HospitalInspections.org

Based on review of medical records, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Bylaws, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, Medical Staff Bylaws, Policies, and Rules and Regulations: Credentials Policy, policies and procedures, Physician Central Access Information Sheet, Transfer Center recordings, Medical Staff Roster, ED physicians' schedule, on-call schedules, staff interviews, personnel files, credential files, Corporate Ethics and Compliance Office, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities or facilities if the receiving hospital had the capacity to treat the individual. This affected 1 of 20 sampled patients (#1). Refer to findings in tag A-2411.

Based on review of medical records, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Bylaws, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, Medical Staff Bylaws, Policies, and Rules and Regulations: Credentials Policy, policies and procedures, Physician Central Access Information Sheet, Transfer Center recordings, Medical Staff Roster, ED physicians' schedule, on-call schedules, staff interviews, personnel files, credential files, Corporate Ethics and Compliance Office, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities or facilities if the receiving hospital had the capacity to treat the individual. This affected 1 of 20 sampled patients (#1).


Findings were:

Review of the Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Bylaws, dated 02/22/11, revealed in Article 2.A.3.a, that active staff were responsible for emergency call.

Review of the Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, dated 02/22/11, revealed in Article 1 Section 1.a, that patients were to be admitted to the facility only by order of a Medical Staff appointee who had been granted admitting privileges.

Review of the Medical Staff Bylaws, Policies, and Rules and Regulations: Credentials Policy, dated 02/22/11, Article 3 B.1.b., required the Medical Staff to abide by all Bylaws, policies (including but not limited to, the Medical Staff Code of Conduct, Physician Health Policy, and the Quality Policy and Procedure Manual which included Behavioral Expectations), and Rules and Regulations of the Hospital and Medical Staff in force during the time the individual was reappointed.

Review of the facility's policy entitled "Transfer Center", policy number N046.00, last revised 11/30/11, revealed outlying physicians were to be connected with a physician from the facility. All Transfer Center calls were to be screened by the operator to determine if the request was and ED to ED transfer or a physician to physician inpatient admission request. For outlying ED patients, the operator was to connect the caller with the requested specialist on-call or the facility's ED physician. The operator was to connect all calls for ED patients with the facility's ED physician after 10 minutes if the specialist had not responded. The policy required, Any request for transfer of a patient in an ED that was not accepted by a specialty physician to be immediately connected with the facility's ED physician. The ED physician was then to follow EMTALA (Emergency Medical Treatment and Labor Act) guidelines to determine whether the patient required transfer. In addition, the policy required the operator to stay on the line and record the call, facilitate transportation if needed, and assist the physician with access to bed control and Access nurses, or Nursing Supervisor to secure an appropriate bed. Furthermore, the policy revealed that when there was a conflict about acceptance the administrator on-call or the Chief Medical Officer was to be contacted.

Patient #1's medical record from the transferring hospital was reviewed. The medical record indicated that on 4/06/2012 patient #1 presented to the emergency room with Chief Complaint, "Pt told to come to er (emergency room) by md (medical doctor) for evaluation of upper lung mass." Further review revealed that the patient's vital signs were Temperature: 97.9, pulse: 89; and Blood Pressure: 149/87. Review of the ED Physician Note dated 04/06/2012 indicated that patient #1 an 84 year old presented to the emergency room with weakness, decreased activity , no chest pain and no fever. The section titled Physical examination, specified in part, ...Musculoskeletal: Generalized weakness...Chest X-Ray: Interpretation by Emergency Physician large left sided mass. Radiology results: Discussed with radiologist, Aortic aneurysm leaking,. Impression and Plan; Diagnosis: Leaking thoracic aortic aneurysm... Notes Dr. (cardio thoracic surgeon on call at MHUMC/credential file #1) refused patient... at 5:20 PM. "You never send me patients." A review of the Patient Transfer Form dated 04/06/2012 at 5:20 P.M. that patient #1 was transferred via air ambulance to another acute care hospital, "Condition on transfer Critical."

