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Based on a review of policies, hospital documents, medical records, and staff interviews, the hospital failed to enforce the EMTALA policy for 1 of 31 sampled patients from 8/2/15 to 10/5/2015 to ensure staff accepted an appropriate transfer from another hospital to the Emergency Department (ED) of the hospital (Patient #33).

Failure to ensure the ED staff accepted an appropriate patient transfer from another hospital in accordance with the hospital's EMTALA policy could potentially result in a delay in patient treatment, harm and/or poor outcomes for the patients.

Findings include:

1. Review of the hospital policy titled "EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT (EMTALA), dated June 12, 2015 revealed, in part... "Policy: Accept appropriate transfers of individuals with emergency medical conditions if the hospital has the specialized capabilities not available at the transferring hospital, and has the capacity to treat those individuals."

Review of Mercy Medical Center North Iowa policy titled, "Physician "On Call" Coverage" Effective March 15, 2013 stated in part, "...Procedure...Upon determination by the emergency department physician of the need for a specialist evaluation of a patient presenting with a possible emergency condition...The Emergency Room physician will contact the on-call specialist...If the on-call specialist is available but refuses to respond to an on-call request...will be reported to the Chief Medical Officer for review..."

Refer to A 2411 for additional information concerning the hospital's refusal to accept an appropriate transfer of Patient #33.

Based on review of hospital documents, medical record and staff interviews, the hospital failed to ensure the Emergency Department (ED) physician accepted an appropriate transfer to the hospital with specialized capabilities not available at the transferring hospital.

Failure to ensure ED providers at a hospital with specialized capabilities not available at the transferring hospital accepted an appropriate transfer for 1 of 1 patient on 9/27/15 in accordance with the hospital's EMTALA policy resulted in the delay of the patient's treatment and could potentially result in patient harm and/or poor outcomes for the patient. (Patient #33)

Findings Include:

1. Review of the document titled, " [Hospital A] Health Services" 10/1/15 revealed Hospital A (transferring hospital) did not have the capability to provide Gastroenterology medical services or patient care in an intensive care unit.

Review of the document titled, "Mercy Medical Center North Iowa Specialist Directory" 03/15, included in part, "...To talk with a physician immediately or to transfer a patient, call Mercy First Call...Specialists Working Together For Your Health...Gastroenterology -Internal Medicine...Emergency Medicine..."

2. Review of Patient #33's medical record from Hospital A revealed a document titled, "The Daily Focus Assessment Report" dated 9/27/15 showed the documentation of the Registered Nurse (RN) I, an Emergency Department RN included in part, "...At 3:35 PM...Chief Complaint: Ingestion of disinfectant, suicidal...Throat pain, hoarseness, some throat irritation...Swallowing without difficulty...Nausea, Vomiting, Abdominal pain, Has vomited 3 times...Suicide Ideation...Patient has a history of hearing voices, cutting and suicidal ideation...states she hates herself and just wanted to die ...states this is why she drank the disinfectant...complains of a sore throat...Therapy Services Notified...."

a. 3:40 PM, ED RN I documentation stated in part, "...Poison control notified, may cause nausea, vomiting, diarrhea, stomach irritation...may need to be scoped (Endoscopy-An upper gastrointestinal procedure.)...At 3:58 PM, Throat pain, Hoarseness, Doctor aware that throat is sore...At 4:35 PM, Patient given ice water, but unable to swallow it and stated it made her throat hurt.... At 4:50 PM Patient had several small emesis and does not swallow saliva.

b. At 5:05 PM, ED RN I documentation stated in part, "...Patient signed consent form for transfer to Mercy Medical Center North Iowa (MMC-NI). Report given to [Mercy First Call RN B] at MMC-NI. (Mercy First Call-RN is a telephone service used to connect and coordinate all incoming calls for patient transfers to providers at MMC-NI.)

c. At 5:10 PM, ED RN I documentation stated in part, "...Transferred to MMC-NI

d. At 5:28 PM, ED RN I documentation stated in part, "...Received phone call from MMC-NI to have ambulance turn around because upon further consideration they would not be accepting the patient. Ambulance notified and they will return with the patient. (Transferring hospital ED Physician J) notified.

e. At 5:40 PM, ED RN I documentation stated in part, "...Ambulance returns with patient. Assessment...Throat: Pain, Hoarseness, Continues to complain of sore throat, Continues to spit out saliva, not swallow it...Nausea, Vomiting, Abdominal pain...Pain throat...Pain Score 6 Scale: 0-10 Numeric.

f. At 5:50 PM, ED RN I documentation stated in part, "...patient reports her stomach is starting to hurt more

g. At 6:05 PM, ED RN I documentation stated in part, "...patient transferred to Hospital C.

