HospitalInspections.org

EMTALA (The Emergency Medical Treatment and Labor Act)



Based on interview, record review, and review of 3 of 3 Emergency Room patient records (ID#'s 11, 15, 16) with a diagnosis of appendicitis on April 10th, 2010 revealed Conroe Regional Hospital failed to: Accept the responsibilities as the recipient hospital with capabilities and capacity for the transfer of two (2) patients (ID#'s 1 and 2) in need of a higher level of care (surgeon).

Findings include:

Record review of transfer documents (face sheets) at Conroe Regional Hospital revealed the Hospital refused to accept the transfer of two (2) patients (Patient ID#'s 1 & 2) from other hospitals on 4/10/2010 with diagnosis of acute appendicitis requiring the services of a surgeon. Conroe Hospital had written on the face sheets of patient ID #'s 1 & 2 "No surgeon on call." According to the face sheets Patient
ID# 1 had VA (Veterans Administration) insurance and Patient ID# 2 had no insurance.

Record review of Emergency Room records at Conroe Hospital revealed three patients with insurance were admitted 4/10/10 with a diagnosis of appendicitis. Surgeons were consulted and accepted care. Each patient had an appendectomy according to the surgery schedule dated 4/10/10.
(Patient ID#'s 11, 15, 16)

Record review of the "On-call" emergency room schedule at Conroe Hospital for April 2010 revealed a "Trauma Surgeon" was on-call 24 hours a day 7 days a week. Trauma Surgeon ID# 61 was on call April 10th, 2010 and accepted care for emergency room patient #'s 11 and #15.

Record review of the credential file for Trauma Surgeon #61 dated 8/24/09 revealed he was granted surgical privileges that included "laparoscopic appendectomy."

Review of the facility's policy titled "EMTALA - Duty to Accept" dated 2/09 stated "Purpose: To require that appropriate transfers are accepted by the hospital. Policy: A hospital with specialized capabilities or facilities shall accept an appropriate transfer of an individual with an emergency medical condition who requires specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual."

The Chief Nursing Officer (CNO) acknowledged 7/5/10 at 11:40 a.m. the Hospital began the process of becoming a Level III Trauma center on April 1st, 2010. The Surgeons on-call beginning April 1st, 2010 were re-classified as "Trauma Surgeons" and the schedules reflected no "surgeons" on-call, only Trauma Surgeons. The CNO stated that this caused confusion within the hospital as to whether a general surgeon was on-call for the month of April 2010. The CNO further stated the hospital began listing a general surgeon on their on-call schedule beginning May 1st, 2010. The on-call schedules for May, June, and July 2010 reflected that the Trauma Surgeons on-call for that time period are the same physicians on-call for "Surgery."

INTERVIEW WITH RURAL HOSPITAL EMERGENCY ROOM PHYSICIAN ID# 91
Interview 7/2/10 at 11:20 a.m. with the Emergency Room Physician at Rural Hospital ID# 89 revealed the Rural Hospital did not provide surgical services. The ER Physician stated that patient ID# 1 presented on 4/10/10 with appendicitis verified by a CT scan. The ER Physician contacted Conroe Hospital and spoke with a Physician (Hospitalist on duty ID# 53) which agreed to accept the patient. The patients facesheet was then faxed to Conroe Hospital. Upon receiving the facesheet the Nursing Supervisor
(ID# 52) called the Rural Hospital back and told them that Conroe Hospital would not accept the patient and it would be better for the patient to go to the VA hospital. The ER Physician stated that this caused a delay in obtaining acceptance at another hospital, therefore causing a delay in patient ID# 1's care. Patient ID# 1 was eventually transferred to another hospital (Hospital ID# 87) but the patients appendix had ruptured prior to the surgery.


Record review of a facility document dated 4/10/10 at 9:46 p.m. written by Nursing Supervisor ID# 52 at Conroe Hospital addressed to their Chief Financial Officer (ID# 60) stated "We denied a transfer (patient ID# 1)from a Hospital Emergency department (Hospital ID# 89) for an appendicitis. Physician ID# 53 informed me to accept the patient, if a VA bed was not available. The VA however did have a bed. In addition we do not have a surgeon on call, only Trauma. I did call the Trauma Surgeon (ID# 61) to see if he would take this patient. However he said the VA would be the best place for this patient, therefore, he denied too."

