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Based on policy review, medical record review, on call log review, audio recording review and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 42 CFR 489.24 by failing to accept transfer upon request of a patient with an emergency medical condition for 1 of 5 patients reviewed (#5) with requests for transfer from other emergency departments. The hospital had nephrology services and beds available at the time of the request.

The findings include:

The hospital failed to accept transfer upon request of a patient with an emergency medical condition for 1 of 5 patients reviewed (#5) with requests for transfer from other emergency departments. The hospital had nephrology services and beds available at the time of the request.

~cross refer to 489.24(f), Recipient Hospital Responsibilities - Tag A2411.

Based on policy review, medical record review, on call log review, audio recording review and staff and physician interviews, the hospital failed to accept transfer upon request of a patient with an emergency medical condition for 1 of 5 patients reviewed (#5) with requests for transfer from other emergency departments. The hospital had nephrology services and beds available at the time of the request.

The findings include:

Review of the EMTALA policy reviewed/revised July 2013 revealed (page 11 of 21), "... D. Receiving transfers from other facilities 1. Duty to accept individuals requiring specialized capabilities - Any (system name) hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or with respect to rural areas, regional referral centers) shall not refuse to accept an appropriate transfer of an individual with an emergency medical condition who requires specialized capabilities or facilities if the receiving facility has the capacity to treat the individual. This duty applies to any hospital with specialized capabilities, whether or not they have a dedicated emergency department. This duty only applies to referring hospitals located within the boundaries of the United States. ..."

Review of a dedicated emergency department (DED) record from Hospital B (transferring hospital) revealed Patient #5, an 81 year-old female presented to the DED on 05/09/2014 at 2230 via ambulance with a chief complaint of "had dialysis today, increased heart rate, decreased pulse per NH (nursing home)." Review revealed a temperature (T) of 97.6 degrees Fahrenheit, pulse (P) 120, respirations (R) 16 and blood pressure (BP) 92/54 on arrival at 2230. Review of the record revealed Physician #1 conducted a medical screening examination and diagnostic testing with an impression of "CHF (congestive heart failure), hypotension/tachycardia, fast A-fib (atrial fibrillation). Review of Physician #1's notes revealed "0100 (Physician #2 name)" and "0145 (Physician #3 name)." Review of the notes revealed "0100 (Physician #2) at (Hospital A) refused to take pt (patient). 'She needs to go to (Hospital C).' Pt was at (Hospital A) for two weeks in April and was just Dc'd (discharged) from there 5/6 after 1 week admit. She wants to go to (Hospital A). ... 0137 (Hospital C) called, will call back. 0145 (Physician #3) at (Hospital A) will call me back. 0205 Taken at (Hospital C) accepted pt. 0212 (Physician C) called back - wanted to get (Physician #2) but she would accept pt. - told her pt going to (Hospital C)." Review of the physician's certification for transfer revealed the benefit of transfer was "Nephrology" services. Review revealed the patient was transferred via ground ambulance with a departure time of 0300 to Hospital C.

Telephone interview on 09/23/2014 at 1610 with Physician #1 from Hospital B revealed he was the DED physician that provided care to Patient #5 on 05/09/2014. The physician stated he called Hospital A's call service (Doctor Connect) and talked with Physician #2 who was the nephrologist on call. Physician #1 stated "He (Physician #2) said he would not accept the patient. He didn't say why. A supervisor called me around 30 minutes later and asked what she could do to help. I told her the patient was there two times in the past month. She said she would do something. The ED physician called me, a female doctor. She understood I was having a problem transferring the patient. She said she would accept her. We have ways of taking care of this patient. They were too late. I had already called (Hospital C). They had accepted her and arrangements were made. After (Physician #2) refused her, I talked with her family and told them we had to transfer her to (Hospital C) and the family was okay with that." Physician #1 stated the patient had congestive heart failure and needed dialysis. Interview revealed nephrology services are not provided at Hospital B. The physician stated he was only concerned about the patient and she had just been to Hospital A twice and wanted to go back there. Physician #1 stated "He (Physician #2) stated he would not accept the patient and hung up."

Review of the on call log for Hospital A revealed Physician #2 was on call for nephrology beginning at 0700 on 05/09/2014 through 0700 on 05/10/2014.

Interview on 09/23/2014 at 1210 with Administrative staff #4 from Hospital A revealed when a call requesting transfer of a patient to Hospital A is received from an outside hospital's emergency department, the call goes through a contract service known as "Doctor Connect." Interview revealed the call center staff collect the patient's information and connects the caller with the appropriate specialty physician. Interview revealed if Hospital A's specialty physician then agrees that the patient is appropriate for the service then call center staff check to see if a bed is available. Interview revealed that all phone call requests for transfers that are received through the hospital's "Doctor Connect" call center are recorded.

