by the hospital (Hospital A). The report showed on 7/5/17, Hospital B's trauma center received a patient via 911 ambulance from Hospital A without an accepting physician from their facility.

An unannounced onsite visit was conducted at Hospital A beginning on 8/28/17.

Review of the hospital's P&P Patient Transfers to an equal or Higher Level of Care-EMTALA 6/25/16, showed:

Policy 2.6 - Transfer of a patient with an emergency medical condition will not occur until the condition is stabilized, unless the individual requests the transfer or a physician certifies in writing that the medical benefits outweigh the risks to the individual from the transfer. Transfer of Patient with an emergency medical condition 3.3.4, the following documentation is required:

- Transfer Acknowledgement and consent, and
- Patient Transfer Information

Review of the Orange County EMS Agency's P&P titled Interhospital Emergency Patient Transfer Guidelines showed, "Immediate Retriage (Call-Continuation)" was defined as the retriaging PRC (paramedic receiving center) physician has determined that an emergency medical technician-paramedic escorted critical patient requires the specialty capabilities of a designated specialty center and that the emergency medical technician-paramedics are still on premises, and that the retriaging physician may request that those emergency medical technician-paramedics immediately transport the patient to the appropriate Orange County EMS designated specialty receiving center."

The ED was toured on 8/28/17 beginning at 0915 hours, accompanied by the hospital's Base Station Coordinator.

The radio room where the MICN managed the radio calls was observed at 0950 hours. When asked, the Base Station Coordinator confirmed the hospital's MICN received the paramedic call about Patient 1 on 7/5/17. The Base Station Coordinator stated the MICN considered sending Patient 1 to a Trauma Center. The MICN's decision to have the patient transported to the hospital was based on the fact the patient did not meet the trauma criteria due to the patient's injury site not being above the elbow. As Patient 1's injury was at the elbow, the MICN felt the vascular surgeons at the hospital could handle the patient's case.

During an interview with ED RN 2 on 8/28/17 at 0958 hours, the RN was asked about the ED procedure when the patient required the transfer to another acute care hospital. RN 2 stated the ED MD contacted the receiving hospital to request a transfer as the ED MD had to obtain the name of the physician who agreed to accept care of the patient. RN 2 stated if the patient was unable to give the consent due to unstable medical condition, two MDs usually signed and documented the benefits of the transfer outweighed the risks. RN 2 provided the form "Patient Transfer Information" for review and stated the physician completed this form.

Review of the transfer form showed the areas for the physician to document the reason for transfer, name of the receiving hospital, and name of the receiving physician with the time/date of consent to accept. If the patient was not deemed stable, the physician was directed to complete the Physician Certification to show the benefits and risk of transfer were explained to the patient. The transferring physician and consulting physician were to sign this form.

Patient 1's medical record from Hospital A was reviewed beginning on 8/28/17. Documentation showed Patient 1 was bought in to the Hospital A's ED by the paramedic ambulance on 7/5/17 at 0215 hours. The MICN's narrative documentation showed Patient 1 had an avulsion laceration to the right AC space.

MD 1 documented in the H&P that MD 2, a vascular surgeon was emergently notified and arrived to the ED to evaluate the patient. After MD 2 evaluated the patient, MD 2 instructed the staff to call 911 to send the patient to the trauma center. The trauma center was notified of the 911 transfer for higher level of care initiated by MD 2.

Documentation by MD 2 showed the patient was intubated with an ET tube and was being appropriately resuscitated. There was evidence of significant bleeding and a pressure bandage was on the patient's right arm. MD 2 advised to transfer the patient to the trauma center for trauma assessment and management of penetrating injury to the arm as per the county trauma criteria.

RN 1 documented on 7/5/17 0317 hours, Patient 1 left the ED via ambulance with the hospital's RN to the trauma center at Hospital B.

However, further review of the medical record showed no documented evidence the transfer form was completed for Patient 1 as per the hospital's P&P.

Review of Patient 1's medical record from Hospital B showed the hospital was contacted at 0230 hours on 7/5/17, by Hospital A's ED MD 1 regarding a patient with a significant injury to the right AC space. Hospital A's vascular surgeon had been notified; "per (MD A) the patient is not accepted as an IFT because of vascular issue, can be addressed by Hoag vascular MD."

