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Based on medical record review, Medical Staff Bylaws review, Policy and Procedure review, audio recordings review, Emergency Department (ED) on-call, list review, ED transfer log review, bed census review, web site review, and staff interview, the hospital refused to accept an appropriate transfer of a stabilized patient who required specialized trauma services from a referring hospital (Hospital #1) within the boundaries of the United States. The hospital had the specialized trauma capabilities and the capacity but refused transfer for 1 (Patient #20) of 20 sampled patients reviewed.
Refer to tag A-2411 for details.

Based on medical record review, Medical Staff Bylaws review, Policy and Procedure review, audio recordings review, Emergency Department (ED) on-call, list review, ED transfer log review, bed census review, web site review, and staff interview, the hospital refused to accept from a referring hospital within the boundaries of the United States an appropriate transfer of 1 stabilized patient who required specialized trauma services (Patient #20) of 20 sampled patients reviewed. Lee Memorial Hospital refused the transfer while they had the specialized trauma capabilities and capacity.

The findings included:

Review of the Florida Agency for Health Care Administration website (FloridaHealthFinder.gov) revealed Hospital #1 has an emergency department and emergency services include general surgery.

Patient #20 arrived at Hospital #1 on 3/1/18 at 10:51 p.m., with two stab wounds to the abdomen. Hospital #1's Emergency Department (ED) Physician obtained a CT (computerized tomography) scan of the abdomen and pelvis. The CT results noted "Hemoperitoneum [blood accumulated in the space between the inner lining of the abdominal wall and the internal organs] with considerable blood noted along the liver and extending in the right lower quadrant. Suspicious linear area of abnormal enhancement most likely representing active bleeding."

Review of the Florida Agency for Health Care Administration website (FloridaHealthFinder.gov) revealed Lee Memorial Hospital has an emergency department and emergency services that include a level 2 trauma center.

Patient #20's clinical record showed the patient was referred to Lee Memorial Hospital because it is a level 2 trauma center. Florida Department of Transportation city-to-city Lehigh Acres to Fort Myers distance is 15 miles.

Review of Patient #20's clinical "Course" showed on 3/2/18, Hospital #1's ED Physician documented the following:
"0051: Dr. [Trauma Surgeon] Lee Trauma Declines transfer without OUR General Surgeon 'coming in and examining the patient and calling her himself'. Will discuss with surgeon.
0056: Surgeon here says we is [sic] willing to talk to trauma surgeon himself.
0114 Surgeon at Lee Refuses transfer. Will discuss with [Hospital #3] medical center.
0124 Patient accepted [Hospital #3] medical center."

The registered nurse (RN) documented in ED Notes of 3/2/18 at 2:11 a.m., "Patient refused by [name] trauma surgeon. Patient accepted by [Hospital #3] trauma center. To be transported by [ambulance service] critical care (all services unable to fly due to weather)."

Review of the Lee Memorial ED log showed that on 3/2/18 at 12:39 a.m., Hospital #1's ED Physician called the Transfer Center. Hospital #1's ED Physician requested to transfer Patient #20 to Lee Memorial for surgical trauma treatment. The Transfer Center nurse contacted Lee Memorial's Trauma Surgeon. A 3-way call was set up with Hospital #1's ED Physician, Hospital #1's General Surgeon, and Lee Memorial's Trauma Surgeon.

On 3/27/18 at approximately 3:20 p.m., the audio recording of the transfer phone request was reviewed. Hospital #1's ED Physician reported that the patient was stabbed in the belly, stable with air and blood in the stomach, CT scan says considerable blood and he was told that the physician interpreting the CT scan thought it was from the bowel. Lee Memorial's Trauma Surgeon responded that the on-call surgeon from the referring hospital should be able to handle it. She stated "I'm not accepting the patient."

During an interview on 3/27/18 at 9:35 a.m. Hospital #1's General Surgeon said, "The patient had to travel 2 hours to the east coast. She had 2 stab wounds in abdomen. Miami did another CT did not find much; she did fine. I have taken care of trauma in the past, it was better if you start from scratch rather than find something after you open the patient up. If trauma comes to us there should not be a question about a hospital with a trauma team taking a trauma patient. I made sure they did another blood count before she left to make sure she was stable for transfer."

Review of Lee Memorial Hospital Medical Staff Bylaws (approved Nov. 5, 2015) revealed basic medical staff responsibilities and requirements including Section 2.7.15: "to recognize the obligations to fulfill the hospital's responsibilities under the Emergency Medical Treatment and Woman in Labor Act (EMTALA), the Access to Emergency Services and Care Act and/or other applicable regulations, requirements or standards and to share in the responsibility for providing physician coverage on an emergency basis in the Emergency Department, in accordance with the provisions of the Medical Staff Bylaws and all applicable facility-specific Rules & Regulations and Medical Staff Policies (On Call Coverage);"

Review of Lee Health Policy & Procedures (Chapter M14, Tab 01, #089), Emergency Department Call Services (reviewed 4/17) revealed the Purpose including:
Expectations of Performance for Physicians Providing ED Call Services, items "8. Comply with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) and the Florida Access to Emergency Services and Care law, including accepting transfers as required under both laws; and 9. Provide care to the patient that falls within the scope of the physicians privileges."

On 3/1/18 and 3/2/18 Lee Memorial Hospital (LMH) was not on diversion. Review of the 3/2/18 LMH Bed Breakdown census report showed there were 4 Intensive Care Unit (ICU) beds open, 9 Surgical Progressive Care Unit (SPCU) beds open, and 17 Medical-Surgical beds on 5N open. From a surgical standpoint, 30 beds were open/available signaling surgical capacity to treat Patient #20. The patient had been stabilized and was appropriate for transfer. The transfer was refused and the patient was sent, by ambulance to another trauma hospital in the Miami area for treatment. The Florida Department of Transportation city-to-city Lehigh Acres to Miami distance is 133 miles.

The hospital Risk Management became aware of the incident in the days afterward. On 3/7/18 the Trauma Program Manager began corrective actions. In a letter dated 3/14/18 the hospital self-reported the EMTALA violation.