Audio review on 09/25/2014 at 0845 of call recorded on 05/10/2014 at 0050 revealed
a phone call from Hospital B to the call center at Hospital A where a request was made to talk with the nephrologist on call regarding Patient #5. The call center nurse collected the patient information and stated that she would call back to Physician #1 at Hospital B. Audio review revealed a return phone call was placed on 05/10/2014 at 0057 from Hospital A's call center nurse to Hospital B, Physician #1 to connect Physician #1 to Physician #2 (nephrologist on call at Hospital A). The conversation continued and is quoted as follows:
Physician #1: "Hi, I have a patient here (Patient #5) who was just down there last month for I think she had pneumonia. Anyway, she is on dialysis, gets it Monday, Wednesday and Friday, had dialysis today, but she went back to the nursing home and they took her vital signs sometime after she got back. She was tachycardic and hypotensive. Her heart rate was 120 when she got here. It was regular sinus (rhythm). Her blood pressure 90/64, it looks like. She is not in any distress. She is not hurting anywhere but she says when she gets like this she usually has pneumonia. Her chest x-ray was read by the radiologist tonight as worsening CHF. I have given her some antibiotics just on precaution but I would like to send her down to your office because we cannot dialyze her."
Physician #2: "Where does she, where does she get dialysis?"
Physician #1: "She gets it here in (local area)"
Physician #2: "Ok. She needs to go to the (Hospital C) nephrologist."
Physician #1: "Well she wants to come down to you all because she just got out of there last month, down there."
Physician #2: "She needs to go to (Hospital C). We are not her nephrologist." (Call ended).

Audio review revealed a phone call from Physician #1 to the call center RN on 05/10/2014 at 0116 where Physician #1 asked the nurse to "pass on to administration that what (Physician #2) did was an EMTALA violation." Physician #1 reported to the nurse that the EMTALA violation would be reported.

Audio review revealed a phone conversation (time unknown) between the call center RN that talked with Physician #1 and her supervisor. The nurse reported that Physician #1 had alleged an EMTALA violation. The call center supervisor stated that she would call Physician #1 and discuss it further.

Audio review of a call on 05/10/2014 at 0133 from Hospital A's call center supervisor and Physician #1 at Hospital B revealed the supervisor connected Physician #1 with Physician #3 (DED physician at Hospital A). The conversation continued and is quoted as follows:
Physician #1: "Got an 81 year-old lady just discharged from your facility about a week ago after 3 or 4 days and then in April was down there for two weeks. She is on dialysis. She had dialysis today, actually yesterday, Friday. She comes in tonight. She got back to the nursing home and got hypotensive and tachycardic. She's in an uncontrolled Atrial fib. She is on Cardizem. Uh, her blood pressure was 90 systolic when she came in. Her chest x-ray the radiologist is reading it as worsening fluid from two weeks ago. But she says she is not that much short of breath."
Physician #3: "Ok."
Physician #1: "She needs dialysis and I have given her digoxin. I can't give her any Cardizem because of the blood pressure and she needs to come to some place, to a specialist. I called (Physician #2) at your facility and he flat out refused saying I will not accept the patient. She needs to go to (Hospital C) because her nephrologist is from (location of Hospital C) and she gets dialysis here in (local area). She wants to go to (Hospital A) and that is why I called (Hospital A) in the first place."
Physician #3: "Ok but if our nephrologist won't see her I can't personally dialyze her. You know what I am saying? I mean, I am happy to, we are happy to accept her but if she is going, if you spoke to (Physician #2) and he is not enthusiastic about seeing the patient because they are not her primary dialysis folks. I know, I mean we deal with this stuff all the time and it puts all of us as the ER docs in a bind because the patient wants X, the doctor, that's the dialyzing doctor wants Y and nobody is on the same page. Did she say why she does not want to go to (Hospital C)?"
Physician #1: "She prefers (Hospital A)."
Physician #3: "Okay. Is there a reason why she did not get her dialysis down here then? Is it just the location thing or?"
Physician #1: "It is a location thing of course. She would have to drive an hour and a half three times a week to get dialysis down there when she can get it here in (local area)."
Physician #3: "Got you. But she lives in"
Physician #1: "(local area)"
Physician #3: "Okay but goes up to her closest nephrologist then to her would be (Hospital C location). Is that right?"
Physician #1: "Right, just for you know her routine checks, just as far as dialysis, it is here in (local area)."
Physician #3: "Got you."
Physician #1: "The dialysis unit I guess is owned by (Hospital C)."
Physician #3: "Okay, got you. Goodness gracious. Um, okay. Well, I am not quite sure what to tell you. I mean we can certainly, we are happy to see her. It is just one of those things where if they"
Physician #1: "You are going to have to dialyze her."
Physician #3: "Yea, I know and somebody is going to have to. Um"
Physician #1: "Right and a nephrologist is going to have to see her tonight."
Physician #3: "Agreed. Is there a number I can call you back so I can actually call him and talk to him myself?"
Physician #1: "Sure"
Physician #3: "Okay, what is the best way to get back to you?"
Physician #1: "I will give you the direct number (phone number) and I hate to throw this out to you but this is a blatant EMTALA violation."
Physician #3: "Oh absolutely. And we totally understand and we always want to do the right thing and help them to understand how to do the right thing but they are often I guess if I was a nephrologist I would be pretty disagreeable all the time too but hopefully right, I will call them and then it is you said (telephone number)"
Physician #1: "Right."
Physician #3: "Ok (Physician #1) I will call you back in just a minute."
Physician #1: "Thank you very much." (call ended)

