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The following reflects the findings of the California Department of Public Health during an EMTALA (Emergency Medical Treatment & Active Labor Act) complaint survey authorized by the Centers for Medicare and Medicaid Services.

The survey was conducted 9/7/22 and 9/8/22, a total of 20 patient records were reviewed.

Aspects of this report will predate the EMTALA Survey authorized by the Centers for Medicare and Medicaid Services (CMS) on 9/7/22. The initial investigation was authorized under the State of California Authority, Facility Reported Incident # CA00800871 on 8/31/22.

The investigation was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

Representing the Department: Health Facilities Evaluator Nurse 22383 and Medical Consultant 26660.

Based on observation, interview, and record review, the hospital (Hospital A) failed to ensure their Transfer Center Staff properly facilitated the communication between Hospital B's request to transfer their emergency room patient to Hospital A.

As a result Patient 1's emergency room physician was not able to speak to the neurosurgeon of Hospital A, for appropriate neurosurgical evaluation and treatment. Patient 1 was transferred to another hospital.

Findings:

On 9/1/22 at 8:07 A.M., an investigation was initiated due to a CMS referred complaint about the incident of a possible EMTALA violation related to the emergency room physicians not being permitted to speak to Patient 1's treating physicians to be transferred to a higher level of care.

A review of Hospital B's emergency room (ER) records for Patient 1 was conducted. Per this record, Patient 1 was a 59-year-old, male, with a diagnosis of a frontal brain mass. Patient 1 was registered as a patient in Hospital B's ER on 8/21/22 at 11:45 A.M. Hospital B's ER sent a fax of Patient 1's information to Hospital A's Transfer Center on 8/21/22 at 2:39 P.M., the fax was requesting a transfer of Patient 1's. The information on the fax request which included, "Dx. Frontal Mass, needs Nuero Surgeon, step down bed"

On 9/1/22 at 2:46 P.M., an interview with Hospital A's Transfer Center Charge Nurse (TCCN) was conducted. Hospital A's TCCN stated, when a fax received from an emergency room, Transfer Center nurse (TCN) would follow up with a phone call. The purpose of the phone call was to clarify who should have been contacted for consult. The TCCN further stated this process should have been documented. For this patient, The Transfer Center did have record of the fax but there was no documented evidence that a follow up phone call was made. Hospital A's TCCN stated she was unclear why there was no other information. Hospital A's TCCN further stated the TCN cannot decide if a request for transfer was an emergency or not. The Transfer Center were to facilitate the communication between the emergency room requesting transfer and the hospital physicians.

A review of a written statement by Hospital B's ER Unit Clerk (UC) was conducted. This written statement indicated, a fax was sent requesting a transfer to a higher level of care that had neurosurgery services. Per this written statement, Hospital B's UC then place a call to the transfer center on 8/21/22 at 3:30 P.M. The UC stated she informed the TCN that Patient 1 arrived at Hospital B's ER for decompensation of mental status and the midline shift (a shift or displacement of brain tissue across the center line of the brain). The UC stated she told the TCN that Patient 1 needed emergent transfer to a hospital with neurosurgery services. The UC stated the TCN said Patient 1 did not meet emergent transfer needs. The UC further stated the transfer nurse was extremely rude and unprofessional, the TCN continued to inform the UC of the process for transfers. The TCN repeated to the UC emergency room to submit documentation via online transfer request. The UC asked the TCN to speak to Hospital A's physician, the TCN stated, "I am not going back and forth with you, I am an RN (registered nurse)", submit the documents for nonemergent transfer". The UC stated she asked the TCN to allow her to speak to the transfer center's supervisor or someone other than the TCN in the transfer center. The UC stated the TCN refused this request, and abruptly ended the call. The UC stated the hospitals TCN then called back to the emergency room and requested to speak to the charge nurse.

