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Based on review of policies and procedures and hospital documents and interviews with hospital staff, the hospital failed to develop and enforce its policy concerning recipient hospital responsibilities.

Findings:

Upon arrival at the hospital on 06/22/2010, the surveyor requested to review the policies and procedures concerning all of the EMTALA requirements. At 1050, when asked the procedure followed when another hospital emergency room (ER) requests transfer of a patient to Woodward Regional Hospital (WRH). Staff B told the surveyor that calls with requests for transfer to WRH can go through the ER physician or the administrative liaison/house supervisor (HS), but they must contact the on-call specialist for acceptance. Later in the day, Staff B and Staff C stated that it was the responsibility of the HS or ER physician to accept or decline the transfer after consulting with the specialty physician. When Staff D was interviewed on 06/23/2010 at 1140, she stated that the HS was the one designated to receive requests for transfers to the hospital. She stated that she gets the information and the contact number for the requesting hospital and then calls the physician on-call. She stated either the specialist on-call or she would call the facility back. Staff D stated that usually the surgeon on-call will contact the requesting hospital and accepts or denies the transfer. She stated that then the on-call will call either the ER or her back and relays the decision.


1. During the course of the investigation on site at the hospital on 06/22 and 23/2010, hospital administrative staff gave the surveyors three different policies addressing recipient hospital responsibilities and duties of the on-call specialty physician. The three policies did not address actions to be taken/procedures to be followed if the specialty physician refused to accept an appropriate transfer. Each policy differed as to the process followed when another hospital ER requested transfer of a patient.

a. Policy A -
On 06/22/2010 at 1245, Staff B and Staff C brought the surveyor the policy, entitled "EMTALA Guidelines", with an effective date of 04/01/2003. They stated that this policy was the current and only policy the hospital used. On page 9 the policy stipulated "A hospital that has specialized capabilities or facilities (e.g., burn unit, shock-trauma unit, neonatal intensive care units, or with respect to rural areas, regional referral centers) or is designated as a regional referral center, may not refuse to accept from a referring hospital an appropriate transfer of an individual requiring such specialized capabilities or facilities if the receiving or recipient hospital has the capacity to treat the individual." On Page 12, Policy A stipulated, "Only the administrator on call and the emergency physician have the right to accept patients on behalf of the accepting hospital." Under the On-Call Physician Responsibilities, pages 12 through 14, Policy A only addressed the responsibility of the on-call physician to respond if that physician is called to come to the facility by the emergency room physician. Policy A did not address the responsibility of the on-call specialty physician if he is the one who responds to the hospital requesting transfer of a patient needing the specialty service.

The hospital did not follow this policy for the request for transfer of Patient #A.
i. The administrator on call nor the ER physician were contacted concerning transfer of this patient. The hospital operator contacted the surgeon on call and he refused the patient.
ii. At the time of the request for transfer of Patient #A, the hospital had the specialized capability and capacity to accept the patient. The request for transfer was denied by the surgeon on-call.

b. Policy B
On the afternoon of 06/22/2010, Staff B and Staff C supplied another policy. They stated this policy, entitled "Emergency Medical Treatment and Transfer Policy" and effective December 1, 2003, was the Board of Trustees' policy. On page 9, the policy, under Acceptance of Transfers, stipulated "The Hospital will accept an appropriate transfer of a person with an emergency medical condition from another hospital if the requires a specialized service (e.g., burn unit, shock-trauma unit, neonatal intensive care unit) available at the Hospital, if: (1) the Hospital has the space and personnel available necessary to treat the person; and (2) the transferring facility does not have the specialized services needed. When there is a dispute as to whether the transferring facility has the specialized services needed, the Hospital will accept the transfer, but work with the transferring hospital after the event to investigate whether an improper transfer occurred." Policy B only addressed the responsibility of the on-call physician to respond if that physician is called to come to the facility by the emergency room physician, but did not contain the procedure to be followed if the specialty physician refused to accept an appropriate transfer.

i. Policy B did not specify who is the appropriate person to accept or deny the transfer request from another ER.
ii. The hospital did not follow this policy. At the time of the request for transfer of Patient #A, the hospital had the specialized capability and capacity to accept the patient. The request for transfer was denied by the surgeon on-call.

