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Based on review of medical records, TeleTracking Transfer Center Transfer Order notes, Transfer Direct Admission Tracking Sheet, on-call Ophthalmology Schedules, Criteria for Delineation of Privileges, Verification letters, Medical Staff Roster, Bed Census Report, Policy and procedure and staff interviews, the facility failed to accept from a referring hospital an appropriate transfer who required specialized capabilities (Ophthalmologist) and had capacity to treat one (SP) #1 out of 22 sampled patients. (Refer to A-2411).

Based on review of medical records, TeleTracking Transfer Center Transfer Order notes, Transfer Direct Admission Tracking Sheet, on-call Ophthalmology Schedules, Criteria for Delineation of Privileges, Verification letters, Medical Staff Roster, Bed Census Report, Policy and procedure and staff interviews, the facility failed to accept from a referring hospital an appropriate transfer who required specialized capabilities (Ophthalmologist) and had capacity to treat one (SP) #1 out of 22 sampled patients.


The findings:

Review of the medical record from the transferring hospital (Hospital #2) revealed that on 05/12/16 at 11:23 AM Sample Patient (SP) #1 presented to ED (Emergency Department) at the transferring hospital with chief complaints of sore throat for 2 days and blurry vision to the right eye the morning of coming to the ED.

Review of the (transferring hospital's) Consultation Report of Ophthalmologist MD-D dated 05/12/16 and dictated at 9:02 PM revealed that SP#1 came to ED due to painless right eye loss of vision that occurred the morning pt. presented to ED. Physical Examination revealed that SP#1 with counting fingers was found to have a visual acuity of 20/30 to the right eye. Pupils were dilated and evaluation of the retina demonstrated areas of bleeding in the peripheral retina of the right eye. The left eye had areas of bleeding but did not affect the patient's center vision. Recommendations and plan include transferring the pt. to another facility for evaluation of a retinal specialist that could determine whether surgery or observation is needed.

Review of the (transferring hospital's) Emergency Patient Records: Patient Notes dated 5/12/16 authored by nurse, showed that SP #1 was transported at 11:37 PM via ambulance in a stable condition to the receiving facility (Facility #3).


Review of the transfer center (TC) notes regarding SP #1 from the transferring hospital showed on 05/12/2016 at 4:00 PM-7:21 PM, the [named] on-call Ophthalmologist MD-A-recommends transfer to (Named) Cancer Center (Facility #5), if they do not accept, he will take the patient at this hospital [UM]. The TC noted -stated that they wanted the medical records faxed. No face sheet. At 7:20 PM, the transfer center noted -stated she received the paperwork and she will contact the E.R. (Emergency Room) for acceptance. Dr. [named] requested to be connected with UM [University of Miami] hospital and she advised [name] that she wanted the patient to be transferred ASAP (As soon as possible). [Named] explained to Dr. [named] that she has a process to follow and the ER physician at UM hospital stated to send the patient to facility #5. Facility #5 stated they do not have an ER and send the patient to [UM] this hospital. At 7:20 pm [named] called to advise she spoke with the on-call Ophthalmologist MD-A and he will not accept the patient. There is also a stroke alert, sepsis alert and cardiac alert and this hospital is on the verge of calling a code purple (Hospital Capacity). Recommend transfer to the [named] receiving hospital (Facility #3).

A request for an ED- to- ED transfer from the transferring hospital occurred on 5/12/2016. There are no medical records related to (sampled patient) SP#1, only TELETRACKING Transfer Center notes.

The review of SP #1 TELETRACKING Transfer Center Transfer Order (University of Miami hospital) showed the transferring hospital, and the referring unit is the ED (Emergency Department). Pt demographics showed named of SP#1, date of birth, and age. The Transfer Reason showed Higher Level of Care. The Destination is this hospital's emergency room. Pt Diagnosis showed Decreased blurry vision in Right eye, New Acute Leukemia.