i. ED Physician J at hospital A (transferring hospital) documented on a untitled document, dated 9/27/15 which stated in part, "...History of Present Illness...brought in by ambulance after ingesting floor cleaner...Betco PH7Q...mild base cleaner...according to Poison Control, symptomatic treatment, causes irritation in stomach...needs to watched for swelling and more generalized support...problems with bulimia...ongoing problem for her trying to harm herself, hence, critically is under monitoring program at facility...Posterior pharynx is swollen...Tender in epigastric area....Impression: Ingestion of floor cleaner and depression.

j. Further review of ED Physician J ' s documentation on the untitled document stated in part, "...Plan: Did talk to...Hospitalist D... in Mason City who will be the receiving physician. We will transfer via ambulance to their facility for further close observation as well as possible scope yet tonight.

k. ED Physician J ' s documentation on a document titled, "Orders Report" 9/27/15 stated in part, "...Transfer to MMC-NI...Hospitalist D... receiving...EMTALA/TRANSFER..."

l. Review of document titled, "Important Legal Notice" 9/27/15 stated in part, "...The patient may be at risk for deterioration from or during transport...Reason for transfer: Medically indicated, equipment or services not available at this facility...GI (Gastrointestinal) consult...Medical Benefits: Services at Receiving Facility...The receiving hospital has the capability for treatment...and has agreed to accept the transfer and provide appropriate medical treatment...North Iowa Mercy Health Center...Receiving MD/DO...Hospitalist D...Report given to...First Call RN B at 5:15 PM...Discharge time 5:22 PM..."

2. During an interview on 10/7/15 at 11:10 AM, Hospital A ED RN I reported on 9/27/15 about 5:15 PM ED Physician J at Hospital A talked to Hospitalist D at Mercy. ED RN I stated she gave nurse to nurse report to First Call RN B. ED RN I stated she reported the patient had ingested floor cleaner, vomited and had a swollen throat. ED RN I stated after the acceptance, the ambulance was transferring the patient to Mercy, they were out of the building when Hospitalist D at MMC-NI called back about 5 minutes after the patient left in the ambulance and said he consulted with GI and GI said they couldn't meet the needs of the patient. ED RN I stated, "I asked him...do you want us to call the ambulance back to town?" ED RN I stated, "They said yes, get the patient back and transfer to another hospital."

During an interview on 10/7/15 at 11:05 AM, Hospital A ED Physician J stated he transferred the patient to Hospitalist D at MMC-NI. ED Physician J stated the patient swallowed cleaning fluid and had a swollen throat. ED Physician J stated Hospitalist D accepted then called back and said he could not accept, the patient needed a tertiary hospital (Specialized consultative care). ED Physician J stated Hospitalist D called him after the patient was transferred to Hospital C (second transfer from Hospital A). ED Physician J reported Hospitalist D reported he had talked with the GI Specialist and he refused acceptance, he thought they could not care for the patient. ED Physician J reported the patient had left, was in the ambulance, and approximately 10 minutes en route to MMC-NI when the refusal came in. ED Physician J stated, "Usually patients go to the accepting ED and transfer from there if they are unable to care for them." ED Physician J reported Hospitalist D initially talked with ED RN I about the refusal.

3. During an interview on 10/5/15 at 1:45 PM, First Call RN B reported she worked for First Call at MMC-NI. RN B reported she received transferring hospital calls. RN B reported physicians discuss the cases with the sending physicians and determine if we can accept. RN B stated, "If accepted, I talk to the sending facility for nurse to nurse report communication. If we don't have a "specific specialty" on call...I explain no coverage at that time and the physician can talk with a Hospitalist. If a Hospitalist discusses with the sending physician and determines we can provide that care, they can accept."

a. When asked if she recalled a time when a physician accepted a patient for a transfer and then canceled the patient transfer when the patient was en route to Mercy, RN B stated, "A while back, one to two weeks ago...a family practice physician accepted a transfer from a hospital...discussed the case with a GI Specialist...they determined they could not treat the patient. When asked who decided they could not treat the patient, RN B stated, "The Hospitalist and the GI Specialist." RN B stated, "I called the sending facility back and said we could not accept transfer because the Specialist could not treat."

b. During a follow-up interview with First Call RN B on 10/6/15 at 10:20 AM, RN B reported she received a call on 9/27/15 at approximately 4:00 PM from [Hospital A, ED Physician J]. RN B stated the physician requested a transfer for a patient that had ingested some floor cleaner. He contacted Poison Control. The patient required monitoring, the patient had vomited, and had a swollen throat. RN B reported she called [Hospitalist D] and gave him the information and then connected him to [ED Physician J]. RN B stated she remained on the telephone call when [Hospitalist D and ED Physician J] discussed the case. RN B stated "...[ED Physician J] repeated the information given to me." RN B reported [Hospitalist D] accepted the transfer. RN B said she completed a nurse to nurse report with ED RN I from the transferring hospital. RN B reported about 15 minutes after [Hospitalist D] accepted the transfer he called RN B and said he discussed the patient's case with the [Attending Physician H and the Gastroenterologist (GI) Specialist G] and the GI Specialist did not feel the hospital was capable of handling the transfer in case the patient had complications needing surgery and the patient would need more tertiary care.

