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Based on review of medical records, transfer notes, policies and procedures, Medical Staff Roster, facility license, Core privileges for Urology, Urology on-call schedules, Bed Census Report, and Physician and Risk Manger interviews, the facility refused to accept from a referring hospital an appropriate transfer of an individual who required the Urologist specialized capabilities and facilities for one (SP) #1 out of 23 sampled patients. (Refer to A-2411).

Based on review of medical records, transfer notes, policies and procedures, Medical Staff Roster, facility license, Core privileges for Urology, Urology on-call schedules, Bed Census Report, and Physician and Risk Manger interviews, the facility refused to accept from a referring hospital an appropriate transfer of an individual who required the Urologist specialized capabilities and facilities for one (SP) #1 out of 23 sampled patients.



The findings:

The procedure to support the 900-Administrative Policy" Medical Screening (EMTALA) " (revised: 03/2013) showed under Obligation to Accept Transfers: A Hospital that has specialized capabilities or facilities( including, but not limited to, such facilities as burn units, neonatal intensive care units) may not refuse to accept from a referring hospital an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual.


The procedure to support the 900-Administrative Policy " Handling Transfers Through the [named] Hospital Systems" (date:10/5/2016), After an appropriate medical screen examination is completed and determined that the patient needs services not provided at the current facility, a transfer should be requested through the Transfer Center. The Transfer Center will coordinate transfers into and from a [hospital system] facility through collaboration with the transferring facilities and physicians. Escalation policy: In the event there is a delay in response from the on-call physician or a possible denial from the receiving facility, the nurse at the Transfer Center will escalate to the appropriate administrative personnel at the receiving facility for final determination regarding acceptance. Denial should only be based on the facility's capacity or provider's capability to provide service or treatment. Other reasons for denial will be referred to the appropriate facility for a quality review and for determination if reporting is necessary to the applicable agency.



Review of South Miami Hospital (Facility #1) license showed the following documentation: Class 1 Hospital; Number of Licensed Beds: Acute Care: 403; NICU Level 2: 34; NICU Level 3: 15. Total Capacity 452 and Expiration Date 06/30/2017. Licensed Programs: Level 2 Adult Cardiovascular Services, Primary Stroke Center; Dedicated Emergency Department Emergency Services for which includes but not limited to Cardiology, Cardiovascular Surgery, Emergency Medicine, Nephrology, Neurology, Neurosurgery, Pulmonary Medicine, Radiology, Thoracic Surgery, Urology, Vascular Surgery.


Review of sampled patient (SP) #1 medical record from the transferring hospital showed he was uninsured. He presented himself to the emergency department on 04/30/2016 at 23:35 PM with chief complaints of vomiting and epigastric pain. SP#1 has no medical or surgical history. The results of the Computer Tomography (CT) without contrast of the abdomen showed a large heterogeneous left renal mass measuring at least 8.5 x 6.8 x 8.8 centimeters (cm), likely representing a renal cell carcinoma; marked neo-vascularity throughout the perinephric space causing marked dilation and tortuosity of the left renal vein and dilation of the inferior vena cava (IVC) and bilateral adrenal masses. Differential diagnosis includes hematoma surgeon neoplasms. The results of the findings were discussed by phone with the ED Physician and the radiologist on 5/1/2016 at 5:47 AM. At 8:26 AM, the case was discussed with the transferring hospital's urologist who agreed to transfer the patient (pt.) because the pt. needs interventional radiology. The Transfer Center (TC) was called. Further documentation in the medical record revealed on 5/1/2016 at 8:29 am the transfer center was recalled and they will contact Facility #3 or South Miami Hospital. At 10:27 am documentation revealed in part, " Transfer center called the Urologist on call (MS-A) who refused to accept the transfer and states pt. (patient) needs to be transfer to interventional radiology, when case was presented to MS-D (interventional radiologist) , he was willing to consult but stated the case needed to accepted by a Urologist."

Review of SP #1 ED provider's notes (from the transferring hospital) showed the disposition: transfer. The reason for transfer: After extensive discussion with different urologist at the [named hospital] within the hospital system, none feel competent to manage the case at their institution.
Record review of the Transfer Center notes (from the transferring hospital) dated 05/1/2016 showed that extensive efforts towards transfer arrangements of SP #1 was done. The sequence of the transfer arrangements showed: Facility #3 (main hospital), South Miami Hospital, and Facility #5 (Acute Care Hospital) all facilities are with in the hospital system:
Facility #3 was overcapacity;
Facility #1 South Miami Hospital urologist did not accept the pt.
Facility #5 urologist refused to accept the pt. because of the complexity of the case;
Facility #5 IVR does not perform kidney biopsy;
Finally, the case was presented to Facility #2 accepting acute care facility that accepted SP #1 for transfer.