Review of Memorial Health University Medical Center (MHUMC) form titled the "Physician Central Access Information Sheet" dated 04/06/12, indicated that MHUMC received a call at 5:08 p.m. from the transferring facility's Emergency Department (ED) physician. The form noted that the transferring ED physician was requesting a cardio-thoracic surgeon. Documentation revealed the physician on-call for that service was physician / credential file #1. The form revealed the ED physician was attempting to transfer a patient (#1) who had a leaking aortic aneurysm (swelling of the vessel). The form noted that initially the facility's ED physician /credential file #2 had agreed to accept the patient. In addition, the form noted that the cardio-thoracic surgeon refused to accept the patient after speaking with the transferring ED physician and instructed the Transfer Center to notify the facility's ED physicians not to accept the patient. The facility refused to accept from a referring hospital patient #1 on 4/6/2012, who required the hospital's specialized capability and capacity to treat this patient.

Review of the Transfer Center's recordings at 12:35 p.m. on 04/18/12 in the Clinical Compliance Officer's (COO) office revealed the following conversations between the transferring ED physician, receiving facility's ED physician, on-call cardio-thoracic surgeon, and the Transfer Center operator. These recordings were dated 04/06/12.

Recording number 1 was recorded at 5:09 p.m. In this recording, the transferring ED physician told the Transfer Center operator that he wanted to transfer a patient that had a leaking thoracic aorta aneurysm. The physician gave his name, the transferring facility's name, his telephone number, the patient's name and date of birth, and confirmed that the patient was in the ED at the time of the call.

Recording number 2 was recorded at 5:10 p.m. The Transfer Center operator confirmed that the transferring ED physician wanted to speak with a cardio-thoracic surgeon.

Recording number 3 was recorded at 5:11 p.m. The operator informed the transferring ED physician that physician / credential file #1 was on-call for that specialty and that the Transfer Center would page the surgeon and call the ED physician back. The transferring ED physician then asked to speak with the facility's ED physician.

Recording number 4 was recorded at 5:12 p.m. The operator informed the facility's ED staff member that the transferring ED physician wanted to speak with one of the facility's ED physicians. Physician / credential file number 2 informed the operator that he/she was busy evaluating a patient and the operator stated the transferring ED physician had hung up.

Recording number 4 was recorded at 5:18 p.m. The Transfer Center operator informed the transferring ED physician that the cardio-thoracic surgeon had not called back and connected the ED physician with the facility's ED physicians. The transferring ED physician informed the facility's ED physician that he/she wanted to transfer a patient who had a leaking aortic aneurysm. The facility's ED physician replied he/she could not accept the patient without a cardio-thoracic surgeon. The transferring ED physician states the transferring facility's name, the patient's age, and reported that the patient had no chest or back pain. The transferring physician told the facility's ED physician that a CT (computerized tomography - specialized x-ray) confirmed that the patient had a leaking aortic arch aneurysm. The transferring ED physician stated the patient's blood pressure was 150/87 and that he/she was going to start an Esmolol drip to bring the patient's blood pressure down. In addition, the transferring ED physician stated the patient was "actually pretty stable". The facility's ED physician stated that it would be inappropriate for him/her to accept the patient without an accepting cardio-thoracic surgeon and added he/she would try and contact the cardio-thoracic surgeon and asked the transferring facility to send a copy of the CT disc with the patient.