Record review of SP #1 "Transfer/ Direct Admission Tracking Sheet" showed Transfer Direct Admission Initial Contact Date: 5/12/16 Time: at 3:10 PM with the Transferring Physician, Bed type: ER (Emergency Room), Reason for transfer is patient need retinal specialist. The Diagnosis: Decreased blurry vision in R (Right) eye, New Acute Leukemia. The (Registered Nurse) RN review comments indicated, "their ophthalmologist told them to send the pt. to facility # 4 (a hospital within the hospital system- Eye Institute)".

Review of the "Admission /Direct Tracking Sheet dated 05/12/2016 showed at 15:30 PM- Paged Ophthalmologist MD - B, retinal specialist. At 15:33 PM - Ophthalmologist MD - B had me transfer to facility #4 ER. Transferred to [named] office, told [named] Hospitalist was on call retinal. Called the on-call Ophthalmologist MD - A, facility #4 (Ophthalmologist MD - B) on call. At 15:53 PM - Connected the on-call Ophthalmologist /MD - A to the transferring ED physician, said to send pt. to facility #5 ER (he s/w (spoke/with) a colleague and his wife who's an oncologist) if not send to this UM hospital. The University of Miami had the capability to provide the needed specialized Ophthalmology capabilities for SP#1 on 05/12/2016.

The "Transfer Center Transfer Order" Consult notes showed the following:
On 5/12/2016 an entry from the Transfer Center Coordinator/ Staff - E at 16:16 PM showed on-call Ophthalmologist MD - A said he spoke with a colleague and his wife, who is an oncologist, and they advised that the patient should go to the facility #5 ER (Emergency Room).

On 5/12/2016 an entry of Transfer Center Coordinator /Staff - C note at 19:50 PM- transferring hospital called at 18:45 PM saying that facility # 5 said no, so we have to take the patient. I told them to send me the medical records without the face sheet. I then took the medical records to the Registered Nurse Admitting/Staff - J to get her opinion. She told me to call the physician and offer to send him the records and decide afterwards.

On 5/12/2016 at 19:53 PM - Transfer Center Coordinator /Staff - C documented that, spoke with nursing supervisor and ER and they informed me that there was a stroke alert, Sepsis alert and STEMI (ST elevation heart attack) alert currently in the ER and they were almost on Code Purple (Hospital Capacity). Paged the on-call Ophthalmologist MD - A through physician referral on call when he called back, I offered to send him the medical records and informed him of the ER's status. I asked if he would prefer facility # 3 and he said to send the patient to facility # 3 and he could see him there.

On 3/21/17 at 10:47 am, Director of Risk Management stated that the only document related to the non- acceptance of SP#1 is the tele tracking transfer center documentation. No other documents or records related to the non -acceptance of SP#1.

Record review of Transfer/ Direct Admission Tracking Sheet did not show an Administrator On Call and ED physician acceptance or denial for SP #1 transfer.

On 3/21 /2017 1:00 pm, the interview with the Director of Risk Management and Assistant Vice President of Quality and Patient Safety stated that the HEALTHSYSTEM include several hospitals, each has its own license and CMS (Centers for Medicare and Medicaid Services) agreement:
This facility, Facility# 4 (Eye Institute), and Facility #5 (Cancer Center). There is no documentation from the CEO that assigned who was the designated person to accept or deny transfers.

The hospital's bed census report for 5/12/2016 (Run date of report was 05/13/2016) was reviewed. The bed census report revealed that the hospital had available beds (Capacity) on 5/12/2016 when the transferring hospital requested a transfer for SP#1 on 5/12/2016.

Interview with Staff - C on 3/21/2017 at 1:55 pm revealed she was one of the Transfer Center Coordinators, who documented in the Tele tracking sheet on 5/12/2016. She stated that during the change of shift, Staff - E gave me the tracking sheet. I spoke with the on-call Ophthalmologist MD - A. I wrote down everything we talked about. I also told him that the hospital Emergency Department was almost in a Code status. The on-call Ophthalmologist MD - A sent what I wrote in the Tele tracking sheet. Then, I called transferring hospital and told them about what the on-call Ophthalmologist MD - A said. I usually document immediately.



