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Based on review of physician written statements, facility policies and procedures, facility logs and physician on-call lists, Intensive Care Census records, Daily Census Summary, transfer process document (take this word out -facility data because I replace it with ICU census records and Daily Census Summary and transfer process, as you have it listed in the findings) , physician and staff interviews, and review of the transferring hospital's medical record (#21), it was determined that the facility failed to ensure compliance with 42 CFR 482.24 Special Responsibilities of Medicare Participating Hospitals in Emergency Cases.
Findings were:
Cross-refer to A2404 as it relates to the facility's failure to maintain an on-call list that accurately identified a physician on-call for vascular surgery services.
Cross-refer to A2411 as it relates to the facility's failure to accept an appropriate transfer of an individual (#21) on 4/22/2012 requiring the facility's specialized capabilities, and failure to document the basis for denial, as required by facility policy.

Based on review of the physician's on-call list, physician written statements, policies and procedures, physician interview, it was determined that the facility failed to maintain an on-call list that accurately identified the physician on-call for vascular surgery services.

Findings were:

The facility's policy #30110-212-09 entitled "Treatment and Transfer of Individuals in Need of Emergency Medical Services", date 12/06, Section K: On-Call Physicians, stipulated that the facility maintain a list of individual physicians who are on-call.

A review of the Emergency Department (ED) on-call log revealed that physician #2 was the vascular surgeon responsible for vascular surgery on-call coverage on 04-22-12.

An interview (interview #10) was conducted with physician #2 at 12:20 p.m. on 11/14/12 in the Administrative Conference Room. The interviewee stated that according to his/her records he/she was not on call for the vascular service practice on 04/22/12. He/she explained that the name recorded on the ED on-call list did not always reflect the correct name of the vascular surgeon taking call for the vascular surgery practice. The physician related that calls made from the ED to the number listed for the on-call physician would go to the practice answering service. The answering service would contact the correct physician on-call. This was supported by a written statement provided by the physician on 11/14/12. He/she also related that according to his/her practice records, physician #8 was responsible for providing on-call vascular surgery ED coverage on 04/22/12.

In a written statement provided to the surveyors on 11/19/12, physician #8 confirmed that he/she was on call for vascular surgery services on 4/22/12.

Based on review of a physician's written statement, facility policy and procedure, facility logs, Intensive Care Unit Census, Daily Census Summary, Transfer process document (Delete this -facility data), physician and staff interviews, and review of transferring hospital medical record #21, it was determined that the facility failed to accept an appropriate transfer of an individual on 04/22/12 requiring the facility's specialized capacity, and failed to document the basis for denial, as required by facility policy.

Findings were:

A review of policy #30110-212-09 entitled "Treatment and Transfer of Individuals in Need of Emergency Medical Services", dated 12/06, Section M: Obligation to accept Certain Transfers - Specialized Capacity, reflected that to the extent that the Hospital has specialized capabilities or facilities, that are not available at a facility that has requested the Hospital to accept the transfer of an individual needing those capabilities or facilities, the hospital should accept appropriate transfers of such individuals if the Hospital has the capacity to treat the individual. A request for transfer should be documented along with the response to the request, and the basis for any denial of such a request.

A review of patient #21's medical record from the transferring facility revealed that the patient 73 year old presented to the facility's emergency department (ED) via emergency medical system (EMS) ambulance on 4/22/2012, with a chief complaint of back pain and pain and numbness in the right leg. Diagnostic studies (ultrasound and CT scan) identified a massive aortic abdominal aneurysm (AAA - a swelling or bulging of the body's largest blood vessel, the aorta, in the abdominal area which can become life threatening if a rupture occurs) with rupture. Further documentation by the ED physician at the referring hospital revealed in part, " The patient appears to be cold, acutely ill appearing, and there is word from EMS that he spent the last 10 days in a tent in a campground. . . . Medical Decision Making: I (ED physician at referring hospital) felt the patient immediately needed to be transferred for definitive care, specifically surgery, but we needed a CT scan (specialized x-ray). .. Immediately I went to CT with him Blood pressure waxed and waned, sometimes going down to the 80 ' s and 90 ' s which required fluid boluses (rapid infusion of intravenous fluid), otherwise I would cut the fluid off so that we would not over resuscitate him causing him to bleed more. " The radiologist confirmed that the patient had a massive ruptured AAA with significant bleeding and no blood flow to the iliac arteries (arteries below the umbilicus that branch off the aorta to the left and right) of femoral arteries (vessels that supply blood to the legs). Additionally, the ED physician documented in part, " at 2:17 p.m., radiologist called me stating that there was evidence of COPD (Chronic obstructive Lung Disease- this disease limits airflow to and from the lungs causing shortness of breath) from the CT scan, coronary artery disease and left kidney appeared to be quite abnormal, and there was bleeding towards and around it. " The ED physician's documentation revealed that he/she contacted the vascular surgeon on-call at Saint Joseph's Hospital of Atlanta (SJHA). The physician (SJHA's on-call vascular surgeon) initially agreed to accept the patient, then questioned the availability of an on-call vascular surgeon at the transferring facility. SJHA's on-call vascular surgeon told the ED physician that the on-call vascular surgeon at the transferring facility would have to provide the patient's care. The hospital failed to accept an appropriate transfer of patient #21 who required the specialized vascular capability and capacity to treat this patient with an identified emergency medical condition on 4/22/2012. Patient #21 was finally accepted at another acute care hospital transported via helicopter and taken emergently surgery.
The transferring facility's ED physician documented that he/she placed another call to the vascular surgeon at SJHA after confirming that the on-call physician at his/her facility was unable to provide the required surgery and patient care at the transferring facility. The ED physician told the on-call vascular surgeon at SJHA that the patient's blood pressure was dropping, that the transferring facility's on-call vascular surgeon could neither do the required surgery at the transferring facility, nor be able to take care of the patient. After receiving this information, the SJHA vascular surgeon confirmed that he/she would not accept the transfer.

