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Based on medical record review, medical staff bylaws, policy review and staff interviews it was determined the hospital failed to accept a transfer from another facility for a higher level of care when the facility contacted the Emergency Department (ED) directly in one (1) of one (1) transfers refused by the attending physician in the (see tag A-2411).

Based on record review, medical staff bylaws, policy review and staff interviews it was determined the hospital failed to accept a transfer from another facility for a higher level of care even though the hospital had capacity and capability at the time of the request in one (1) of one (1) transfers refused. This failure has the potential for all patients requiring a transfer to a higher level of care to have a delay in care that may cause life altering consequences to the patient.

1. Review of the medical record for patient #1 revealed the medical record had been opened by unit secretary #1 on 07/12/19 at 8:47 p.m. and dismissed by Charge Nurse #1 on 07/13/19 at 2:23 a.m.

2. Review of the medical staff bylaws with an effective date of 10/27/15 states in part: "Request for Transfer from External Hospitals: a. When a physician with privileges at West Virginia University Hospitals, Inc is contacted by an external hospital regarding acceptance of a patient, the physician may not refuse to accept the patient in transfer if : 1. The patient requires specialized services that West Virginia University Hospitals, Inc. provided; 2. West Virginia University Hospitals, Inc. has the capacity to provide the services. 3. The patient is stable for transfer."

3. Review of the policy titled Emergency Medical Treatment and Labor Act (EMTALA) with a last revision date of 02/26/16 states in part: "A physician practicing at WVUH will accept an appropriate transfer of an individual with an emergency medical condition based upon WVUH capabilities and capacity."

4. A review of bed capacity for 07/13/19 at 4:30 a.m. revealed at the time the Medical Access Referral System (MARS) line was backed up the hospital had forty-eight open beds and five observation beds for a total of fifty-three open beds for patient placement. This was verified during the review of bed log on 08/06/19 at 2:00 p.m. by the Director of the MARS department.

5. A review of services offered and physician call log for 07/12/19 revealed the hospital had an on call orthopedic physician and a plastic surgeon. Further review revealed the hospital has an orthopedic specialist for hands.

6. A review of the call log for 07/12/19 revealed a phone number matching Washington Greene Hospital was found on the log to the MARS line at 8:21 p.m. and a log of a phone call to the Emergency Department (ED) at 9:01 p.m. with a total of twelve (12) calls made to the MARS line prior to contacting the ED.

7. An interview was conducted on 08/05/19 at 1:00 p.m. with the Director of the MARS department. I asked if the MARS line was down on 07/12/19, and if so, what the protocol is for the ED to accept patients. He stated in part: "After doing research the MARS line was not down on that day but that evening we had a high influx of calls and the line was backed up. We had twenty-eight physicians waiting in que. We haven't had that high of an influx before and there is no procedure in place for when that happens but our throughput Nursing Supervisor is stationed in the room with the staff and he began helping them to get the lines answered. The night that this happened, from 7:00 p.m. until midnight, we had a total of thirty-two dropped calls for a total abandon rate of 19.6%. After checking Washington did not get through on the MARS line."

8. An interview was conducted on 08/05/19 at 2:00 p.m. with attending physician #1. I asked if she remembered there being a problem with the MARS line for accepting patients and if she had been made aware of hospitals calling the ED directly for admissions. She stated in part: "Well, we started a new procedure a couple of months ago that the physicians no longer call the ED they call the MARS line to get a transfer to the hospital. We are supposed to send them to the MARS line." When asked if she knew of any problems on 07/12/19 with the MARS line she stated in part: "It wasn't down it was backed-up. I do remember someone saying they were on hold for a transfer and told them I couldn't take them they would have to go through the MARS line. We only take physician to physician for traumas." When asked if she contacted anyone when she was given the information that physicians were calling the ED to say there was a problem with the MARS line she stated in part: "Well, I would expect the Nursing Supervisor to notify us of what to do." When asked if she contacted her Medical Director for guidance on what to do when physicians are contacting the ED and needing to transfer patients when the MARS line is backed up she stated in part: "No."