On 9/8/22 at 8:07 A.M., an interview with Hospital B's Charge Nurse (CN) was conducted. The CN stated after Patient 1 was evaluated in Hospital B's ER, a fax was sent by the UC with a follow up phone call to Hospital A for transfer. The CN stated he received a phone call from the TCN to complain about her interaction with the UC. The CN stated that TCN was rude and dismissive. The CN said he explained to the TCN the patient needed an ICU bed. The CN further stated, the TCN told him Patient 1 did not qualify for an ICU bed. The TCN had no reason or rationale for this patient not to qualify. The CN stated, he explained to the TCN that his physicians assessed Patient 1 and determined an ICU bed was needed. This was due to the midline shift in Patient 1's brain. The CN said the TCN demanded more documentation, but could not explain what documentation she wanted and said, "we are not taking the patient". The CN offered to have his physician speak to the TCN, but TCN did not want to talk to the physician. The CN requested the TCN to contact neurosurgeon to talk to the Hospital B's ER physician. The TCN refused and stated Patient 1 did not qualify for an ICU bed. The TCN stated she would not page Hospital A's neurosurgeon, and that contact was never made.

Patient 1 was subsequently transferred to a different local hospital for treatment at a higher level of care.

On 9/8/22 at 9:33 A.M., an interview with Hospital B's TCN was conducted. The TCN stated she was fairly new to the transfer center. The TCN stated she did not remember anything about this fax or this patient. The TCN further stated she did not recall ever having an interaction with Hospital B's UC. The TCN stated the transfer center frequently got push back when asking for documentation. The TCN stated she was doing what she was instructed to do. The TCN also stated when a fax was received, a follow up phone call should have been done. This process should have been documented in the transfer center's system. The TCN stated she had no explanation of why this was not done and documented. The TCN stated in a situation like this, she would have paged the neurosurgeon so he could have spoken to Hospital A's ER physician. The TCN further stated the Transfer Center Nurses do not make decisions about who needed emergency or ICU level of care, but she stated she would have notified Hospital A if Hospital B hospital was at capacity, or if that particular service was closed to admissions. The TCN could not remember if either of those two conditions existed on the day of the incident. The TCN further stated, frequently a hospital emergency room will go around the transfer center and call a specific service or a physician directly on behalf of their patients.

On 9/7/22, a review of TCN's personal file was conducted. The personal file indicated TCN had started working on 7/25/22 and had only worked independently for 12 days. Per the same record, TCN received training related to transfer center policies and EMTALA regulations.

On 9/8/22 at 9:57 A.M., an interview with Hospital B's Transfer Center Manager (TCM) was conducted. The TCM stated, based on the information, the transfer center should have contacted the neurosurgeon to speak to Hospital B's ER physician about Patient 1. The TCM stated, all of this should have been documented in the transfer center's system. The TCM stated she was unsure why it was not done. The TCM stated neurosurgery department was never closed to admissions, and on that particular day, the hospital was not at capacity. The TCM stated that the hospital had just started a trial of hiring a RN with case management experience to work in the transfer center. She stated this was done in hopes of better outcomes for patients being transferred to the hospital. The trial had started last month. The TCM stated they had no metric being used to determine if this trial was beneficial. She was also asked to provide the information used by Quality Assurance Performance Improvement to determine if the Transfer Center Nurses were following policy, they had no information or metric used for this process. The TCM was asked to provide the total number of faxes the transfer center department received in August 2022. The TCM was also asked to provide the number of faxes that were entered into the transfer center's system and the number of faxes with no follow up. The TCM only provided the total number of faxes received.

A review of Hospital A's policy and procedure titled, Transfer and Compliance with EMTALA, dated March 17 2020, was conducted. This policy indicated, ".... XIII. Triage and Evaluation of Requests: A. When a requset to transfer is received, the Transfer Center will initiate the Transfer Request... The Transfer Center will triage the request to the appropriate attending physician for medical screening. ... C. Transfer requests received from the Emergency Department of another hospital will be forwarded to UC (name of hospital) Emergency Department attending physician for medical screening..."