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Based on documentation and interviews, the hospital failed to ensure compliance with requirements of 42 CFR 489.24, when the hospital failed to accept an appropriate transfer of a patient from another hospital resulting in deficient practice cited at 42 CFR 489.24 (f) A2411.

Based on observations during a tour of the emergency department on April 8, 2011 and interviews, the hospital failed to post conspicuously in the emergency department or in a place likely to be noticed by individuals waiting for examination and treatment in the emergency department (ED) signs specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment in the emergency room. The findings include:

A tour of the ED was conducted on April 8, 2011 at 10:00 a.m. with employee (B)/nurse. It was observed that there was not a sign referencing EMTALA rights in the entrance of the ED, the triage area, or any other visible area in the ED. Although there was one small (approximately 9" x 13") sign in a small alcove area adjacent to the waiting room where the vending machines are located, it was not in a highly visible area that would be noticed.

This was confirmed with employee (B) during the tour. Employee (B) indicated that previous management staff took down signs due to the walls appearing "cluttered" and they may have taken down EMTALA signs. In addition, employee (A)/administrative staff indicated that there has been recent construction which may have affected the signage.

Based on documentation and interviews, the hospital failed to accept an appropriate transfer from Hospital #1, of a patient (patient #1) who required specialty care because she was in the process of a miscarriage and required a dilation and curettage (D and C) (a surgical procedure to dilate the cervix and remove the contents of the uterus). Findings include:

Review of patient #1's Emergency Department (ED) record from Hospital #1 revealed that patient #1 presented to the ED on Saturday, 01/29/2011 in the process of a miscarriage. She had been in the clinic the day prior and was found to have fetal demise on ultrasound. The patient had opted to try and manage this conservatively by allowing the process to happen naturally at home. She had been advised to present to the ED with heavy bleeding or pain. On the morning of 01/29/2011, patient #1 reported that she had a lot of heavy bleeding, passed clots, but no tissue. She had cramping and was not feeling well and presented to the ED.

Physician (D)/hospital #1 ED physician was interviewed on 04/14/2011 at 3:00 p.m. Physician (D) stated she completed a medical screening examination (MSE) when patient #1 arrived to hospital #1's ED on 01/29/2011. The patient had a normal blood pressure and pulse and was not actively bleeding. Physician (D) discussed management with Cytotec (a medication used intravaginally to dilate the cervix and assist in the treatment of incomplete miscarriages), watchful waiting, or a D and C. Patient #1 opted for the Cytotec intravaginally. After this was given, patient #1 became light headed and fainted. Although initially she had a low blood pressure, she was given intravenous (IV) fluids and her blood pressure returned to baseline. Physician (D) re-examined patient #1 and indicated that the patient's cervix was slightly dilated, but she continued to have no active bleeding. Physician (D) removed the Cytotec and ordered laboratory values. The laboratory values showed that patient #1's hemoglobin was at 11.1, which was down from 13.9 two days prior. Because of the incomplete miscarriage, drop in hemoglobin, and the patient's fainting episode, physician (D) felt it was imperative that patient #1 have a D and C. Hospital #1 did not have an OB/GYN available and patient #1 required a higher level of specialty care in order to complete the miscarriage. She contacted physician (E)/the OB/GYN on call at University Medical Center - Mesabi in Hibbing, MN regarding accepting this patient for transfer. This hospital is approximately 35 miles away from hospital #1. Although physician (D) indicated that she reassured physician (E) that patient #1 was currently stable and not actively bleeding, physician (E) indicated that she felt the patient was unstable and refused to accept the patient. Physician (D) subsequently contacted Physician (F)/the OB/GYN on call for hospital #2, which was the next closest hospital. This hospital is in Duluth, MN, approximately 90 miles away from hospital #1. Physician (F) accepted the patient in transfer and patient #1 was transferred to hospital #2 via ambulance.

Physician (E) was interviewed on 04/26/2011 at 10:20 a.m. and verified that she was the on-call OB/GYN for University Medical Center - Mesabi on 01/29/2011 and she is able to perform D and Cs. She received a phone call from physician (D) (exact time unknown). She indicated that the telephone report she received from physician (D) implied that patient #1 was unstable. She indicated that physician (D) reported the patient was actively bleeding, had a fainting episode, and had a blood pressure of 80/40. She did not accept the patient in transfer because she felt the patient needed stabilization and more care than University Medical Center - Mesabi could offer. She recommended the patient be transferred to a larger hospital, hospital #2, secondary to the patient's condition.

According to hospital records from hospital #2, patient #1 presented to hospital #2 on 1/29/2011 at 11:00 p.m. Physician (F) performed a D and C with no complications.

University Medical Center - Mesabi (a hospital part of Fairview Range Regional Health Services) EMTALA policy and procedures, dated 06/01/2009, were reviewed and indicated that "EMTALA is applicable when...An individual is at another hospital and this facility requests a transfer to Fairview Range because it has specialized capability or facilities not present in that other hospital; in such cases, if Fairview Range has the capacity, it must accept the transfer of the individual."

University Medical Center - Mesabi had the specialized capabilities to complete a D and C for patient #1. The hospital has a dedicated emergency room and has 24 hour emergency physician services, including on-call OB/GYN staff who are able to perform D and C procedures.