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Based on a review of the facility's emergency department (ED) event log, a review of a transfer log, a review of an Interventional/STEMI (ST-Elevation Myocardial Infarction) cardiology call schedule, a review of a census breakdown summary, a review of the transfer center audio recordings, a medical record review, interviews with staff, and a review of policies and procedures, it was determined that the hospital with specialized capabilities and facilities failed to accept an appropriate transfer from a referring hospital for a patient with an emergency medical condition for one Patient (P) (#1) of 20 sampled patients. Specifically, on 12/15/22 a referring hospital requested to transfer P#1 with a diagnosis of STEMI that required specialized services of the on-call cardiac capabilities; and the hospital had the capacity to treat P#1 at the time of the request.

Cross refer to A-2411 as it relates to the facility's failure to accept an appropriate transfer of P#1 within the facility's capability and capacity.

Based on reviews of the facility's emergency department (ED) event log, a review of a transfer log, review of an Interventional/STEMI (ST-Elevation Myocardial Infarction) cardiology call schedule, review of the census breakdown summary, review of the transfer center audio recordings, medical record reviews, and review of policies and procedures and interviews with staff, it was determined that the hospital (Hospital A-South Georgia Medical Center) with specialized capabilities and facilities failed to accept an appropriate transfer from a referring hospital (Hospital B) for a patient with an emergency medical condition for one Patient (P) (#1) of 20 sampled patients. The Patient was subsequently transferred to Hospital C in critical condition.

Findings included:

A review of P#1's medical record from the transferring facility (Hospital B), revealed that P#1 had arrived on 12/14/2022 at 10:42 p.m. with chest pain and a non-ST elevation myocardial infarction (NSTEMI) (a heart attack with partially blocked blood vessels to the heart). Documentation by the ED Nurse on 12/15/2022, revealed in part, "0606 SGMC charge nurse called back stating that the patient would need to be transferred to the closest facility, and they would not be accepting the Patient (#1)." On 12/15/2022 at 6:15 a.m., P#1 was discharged with a diagnosis of ST-elevation myocardial infarction (STEMI) (a heart attack with completely blocked blood vessels to the heart) in critical condition and transferred to (Hospital C) near the transferring facility.

A review of the facility's emergency department (ED) event log for 12/15/2022 failed to reveal a central log entry for P#1.

A review of the facility's transfer log revealed that on 12/15/2022, no time documented, a request to transfer P#1 was received. Further review of the transfer log revealed that ED physician (AP) BB accepted P#1; however, the cardiologist on call, AC EE, declined to accept the patient. The transfer log revealed that P#1 had been diagnosed with a STEMI.

A review of the facility's Interventional/ STEMI Cardiology Call Schedule revealed that the accepting cardiologist (AC EE) was on call from 7:00 a.m. on 12/14 22 through 7:00 a.m. on 12/15/22.

A review of the ED event log revealed that there was a census of 170 patients in the ED on 12/15/22. Further review revealed that at 6:00 a.m. census breakdown of the ED was: 58% capacity in Zone I; 57% capacity in Zone II; and 100% capacity in Zone III. There were no patients in the waiting room or in the hallways. A review of the hospital ' s Census Breakdown Summary: SGMC (South Georgia Medical Center) dated 12/15/2022 at 1:45 A.M., revealed the facility had capacity (open beds) in the ICU (Intensive Care Unit) and Medical Surgical Units to accept patient #1 on 12/15/2022.

A review of an audio recording from the facility's transfer center revealed the transferring facility's Emergency Communication Center's Clerk (ECC) requested that P# 1, who was diagnosed with a STEMI, be transferred to the facility. The transfer center's Patient Flow Coordinator, (PFC) AA transferred the call to the facility's accepting physician (AP BB). The transferring physician, (TP) FF, told AP BB that P#1 was stable, and the transport would take 45 minutes. AP BB informed TP FF that he would notify the accepting cardiologist (AC EE). Continued review of the audio recordings revealed that PFC AA requested P#1's face sheet from the ECC.

A detailed review of the second audio recording revealed that the facility's house supervisor (HS) HH informed the transferring physician that another facility, which had been called prior to the facility, should have accepted P#1 and AC EE was concerned about accepting P#1 due to EMTALA violations. HS HH further explained that TP FF should contact that facility again and could call back if given a hard time.