Recording number 6 was recorded at 5:25 p.m. The cardio-thoracic surgeon called the Transfer Center and was connected with the transferring ED physician. The transferring ED physician told the surgeon his/her name and the transferring facility's name. The transferring physician informed the surgeon that the CT revealed the patient had a leaking thoracic aortic aneurysm at the top of the aortic arch, that the patient's blood pressure was 150/87, and that the patient had no chest or back pain. The surgeon asked who had read the CT? The transferring ED physician replied one of our radiologists and informed the surgeon that he/she had seen the CT and that it "looked pretty scary". The surgeon asked if it was ascending or descending and the transferring ED physician replied let me look. The surgeon asked again which Radiologist read the CT and was informed that the transferring ED physician did not know. The surgeon asked whether the ED physician was calling from Statesboro or Brunswick and when the transferring ED physician replied Brunswick, the surgeon stated from Brunswick, you can ship him south brother, send him right on down to Jacksonville. The transferring physician then asked "You don't want him, that's what you're telling me?" The surgeon replied, that's what I'm telling you, ya'll send everything south. The transferring ED physician stated that was BS (curse word) and told the surgeon that the transferring facility sent everything to the receiving facility. The surgeon replied I don't get crap from ya'll. The ED physician stated he/she sent trauma patients to the facility. The surgeon replied trauma may come but I'm not a facility employee and I can tell you cardiac and all that stuff goes to Jacksonville. The ED physician asked, so you aren't accepting this patient? To which the surgeon replied, you got it, yep you can send him south. Yep, call the cardiac surgeons in Jacksonville where all the other stuff goes. You may send trauma up here but cardiac does not come up here. We don't get any of it none of the elective stuff, zero. So he can go south.

Recording number 7 was recorded at 5:28 p.m. The Transfer Center operator informed the surgeon that the transferring ED physician had hung up. The surgeon stated I'm not accepting when we don't get any of their cardiac business at all, it's just not fair. They send us someone with major problems and we get none of their elective work, it's not fair. I'm not gonna do it anymore. I'm happy to help anyone who helps us on a regular basis. On Friday afternoon when it's convenient and they don't want to mess with a Jacksonville referral. I'm not doing it. Make sure the ED physicians know not to accept this patient. The Transfer Center operator replied she would call the ED and inform them not to accept the patient. The surgeon stated the patient needed to go to Jacksonville where Brunswick sent all their cardiac work and that he/she was not available to take the patient.

Recording number 8 was recorded at 5:30 p.m. The Transfer Center called the ED and informed the ED physician / credential file #2 that the cardio-thoracic surgeon on-call had refused to accept the patient and that the surgeon had wanted the ED informed that they were not to accept the patient.

Review of facility policy entitled "Physician On-Call", policy number MS 1011, effective date 05/2010, revealed the facility was to maintain an on-call schedule of physicians who were required to fulfill on-call duties. On-call was defined as "qualified active medical staff member with clinical privileges who shall be responsible for rendering care to unassigned patient." This policy required the chairperson of each department to be responsible for developing an on-call rotation schedule. The on-call physician was required to: a.) be immediately available at least by telephone, b.) respond in person to emergencies within 30 minutes and non-emergencies within 60 minutes when requested to respond by the ED physician.

Review of the current Medical Staff Roster revealed all four (4) physician's whose credential files were reviewed were active Medical Staff members.

Review of the ED physician's schedule revealed physician / credential file #2 was working in the ED on 04/06/12 from 3:00 p.m. until 1:00 a.m.

During an interview (#1) on 04/18/12 at 1:30 p.m. in the Conference Room, the Customer Service Representative (Transfer Center Operator - TCO) confirmed the recorded events of 04/06/12 related to patient #1. The interviewee explained that the facility's policy was to contact the ED physician if a specialist refused a patient, and try to get the patient accepted. The operator added that if the ED physician had accepted the patient he/she would have had to call the on-call cardio-thoracic surgeon. The operator added there had never been a situation like this one before. He/she explained that on-call physicians did not normally refuse to accept patients. The operator stated the specialist would refuse a patient after speaking with a transferring ED physician and the two physicians determined that the patient did not need the specialist's services. The operator explained that in the event a physician refused a transfer the Transfer Center staff were to notify their supervisor and that he/she had tried to call the supervisor once during his/her shift and once when he/she got home. The operator stated he/she had been unable to reach the supervisor that evening. The TCO added that he/she had had EMTALA training "about four (4) years ago".