Documentation showed at 0315 hours, Hospital B was "notified by (Hospital A) ED MD 1 that the vascular surgeon refusing to Tx the patient, calling 911 to send Pt (patient) to Hospital B. Report indicated Pt is intubated, tourniquet in place to RUE (right upper extremity) ... RN to come with patient." The patient arrived at Hospital B on 7/5/17 at 0336 hours. The admission assessment at Hospital B showed the patient arrived with a deep laceration to the right AC space.

Hospital B's OR document showed Patient 1 was in the OR on 7/5/17 from 0457 to 0745 hours, for the right arm exploration, evacuation of hematoma (a localized collection of blood outside the blood vessels, due to a trauma or injury that may involve blood continuing to seep from broken capillaries), repair of the brachial artery (the main arterial supply of the upper limb providing the blood supply to nearly all of its structures) with interposition and graft placement (a surgical procedure performed to redirect blood flow from one area to another by reconnecting blood vessels), ligation of the venous bleeding (a surgical procedure to clamp and seal a bleeding vessel), thrombectomy (the emergency removal of a blood clot or blood clots from the body), and ligation of the saphenous vein (a surgical procedure to clamp and seal the large venous blood vessel running near the inside surface of the leg from the ankle to the groin).

A telephone interview was conducted with Hospital B's staff, RN A, on 8/28/17 at 1315 hours. RN A who was the RN Trauma Coordinator confirmed he was contacted at approximately 0230 hours on 7/5/17, by ED MD 1 from Hospital A. RN A stated MD 1 informed him of the patient with traumatic injury to the right AC space with a tourniquet in place and no distal pulse. MD 1 requested an accepting MD at Hospital B for a transfer. RN A stated he then spoke with MD A who was the trauma surgeon on duty. RN A stated MD A had refused the transfer as it was a vascular issue. RN A stated MD A informed him that the patient's injury did not meet the "above the elbow" criteria for trauma as per the Orange County EMS's guidelines. MD A felt Hospital A's vascular surgeon could perform the surgery.

When asked if a copy of Patient 1's medical record from Hospital A was transported with the patient, RN A stated no, only the verbal report was given by the RN accompanying the patient.

RN 1 from Hospital A was interviewed on 8/29/17 at 0805 hours. RN 1 confirmed she was the primary RN assigned to Patient 1 upon the arrival to the ED. RN 1 stated the MICN at the Base Station located in Hospital A directed the patient to their ED. RN 1 stated MD 2 came quickly to evaluate the patient but stated he did not know why the patient was brought to the ED, not to the trauma hospital. RN 1 stated the paramedics who brought Patient 1 had left sometime after MD 2 arrived.

MD 1 from Hospital A was interviewed on 8/28/17 at 0830 hours. MD 1 stated Patient 1 arrived at the ED on 7/5/17 at 0215 hours. MD 1 stated the patient had punched the plate glass window and sustained the right arm laceration. When brought in by the paramedics, the patient was hypotensive (low blood pressure). The BP cuff was applied as a tourniquet. The IV lines were inserted, blood was transfused, and medications were administered to maintain the patient's BP. MD 1 stated many things were happened at the same time. MD 1 stated he called Code 99 and a Code RBC. MD 1 explained Code 99 was an immediate alert that the patient might be going to the OR, to gather the needed OR staff. When asked if the OR staff responded to the code, MD 1 stated he thought the surgical technician came at some point. MD 1 stated he was not sure about the anesthesiologist.

MD 1 stated he called Hospital B's trauma center. MD 1 stated the Trauma Coordinator RN informed him the trauma surgeon did not feel the patient met the trauma criteria as it was a vascular case.

MD 1 stated he then called the hospital's on-call vascular surgeon, MD 2 who was enroute. He informed MD 2 Hospital B's trauma center had refused to accept the patient. MD 1 stated after MD 2 came to evaluated the patient, he again called Hospital B's trauma center, spoke with the RN Coordinator, and told the RN Coordinator he wanted to do a "continuation run." When asked if he requested to speak directly with the trauma surgeon at this time, he stated "no, at this facility you only get to speak to the trauma coordinator, not the MD." MD 1 stated when he informed the RN Coordinator of the transfer, he was not told "no" and got the feeling that they were not unhappy with the understanding that the patient was coming to them.

