HospitalInspections.org

Based on record review and interview the hospital failed to be in compliance with 42 CFR ?489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR ?489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:

failing to ensure the physician who is On-Call to the Emergency Room for unassigned patients, specifically neurosurgery, based the decision to transfer a patient on the capacity and capability of the hospital for 2 (#9, #10) of 2 (#9, #10) patient transfers of patients in need of evaluation by a Neurosurgeon. Both patients were transferred to the physician at hosp "a". (see findings at A2404)

Based on record review and interview the hospital failed to ensure the physician who is On-Call to the Emergency Room for unassigned patients, specifically neurosurgery, based the decision to transfer a patient on the capacity and capability of the hospital for 2 (#9, #10) of 2 (#9, #10) patient transfers of patients in need of evaluation by a Neurosurgeon. Both patients were transferred to the physician at hosp "a". Findings:

Review of a document provided by the Director of Nursing on 8/22/13 at 9:02 a.m. lists services provided by Touro Infirmary. Review of page 2 revealed that Touro Infirmary lists Neurological Services and Medical Surgical Intensive Care as a provided service.

Review of a document titled "Professional Services Agreement" revealed in part: "This Professional Services Agreement, effective as of March 1, 2013, by and between the Board of Supervisors of Louisiana State University (LSU) and Agricultural and Mechanical College on behalf of its Louisiana State University Health Sciences Center - New Orleans, Department of Neurosurgery, School of Medicine in New Orleans (hereinafter referred to as "Contractor"), appearing through its authorized representatives, as set forth on page 10 of this Agreement ...and Touro Infirmary ......2. The parties hereto enter into this Agreement to establish a mechanism by which Contractor Professionals, as employees of, and under the direction, control, and supervision of the Contractor shall perform Professional Services at Contracting Entity for purposes of community service ...

Attachment A: "Scope of Services". Contractor shall provide services of mutually agreed upon Physician(s), hereinafter referred to as Contractor Physician(s) to provide services to Contracting Entity as follows: On-Call Coverage.

1. Contractor will provide on-call coverage 24 (twenty-four) hours per day, 365 (three hundred sixty-five) days for the period of this contract. "On-Call Coverage" is defined as the Contractor's availability to respond to a call from Contracting Entity for service by phone or by arriving on the Contracting Entity's premises within 30 (thirty) minutes of receipt of the call for service, as appropriate. If Contractor is unable to be on Contracting Entity premises within 30 (thirty) minutes of call, then Contractor shall respond by telephone within 30 (thirty) minutes of call.

2. On-Call coverage services are compromised of physician availability to provide Neurosurgery Physician Services to Medical Staff, including the emergency coverage unit. Services shall include medical, surgical, and case management of patients presenting to the emergency unit while on call, including referral for additional consultations as deemed necessary by a patient's condition, including appropriate response to Medical Staff requests for information related to neurosurgical patient care.

3. In the event a patient presents requiring neurosurgery services, and Contracting Entity calls Contractor to provide such services, clinical services performed upon receipt of a call may include, but are not limited to, provision of comprehensive neurosurgical evaluation; patient care, examination, evaluation and referral for laboratory and other tests; patient care follow up, including telephone calls, documentation in accordance with Contracting Entity policies. Neurosurgery services shall be provided in accordance with current acceptable standards of practice.

4. Contractor agrees that Contractor Physicians assigned to provide services will admit and attend to patients whose condition warrants admission as an inpatient and comply with the Emergency Medical Treatment & Labor Act (EMTALA) ...

6. Contractor warrants that Contractor Physicians assigned to provide Services shall be Board Certified or Board-Eligible in Neurosurgery.

7. Contractor agrees to provide Contracting Entity a monthly call schedule with appropriate contact information of all Contractor Physician(s) assigned to provide coverage pursuant to this agreement to include, but not limited to office, page, cellular phone numbers.

