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Based on review of medical records, Transfer Center logs, review of Transfer Center audio recordings, and staff interviews, the facility refused to accept from referring facilities within the boundaries of the United States appropriate transfers of individuals who required specialized capabilities or facilities for 3 (# ' s 11, 15 &17) of 10 transfer request from emergency room physicians from other referring facilities. The facility also failed to have policies and procedures that addressed Recipient Hospital Responsibilities (489.24 (f).


Cross reference:
2411- Recipient Hospital Responsibilities

2411
Based on review of medical records, Transfer Center logs, review of Transfer Center audio recordings and staff interviews, the facility refused to accept from referring facilities within the boundaries of the United States appropriate transfers of individuals who required specialized capabilities or facilities for 3 (#'s 11, 15 &17) of 10 transfer request from emergency room physicians from other referring facilities.

Findings include:

1. Patient #11 ' s medical record from the referring hospital was reviewed. The medical record revealed that patient #11 presented to the referring hospital's emergency department (ED) on 10/31/2015 at 2:56 p.m. The ED triage report revealed that the patient ' s chief complaint was " Head Injury " . The section titled Patient narrative stated in part, " Apparently, assaulted, noted swelling to occipital (back of the head) area, bleeding controlled, unknown LOC (Loss of Consciousness), pupils sluggish , to react, (L) (left) pupils larger, approximately 3mm (millimeter), (R) (right) pupil approximately 2 mm, strong ETOH (alcohol) with slurred speech. Review of the CT (computerized tomography) scan for patient #11 was completed on 10/31/2015 at 3:48 p.m. The results of the CT scan revealed, an acute subdural hematoma on the right side which had increased in size, compared to 10/14/2015. The findings were discussed with the ED physician on the phone on 10/3/2015 at 4:15 p.m. Documentation by the ED physician on the addendum note at 5:52 p.m., revealed in part, " He presents here today with a new injury and CT report shows a new subdural on top of old subdural. This is larger than noted on previous CT October 14, 2015. I discussed case with Dr. (name) who also stated there are fresh blood products within this new injury ...I spoke to Dr. (Neuro-surgeon on-call at Phoebe Putney Memorial Hospital) who refused to take this patient. She stated that he (Pt. #11) did not need admitting with his previous injury and should never had been transferred ...she stated that she would not take him for this new injury ...I did make it clear that this was a new injury with fresh blood products within the hematoma (blood clot) and that it was larger than on the previous CT with some midline shift. She still adamantly refused ...she was not advising to send him home she was not accepting him in transfer. I did advise her we have no neurosurgeon (at referring hospital name). " Patient #11 was transferred to another acute care facility for proper management of his injury.

Review of Phoebe Putney Memorial Hospital the facility's Transfer Center log revealed: 1. Patient #11, a 54 year old patient with need for neurosurgery services on 10/31/15. The Actions Taken and Reason Not Accepted column indicated that the physician didn't accept (not a higher level of care, services available closer to facility, care available at)