An interview took place with the Director of Care and Resource Management (DCRM) CC on
1/10/23 at 4:02 p.m. DCRM CC explained that the facility was considered at full capacity when there were 15 patients on hold in the ED and no available inpatient beds. She acknowledged that she was aware of P#1 and that her responsibility included leading the transfer center. DCRM CC explained that when the transfer center received a call, the transfer center would determine if they had capacity and capability to receive the patient. DCRM CC recalled that when the request to transfer P#1 to the facility was received on 12/15/22, they had the capacity to accept and was not on diversion. DCRM CC further explained that patients with a STEMI, stroke, or in labor were accepted regardless of capacity. DCRM said STEMI patients were transferred to the catheterization lab immediately. DCRM CC explained that regarding P#1, the transfer center received a call from the transferring facility's ECC, who said that P#1 had a STEMI; however, the transferring facility had previously called another nearby facility, and the nearby facility said they had another patient with ST elevation myocardial infraction on the table and did not have capacity. DCRM CC stated AP BB accepted P#1, a STEMI code was called, and AC EE was paged. DCRM CC explained that after a discussion between AP BB and AC EE, AC EE called HS HH and told HS HH that it was an EMTALA violation for the nearby facility to reject P#1. DCRM CC said that PFC AA contacted Chief Medical Officer (CMO) GG after being informed that AC EE refused to accept P#1. CMO GG told AC EE he had to accept P#1; however, by the time PFC AA called the transferring facility P#1 had already been transferred to another facility.

An interview took place with the PFC AA on 1/10/2023 at 10:04 p.m. PFC AA recalled that she received a call from the transferring facility requesting to transfer P#1, a STEMI patient to the facility. PFC AA said she connected the call to AP BB, who accepted the patient. PFC AA said she called HS HH to inform her that P#1 was coming. PFC AA explained that while she was on the call with AP BB, TP FF mentioned that he had previously called a nearby facility that rejected P#1 due to capacity. AP BB contacted AC EE and mentioned that a nearby facility had contacted previously. AC EE told HS HH that it was an EMTALA violation for the nearby facility to reject P#1 even if they are currently caring for a STEMI patient. HS HH informed TP FF to call the other facility again and advise them to take P#1. PFC AA said she immediately contacted the CMO, who said P#1 should be accepted. The transferring facility was called to inform them to bring P#1; however, P#1 had already been transferred to another facility.

An interview took place with AC EE on 1/11/2023 at 11:25 p.m. AC EE acknowledged that P#1's incident was memorable. AC EE stated he was paged around 6:00 a.m. and was informed that P#1 was to be transferred to the facility. AC EE said that AP BB shared that P#1 had been in the transferring facility's ED for some time and P#1's condition changed to a STEMI. The transferring facility had called another nearby hospital before calling the facility, and the nearby hospital declined to accept P#1. AC EE recalled that he had been concerned as there had been severe weather conditions in the area at the time that affected the arrival time. AC EE spoke to HS HH and appraised that P#1 receive stabilizing treatment before transfer. AC EE stated that he had been willing to accept P#1 but was not sure of the timeline to know the best treatment plan for P#1. AC EE explained that P#1 needed to reach the receiving facility within 120 minutes or be administered a thrombolytic (medication that breaks up or dissolves blood clots) before transfer. AC EE stated that when he later spoke to HS HH, HS HH informed him that P#1 had been accepted by the other hospital that previously declined P#1.

An interview took place with AP BB on 1/11/2023 at 11:53 a.m. AP BB acknowledged remembering P#1's incident. AP BB stated he was on a call with TP FF, who said a STEMI patient needed to be transferred to the facility. AP BB said he accepted P#1 and informed AC EE that P#1 would be at the facility in about 45 minutes. AP BB said AC EE asked him why P#1 was not going to a nearby facility 15 minutes from the transferring facility. AP BB explained to AC EE that TP FF said the nearby facility had a STEMI patient and could not take P#1. AP BB said AC EE told him he would investigate it. AP BB said he accepted P#1, and the transferring facility sent P#1's face sheet. AP BB said he was unaware of why P#1 never came to the facility.


An interview took place with HS HH on 1/11/2023 at 10:30 p.m. HS HH recalled that the transfer center had received a request to transfer a STEMI patient that had been accepted by AP BB. HS HH received a call from AC EE and was told that she should call the transferring facility back and instruct them to call the closer facility that had rejected the transfer and inform them that they were not allowed to decline a patient. HS HH informed the transferring facility to call back if they had any issues.


The facility's policy titled " Emergency Medical Treatment and Patient Transfer Policy (EMTALA), Policy # 2.002 (HPP105), Original adoption Date: June 1991, revised 12/22/21 was reviewed. The section of the policy titled "E. RECEIPT OF TRANSFERS", revealed in part, "Transfer from other facilities shall be accepted of an individual who required specialized capabilities if SGMC (South Georgia Medical Center) had such specialized capabilities or facilities and had the capacity to treat the individual."

The facility failed to ensure that their policy and procedure was followed, as evidenced by failing to accept patient #1 on 12/14/2022, as the facility and capability (Interventional /STEMI Cardiologist) and Capacity (open beds were available, and a Cath lab).