Attachment B: "Contracting Entity Obligations and Responsibilities" 1. Contracting Entity shall furnish and maintain suitable work space, equipment, supplies, and support staff as may be required for the performance of Contractor Physician's duties ...Contractor: Board of Supervisors of Louisiana State University and Agricultural and Mechanical College. Contracting Entity: Touro Infirmary." The document is signed by all both parties.

Review of a hospital policy titled "EMTALA Transfers", policy number 87, effective date: 6/03, last revised 1/12, presented as current hospital policy, revealed in part:

"Primary Responsibility: Emergency Department ...

Purpose: To ensure that an "appropriate" transfer is effected when the Hospital lacks either the capability* or the capacity to treat an individual who presents at Touro Infirmary with an emergency medical condition ("EMC")*.

Definitions: *Where asterisk is noted, refer to DEFINITIONS in Appendix A for an explanation.


Responsibility: The Director of the dedicated emergency department ("DED")* and Department Heads of all Hospital departments, including labor and delivery, are responsible to ensure compliance with and implementation of this policy.

Policy: I. If a patient comes to the DED seeking or appearing to require medical treatment or presents anywhere else on Hospital property* seeking or appearing to require treatment for an EMC, Touro Infirmary must provide either:

(i) a medical screening examination ("MSE")* and such treatment, including inpatient care, as is necessary to stabilize* the EMC within the capabilities of the staff and facilities available at the Hospital; or

(ii) an "appropriate" transfer to a facility with the needed specialized capabilities.

II. The Hospital may not transfer a patient with an EMC who has not been stabilized unless:

(i) the physician has certified that the medical benefits to be received at another Hospital outweigh the increased risks to the individual or

(ii) the patient, or a legally responsible person acting on the patient's behalf, requests the transfer, after being informed of the Hospital's obligations under EMTALA and of the risks and benefits of transfer ...

Procedures: I. Regarding Transfers.

A. For transfer with physician certification: 1. For an unstable patient requiring transfer (other than inpatient), a physician must sign a certification that, based on the information available at the time of the transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks of transfer for the individual ..

a. An express written certification is required. A physician certification cannot be implied from the findings in the patient medical record and the fact that the patient was transferred.

b. The certification must state the reason(s) for transfer. The rationale may be documented on the certification form or elsewhere in the medical record.

c. The certification must summarize the benefits and the risks upon which it is based, and it must be specific to the condition of the patient upon transfer ...

Appendix A - Definitions: Capabilities refer to:
(1) The Hospital's physical space, equipment, supplies and services (e.g. trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry), including ancillary services, that the facility provides.

(2) The capabilities of the facility's staff mean the level of care that the Hospital's personnel can provide within the training and scope of their professional licenses ..."

Review of the Medical Staff Rules and Regulations, last revised 11/27/12, presented as current Medical Staff Rules and Regulations, revealed in part:

".....III. Patient Admission and Discharge ...
E. A patient in the Emergency Department without a private practitioner shall be seen by the ED physician who will evaluate the need for admission. Such patients shall be referred to physicians on the ED on-call schedule provided by the Medical Staff Office. The staff member whose name is listed on the On-Call schedule is responsible for every patient that is referred to him/her while he/she is on call. If the on-call physician is not available and is signed out to another staff member, the covering physician must promptly and appropriately respond, if called, the same as if he/she were on call ..."

Review of the Credentialing File for S14MD, Neurosurgery, revealed the following:

"Delineation of Privileges - Provider Name; (S14MD) - Active. Appointment: 03/29/2012 - 03/28/2014. Privilege Status. Neurosurgery. Peripheral Nerve entrapment syndrome, Peripheral nerve surgery, Anterior cervical fusion, Laminectomy, Discectomy with and without interbody fusion, Vascular surgery bypass (intracranial-extracranial), Craniotomy, Craniectomy, Ventricular including shunt and reservoir insertion, Cranioplasty (including debridement, elevation of bone fragments), Encephalography and Ventriculography, Muscle biopsy, Microneuro surgical procedure, transphenoidol surgery, Sterotactic Surgery, Spinal surgery with instrumentation."