Review of Transfer Center recordings on 1/26/16 with employee #10 revealed the following conversation:
ER MD: Hello
MD #1: Hello
ER MD: Hey, this is Dr. ------, ER, I have a fellow here that you admitted October 14th with a- well the report was a epidural bleed, but the radiologist here today says it was actually a subdural, anyway, he says he was kept 5 days, then discharged, no surgery. He's been involved in an altercation and somebody struck him in the head. He says he doesn't know with what, but I scanned him, and he now has an acute on chronic subdural on the right side. Its larger than it was previously two weeks ago; there's about a 3 millimeter midline shift. He's awake, alert, oriented, intoxicated. We have no one here to take care of him.
MD #1: Yeah you guys sent me this guy before, and it wasn't even remotely something surgical. I got fed that line before and I got stuck with a drunk guy intubated, having seizures, that I babysat for about a week, and I sent home about a week ago. So, you know, I did not feel like this gentleman required any sort of surgical intervention before, so um, I am happy if they want to babysit him over there, and sober him up. I believe he has a follow up in my office, but every time this guy gets hit in the head over there in (name of referring hospital), I'm not going to have this guy getting transferred over here based on a radiology report. So um, like I said, If you want to speak to somebody on the medical service- because I ended up being a medical doctor for this gentleman for a week. That was just a week ago I sent him home. So I'm not going to take this guy and transfer him based on that radiology report, especially if the gentleman is awake and talking with you guys, and is intoxicated again like he was before. I am happy to see him in my office for this, but I am not going to take this guy.
ER MD: Well there is new blood products.
MD #1: Well yes, I understand. What he probably has is some resolution or some changes in the subdural that he had before. So, again you guys had sent me this guy for a week, so I'm not going to take this guy in transfer every time he gets hit in the head over there in (referring hospital name). I fully evaluated this gentleman, I took care of him, I discharged him. He had no neurologic issues. So, I know he's been hit and I'm happy to see him and follow up in my office, but I'm not going to take him based on another scan report.
ER MD: Okay I'll call someone else
MD #1: That's fine
ER MD: He has a new injury and a new bleed, so I'm not comfortable sending him home.
MD #1: And I didn't say send him home. What I said is, as far as neurosurgical transfer you are welcome to find someone else. I have already assessed this gentleman before and this is not going to be sort of a recurrent thing based on a scan. So, like I said, I am happy to evaluate this gentleman in my office. If you want him transferred to a neurosurgical service, then you will have to check with someone else.
ER MD: Okay, I'll do that.
MD #1: Thank you
ER MD: Thank you

Telephone interview with MD #1 on 1/26/16 at 2:45 PM revealed:
After listening to the Transfer Center audio recording, the physician confirmed that he/she was on call the day of the incident, and stated that he/she received transfer patients from anybody who calls. MD #1 explained that the patient eventually was admitted to medical service in Macon, Ga. He/she also stated that at this facility, people transferred him/her everything, adding that the surveyor was right- whatever the law is, he/she didn't take the patient. The physician explained that he/she had accepted the patient before, had provided medical management, treatment of seizures, and everything. MD #1 continued on stating that he/she had been counseled, and, that whatever the hospital instructed him/her to do, he/she would do it. He/she went on stating that he/she got a lot of non-neurological patients, and there is only one of him/her. The MD stated that he/she was happy to consult on patients, but 99% of what he/she got was medical, not Neuro. The facility refused to accept an appropriate transfer from a referring hospital Patient #11 on 10/31/2015, who required Phoebe Putney Memorial Hospital (PPMH) specialized Neurosurgical services for treatment.

2. Patient #15's medical record from the referring hospital was reviewed. A review of the ED Visit Summary sheet revealed that Patient #15 arrived to the referring hospital on 12/12/2015 at 10:30 p.m. via ambulance receiving oxygen via nasal cannula. The patient was triaged as a Priority 4. Documentation in the medical record revealed the patient's stated complaint and Chief Complaint was listed as "Congestion." The patients vital signs at 10:36 were: Blood Pressure: 77/64 (United States National Library of Medicine -B/P normal range 90/60 -120/80); Pulse oximetry 88% (normal oxygen saturation is 94% -100%). Documentation by the ED physician on the form titled " SOB (shortness of Breath) " revealed a 90 year old presented to the ED complaining of SOB, cough, rattling in chest and history of Congestive Heart Failure (CHF). Further documentation by the ED physician revealed in part, " Seeks evaluation for same. Pt (patient) has other complaints this time seeks evaluation. The patient ' s final diagnosis was listed as Atrial Fibrillation, CHF, Hypotension (low blood pressure). Patient #15 ' s medical condition was listed as " Poor. " Phoebe Putney Memorial Hospital refused to accept Patient #15 as an appropriate transfer on 12/13/2015. The patient was transferred to another acute care hospital on 12/13/2015.

Review of Phoebe Putney Memorial Hospital Transfer Center Log for Patient #15, revealed, a 90 year old patient with need for general medical services on 12/13/15. The Actions Taken and Reason Not Accepted column indicated "other". The notes column indicated patient deemed too unstable for transfer at this time. Dr. recommended calling back if patient stabilized for transfer.

