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Based on interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for one of 27 patients, (Patient 1) when Hospital B contacted Hospital A on 3/1/23 to transfer Patient (Pt) 1 who was diagnosed with acute appendicitis, required surgical services and Hospital B did not have the capability to provide the required surgical services to treat and stabilize Pt 1. Hospital A did not accept transfer and had the capacity to provide surgical services to Pt 1. Hospital A did not follow its policy and procedure to document and log requests for inbound transfer patients and the reason(s) to support a decision to accept or deny transfer for Pt 1. Hospital A failed to have a system to log and document all requests for patient transfers and to list the reason to accept or deny the requested transfer in accordance with hospital policy and procedure. These failures resulted in Pt 1 being transferred on 3/1/2023 in stormy weather to a hospital 250 miles away, arriving approximately 17 hours after the request to transfer was initiated, which delayed Pt 1 ' s access to the surgical services her condition required, and placed her at risk for a ruptured appendix. Hospital A was less than 75 minutes away from Hospital B. The hospital ' s current and past failure to maintain a transfer request log or follow their own policy ' s process for determining whether to accept a patient transfer request resulted in the inability of the hospital to support their compliance with Recipient Hospital Responsibilities. (Refer to A 2411)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on interview and record review, Hospital A failed to meet its Recipient Hospital Responsibilities for one of 27 patients (Patient 1), when Hospital B contacted Hospital A on 3/1/23 to transfer Patient (Pt) 1 who was diagnosed with acute appendicitis, required surgical services and Hospital B did not have the capacity to provide the required surgical services to treat and stabilize Pt 1. Hospital A did not accept transfer and had the capacity and capability to provide surgical services to Pt 1. Hospital A did not follow its policy and procedure to document and log requests for inbound transfer patients and the reason(s) to support a decision to accept or deny transfer for Pt 1.

These failures resulted in Pt 1 being transferred on 3/1/2023 in stormy weather to a hospital 250 miles away, arriving approximately 17 hours after the request to transfer was initiated, which delayed Pt 1's access to the surgical services her condition required, and placed her at risk for a ruptured appendix. Hospital A was 75 minutes away from Hospital B. The hospital's current and past failure to maintain a transfer request log or follow their own policy's process for determining whether to accept a patient transfer request resulted in the inability of the hospital to support their compliance with Recipient Hospital Responsibilities.

Findings:

During a review of Pt 1's face sheet from Hospital B, the face sheet indicated Pt 1's encounter date was 3/1/23 with an Admitting Diagnosis of acute Appendicitis (a serious medical condition in which the appendix [a tube-shaped sac attached to an opening into the lower end of the large intestine in humans] becomes inflamed and painful).

Pt 1's document titled "Transfer Call List", dated 2/28/23 was reviewed. The "Transfer Call List" indicated Hospital B called Hospital A on 3/1/23 at 12:15 a.m. and was informed that Hospital A could not take Pt 1 due to them having no capacity (the ability of the hospital to accommodate a patient needing examination or treatment at the request of another medical facility or physician and encompasses the number and availability of qualified staff, beds, equipment and the hospitals ability to accommodate patients in excess of its occupancy limits).

During a review Hospital A's document titled "House Supervisor Transfer Log" dated 11/30/22 thru 4/2/23, the "House Supervisor Transfer Log" indicated Hospital A received a transfer request from Hospital B on 3/1/23 at 12:16 a.m. and was "declined" due to over 35 Emergency Department (ED) beds holding (the practice of holding patients in the emergency department after they have been admitted to the hospital). The document did not include the transfer patient's name (Patient 1).

During concurrent interviews on 5/30/23 at 11:15 a.m., with the Emergency Department Director (EDD) and Emergency Department Manager (EDM) 1, the EDD stated approximately 220- 250 patients were evaluated in the ED daily. EDM 1 stated the ED had a total of 60 beds with the capacity to extend an additional 26 beds in the ED hallway if needed. EDM 1 stated patients admitted to the hospital and waiting to be transferred to the floor typically occupied the beds in the ED hallway. The EDD stated Hospital A did not utilize a hospital transfer center (a centralized location managing all components of a patient's transfer into a hospital system) to manage transfers. The EDD stated house supervisors received and screened calls from hospitals requesting patient transfers to Hospital A's ED. The EDD stated the house supervisor on duty determined whether the transfer request was accepted or declined. The EDD stated house supervisors did not typically consult ED managers when determining whether to accept or decline transfer patients.