The cover letter revealed a letter that read in part: " ...I am pleased to advise that upon recommendation of the Medical Executive Committee, the Governing Board of Touro Infirmary has approved your appointment to the Medical Staff of Touro Infirmary. Effective: 03/29/2012 ...Division: Surgery. Specialty: Neurosurgery. Privileges: You were approved for clinical privileges as outlined in the attached Delineation of Privileges." The document is signed by S1President, Touro Infirmary.

Review of a document titled "Touro Infirmary OR (operating room) Log" from 3/1/13 to 8/2/13 requested to show all Neurological Surgeries performed at Touro Infirmary revealed the following:

"Case Date: 3/19/2013 Neck Anterior Cervical Fusion.

Case Date: 3/26/2013 Back Lumbar Laminectomy W/ Instrumentation.

Case Date: 4/2/2013 Back Lumbar Micro Laminectomy/Discectomy.

Case Date: 4/9/2013 Craniotomy Tumor Removal/Resection.

Case Date: 4/16/2013 Neck Anterior Cervical Fusion.

Case Date: 4/1?/2013 Neck Posterior Cervical Laminectomy/Decompre(ssion?).

Case Date: 4/22/2013 Back Laminectomy Lumbar.

Case Date: 4/23/2013 Back Lumbar Micro Laminectomy/Discectomy Single.

Case Date: 4/23/2013 Back Lumbar Laminectomy W/ Instrumentation.

Case Date: 4/30/2013 Craniotomy Removal of Brain Tumor.

Case Date: 5/7/2013 Back Lumbar Micro Laminectomy/Discectomy Multi.

Case Date:5/14/2013 Neck Anterior Cervical Discectomy W/Wo Fusion.

Case Date: 5/28/2013 Back Lumbar Micro Laminectomy/Discectomy Multi.

Case Date: 5/28/2013 Back Lumbar Laminectomy W/ Instrumentation.

Case Date: 6/4/2013 Shunt Vent Peritoneal Insertion.

Case Date: 6/4/2013 Neck Anterior Cervical Fusion.

Case Date: 6/18/2013 Neck Anterior Cervical Fusion.

Case Date: 6/25/2013 Vagal Nerve Stimulator (removal of battery).

Case Date: 7/9/2013 Back Thoracic Micro-Laminectomy/Discectomy.

Case Date: 7/23/2013 Back Lumbar Laminectomy W/ Instrumentation.

Case Date: 7/23/2013 Back Lumbar Micro Laminectomy/Discectomy.

Case Date: 8/2/2013 Burr Holes/Evacuation Hematoma.

Case Date: 8/2/2013 Back Thoracic Laminectomy/Discectomy.

Case Date: 8/6/13 Back Lumbar Hardware Removal."

All of the above listed Neurosurgeries were performed by S11MD, Neurosurgery.

In an interview on 8/22/13 at 10:53 a.m. with S2CNO she stated that Touro Infirmary does offer Neurosurgery through an agreement with LSU. She further stated that the Neurosurgeon makes the determination on where the patient is treated. S2CNO stated that Neurological Surgeries such as hematoma evacuations have been done at Touro Infirmary in the past but stated she was not sure if any had been done since the Professional Services Agreement was signed with LSU. S2CNO could not explain what criteria made (hosp "a") higher level of care per the transfers of patient #9 and patient #10's transfer form documentation.

In an interview on 8/22/13 at 11:10 a.m. with S10MD, Neurosurgery, he stated that he is one of the Neurosurgeon's that provide unassigned On-Call specialty services to the ER at Touro. He further stated that S11MD, Neurosurgery, does elective Neurosurgeries at Touro which are primarily spinal surgeries but he performs Cranial Surgeries at another hospital. S10MD stated that he primarily does Cranial surgery.