Review of Transfer Center recordings on 1/26/16 with employee #10 revealed the following conversation:
(phone rings)
Person answering phone: Yeah this is ---------, how may I help you?
Transfer Center: this is ---------, transfer center (names facility)
Person answering phone: Hey
Transfer Center: (provides PA's name), is that a PA?
Person answering phone: he is
Transfer Center: Okay, I've got Dr --------- on the line for him please
Person answering phone: Dr Who now?
Transfer Center: (provides MD name, then spells it)
Person answering phone: Hold on
ER PA: Hello, this is (provides name), I'm one of the PAs working with Dr. ------------- this evening
Transfer Center: Hey ----------, this is --------- at the (names facility) transfer center, I've got Dr ---------- on the line. This is a recorded call. You can go ahead sir.
ER PA: Okay. Yeah Dr., this is (provides name), one of the PAs working with Dr. --------- over here in (name of a city). I've got a patient who just left your hospital 3 days ago, his name is (provides patient's name, then spells it), he's a 90 year old individual who was there for congestive heart failure, decompensated, was there for about 10 days, then sent here to (name of a city) to a nursing home. Came in this evening grossly short of breath, he is basically completely full of fluid. His sats (saturations) were about the mid 80's. Blood pressure about 75 systolically when he hit the door, his pulse rate was 84, respiratory rate was only 18- he's not working to breath, he's just full of fluid. Not really retracting, no accessory muscles use. He's afebrile. Chest X-ray just shows pulmonary vascular congestion. I'm looking at his labs, he's got a pro-BMT of 12,400; his cardiac enzymes were negative; his BUN/Creatinine were actually in good range- let me actually look at that one second, I don't have it written down. His BUN/Creatinine were actually 23 and 1.2. Anyway, we've got this gentleman on a non-re-breather, he wasn't doing well with just 2L, and then we tried a simple mask- unsuccessful, then we tried the non-re-breather, and we really only have him on about 90% right now. We've got him on a Dopamine drip at 10 mcgs. We've got a pressure right now that's about 75 systolic, still. We are giving IV fluid, and we started Lasix IV. So, we're kinda working on this guy the best we can, and the family wants- he's a DNR, but the family still wants as much as possible other than intubation. We don't have critical care here at the hospital this weekend, and he just left your hospital, so they want us to try to go ahead and get him back to you guys, and that's the reason why we're calling.
(silent pause)
ER PA: Dr. -----------?
Transfer Center: Well, hold on a minute, it's a disconnect, hold on.
ER PA: okay
Transfer Center: Dr. --------? Hello? Hello? Dr. -------? Dr --------? Oh, man. I guess I'll have to page her again, I don't know what happened.
ER PA: okay, no problem
Transfer Center: She was just on the line, but I'll be getting right back to you
ER PA: okay, that's fine. Do you want me to stay on hold?
Transfer Center: No, I'll call you right back
ER PA: okay, that's fine, thank you
(phone rings)
Person answering phone: Yeah, this is ---------, how may I help you?
Transfer Center: Hey ---------, I need (names PA) again
Person answering phone: Okay, hold on
(silent pause)
ER PA: Hello
Transfer Center: I've got Dr ---------, Dr --------? are you there? Dr --------? (chuckles) Wow, I don't know what's going on, this is strange. Dr -------? Okay, I'll get back to you (names PA), I'm sorry
ER PA: No its no problem. Okay, bye
(phone dialing, then rings)
(names facility) (inaudible), this is ----------
Transfer Center: Hey ---------, this is -------
Person answering phone: Hey ---------
Transfer Center: Is Dr ------ sitting there somewhere?
Person answering phone: She might be around the corner
Transfer Center: can you check for me?
Person answering phone: Sure, hold on one second.
(phone rings)
MD #8: Yeah
Transfer Center: Does it keep disconnecting you Doc?
MD #8: Yeah
Transfer Center: I don't know what to do
MD #8: Well, first get him on the line
Transfer Center: Okay, I'll get him on the line, then I'll call you
MD #8: Okay. Yeah, because I have to dictate, and I'm sitting here doing nothing because of this
Transfer Center: Yes ma'am, I'll get him on the line
(phone dialing, then rings)
Person answering phone: Yeah, this is --------, how may I help you?
Transfer Center: Hey ---------, this is -------- with (names facility), I need to speak to (names PA) again
Person answering phone: Uh huh, hold on
ER PA: This is (provides name)
Transfer Center: Hey (names PA), this is ----------.
ER PA: Hello
Transfer Center: We're going to try to do this in reverse, okay? Hang on just a second, okay?
ER PA: Okay, no problem
(phone dialing, then busy signal)
Transfer Center: (sighs) Are you still with me?
ER PA: I am
(phone dialing, then busy signal)
(phone dialing, then rings)
(someone answers, inaudible)
Transfer Center: Hey -----, I need to get Dr --------- hang on a minute, let me see if this call is going to connect. Hey (names PA) , are you there?
ER PA: I am
Transfer Center: Okay, great. I need Dr. ---------- please
ER PA: Alright
Transfer Center: I don't know what's going on with this phone today