9. An interview was conducted on 08/05/19 at 3:05 p.m. with unit clerk #1. I asked if she remembered that day and receiving a phone call from Washington Greene Hospital to transfer a patient with a hand laceration that involved tendons, and if so, to please explain the phone call and what occurred. She stated in part: "I do remember that night we had a few phone calls that day. Two (2) calls at the same time to tell us they couldn't get through to the MARS line and needed to transfer their patients. I talked to the Charge Nurse and we sent the other call back to the MARS line and I talked to this hospital and asked if I could place her on hold. I then called the MARS line and was on hold to the MARS line and they never answered the line so I hung up and talked to the Charge Nurse and then transferred the call to him. He talked to the physician and they told him they couldn't accept the patient, they would have to send them to the MARS line." When asked how the patient was placed in their Electronic Health Record if they didn't accept the patient, she stated in part: "I believe I talked to (states the charge nurses name) and he told me to put them in the system and he would talk to them. Later he placed them in Arrived in Error because that is what we do when the patient does not come." When asked if the physicians in the ED were aware of the MARS line having difficulty that evening she stated in part: "Yes, we had multiple physicians calling the ED complaining about it and they were aware."

10. A telephone interview was conducted on 08/06/19 at 8:25 a.m. with Charge Nurse #1. I asked if he remembered Washington Hospital calling the ED for a transfer of a patient with a laceration to his hand that involved tendons. He stated in part: "Yes, I put the Nurse Practitioner on hold because we had information that the MARS line was backed up. I talked to (stated attending physician #1's name) and she said, "I can't accept it, it has to go back to the MARS line." I got back on the line and explained the process of the MARS line and she told me she's been on hold with them and they weren't answering, that she would have to send the patient somewhere else." When asked if when he needed to admit a patient if he had beds available and he stated in part: "Yes, I was getting beds for patients when I called the supervisor."

11. An interview was conducted on 08/06/19 at 12:47 p.m. with the Medical Director of the ED. I asked if he was aware of a problem with the MARS line on 07/12/19 and if any of his attending physicians had called him for guidance on what to do about other facilities calling the ED for transfers. I also asked what his expectation was of his staff in the event there is a problem with the MARS line. He stated in part: "I was made aware that there was a problem with the MARS line that evening although I wasn't notified that evening. My phone is on pretty much all the time and all of the attendings know that but I did not receive any phone calls that night. I would expect if a physician calls and says there is a problem with the MARS line that the call would be taken and the patient accepted."

12. An interview was conducted with the Chief Medical Officer on 08/06/19 at 1:28 p.m. When asked if she oversees the attending physicians in the ED she stated in part: "Yes, the buck stops here." When asked the expectation of an attending refusing a patient through the Charge Nurse when the MARS line is having a huge influx of patients she stated in part: "My expectation is someone in the ED should've called someone. One doctor exercised poor professional judgement."

13. A telephone interview was conducted on 08/07/19 at 8:26 a.m. with the Assistant Medical Director of the ED. When asked if he was aware of the MARS line being backed up with phone calls on 07/12/19 he stated in part: "I wasn't aware at the time but I came into work at about 10:45 p.m. that night and they asked for guidance and I told them that if a critically ill patient is being called to the ED you need to accept it." I asked if he was aware that attending physician #1 was aware of the MARS line having problems and refused to take the phone call and told the Charge Nurse to tell them he couldn't accept that patient send them to the MARS line. He stated in part: "No I wasn't but I would expect the physicians to pick up the line and take the call if the MARS line is not functioning."

14. A joint interview was conducted with Information Technology Specialist #1 and #2 on 08/07/19 at 11:30 a.m.. They both concurred that multiple phone calls were made from Washington Greene on 07/12/19. When asked how long the phone calls lasted to see how long the Nurse Practitioner was on hold IT #1 stated in part: "There is no way to tell, once they are put on hold it stops monitoring the length of the call."

15. An interview was conducted on 08/06/19 at 12:47 p.m. p.m. with the Medical Director of the ED. He concurred attending physician #1 should have accepted the patient when the MARS line was having an influx of calls and hospitals were contacting the ED for transfer.