He further stated that S14MD, Neurosurgery, does both spinal and cranial surgeries and that S13MD, Neurosurgery, does primarily spinal but some cranial surgeries. S10MD stated that as part of the On-Call responsibilities to the unassigned ER patient the Neurosurgeon comes to see the patient when consulted by the ER Physician and evaluates the patient. S10MD stated "routine" cases can be done at Touro. S10MD stated that (hosp "a") is not a higher level of care but "places with higher volume are safer and have better outcomes. The nurse's (at Touro) don't see neurosurgery patient's every day. I talk to the patient's but if they want to stay at Touro they can. I tell the patient's they need (whatever the case requires) ...You have two options, you can stay here or I recommend they move (to hosp "a")."

In an interview on 8/22/13 at 11:30 a.m. with S2CNO, after the telephone interview with S10MD, Neurosurgery, she agreed that the transfer of the patient's to (hosp "a") was not due to a capability issue but was physician preference.

Patient #9.

Review of the medical record for patient #9 revealed that he was an 80 year old male who presented to the Emergency Room on July 19, 2013.

Further review of the medical record revealed: "Nurse's Notes - Arrival: 7/19/13 11:09. Chief Complaint: Body aches. Presentation: 11:11: pt to ED with c/o generalized body aches with multiple trip and falls and per wife has been confused at times ...Acuity: 3

...Triage Assessment: General: Appears well nourished, well groomed. Behavior is appropriate for age ...PMHx (patient medical history): HTN, Diabetes - NIDDM (non-insulin dependent Diabetes Mellitus). PSHx (paritne surgical history): None.

Home Meds: Captopril, Januvia, Amlodipine, Gabapentin, Metformin, Tamsulosin, Glyburide ...11:32 Assessment: MEND (Miami Emergency Neurological Deficiency) Exam: LOC (level of consciousness): awake and alert. Speech: repeats "You can't teach an old dog new tricks" using correct words and no slurring. Questions: correctly states the month and their own age. Commands: closes and opens eyes to command. Neuro: Level of Consciousness is awake, alert, Oriented to person, place. Grips are equal bilaterally ...

12:19: (S16MD), MD is Admitting Physician.

12:21: Admit ordered by MD.

12:59: awaiting admission orders and bed assignment.

14:00: tried calling report and nurse busy at this time states she will call back in a minute.

15:14 ER care complete, transfer ordered by MD.

15:20 Transferred by EMS ground. Condition: good, improved. Handoff Report (hosp "a") patient going to ICU (intensive care unit) 4.

Physician Documentation:

12:07: This 80 year old African American presents to ED via Walk In with complaints of frequent falls, memory problems. The patient's problem is reported as frequent falls and confusion. Onset: gradually three weeks ago. Duration: The episodes are intermittent. Associated signs and symptoms: Pertinent positives: confusion, weakness ...ROS (review of symptoms):

12:11: Neuro: Positive for confusion and frequent falls. Exam: Awake, alert, with orientation to person, place and time ...NIH (NIHSS - National Institutes of Health Stroke Scale) Stroke Scale - total Score - 0. Eyes: Pupils: equal, round, and reactive. Extraocular movements: intact throughout ...Musculoskeletal/extremity: ROM (range of motion): intact in all extremities, full active range of motion. Neuro: Orientation: is normal. Mentation: is normal, lucid. Cranial Nerves: CN II-XII are normal as tested. Cerebellar function: Romberg testing is abnormal, falls backwards. Motor: moves all fours, strength is normal. Sensation: no obvious gross deficits. Gait: is unsteady, wide based, able to walk while holding my hand but leaning backwards ...

MDM (medical decision making):

11:11 ED course: SORT provider note: Patient presents to the ER with frequent falls, unsteady gait and confusion x's "several weeks." Wife reports he has fallen in her presence 3 times since initial onset of symptoms. Patient denies CP (chest pain) or SOB (shortness of breath). Patient ambulated with a cane into ER. Patient transferred to the mainside for further evaluation/management. I have initiated orders but have not assumed care.

11:19: Patient medically screened.

12:19: Admission Orders: after a detailed discussion of the patient's condition and case, the admit orders are written by me. Physician consultation: (S16MD), regarding patient's condition, and will see patient in inpatient room. Data reviewed: vital signs, nurses notes, EKG (electrocardiogram), radiologic studies, CT (computed tomography) scan, CT report received.