During an interview on 5/31/23 at 10:10 a.m., with House Supervisor (HS) 2, HS 2 stated the house supervisors received the requests from other hospitals to transfer patients to Hospital A. HS 2 stated the availability of beds and the physician agreeing to accept the transfer where the two main determining factors considered when accepting or declining a transfer patient. HS 2 stated Hospital A could accept most transfers except transfers that required neurosurgery or treatment for severe burns. HS 2 stated Hospital A always had and surgeon on call and had the capability to treat and acute appendicitis. HS 2 stated all transfer requests were documented on a transfer log and house supervisors were required to complete a transform form when the transfer was accepted. HS 2 stated transfer forms were not completed when the transfer patients were declined. HS 2 stated the expectation was that each house supervisor document all transfers on the transfer log and on a transfer form to "keep information organized," however the process was not consistently followed. HS 2 stated Hospital A used to have a "Transfer Committee" that reviewed transfers, but the Committee had since disbanded. HS 2 stated Hospital A had no system in place that provided oversight of transfers accepted and/ or declined.

During concurrent interviews and record review on 5/31/23, at 9:00 a.m., with the Operating Room Charge Nurse (ORCN) and the Surgical Services Director (SSD), Hospital A's "2 Main OR Surgery Schedule" dated 2/28/23 and 3/1/23 were reviewed. ORCN stated, on 2/28/23, the last surgical case started at 6:30 p.m. and ended at 7:40 p.m. The ORCN stated on 3/1/23, the first case started at 7 am and there were no "add on" surgical procedures the night of 2/28/23. SSD stated there was an entire operating room (OR) team on call and OR rooms available to perform a surgery on 3/1/23 if needed. SSD stated the OR had the capacity and capability to accept Patient 1 on 3/1/23. The ORCN stated the house supervisor on duty did not contact the OR on 3/1/23.

During a concurrent interview and record review on 6/1/23, at 10:40 a.m., with the Nurse Manager (NM) for Hospital A's 5- Main and 6- North Floors, Hospital A's "ED Shift & Safety Huddle/ Report info" dated 2/28/23 at 7 p.m., was reviewed. The NM stated both floors (5- Main & 6- North) provided care to medical surgical patients (patients with medical, surgical, or a combination of both conditions) and telemetry patients (patients with a heart condition that require electronic monitoring of the heart's activity) on these two floors. The NM stated, on 2/28/23 and 3/1/23, there were 20 occupied beds on 5- Main and 24 occupied beds on 6- North leaving 20 unoccupied beds between both floors. The NM stated either floor could have admitted a patient directly to the floor and then take the patient to surgery. The NM stated Hospital A had done this in the past, but not often. The NM stated 5- Main and 6- North Floors had the capability and capacity to accept Pt 1.

During an interview on 6/2/23, at 7:30 a.m., with HS 1, HS 1 stated a house supervisor took one to three calls each night requesting transfer from a "smaller" hospital to Hospital A. HS 1 stated most transfer requests involved GI (gastrointestinal- pertaining to the stomach and intestines) or cardiovascular (pertaining to the heart and blood vessels) cases because Hospital A could provide these services. HS 1 stated, "Anything we have a service for we can take." HS 1 stated the process was to check with the ED "bed control" and possibly a specialist when calls came in, depending on the call. HS 1 stated house supervisors just considered ED capacity to determine if Hospital A had capacity to receive a transfer. HS 1 stated, on 3/1/23, he received a call from Hospital B to transfer Pt 1. HS 1 stated he did not call the OR nor the floor to inquire about Hospital A's capability to receive Pt 1 because the ED was already over capacity. HS 1 stated he would never consider a direct admit to Hospital A on nights unless it was "absolutely" emergent. HS 1 stated he would not call a surgeon or surgical team at night, because "they are on call." HS 1 stated the normal flow was to transfer patients to the ED because of limited resources at night. HS 1 stated he would not directly admit at night because "some" hospitals were not always honest about the acuity of the patients and the patients' conditions and could change on the ride over. HS 1 stated the main goal was to continue the flow in the ED. HS 1 stated if Pt 1 had walked into the ED, they would have evaluated and treated Pt 1.