Phone interview with the Nursing Supervisor - A on 3/23/2017 at 9:15 am revealed she was the Nursing Supervisor on 5/12/2016 from 8P- 8A. She stated the Administrator On-Call makes the final decision once the request is accepted. We do not tell them no; we just accept the patient. We cannot deny.


Phone interview with Ophthalmologist MD - B on 3/23/2017 at 10:15 am that he was a Board Certified Ophthalmologist with an ocular oncology fellowship, completed. He is also the Clinical Instructor at this hospital and facility #4. He is credentialed at University of Miami Hospital. Review of the University of Miami Hospital MD-B Medical Staff Credentials Criteria for Delineation of Privileges Ophthalmology Core Privileges revealed that he specialized in Vitreoretinal Surgery, which included "Retinal Detachment Repair."


The Manager of the Medical Staff Services provided the "On call Ophthalmology for the health care system" that showed: The on-call Ophthalmologist MD-A was on call on May 12, 2016 as the general ophthalmology.

Review of the on-call Ophthalmologist MD-A University of Miami " Criteria For Delineation Of Privileges, Ophthalmology Core Privileges" dated 05/4/2015 showed Ophthalmology Core Privileges are granted as a single entity for comprehensive examination, consultation, diagnosis and treatment of ocular muscles eyelids and orbits, including: retinal treatment

Review of the Verification Letters provided by the Manager of the Medical Staff on 3/22/2017. The letters from the Credentialing Office showed: The on-call Ophthalmologist (MD-A) has membership and clinical privileges under the Department of Ophthalmology at this hospital, Facility #4, and Facility #5 and is at good standing as of May 2016. The on-call Ophthalmologist MD-A end date of his clinical privileges was on July 2016.

Review of the Medical Staff credentials and privileges with the Manager of the Medical Staff on 3/21/2017 showed that On call Ophthalmologist MD-A is no longer part of the medical staff. It was noted during the review that MD-A is an active medical staff under the Department of Ophthalmology on 5/12/2016 and did not have privilege for subspecialty in retina / vitreous surgery.

Interview of the Chief of Ophthalmology at 2:27 PM on 3/21/2017 described his role and stated worked approximately 6 years on the position. He stated he is familiar with the practice performance of the ophthalmology of staff. He does not recall retina specialist performing a procedure to the retina. A detached retina can be detected by an ophthalmologist and can be identified, but the repair be done only by the retina specialist. He recalls on-call Ophthalmologist MD-A as previous a medical staff and credentialed as ophthalmology, but at Facility#4 is a glaucoma fellow. Glaucoma fellow cannot do retina surgery. He can perform comprehensive ophthalmology evaluation and diagnose, but cannot treat retinal detachment.

Review of the "Medical Staff Roster' as of May 2016, showed over 50 ophthalmologist on staff.


Review of the "EMTALA Policy" Effective 6/2016 states: A receiving hospital with specialized capabilities or facilities that are not available at the transferring hospital (including, but limited to burn units, shock-trauma units, neonatal intensive care units or with respect to rural areas, regional referral centers) must accept an appropriate transfer of an individual with an EMC (Emergency Medical Condition) who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual.

The "EMTALA Policy" also states the CEO must designate in writing the position of the hospital representative who is authorized along with the Emergency physician to accept or deny transfers of individuals with (EMC's) Emergency Medical Conditions from other facilities. On page 5 of 16, #3, Authority to Accept a Transfer: The Emergency Physician and the CEO or designee, such as the AOC (Administrator On Call) are the ONLY individuals authorized to accept or refuse the transfer of an individual from another facility on behalf of the receiving hospital. The policy further states at the Emergency Physician's request, the transfer center must facilitate a discussion between the Emergency Physician and the on-call physician of the receiving facility. The on call physician does not have the authority to refuse an appropriate transfer on behalf of the facility. The facility failed to follow their own policy when the transferring hospital requested an appropriate transfer for SP#1 on 05/12/2016.