Interview on 09/25/2014 at 1200 with Physician #2 revealed he was on call when he received a call from Physician #1 at Hospital B regarding Patient #5 on 05/10/2014. The physician stated he talked with Physician #1 regarding the patient being under the care of (nephrologist at Hospital C). The physician stated "We felt it would be appropriate for her to go to (Hospital C). I understood that he was asking for a transfer here. I felt that was not in the patient's best interests. It was 0100. It did not occur to me that it could be an EMTALA violation. I did not get push back. I thought it was okay. I never heard further that night of any concerns. I just heard yesterday of a problem. This was unusual. I have never had a patient that requested to be seen outside of their regular providers."

Interview on 09/24/2014 at 1715 with Physician #3 revealed she was the DED physician at Hospital A that talked with Physician #1 at Hospital B regarding Patient #5 on 05/10/2014. The physician stated she had received a phone call regarding a request to transfer the patient. The physician stated she understood the patient usually went to (Hospital C area) for nephrology care, but had recently been seen at Hospital A and was requesting to come to Hospital A for further care. The physician stated she needed a nephrologist to be available to provide care for the patient and stated she accepted the patient and requested to call the on call nephrologist to discuss any concerns and to be sure of his availability. Physician #3 stated she called Physician #2 (nephrologist) and he told her that the nephrologists from Hospital C did not take good care of their patients like the nephrologists from Hospital A does and he felt this was a pattern. Physician #3 stated she told Physician #2 that they needed to take care of the patient and deal with this later. The physician stated she called back to Physician #1 at Hospital B and confirmed that she accepted the patient. The physician stated Physician #1 at Hospital B told her that Hospital C had already accepted the patient and the patient was going to Hospital C.

Interview on 09/26/2014 at 1045 with Administrative staff #5 revealed there was capacity to admit Patient #5 and nephrology services are provided at Hospital A. The staff member stated there were renal beds available on 05/10/2014 at 0000.

Review of Patient #5's closed medical record from Hospital C revealed Patient #5 arrived via ambulance on 05/10/2014 and was admitted with shortness of breath and generalized weakness. Review of the admission History and Physical dictated on 05/10/2014 at 0540 revealed the patient had fluid overload likely secondary to end-stage renal disease. Review revealed a nephrology consult and management was requested. Record review revealed the patient received an extra hemodialysis treatment on 05/10/2014. Further review revealed the patient had atrial fibrillation and cardiology was consulted for management of this problem. Review of the discharge summary dated 05/16/2014 at 1251 revealed a discharge diagnosis of "acute or chronic congestive heart failure - diastolic / Afib with RVR (rapid ventricular response)." Review of the medical record revealed the patient was discharged back to the nursing facility on 05/16/2014.

Interview on 09/24/2014 at 1445 with administrative staff revealed they had discovered a problem the morning of 09/24/2014 related to a transfer request for Patient #5. Interview revealed administrative staff reviewed the audio recording from Hospital B to Hospital A requesting a transfer of Patient #5 and found that the patient was not accepted for transfer. Administrative staff reported there was a process in place to review requests for transfers from a daily call log and to investigate any patients that were not accepted. Interview revealed this patient did not show up on the log as a request for transfer, but was incorrectly coded as a request for consult. Based on the findings, the facility reported an immediate action plan that included:

Re-education of all ED providers and all medical staff; education of Patient Relations Representatives related to EMTALA policy and escalation of transfer issues; education to Doctor Connect call center staff regarding EMTALA policy and escalation of transfer issues; one to one counseling with Physician #2 and DED Medical Director; notification to hospital system Chief of Staff, Vice Chief of Staff and Chief Medical Officer; execute an agreement between hospitalists and nephrology to collaborate to share the coverage of nephrology patients beginning October 1, 2014; and develop and implement sampling methodology of consults from the Doctor Connect call center log to confirm appropriate classification and monitor acceptance/refusal of transfer requests by September 26, 2014.

Consequently, a DED physician at Hospital B contacted an on call nephrologist at Hospital A requesting transfer of Patient #5 at the patient's request for an emergency medical condition that was not resolved. Hospital B did not have nephrology services available that the patient needed. Hospital A had capacity and capability to accept the patient. The nephrologist at Hospital A refused to accept the patient. The patient was transferred to Hospital C for further treatment and discharged home on 05/16/2014.

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