MD 1 stated he activated a "Call Continuation of a paramedic run" per the Orange County EMS's guidelines. MD 1 stated the stabilization of the patient took time in couple of hours. When asked if the paramedics were still on site during the stabilization, MD 1 stated the paramedic team had left the hospital as they were needed in the field. MD 1 stated he had transferred the patients this way several times before, "In my mind, this was a continuation and the patient needed to be moved on."

When MD 1 was asked about the need for the accepting MD at Hospital B for the transfer, MD 1 stated he was not told "no" for the second time, it was a casual conversation, they said "OK." MD 1 stated he did not think he needed the accepting MD. MD 1 stated he thought Hospital B's Trauma Center knew that he was asking for a "Call Continuation."

When asked, MD 1 stated MD 2 did not talk to Hospital B's trauma center, but if Hospital B had said no for the second time, there would have been an option to consider. When asked why the Interfacility Transfer form was not completed for Patient 1, MD 1 stated he did not feel it was a transfer, but stated again the transfer was a "Continuation Run."

When asked if he had received any training regarding the EMTALA regulations, MD 1 stated he did when he was recertified and the last time was seven years ago.

MD 2 was interviewed on 8/29/17 at 0900 hours. MD 2 stated he was the on-call vascular surgeon on 7/5/17, for Patient 1. MD 2 stated his background was a trauma surgeon prior to specializing in vascular surgery.

MD 2 stated he received a call from the ED physician, MD 1, regarding Patient 1 on 7/5/17 at approximately 0300 hours. He was told the patient had a penetrating injury above the elbow. MD 2 stated he told MD 1 the patient should go to a trauma center. When he was enroute, he was called and told the trauma center refused the patient as the patient's injury was not above the elbow. When asked, MD 2 stated the AC injury was above the elbow and met the trauma criteria as the arm was at risk for no blood flow. There was no pulse and the patient's BP was low.

MD 2 stated when he evaluated Patient 1 in the ED, he did not directly see the patient's injury as the patient had the BP pressure cuff applied as a tourniquet and the pressure dressing was on the injured arm. Even with the pressure management, MD 2 stated there was still some blood seepage. MD 2 stated he felt it would be best for the patient to be also evaluated by other specialists; for example, the hand/orthopedic specialist to evaluate for other injuries besides the vascular damage. MD 2 stated he did not feel comfortable to perform the surgery for Patient 1 without the hand surgeon to evaluate the patient. When asked, MD 2 stated he was not aware that MD 1 had not spoken directly to Hospital B's trauma surgeon when requesting the transfer.

When asked, MD 2 stated he did not write the detailed note regarding Patient 1 as the hospital's dictation system was down, He had to write a narrative directly into the electronic health record. MD 2 stated, "He did not fill out an Interfacility Transfer form as this was not a transfer." MD 2 stated he later wrote the more detailed note in his office chart for Patient 1.

When asked if he was familiar with the 911 transfer continuation protocol, MD 2 stated no. MD 2 was asked if he had received education regarding the EMTALA regulations. MD 2 stated he had not and was not familiar with the EMTALA transfer requirements. MD 2 stated he thought the EMTALA regulations addressed the admitted patients.

During an interview with the Director of Patient Safety and Compliance on 8/28/17 at 1100 hours, the Director of Patient Safety and Compliance confirmed Patient 1's medical record did not contain the "Patient Transfer Information" form used for interfacility transfers.

During an interview with Hospital A's ED Educator on 8/29/17 at 1000 hours, he stated the hospital assigned one RN who went with Patient 1 on the 911 ride on 7/5/17. However, due to the urgency of the transfer, the RN only took some documents such as the blood transfusion slips and RN A's hand written notes to the trauma center. The copy of the complete medical record for Patient 1 was not sent to the trauma center at Hospital B at the time of transfer or at any time after the patient had left the hospital.