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Based on interview, record review, audio review and facility document and policy review, the facility failed to accept the transfer of a patient who had an emergency medical condition from a referring hospital that did not have the capability to treat the patient for 1 (Patient 21) of 11 patients reviewed for transfers. The failure had the likelihood of resulting in patient care being delayed during a medical emergency.

Findings Include:

A facility policy titled, "Emergency Medical Treatment and Active Labor Act Compliance (EMTALA)," revised in 08/2023, indicated, "Accepting Patient Transfers. It is the policy of [hospital name] to accept patients in emergency transfer from within the boundaries of the United States who are suffering from Emergency Medical Conditions that are in need of stabilizing treatment within the capabilities and capacity of this Hospital but not available at the original facility treating the patient. Such acceptance will be without regard to the financial ability or method of payment of the patient, or the age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression of the patient to the extent that such disability is not a decisive medical factor in the ability of this hospital to care for the patient. The procedures in this policy apply to all departments of the Hospital and Medical Staff. 1. Requests for transfer will be referred to the Transfer Center. The Transfer Center will determine the caller and the subject of the call. When the caller is a health care provider requesting to transfer a patient from another hospital, the Transfer Center will specifically ask the caller if the patient has an emergency medical condition. If yes, the Transfer Center will ask if the transferring Hospital has the capability and/or capacity to care for the patient. 2. When the caller requests to transfer a patient with an emergency medical condition from a Hospital that does not have capability or capacity to care for the patient, the Transfer Center will automatically accept the transfer or page the appropriate attending based on the on call list and the requested service. The attending will speak with the caller requesting transfer." Further review revealed "5. Only an Attending physician can decline transfer of patient with an emergency medical condition from a hospital without capability or capacity to care for the patient. 6. The Nursing Director or designee, in collaboration with the medical staff or Administrator on call can make the determination on behalf of the Hospital that Hospital does not have capability and/or capacity to accept the patient. The Nursing Director will notify Transfer Center prospectively of any limits on Hospital capability and/or capacity. 7. Before denying transfer of a patient with an emergency medical condition from a hospital without capability or capacity to provide care, the Transfer Center will consult the Nursing Director or Administrator. 8. If there is a question of capacity, the accepting attending will immediately verify with the Nursing Director or designee whether this facility has the capacity to accept the patient. 9. When the Nursing Director is notified that a transfer may be declined under circumstances where the hospital may be obligated to accept the patient or the transfer request has not been appropriately responded to in timely manner, the Nursing Director will contact the responsible physician and follow chain of command as necessary. 10. Once the patient has been accepted, the Transfer Center will facilitate the transfer including bed assignment, communication between providers, and notification of the Emergency."


Patient 21

Review of a recorded conversation from the above-named hospitals transfer center regarding stroke consultation and transfer request for Patient 21 dated 12/24/24 revealed Staff G, Physician from Facility A, Staff I Physician, and Staff F, Registered Nurse (RN) from the above named hospital were on the call together. Staff G asked to transfer Patient 21, Staff I accepted the transfer, and Staff F began coordinating the transfer. The recording revealed Staff I asked Staff G if he usually cared for stroke patients after giving tenecteplase at Facility A and Staff G responded by saying he usually admitted them to ICU, but he did not have any ICU beds available, he did not have the resources to care for Patient 21 at Facility A, and if they declined his request for transfer he would have to find another facility to accept the patient. The recording revealed Staff I stated she did not see a large vessel occlusion on the CTA, then Staff F, RN stated that if there was no intervention indicated that perhaps Staff G could call Facility C or somewhere else to request transfer for Patient 21. Staff G, then thanked those on the call and added that he would try Facility C, and the call ended.


Review of the Transfer Center Report from the above-named hospital dated 12/24/24 at 1:47 PM, revealed Staff G, Physician from Facility A called the Transfer Center on 12/24/224 at 1:47 PM to request transfer of Patient 21. Staff I consulted with Staff G to discuss the patient's condition; Staff I reviewed images and found that there was no large vessel occlusion, and it was noted by Staff F, RN that the patient would go to another facility for monitoring.


Review Patient 21's "H&P [History and Physical]" from Facility A, dated 12/24/24, revealed the patient arrived at the Emergency Department (ED) on 12/24/24 at 1:11 PM for stroke-like symptoms.

Review of Patient 21's "ED Provider Note" from Facility A, dated 12/24/24 at 1:49 PM, revealed that Patient 21's initial head CT was consistent with an acute left middle cerebral artery (MCA) stroke.

Review of Patient 21's "ED Provider Note" from Facility A, dated 12/24/24 at 1:55 PM, revealed that Staff G, Physician from Facility A discussed Patient 21's medical emergency with Staff I, Physician, from the above-named hospital. Per the note, Staff I reviewed the images that were electronically sent to above-named hospital, and Staff I directed Staff G to administer tenecteplase (medication used to break up blood clots) to the patient after their blood pressure had improved. The note indicated that, after tenecteplase was administered and more images were reviewed, the above-named hospital declined transfer of the patient and recommended transfer to another intensive care unit (ICU).

Patient 21's "ED Provider Note" from Facility A, dated 12/24/24 at 2:24 PM, revealed that Staff G discussed the case with Staff H, Physician, at Facility C, and he accepted Patient 21 for transfer.

Review of the Neuro ICU Staffing for 12/24/24 indicated that the unit was staffed with 8 nurses during the daytime shift.

The Neuro ICU census indicated that on 12/24/24 at 5:00 AM there was a total of 16 patients.

Review of the Neurology Schedule indicated that a Neurology Stroke Attending physician was available on 12/24/24 from 7:00 AM to 6:00 PM and a Neurology ICU Resident was available on 12/24/24 from 7:00 AM to 5:00 PM.

During an interview on 04/16/25 at 10:49 AM, Staff I, Physician stated that tenecteplase was given to Patient 21, noting the patient was at risk of hemorrhaging due to the mass that was still present per imaging. Staff G stated that he called the above-named hospital to request transfer but was denied, noting Facility A did not have the ability provide the care Patient 21 needed. Staff G stated that he called Facility C to request a transfer and they accepted the transfer of Patient 21.

During an interview on 04/15/25 at 4:52 PM, Staff F, RN stated that he suggested Staff G call Facility C because that was Facility A's associated facility.

During an interview on 04/15/25 at 3:33 PM, Staff E, Nurse Manager for Patient Placement and Transfer Center (NMTC) for the above-named hospital stated that, when a facility called for a consultation or a transfer, the call went to a transfer nurse in the Transfer Center. Staff E stated that the transfer nurse could speak to the sending provider, but the attending physician would ultimately accept or deny the transfer. Staff E stated that a nurse should never make the determination regarding whether a patient should be accepted as a transfer or make recommendations for transfer to other facilities.

During an interview on 04/16/25 at 3:50 PM, Nurse Manager of Neuro Intensive Care Unit stated that the unit has a total of 28 beds. She indicated her review of staffing records for 12/24/24 showed that the unit was staffed with 8 RNs, one unit clerk, and one stroke nurse who typically did not carry a patient assignment and was available to assist other RNs with their patients. She also stated on 12/24/24, the unit was fully staffed based on the unit census, and they had to float one of the assigned nurses to another unit during that day shift. She stated from 7:00 AM to 3:00 PM on 12/25/24, there were 18 patients on the unit, and from 3:00 PM to 7:00 PM, there were still 18 patients on the unit. She stated that on 12/24/24, there were open beds in the neuro ICU.