PHYSICIAN ID# 53 (Accepting Physician at Conroe)
Interview 7/9/10 at 10:35 a.m. with Physician ID # 53 revealed he was the accepting physician for Patient ID# 1 on April 10th, 2010 from the Rural Hospital. Physician ID# 53 stated he had contacted the surgeon on call (ID# 61) which agreed to accept the patient. The Physician admitted telling the nursing supervisor (ID# 52) to let the Veterans Hospital know about the patient and see if there was a VA bed available. Physician #53 stated he accepted the patient and did not place any stipulations on the admission. Physician #53 further stated that he was surprised the evening of 4/10/10 to find out that patient ID# 1 was transferred to another hospital.

NURSING SUPERVISOR AT CONROE HOSPITAL (ID# 52)
Interview 7/9/10 at 9:15 a.m. per telephone revealed she was the Nursing Supervisor on duty 4/10/10. The Nursing Supervisor stated that Conroe Hospital initially accepted patient ID# 1 from Rural Hospital # 89. The Hospitalist on Duty (Physician ID# 53) agreed to take the patient if the VA did not have a bed. The nursing supervisor stated that she reminded the Hospitalist on duty that the hospital did not have a "general surgeon" on-call. The nursing supervisor contacted the Rural Hospital and told them that they did not have a surgeon on call and that the VA hospital had beds available, therefore the patient would not be accepted.


FACESHEETS
Record review of transfer documents (facesheets) at Conroe Regional Hospital revealed the hospital refused to accept the transfers of two patients (ID# 1 & 2) with a diagnosis of acute appendicitis requiring the services of a surgeon on 4/10/10. Conroe Hospital had written on the facesheet for patient ID# 1 "VA bed available and no surgeon on call." Conroe Hospital had written on the facesheet for patient ID# 2 from Rural Hospital # 88 "No general surgeon on call." The facesheet for patient ID# 2 stated the patient was "self pay."


PATIENT ID# 1 at Rural Hospital # 89
Record review of the emergency room record for patient ID# 1 dated 4/10/10 revealed the patient presented to the ER at 4:03 p.m. complaining of abdominal pain per the triage notes. The physician notes stated "Clinical Impression: Abdominal pain acute appendicitis and Right Renal Mass. Attempted VA Hospital transfer but VA agreed for patient to go to Conroe Hospital given time delays." A physician note at 7:25 p.m. stated "I have MD acceptance at Conroe Hospital from physician ID# 53. However, we mentioned patient is VA status. We called the VA Hospital in Houston to ensure they approve and authorize the transfer to Conroe Hospital as a courtesy to patient to avoid undenied coverage. VA graciously agrees patient should in fact go to Conroe Hospital for most expeditious care. The Nursing Supervisor (ID# 52) at Conroe Hospital refuses to accept patient - wants us to go to the VA hospital but VA has some concern as us and wants us to go to Conroe Hospital."

A CT scan 4/10/10 at Rural Hospital ID# 89 for patient ID# 1 stated "Impression: Retrocecal appendix which is inflamed with periappendiceal inflammatory change. Solid mass right kidney."

The Memorandum of Transfer sheet for patient ID#1 at the Rural Hospital stated an accepting hospital was secured at 9 p.m. on 4/10/10. (one-hour and thirty-five minutes after Conroe Hospital accepted and then denied the transfer). The nursing notes stated on 4/10/10 at 10:27 p.m. that the "patient will be flown to hospital ID 87."


Interview 7/9/10 at 12:30 p.m. with the "House Nursing Supervisor" (ID# 50) at Conroe Hospital revealed the hospital did not track how many patients were refused transfer for surgical services in April 2010 due to no surgeon on-call.

Record review of a policy at Conroe Hospital titled "EMTALA - Transfer Policy" dated 02/09 stated "Refusal To Accept a Transfer: For those situations in which the hospital refuses to accept a transfer from another facility, the hospital should have in place a procedure to review any potential refusals and / or monitor any refusals of transfer from other facilities."