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Based on review of facility policies and procedures, Medical Staff Bylaws/Rules and Regulations, facility logs, and physician and staff interviews, and physician and staff statements, 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 A2406 as it relates to the facility's failure to identify in the Medical Staff Bylaws/Rules and Regulations those individuals qualified to perform medical screenings .

Cross refer to A2411 as it relates to failure to accept an appropriate transfer of an individual requiring the facility's specialized capabilities.

Based on review of Medical Staff Bylaws/Rules and Regulations, and staff interview, it was determined that the facility failed to identify in the Medical Staff Bylaws/Rules and Regulations those individuals qualified to perform medical screenings .

Findings were:

Review of the Medical Staff Bylaws/Rules and Regulations revealed a lack of documented evidence of individuals who were determined qualified to perform medical screenings.

An interview with the Chief Medical Officer at 11:20 a.m. on 01/12/2010 confirmed that medical screening was not addressed in the in the Medical Staff Bylaws/Rules and Regulations but was addressed and implemented by facility policy.

Based on physician interview, staff interviews, written statements from physician and staff, review of facility policy, facility logs, and facility data, it was determined that the facility failed to accept an appropriate transfer of an individual on 12/23/2009 requiring the facility's specialized capability.

Findings were:

An interview at 11:50 A.M. on 01/13/2010, with the on-call general and trauma surgeon (interview #6) for 12/23/2009, revealed that the surgeon received a call from Hospital A around 9:00 or 9:30 p.m. regarding a transfer of a patient with an appendicitis and in need of surgery. The surgeon stated that he/she suggested that another hospital (Hospital B) provide the service. The surgeon related that the facility was a trauma center and always accepted trauma cases because the facility was most appropriate. For non-trauma patients, the facility might not be the most appropriate. According to the surgeon, it was his/her understanding that a facility may need to take a transfer because they were closer and most appropriate. In this case, Hospital B was two (2) miles closer and had the capability for general surgery. When questioned about the distance, the surgeon stated "two (2) miles was not much, but closest is closest". The surgeon also stated he/she informed Hospital A that the facility's ED was very busy and very full and that the Operating Room (OR) was also busy. The surgeon reported he/she had been with trauma cases all afternoon and evening in the ED but was not at the facility when he/she received the call. According to the interviewee, later in the evening, the Service Line Manager (house supervisor) called to discuss the patient transfer. The surgeon believed that Hospital B had called the Service Line Manager and questioned why the transfer had not been accepted. In a written statement, provided by the surgeon at 2:00 p.m. on 1/13/2010, the surgeon disclosed that he/she specifically reiterated to the Service Line Manager that because the OR team was tied up and there was potential for new trauma coming into an extremely crowded emergency room, it was preferred that Hospital B provided the care.

A review of policy #PS. 236 entitled "Patient Transfers into TMC", effective 12/06, last reviewed and approved 02/15/09, revealed that the policy failed to address acceptance of patient transfers with emergency medical conditions. Also, the policy failed to identify who at the facility had the authority to make the decision regarding these transfers.

The Chief Executive Officer (CEO) and the Chief Medical Officer (interview #10 and #3) confirmed in an interview at 4:15 p.m. on 01/13/2010 that there was no facility policy to address acceptance of patient transfers with emergency medical conditions or identify who at the facility had the authority to make the decision regarding these transfers. The CEO and the Chief Medical Officer were questioned regarding the on-call physicians's authority to speak for the hospital. The Chief Medical Officer, and confirmed by the CEO, stated that the on-call physician made an assessment of the facility's capability and capacity in regard to a transfer. The physicians's input regarding the transfer was then to be shared with a hospital employee (Service Line Manager and/or Access Case Manager). Both the physician and the hospital employee were to be involved in the final decision.

Telephone interviews at 11:30 a.m. and 11:40 a.m. on 01/13/2010 with the ED charge nurse (interview #4) and the ED flow coordinator (interview #5), respectively, revealed that neither received a call regarding a transfer from another hospital requesting the services of a general surgeon. When questioned about their understanding of the hospital's responsibility to accept emergent patient transfers from other hospitals, both stated that if general surgery was required, the on-call surgeon was notified. If the on-call surgeon agreed to accept the transfer, the hospital was notified by the accepting surgeon.

Information provided by the Director of Quality Management revealed that the facility had the capability for two (2 ) after hours surgical teams for emergency cases.

A review of the surgery log for 12/23/2009 between the hours of 3:00 p.m. and 12:00 midnight and a review of ED trauma patients for the same hours on 12/23/09 revealed that the on-call surgeon (#6) was in the ED for trauma call at 4:31 p.m. and 7:43 p.m. Neither of the trauma patients, according to the surgery log, required surgery. The log indicated that between 3:50 p.m. and 5:25 p.m. and between 8:30 p.m. and 10:15 p.m. there were two (2) orthopedic cases in the OR. ED information revealed that there were six (6) patients being held in the ED awaiting room assignments and all were assigned by midnight, at which time there were four (4) new patients awaiting rooms. The surgery log indicated there were two (2) surgery cases after midnight (12/24/2009), one was general surgery from 12:10 a.m. to 1:18 a.m. and a neurosurgery case from 12:52 a.m. to 3:28 a.m.