During an interview on 6/2/23, at 8:20 a.m., with the interim Chief Medical Officer (CMO), the CMO stated Hospital A was required to evaluate and treat all patients if Hospital A had the capacity and capability to do so. The CMO stated house supervisors had the authority to decide when to accept or decline a transfer patient based on Hospital A's capacity and capability at the time the transfer request was received. The CMO stated Hospital A did not have a system in place to review the transfers or transfer requests of patients with an emergency medical condition for appropriateness and completeness.

During a review of the hospital's policy and procedure (P&P) titled, "Medical Staff Policy/ Procedure Incoming Transfer Policy (MS 127)", dated 3/29/19, the P&P indicated, "to provide a policy and procedure in compliance with EMTALAregulations to be followed when transfer of a patient to [Hospital A] ("Hospital") is requested by another medical facility, 2 (i) ensure safe transfer of patients from other medical facilities, (ii) verify availability of appropriate hospital capacity and capability and appropriate physicians to provide the necessary higher level of care to transfer patients, and (iii) appropriately handle situations when hospital capacity and capability and appropriate physicians are not available... All requests from other medical facilities for transfer of patients shall require verification of both hospital capacity and capability and availability of specialized physician coverage... All calls requesting transfer should be directed to the transfer nurse (the nursing supervisor on duty) who shall be responsible to verify the availability of appropriate hospital capacity and capability and physician resources... All transfer request communications and related decisions will be appropriately documented... The transfer nurse shall verify the availability of an appropriate bed (Med-Surg., Telemetry, ICU, etc.) and other necessary hospital resources. Hospital capacity and capability shall be assessed by the transfer nurse and if needed administrator on call... The transfer nurse shall contact the medical staff member(s) on call for such requested/ necessary service or specialty(ies) or as requested to inform such physician(s) of the requested transfer (including status of the patient and anticipated medical needs) and status of hospital capacity and capability, and shall inquire as to whether the medical staff member(s) are able to provide the necessary care for the patient... The transfer nurse may consult with the ED coordinator, ED physician, physician specialists, ICU coordinator, administration, or admitting as necessary to make a final determination regarding availability of hospital capacity and capability and physician resources... All actions communications and decisions regarding requested transfers and their disposition shall be appropriately documented by the transfer nurse (including, when applicable, documentation of the inability to accept the transfer, including detailed information regarding the factors limiting the medical staff member's ability to provide the necessary care) ..."

During a review of the Mayo Clinic reference article "Appendicitis," dated 8/7/21, the article indicated, "...Appendicitis is an inflammation of the appendix, a pouch that projects from the colon on the lower right side of the abdomen...Appendicitis causes pain in the lower right abdomen...As inflammation worsens, appendicitis pain increases and eventually becomes severe...A blockage in the lining of the appendix that results in infection is the likely cause of appendicitis. The bacteria multiply rapidly, causing the appendix to become inflamed, swollen and filled with pus. Severe abdominal pain requires immediate medical attention. If not treated promptly, the appendix can rupture. A rupture spreads infection throughout the abdomen. Possibly life-threatening, this condition requires immediate surgery to remove the appendix and clean the abdominal cavity..."

During a review of Hospital A's document titled, "General Surgery On-Call" for the month of February 2023, the document indicated on 2/28/23 there was a surgeon on-call to provide 24-hour surgery coverage. During a review of Hospital A's "General Surgery On-Call" for the month of March 2023, the document indicated on 3/1/23 there was a surgeon on-call to provide 24-hour surgery coverage.

During a review of Hospital A's document "Surgery Schedule," dated 2/28/23, the document indicated the start time of the last scheduled surgery on 2/28/23 was 5:45 p.m.

During a review of Hospital A's document "Surgery Schedule," dated 3/1/23, the document indicated the start time of the first scheduled surgery on 3/1/23 was 7 a.m.

During a review of the Weather Underground website data for the historical weather conditions in the area of Hospital B, the data indicated for the period of 2/28/23 at 10 p.m. until 3/1/23 at 7 a.m. the weather was rainy off and on, with temperatures between 37 to 46 degrees Fahrenheit, winds up to 28 miles per hour (mph) with wind gusts up to 41 mph.