c. Policy C
On 06/23/2010, the surveyors received a third policy. Policy C, entitled "EMTALA - Duty to Accept Transfers to WRH" with an approved date of 08/22/2005, stipulated, "EMTALA requirements mandate that facilities that have specialized capabilities may 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." Policy C further stipulated, "The house supervisor is the transfer coordinator for all activity involving requested emergency transfers to Woodward Regional Hospital." On page 2, Policy C continued, "3. The house supervisor notifies the specialty or ER on call physician of the transfer request with the available medical information. The physician then approves or refuses the transfer, based upon ability to handle the transfer. 4. The house supervisor returns a call to the physician/facility requesting the transfer with an appropriate response for acceptance or denial. 5. The EMTALA transfer (sic) Acceptance or Denial Form (ER030306) is completed. If the patient is accepted the white form becomes a part of the record, the yellow form is maintained by the ED nurse manager and the pink form is forwarded to RM/QA. If the transfer is not accepted, the white and yellow copies are maintained by the ED nurse manager and the pink copy is forwarded to RM/QA." Policy C did not address the steps to follow is the specialty physician refused to accept an appropriate transfer.

The hospital did not follow this policy:
i. The house supervisor did not coordinate the request for transfer for Patient #A. She was not contacted concerning transfer of this patient. The hospital operator contacted the surgeon on call and he refused the patient.
ii. At the time of the request for transfer of Patient #A, the hospital had the specialized capability and capacity to accept the patient. The request for transfer was denied by the surgeon on-call.
iii. On 06/23/2010 at 1150, Staff D told the surveyors she did not complete a Transfer Acceptance or Denial form for Patient #B.
iv. When the surveyors asked on the afternoon of 06/23/2010 to see other Transfer Acceptance or Denial forms, Staff B stated they did not have any - they could not be found.

2. The Rules and Regulations of the Medical Staff, with a date identifier of 01/22/2009, only addresses the responsibility of the on-call physician to respond if that physician is called to come to the facility by the emergency room physician. The Rules and Regulations of the Medical Staff did not address:
i. The hospital's responsibility to accept an appropriate transfer if the hospital had the specialized capability and capacity.
ii. They did not specify the appropriate person to accept or deny a transfer request from another ER.
iii. They did not address actions taken if the specialty physician refused to accept an appropriate transfer.

Based on review of medical records and hospital documents, and interviews, the hospital failed to accept from a referring hospital an appropriate transfer of an individual who required the specialized capabilities and facilities of the hospital in one of five medical records (Patient #A of Patients #A, 5, 13, 19, and 20) reviewed of patient. On the date and time of the proposed transfer for one patient (Patient #A), the hospital had the capability and capacity to treat the individual.

Findings:

1. Patient #A presented to another emergency department (ER) on 05/29/2010 at 2330 with complaints of abdominal pain - according to the patient he was lying down in bed and felt a "pop" in abdomen and had been in a fight approximately a week prior. The nurse charted the patient had tenderness in all quads with pain in back and shoulder with vital signs of blood pressure- 87/59, sinus tachycardia, pulse- 130, and respirations- 44. Intravenous fluids were administered and the patient's blood pressure improved to 137/90 with a pulse rate of 98 by 0231 on 05/30/2010. The physician assistant (PA) ordered a computerized tomography (CT) scan of the patient's abdomen and pelvis. The radiology report recorded abnormal findings including fractured ribs, pneumothorax left lower lung, and an enlarged spleen with a region suggesting internal acute hemorrhage/hematoma. The radiologist called the PA with results of the CT scan at 0213 on 05/30/2010. The PA notes documented he called the surgeon on call at Woodward Regional Hospital (WRH), discussed the CT findings and that the surgeon refused the transfer stating the patient should be transferred to another hospital that had a contract with the Department of Corrections (DOC), but did state that he would accept the patient if the other hospital could not take the patient. Nursing notes reflected that the on-call surgeon at WRH (35 miles away) was contacted at 0220 and refused the transfer. The patient was transferred by helicopter (fixed wing airplane) at 0335 to another hospital approximately 175 miles away. At this time, the patient's vital signs were blood pressure - 98/77, pulse - 99 and respirations - 24 with oxygen saturation at 100% on oxygen. When interviewed on 06/05/2010, the PA stated he tried to transfer the patient to WRH because, although the patient ' s blood pressure was back within normal range after the bolus of fluids, he was afraid it would deteriorate during transfer to the hospital with the DOC contract.

2. Review of the on-call specialty schedule showed the hospital did have surgery coverage on the week of 05/24 through 05/30/2010 at 0700.

3. On 06/23/2010 at 1430, the surveyors interviewed the surgeon on-call, Staff H, for the above time period. Staff H confirmed he was on call for that time period. Staff H stated he did have privileges to perform the surgery the requesting facility felt needed to be performed. (This was confirmed with file review.) Staff H agreed that the PA requested a transfer of Patient #A to his surgical care at WRH. Staff H told the surveyors that he felt the patient was stable and requested the patient (Patient #A) be transferred to another hospital that had a contract with the Department of Corrections.