During an interview (#2) on 04/18/12 at 1:45 p.m. in the Conference Room, the Customer Service Coordinator (CSC) confirmed that the above operator had not gotten in touch with him/her. The CSC explained that he/she had gone home sick that day. The CSC stated he/she had taken some medicine that had put him/her to sleep. He/she added that for all refused transfers the operators were to call him/her whether he/she was on-call or not. The CSC went on to explain that he/she tried to call the operator at home at 9:00 p.m. and had not gotten an answer. The CSC explained that had he/she spoken with the operator he/she would have suggested the operator contact the Administrator on-call. He/she added that the staff knew the protocol was to call the Administrator on-call.

During an interview (#3) on 04/18/12 at 2:00 p.m. in the Conference Room, the Manager of the Transfer Center (MOTC) stated that if the on-call physician refused to accept the patient the operators were to call the ED physician and get the patient accepted. He/she stated the operator had called the CSC but had not called him/her that evening. The MOTC added that the operator should have called the Administrator on-call. The MOTC went on to say he/she had been the MOTC for three (3) years and did not remember a situation like this occurring before. There was no documented evidence on patient #1's "Physician Central Access Information Sheet" to indicate that Administrator on-call or the Chief Medical officer was called since there was a conflict about the acceptance of patient #1. The facility failed to ensure that their Transfer Center policy was followed as it related to the acceptance of patients from transferring hospitals.

During an interview (#4) on 04/18/12 at 3:10 p.m. in the COO's office, the cardio-thoracic surgeon / credential file #1 stated he/she recalled the telephone call with the transferring physician on 04/06/12. The surgeon went on to say he/she agreed with what was said on the recording. The physician explained that the patient had not been in any pain, was stable, had a CT that showed a leaking aortic aneurysm, and was being put on medication to lower the patient's blood pressure. The physician stated he/she had questioned who had read the CT. In addition, the physician stated he/she had never seen a patient with a leaking aneurysm who was not having pain. The surgeon stated the transferring facility sent all their cardiac patients to Florida and that he/she had told the transferring physician, "why don't you send the patient to Jacksonville". The physician stated Jacksonville was closer to the transferring facility and that if the patient needed to be seen immediately the transferring facility had a relationship with the Jacksonville facility which was closer. Review of the Vascular and Cardiac on-call schedule revealed and verified physician / credential file #1 was on-call on 04/06/12. The facility failed to ensure an appropriate transfer was accepted for an individual (Patient #1) who required the specialized capabilities of the cardiothoracic surgeon on 04/06/2012.

During an interview (#5) on 04/19/12 at 9:50 a.m. in the Conference Room, the Medical Director of the ED/President of the Medical Staff explained that if the specialist refused the patient the policy was to call the ED physician for acceptance. The physician stated the ED physician could then call the on-call specialist. The physician stated that when the Transfer Center received a transfer request and the facility could provide the service and had a bed the transfer should be accepted. The physician added that even if the request came from California the transfer should be accepted in order to comply with EMTALA regulations.

Review of five (5) of five (5) personnel files revealed the two (2) Transfer Center staff members (#'s 1 and 2) had no documented evidence of EMTALA training. Employee files #s 3, 4, and 5 (nurses) revealed the nurses received EMTALA training between 12/09 and 08/11.

Review of four (4) of four (4) credential files revealed all four (4) physicians had signed the "Code of Business Practice Certificate of Receipt" between 04/12/11 and 02/01/12. By signing this form, the physicians attested that they would abide by the Medical Staff Bylaws and Medical Staff Rules and Regulations, and had received and reviewed the EMTALA information provided which consisted of written material and a CD - ROM (compact disc read only memory). Review of the Corporate Ethics and Compliance Office, revised 02/2011, revealed the EMTALA information was to be reviewed and signed by Medical Staff members at their appointment and reappointment.