14:20: spoke with (S14MD), would like pt transferred to (hosp "a") for possible intervention. Disposition: 15:14: Transfer ordered to (hosp "a"). Diagnosis are Subdural Hematoma, Hypertension. Reason for transfer: Higher level of Care. Accepting physician is (S14MD). Condition is satisfactory..."

Review of a CT report dated 7/19/13 read as follows:

"Name: (patient #9) ...Brain CT without Contrast.

Clinical Information: Unsteady Gait ...Findings:There is acute on chronic subdural hematoma of the left frontal, parietal, and temporal convexities measuring up to 2.8 cm in thickness with associated with line shift from left to right as measured on image 15 of approximately 6 mm.

There is also predominately chronic appearing subdural hematoma along the frontoparietal convexities measuring up to 1.7 cm in thickness. There are minimal areas of increased density within this right subdural collection suggest small acute components.

There are atherosclerotic calcifications of the carotid siphons bilaterally. The calvarium is intact. Visualized paranasal sinuses and mastoid air cells are clear.

Impression: Acute on chronic left frontal temporoparietal subdural hematoma measuring up to 2.8 cm in thickness. Predominantly chronic. subdural hematoma in the right frontoparietal convexities measuring up to 1.7 cm in thickness. There is a midline shift from left to right of approximately 6 mm. These findings were communicated to (name) at 12:10 p.m. July 19, 2013." The document is electronically signed by the Radiologist on 7/19/13 at 12:13 p.m.

Review of a Physician's Order Sheet dated 7/19/13 at 12:32 revealed: "...Admit to (S16MD). Status: Inpatient. Level of Care: ICU. Diagnosis: Subdural Hematoma; HTN (hypertension); DM ...Consult (S14MD) - NSG (neurosurgery) - subdural hematoma. Consult Neurologist - Dr. (S18MD, LSU Neurology Faculty) - subdural hematoma" ...Signed by (S4MD, ER) on 7/19/13 at 12:35 p.m.

Review of the "Consultant's Report" documented by S17MD, LSU Neurology resident, revealed that he saw patient #9 on 7/19/13 at 1:20 p.m. as a result of the consult written on the Admission Orders written by S4MD, ER. Further review revealed: " ...Recommend admission for neuro monitoring and neurosurgical drainage via burr holes ...7/19/13 Neurology Staff (illegible word). Unquestionable bilateral subdural hematomas. Left may be subacute. The patient needs neurosurgical evaluation." Signed by LSU Faculty Neurologist.

Review of a document titled "Request for Transfer, Consent to Transfer, Certification for Transfer" revealed:

"Date: 7/19/13. Stability of Patient on Transfer: (neither Unstable or Stable are checked). Receiving Facility: (hosp "a"). Name and Title of Accepting Staff: (name) (no time contacted). Name of Accepting MD: (S14MD). (no time contacted).

Transported By: ALS (advanced life support) Ambulance. Accompanied By: Paramedic ...Risks of Transfer: (check boxes) Transportation risks (involvement in accident).

Benefits of Transfer: (check boxes) Availability of a specialized level of (handwritten) Neurosurgery care. Availability of physician specialty. Physician or Qualified Medical Person's Certification for Transfer: (Required for Transfer of Unstable Patient). On this date, 7/19/13, and at this time, 1530 PM, I confirm the patient's condition and the benefits/risks of transfer as stated above. Based on the information available at this time, I have determined that the medical benefits reasonably expected from the provision of appropriate medical care at the receiving facility outweigh the increased risks to the patient ..." The certification is not signed by the physician or qualified medical person. "Patient consent to Transfer/Request for Transfer/Refusal of Transfer (check applicable Box). I am aware that I have an emergency medical condition and that Touro Infirmary is obligated to treat me, within its capabilities, regardless of my ability to pay. I have also been informed of the risks and benefits of transfer noted above to the receiving facility, and, on this date, 7/19/13, and at this time, 1530 PM, I hereby: (check box) Consent to Transfer (go directly to signature line)." Request transfer is not checked. "Patient/ Responsible party signature: (illegible - patient #2?) ..."