MD #8: Hello
Transfer Center: Dr --------, (provides name of PA) is on the line from (provides name of facility). This is a recorded line. You can go ahead ma'am
ER PA: Okay. Hey Doc, this is (provides name), one of the PAs working with Dr. (provides physician's name) this evening. I've got a patient who...
MD #8: (interrupts) Dr. -----------what? I need to write it down please, could you spell it?
ER PA: Dr. (provides physician's name, then spells last name)
MD #8: (repeats spelling), okay
ER PA: Alright. The patient, his name is (provides patient's name, then spells it) He was with you guys, and he was discharged about 3 days ago. Apparently he was admitted with you guys with decompensated congestive heart failure, and was with you guys for about 10 days according to what the family members are saying...
MD #8: And how old is he?
ER PA: He's 90 years old. He is a DNR, but the family wants everything short of intubation done on this patient. He comes in from the nursing home this evening full of fluid. He's got rattles
MD #8: He's at the nursing home from us?
ER PA: He did, here in (name of city).
MD #8: Okay
ER PA: Okay, so we're about 45 minutes from you guys. So, he comes in, he's got a blood pressure of 70 systolic. His sats were about 75%, his sats were about 80% when he first got here. On 4 liters nasal cannula, we really couldn't get him up, we've got him right now on a non-rebreather, hanging at about 90%. His lungs are full of fluid, he's got pulmonary vascular congestion, and he has a pro-BMT of just short of 13,000; his cardiac enzymes were negative
MD #8: Okay, here's the question, I would like to get his chart when he was discharged, as to how were his lungs? and, you know, was he like compensated at that time?
ER PA: I'm not sure because he was in your system, and not ours, and I don't have access to any of those records over here. So, I...
MD #8: ---------, have you had a chance to look at those?
Transfer Center: I have not, I can do that though.
MD #8: Yeah because if he's a DNR, it may have been sometime like you know they just say, okay, we have done what we could, because that's a huge change in 3 days, you know?
ER PA: Yeah, the family says that he was stable when he left, and of course I don't know if that's true or not, but that's what they're telling me. But, anyway, so, um, we have him on a Dopamine drip, we have him currently on a non-rebreather. He's been given IV Lasix for diuresing, and basically right now what we got is a heart rate of 113. We have a pressure that is 70/40 right now, and he's still on a Dopamine drip right now at 10 mcg
MD #8: (interrupts) That's not stable. That's not a stable person for transfer though. 70/40 is pretty low, and that's on Dopamine. is it possible that your intensivist (also known as a critical are doctor with special training and experience in treating critically ill patients).
ER PA: Okay
MD #8: Is it possible that your intensivist could monitor him?
ER PA: That's the problem. We don't have critical care here at this hospital this weekend, we don't have anybody on...
MD #8: You're (names facility), right? (name of City)
ER PA: that's right
MD #8: Isn't Dr (inaudible) still there?
ER PA: He is, but he's the only person and so he doesn't take call everyday. He's on 10 days a month, then whenever he's available during the week, he'll come in, but his wife just had a baby, and he's actually off this weekend.
MD #8: Oh...okay, but the pressure needs to come up some, you know.
ER PA: Right...
MD #8: That doesn't sound like a stable transfer on a 90 year old. 70/40.
ER PA: Okay
Transfer Center: Doc, his discharge summary by Dr --------- says echo performed showed an ejection fraction of less than 20%. Agree the patient be treated with conservative medical management. He was started on Lasix, uh, let me see what else we got here...
MD #8: (names ER PA), tell me this: what is his renal function like?
ER PA: He's actually good. He's got a BUN of 23, and a Creatinine of 1.2, so...
MD #8: 1.2. You know what would help him, I mean you're giving him Lasix, absolutely that's the right way, but if you give him a dose of Metolazone (medication used to treat buildup of excess fluid in the body), that should help with the diuresis a lot more as well. Because his EF is only 20%
ER PA: Right
MD #8: You know what I'm saying?
ER PA: Oh yeah, I completely understand
MD #8: That is something, because the Lasix, yes, the pressure would probably come down more even
ER PA: Right
MD #8: Metolazone would not bring the pressure down so much
ER PA: Okay
MD #8: So that could be like uh 2.5 dose or something, and then once he becomes a bit more stable, you know, then we can talk again.
ER PA: Okay, well that's fine. Well we'll work on it and we'll see what we can do
MD #8: Alright --------?
Transfer center: Yes ma'am
MD #8: I think with his 20% EF and his advanced age, and such low blood pressure, when they call back, I mean, he should go to main...
Transfer center: Okay
MD #8: He would not be appropriate for here.
Transfer center: Okay
MD #8: Alright?
Transfer center: Yes ma'am
ER PA: Dale, we'll work on it on this side, and we'll let you know
MD #8: Alright -------, call us when he is more stable, okay?
ER PA: Okay, we'll work on it. Thank you. Bye
MD #8: Bye