Review of South Miami Hospital's Transfer Center notes regarding SP#1 showed that the TC (Transfer Center) called this hospital's on-call Urologist (Medical Staff -MS-A) on 5/1/16:
At 8:34 AM T/C (Transfer Center) to the [MS-A] on-call ... at this hospital [phone#] Spoke with [named] answering service. She said she will page [named-MS-A] on-call urologist.
At 9:15 AM -09:16 AM, 2nd call to the [MS-A] on-call urologist, Spoke with [named]. She said she will page the Dr. (Doctor) again.
At 9:31 AM- 09:36 AM, 3rd call to [MS-A] answering service. Spoke with [named]. She placed me on hold and said she will try calling him. MS-A came back to the phone and said he did not answer his phone when she called him. [Named] said that is not like him, and she will keep trying to reach him.
At 9:41 AM- 9:45 AM-transfer center to SMH (South Miami Hospital) ED. I was told Dr. [named-MS-A] on-call urologist is on call.
At 09:42 AM to Dr. the on-call (cell number provided). left voicemail as urgent.
At 10:08 AM-10:11 AM, transfer center to [named], answer service for [named-MS-A] on call Urologist.
At 10:10 AM, the Urologist on call (MS-A) said that, he is not on call for the transferring hospital and does not want to talk to anyone at that hospital. I explained, the patient would be transferred to this hospital's ED, and the Urologist on-call still refused to talk to anyone from the transferring hospital, and he refused the patient. I explained, the patient would also need IVR (interventional radiology). The Urologist on-call said to transfer to the hospital interventional radiologist but he will not see the pt.

The Transfer Center called the [MS-D] IVR (interventional radiologist) at this hospital at 10:18 AM and explained the case. The [MS-D] IVR said he would not be doing a biopsy this weekend and he does not know if the schedule would allow time for the biopsy Monday or Tuesday because they are busy. That the Urologist on-call at this hospital refused the case and that the IVR was called. The interventional radiologist said, will need to have a urologist on the case, and maybe SP#1 can be admitted to the transferring hospital, and the pt. seen by the urologist, and then transferred next week for the biopsy.


Review of the "Medical Staff Roster" showed there are 24 urologists and 18 Vascular & Interventional Radiologists on staff.

South Miami Hospital Urology on call schedule for May 2016 was reviewed. The May 2016 On-Call urology schedule for May 2016 verified that MS-A was on call on May 1, 2016 when the referring hospital requested a transfer for SP#1.


Review of the bed breakdown per nursing unit of Facility #2 dated 5/1/16 showed a total census of 347. This includes but not limited to the following:
(1.) critical care unit (CCU) census was 7 for total capacity of 12 beds.
(2.) Intensive care unit (ICU) census was 7 for total capacity of 8 beds.
(3.) Surgical intensive care unit (SICU) census was 4 for total capacity of 8 beds.
(4.) Observation unit census was 6 for total capacity of 12 beds.


Review of on-call urologist "Facility Specific Clinical Privileges" showed his Urology Core Privileges include: Admit, evaluate, diagnose, and treat (surgically and medically) and provide consultation. Core procedures list includes: Open renal biopsy, Renal surgery through established nephrostomy or pyelostomy; surgery upon the kidney.



On 3/24/17 at 10:55 am, the Urologist (on-call urologist) stated, First, I always see pt. for consult and I do not have privileges at [Named] transferring hospital, so I do not give orders for the hospital that I do not have privileges. Second, this pt. (SP#1) is being transferred for renal biopsy and that is not a procedure that I perform. If the pt. need IVR for biopsy I am willing for consult but I cannot do kidney biopsy but it will be inappropriate to coordinate the care. The only reason was no IVR at the [Name] transferring hospital, and so they want to transfer the pt. to this hospital. I refused the patient (SP#1) because I don't perform renal biopsy; I don't talk to physician's in the hospital that I don't have privileges; I was the inappropriate specialty because I do not do the renal biopsy and it's done by IVR percutaneously. To coordinate the care I do not do that, but they could have called a hospitalist to admit the patient, and I am willing to do the consult. This pt. did not need emergent urological surgery. It seems that they needed an elective biopsy and therefore it is inappropriate to coordinate the care. The hospital is capable to do this because they have IVR who can do this. In emergency cases if the pt. is on the table I could do the renal biopsy but I have not done this in my 12 years of being staff at this hospital. The IVR routinely perform the renal biopsy. There is nothing emergent, and it is a routine finding if the pt. has a renal mass, there is no reason for emergent biopsy. I accept patients, who need care, but this patient was recommended for renal biopsy and this is a routine and non-emergent procedure. I am not sure that pt. (SP #1) needed the emergency procedure. He acknowledged that in the future, he will not deny or refuse any patient as the hospital has the capacity and capability of admitting this kind of patient (SP#1). The facility failed to ensure that their policy and procedure regarding Obligation to Accept Transfers was followed as evidenced by the on-call Urologist refusing to accept from a transferring facility an individual (SP#1) who required his Urology specialty services. As this resulted in the delay of stabilizing treatment for SP#1 who had an identified emergency medical condition.


On 3/22/17 at 10:26 am, the Risk Manager stated, regarding the referral of sp#1 from the transferring hospital on 5/1/16 - the [Named] on-call Urologist refused the pt. (Sample Patient (SP) #1) from the transferring hospital for a renal biopsy.

On 3/22/17 at 11:49 am, the CMO (Chief Medical Officer) stated, it was in July when I became the CMO, and I became aware of it (physician refusal to accept the transfer) and I had conference with the [Name] urologist involved at that moment. I explained to him that he had refused the case and that he had suggested that the patient be accepted by interventional radiology if needed, and when I spoke to him, he did not explicitly refused, and that he should not be the accepting physician but the radiologist. I explained further his obligations that unless, he felt no expertise, and that the facility had no capability, that he cannot refuse. I gave narrow exceptions otherwise, he must say yes. In rare occasion if beyond his expertise and facility has no capacity, we must say, yes. It was on the 3rd week of July around 20th -21st when I talked to him.