In an interview on 8/21/13 at 2:04 p.m. with S4MD, ER contracted group, she confirmed she was the ER Physician on duty on 7/19/13 when patient #9 was in the ER at Touro. S4MD stated that she transfers the patient if the Neurosurgeon requests transfer. She further confirmed that S14MD, Neurosurgery, requested transfer of patient #9 after admission orders to Touro Infirmary were written. She confirmed S14MD, Neurosurgery was the Neurosurgeon listed as being On-Call for unassigned patients in the ER at Touro Infirmary.

S9MD, ER Medical Director, and S15AVP (Asst Vice President) Medical-Surgical/Critical Care were present for the interview. It was confirmed during this interview that Touro Infirmary has no defined criteria of when, or if, (hosp "a") is a higher level of care and for which patients. It was stated by S9MD, ER Medical Director, and S4MD, ER contracted group that "(hosp "a") "may have preferred equipment or it may just be physician preference."

Patient #10

Review of the medical record for Patient #10 revealed:

"60 year old female. Arrival: 7/21/13 07:27. CC (chief complaint): Headache.

Presentation: 07:28: Patient states headache X 9 days, recent admission for anemia ...

Acuity: 3. Triage Assessment: 07:29: Headache History: The patient has had previous headaches and this one is similar to previous episodes.

General: Appears in no apparent distress ...Pain: Complains of pain in face. Pain currently is 10 out of 10 on a pain scale. Pain began gradually.

Neuro: No deficits noted ....PMHx: Diabetes - NIDDM; Migraines; CAD (coronary artery disease); Hypertension. PSHx: Cholecystectomy; Hysterectomy.

Home meds: Metformin, carvedilol, Niacin, Lopid, benazepril, Ferrous sulfate, Plavix, Norvasc, Glipizide, Vitamin D, Vitamin C ...

07:30: MEND Exam: ...Facial Droop: both sides move well. Visual Fields: sees fingers in all 4 quadrants. Horizontal gaze: moves eyes completely from side to side. Motor-Arm Drift: raised arms do not drift down. Motor-Leg Drift: raised legs do not drift. Sensory-Arm: (eyes closed) feels touch on each arm. Sensory-Leg: (eyes closed) feels touch on each leg.

Coordination-Arms: finger to nose accurate and smooth. Coordination-Legs: heel to shin accurate and smooth. LOC: awake and alert. Speech: repeats "You can't teach an old dog new tricks" using correct words and no slurring. Questions: correctly states the month and their own age. General: Appears in no apparent distress, uncomfortable. General: Behavior is cooperative, fussy.

Pain: Complains of pain in right side of face 9/10 and does not radiate ...Neuro: Level of Consciousness is awake, alert. Oriented to person, place, time ....08:50: Reassessment: No changes ...

12:05: General: Dr. (S14MD) (neuro) accepted pt. for transfer to (hosp "a"). Face sheet faxed to nursing supervisor @ (hosp "a"). 12:35: Received call from nursing supervisor (name) @ (hosp "a"), who states patient will be admitted to stroke unit room 2304.

12:48: (EMS) called for transport to (hosp "a"). Outcome:..13:32: ER care complete, transfer ordered by MD ...

Physician Documentation: Arrival Date: 7/21/2013. Time: 07:27. Dx: Intracranial Hemorrhage.

HPI (history of present illness): 11:11: The patient complains of pain to the right eye, right frontal and temporal area. The patient describes the headache as aching, constant. Onset: The symptoms/episode began/occurred gradually, 10 day(s) ago. Associated signs and symptoms: Pertinent negatives: altered mental status, dizziness, fever, nausea, neck stiffness, paresthesias, vision changes, vomiting, weakness. Severity of symptoms: At its worst the pain was severe.