During a telephone interview (interview #11) in the Administrative Conference Room at 2:10 p.m. on 11/14/12, physician #8 related that he/she remembered one case where he/she had received a call from the transferring hospital. He/she spoke with the ED doctor there who said that they needed to transfer a patient with a bleeding aortic aneurysm. According to physician #8, he/she accepted the patient, hung up, then called the transferring ED physician back and asked whether they had a vascular surgeon on call. That ED doctor confirmed that they did have a vascular surgeon on call, but that the surgeon did not feel comfortable doing the surgery.

Physician #8 related that he/she told the transferring ED doctor that their on-call vascular surgeon was responsible for the patient, and that he should call him/her to talk about it. Physician #8 expressed that he/she had no memory of the doctor calling back.

Physician #8 further explained that he/she remembered hearing from either the transferring ED doctor or the transferring on-call doctor that the case could be done using an endograft, but that the transferring on-call doctor did not feel comfortable doing an endograft in an emergency. Physician #8 related that if you're on call as a vascular surgeon, you don't have the option- you do the case.

Physician #8 related that he/she did not have any recollection about the patient's status, but that he/she had the understanding after hanging up that the patient would be taken care of--the transferring facility did not call back.

In a written statement provided to the surveyors on 11/19/12, physician #8 confirmed that he/she was on call for vascular surgery services on 4/22/12. In the written statement, the physician also related that "endograft repair (as well as open conventional repair) is a procedure performed electively at [the transferring hospital] by [transferring hospital's on-call vascular surgeon] who is trained, qualified, and credentialed to do these procedures."

During an interview (interview #4) in the Administrative Conference Room at 9:30 a.m. on 11/14/12, the facility's ED Manager related that patients going to surgery for abdominal aneurysms or any other type of aortic surgery would be admitted to CVICU.

During an interview (interview #2) in the Administrative Conference Room at 1:30 p.m. on 11/13/12, the facility's Director of Nursing Operations, after reviewing the Intensive Care Unit (ICU) census records entitled, SJHA Daily Census Summary, for 4/20 - 23/2012, confirmed that the facility had the capacity to take a patient in ICU on 4/20, 21, 22 and 23/2012- ICU was below capacity.

During an interview (interview #6) in the Administrative Conference Room at 10:10 a.m. on 11/14/12, the Unit Director Cardiovascular Intensive Care Unit (CVICU) reviewed the staffing and census records for 7 a.m. - 7 p.m. on 4/22/12 and confirmed that the CVICU could have accommodated and admitted a new prospective or post abdominal aneurysm repair.

During an interview (interview #5) in the Administrative Conference Room at 9:40 a.m. on 11/14/12, the facility's Director of Patient Safety and Quality reviewed the facility's Operating Room Log for 4/22/12 and related that OR staff was available to do an abdominal aneurysm repair even though there was a surgery in progress, because the aneurysms' surgery would have been done in the Cardiovascular OR (CVOR), which was a separate OR suite with separate staff on call who are specially trained to care for the patient. The Director confirmed that the CVOR suite, OR staff, anesthesia and equipment were available.

Facility policy #30110-212-09 entitled, "Treatment and Transfer of Individuals in Need of Emergency Medical Services", dated 12/06, Section K. Inappropriate Refusal of Transfers, stipulated that hospital medical staff and employees report suspected refusals of appropriate transfers to the Hospital Compliance Officer or the Corporate Responsibility Hotline. The policy further stipulated that if found that a transfer was inappropriately refused, the Hospital would determine its responsibilities in the matter as well as potential staff or employee sanctions (if appropriate).

The hospital provided a document which described the facility's current process for receiving transfers from outside facilities. The document explained that it was rare that a referring facility called the transfer staff and indicated that the on-call physician had denied acceptance, but if it did, the transfer staff would make a reasonable attempt to secure another accepting physician for the referring physician. The document also related that it was not customary for either the transfer staff or the ED staff to document the requests from referring facilities for on-call physician contact information. The document did not include a process which required that the on-call physician communicate information related to denial of requests for transfer with hospital ED or Admission staff, or that the denials be documented for subsequent review.

During interviews in the Administrative Conference Room at 11:45 a.m. on 11/13/12 and at 11:50 a.m. on 11/14/12 respectively, the Director of Nursing Operations (interview #1) and the Clinical Nursing Supervisor (interview #9) confirmed that if the on-call physician refused the transfer, this was not recorded anywhere, and that the Transfer Center was not notified.