Request for interview with MD #8 revealed the physician was off service, and could not be reached.
PPMH refused to accept an appropriate transfer from a referring facility for patient #15 on 12/13/2015 who required the hospital's specialized services. As the referring hospital did not have an Intensivist on-call on 12/13/2015 to manage the patient's critical condition.

3. Patient #17's medical record from the referring hospital was reviewed. Review of the Triage Assessment form revealed that patient #17 was triaged by the Triage Nurse on 12/25/2015 at 10:38 p.m.. Patient #17 had a history of Lung Cancer s/p Lobectomy 3 years ago. The patient presented to the ED with complaints of productive cough, fever, shortness of breath for the past 5 days. The ED physician documented on the General med- History and Physical examination in part, " Respiratory-Respiratory exam present: non labored, rhonic, bilateral wheezing and rhonic decreased, decreased air flow in the bases of the lung. The patient ' s vital signs were listed as Temperature 100.1 (normal 97.5-98.6); heart rate: 113 (normal 60-100); Blood Pressure: 132/85; Respiratory-18; Pulse Oximetry: 98%. The patient ' s white cell blood count was 15.7 (normal white blood cell count reference range is 5,000 to 10,000). Further documentation by the ED physician revealed in part, " Course Narrative, Given pt. has no pmd (primary medical doctor) and his age, "I'm worried that pt. needs to be seen urgently for follow-up as his cancer has probably returned with superimposed pneumonia. I have to call pulmonary at ppmh (Phoebe Putney Memorial Hospital ) for possible transfer ...I spoke with Dr. (physician name at ppmh) and relayed pt. ' s past history, current exam, labs, and CT results. He felt pt. could be worked up as an outpatient and didn't need to be admitted/transferred. "

Review of Phoebe Putney Memorial Hospital Transfer Center Log for Patient #17, revealed a 49 year old patient with need for pulmonary services on 12/26/15. The Actions Taken and Reason Not Accepted column indicated the physician recommended office follow up- hospital care not needed. The notes column indicated that MD #7 advised the ER MD that this was probably a recurrent cancer, and that he/she would follow up with the patient in his/her office for workup.