Headache History: Denies prior headaches. The symptoms are alleviated by nothing. The symptoms are aggravated by movement ...ROS:..Neuro: Positive for headache, Negative for altered mental status, dizziness, gait disturbances, hearing loss, loss of consciousness, numbness, seizure activity, speech changes, syncope, weakness. Exam:..Eyes: Pupils equal, round and reactive to light, extra-ocular motions intact ...MDM: 07:48: Patient medically screened.

Differential Diagnosis: cluster headache, migraine, sinusitis, temporal arteritis, tension headache, vasomotor headache, intracranial mass effect. Data Reviewed: vital signs, nurses notes, radiologic studies, CT scan, MRI ...Disposition: 13:32: Transfer Ordered to (hosp "a"). Diagnosis is Intracranial Hemorrhage. Reason for transfer: Higher level of care. Accepting physician is (S14MD). Condition is stable. Problem is new. Symptoms are unchanged."

Review of a radiology report revealed: "CT Head WO (without) Contrast: ...Impression:

1. Focus of intraparenchymal hemorrhage in the right parietal lobe. Differential diagnosis includes hypertensive hemorrhage, underlying mass lesion with hemorrhage, anticoagulation, or vascular malformation. Recommend further evaluation with MRI brain with and without contrast.

2. Atrophy. Findings suggestive of prior small vessel ischemic change. Possible small chronic infarct in right frontal lobe. 3. Findings discussed with Dr. (S8MD) in the ER 8:30 a.m. July 21, 2013 ..."

Review of a second radiology report revealed: "MRI Brain W-W/O (with and without) Contrast: Impression:

1. Right parietal parenchymal hematoma measuring 2 X 2.4 cm with mild surrounding vasogenic edema and no significant midline shift. There are no definite underlying abnormal flow voids or mass. However, these findings can be sometimes obscured by the hematoma. Three-month follow-up MRI is recommended.

2. Thin right temporal subdural hematoma which appears subacute. There are mild adjacent areas of subarachnoid increased FLAIR signal, which may are present regions of subacute subarachnoid blood. No significant mass effect or midline shift. Findings discussed with Dr. (S8MD)." Electronically signed by: (radiologist). Signature Date/Time: 07/21/2013 11:02:57.

Review of a document titled "Request for Transfer Consent to Transfer Certification for Transfer" revealed the following:

"Date: 7/21/13. Stability of Patient on Transfer: (neither Unstable or Stable is checked).

Receiving Facility: (hosp "a"). Name and Title of Accepting Staff: Nursing Supervisor (name).
Time Contacted: 1205 PM. Name of Accepting MD: Dr. S14MD). Time Contacted: 1205 PM.

Transported By: ALS Ambulance. Accompanied By: Paramedic.

Documentation Sent: Complete Medical Record. Risks of Transfer: Transportation risks (involvement in accident). Pain or discomfort on movement. Medical condition could worsen during transport. Death. Benefits of Transfer: Availability of a specialized level of Neuro (handwritten) care.

Physician or Qualified Medical Person's Certification for transfer: On this date, 7/21/13, and at this time, 1205 PM, I confirm the patient's condition and the benefits/risks of transfer as stated above. Based on the information available at this time, I have determined that the medical benefits reasonably expected from the provision of appropriate medical care at the receiving facility outweigh the increased risks to the patient and, in the case of labor, to the unborn child. Signed by (S8MD, ER).

Patient Consent to Transfer/Request for Transfer/Refusal of Transfer (Check Applicable Box). Request for transfer for the following reason(s): (signature required below) Availability of specialized services at receiving hospital. (checked)." The document is signed by the patient and witnessed by an RN on 7/21/13 at 1315 PM.

In an interview on 8/21/13 at 2:04 p.m. with S9MD, ER Medical Director, and S15AVP Medical-Surgical/Critical Care, it was confirmed that Touro Infirmary has no defined criteria of when, or if, (hosp "a") is a higher level of care and for which patients. It was stated by S9MD, ER Medical Director, and S4MD, ER contracted group that "(hosp "a") "may have preferred equipment or it may just be physician preference."