Review of Transfer Center recordings on 1/26/16 with employee #10 revealed the following conversation:
Transfer Center: Hey --------, I've got Dr.------- for Dr. ----------
(Pause)
Transfer Center: Dr. --------, Dr. -------- on the line. This is a recorded call. You can go ahead sir.
ER MD: Hey Dr. -------.
MD #7: Yeah
ER MD: Hey sir, this is Jonathan. I'm at Worth tonight, and I hate to bother you, but I have a patient that I wanted to run by you, and see that maybe if you can take over and kinda get him worked up tonight. Um, it's a guy named (provides patient's name) he moved here about 3 years ago from Florida, and he said before moving, he had been diagnosed with lung cancer on the right. They did a partial pneumonectomy, it was in the apex and had been doing well, and he said that they told him that they had got everything, he didn't have anymore cancer. Um, then he said about 5 or 6 days ago, he started getting more short of breath and was running fevers of about 102 at home, um, productive sputum. Chest x-ray: I didn't really see anything, but he was still tachycardic, heart rate was in the one-teens. Sats were good, but I did a CT to make sure no PE, and there was no PE, but he's got a 2.7 cm speculated density in the anterior upper lung, and he also's got has some parenchyma infiltrates around that. And, he's got another infiltrate of density in the lower medial right lung. He's got a white count of 16-5. I went ahead and did some cultures and gave him some Levaquin, but, uh, he's only 49, and I didn't know if this is somebody you guys wanted to work up or...
MD #7: We need to work up as an outpatient
ER MD: Okay
MD #7: There's no need to admit
ER MD: Okay
MD #7: So, he can call the office on Monday, and we can see him
ER MD:Okay
MD #7: But there's no need to admit him or anything
ER MD: Okay
MD #7: Yeah, so...
ER MD:Okay, that was my question Dr. ---------
MD #7: Yeah, yeah, so that's fine
ER MD: Okay, alright. Thank you
MD #7: Yes sir, thank you

Telephone interview with MD #7 on 1/26/16 at 7:27 PM revealed the following:
After listening to the Transfer Center audio recording, the physician stated that he/she had not refused the patient or anything, explaining that most of the patients with lung cancer are worked up as an outpatient; and, that 90% of the bronchoscopies are done as an outpatient if possible. He/she continued to explain that the emergency room physician was not pushing, so he/she thought it was okay (to not accept the transfer). The facility refused to accept an appropriate transfer from a referring hospital for patient #17 on 12/25/2015, who required the hospital ' s specialized pulmonary services to treat patient #17 ' s identified emergency medical condition.

MD #7 added that he/she thought the physician was okay with not transferring the patient, and believed the emergency room physician was probing into what to do about the patient's lung cancer. The physician also confirmed that having a fever of 102 degrees was not a symptom of lung cancer.

Interview with the Emergency Room Assistant Medical Director on 1/26/16 at 3:10 PM revealed that he/she had been the Assistant Medical Director since September 2015, and as far as he/she understood, there is a transfer center, and they take the incoming calls and make arrangements with the facility. He/she continued on stating that if the facility has the capability and capacity, they accept the patient. He/she explained that once there is a denial, the hospital should do whatever they need to do to make it happen. The Assistant Medical Director stated that the facility had been going through changes with regards to the transfer process and transfer out forms. He/she explained that their department had not been part of the quality team for the transfer center, and he/she thought that they should be. The physician stated that he/she has no involvement in reviewing transfer in requests from the Transfer Center. He/she also stated that his/her staff were directly responsible for reviewing transfers out for the emergency room patient. He/she explained that the emergency room doctor is not involved in accepting transfers in, and that if a doctor called the ER to send a patient, it is usually from a clinic. The Assistant Medical Director continued on stating that he/she had been notified by the legal department that there would be EMTALA training the end of January or the 1st of February, and added that he/she was well versed in EMTALA because he/she used to do training, and has been a physician for 20 years.

Review of facility ' s EMTALA policies failed to reveal a policy which addressed Recipient Hospital Responsibilities.