c. RN B reported [Hospitalist D] called the transferring hospital and spoke to the RN because ED Physician J] had left. The RN said the patient had already left the hospital, the RN called the ambulance back to their hospital. RN B reported [Hospitalist D contacted ED Physician J] and told him the [GI Specialist G] was consulted and he determined the patient would receive more appropriate care at another hospital. When asked if RN B was involved in the conversation between [Attending Physician H, GI Specialist G, and Hospitalist D], RN B stated, "No." RN B reported no incident report was completed because she did not view it as a concern.

During an interview on 10/6/15 at 8:30 AM, Hospitalist D stated on 9/27/15 [ED Physician J] told him [Patient #33] swallowed floor cleaner, required critical care, and may need a scope. Hospitalist D said he thought the patient was appropriate for MMC-NI's critical care unit and accepted the transfer. Hospitalist D stated he spoke with his Attending physician H and she agreed the patient was appropriate for airway management in the critical care unit and transfer to MMC-NI. Hospitalist D reported he then spoke with [Critical Care Physician E] and he also agreed with the transfer. Hospitalist D said he then spoke to on call [GI Specialist G] about the patient transfer. Hospitalist D stated, "I described the patient drank floor cleaner, poison control was consulted and the airway needed to managed and monitored." Hospitalist D stated [GI Specialist G] thought the patient would be better off at tertiary care hospital because if the patient has an esophageal rupture, [GI Specialist G] did not have the capability to provide this type of care, advanced surgery." Hospitalist D stated he updated his Attending Physician H regarding the conversation with [GI Specialist G] and [Attending Physician H] told him to call the hospital back and tell them to send the patient to a tertiary hospital. Hospitalist D reported [GI Specialist G] did not speak with [ED Physician J] at [Hospital A]. Hospitalist D stated, "I am a Resident and I haven't seen a case like this."

During a follow up interview on 10/6/15 at 3:55 PM, when asked if Hospitalist D told [GI Specialist D] he had accepted [Patient #33] at MMC-NI. Hospitalist D stated, "I don't recall if I stated patient transfer was accepted, but I did tell him the patient was already on their way." Hospitalist D said [GI Specialist G] told him the patient should still go to a tertiary hospital and transfer should not be accepted.

During an interview on 10/6/15 at 12:20 PM, Attending Physician H said she was the Attending Physician and [Hospitalist D] was under her at MMC-NI on 9/27/15. Attending Physician H reported [Hospitalist D] told her he had talked to the transferring hospital through First Call about a transfer of [Patient #33] who had ingested floor cleaner, and felt the patient would be safe to be monitored at MMC-NI. The Attending Physician H said she told [Hospitalist D] to consult GI. The Attending Physician H reported [Hospitalist D] accepted the transfer of the patient prior to consulting her and GI. The Attending Physician H said she talked with [Hospitalist D] about 30 to 40 minutes later and he said [GI Specialist G] did not want to accept patient transfer because of possible complications, esophageal bleed or rupture and would be better served in a tertiary hospital. The Attending Physician H reported [Hospitalist D] called the transferring hospital back prior to telling me this. When asked who the First Call RN would notify for a patient transfer Attending Physician H said the Hospitalist is notified first, they consult with the Specialist. Hospitalist frequently accept transfers prior to consulting with Specialists. Attending Physician H stated, "I did not know the patient was en route to Mercy when...notified we couldn't accept the transfer."

During an interview on 10/6/15 at 9:40 AM, Critical Care Provider E stated, "...[Hospitalist D] called me...patient ingested chemicals...if patient had indication...to be intubated...to call me and physician transferring would present the case to me...come directly to ICU (Intensive Care Unit)." When asked about patient admissions/transfers, Critical Care Provider E stated, "Other specialty physicians can admit patients on their own. A Hospitalist can accept patients then I take over. [Hospitalist D] did say he accepted a transfer for 19 year old, ingested chemicals, poison control was called with follow-up for patient." Critical Care Provider E stated, "[Hospitalist D] accepted the transfer. The patient needed to come to ICU and be evaluated for GI and airway management. I said I would accept care. [Hospitalist D] did not call me back after this conversation. I accepted the care from [Hospitalist D] and said GI should be involved with chemical aspiration due to possible complications. I told [Hospitalist D] to inform GI of the transfer. [Hospitalist D] is capable of evaluating and accepting transfers."

During an interview on 10/6/15 at 11:45 AM, GI Specialist G stated "[Hospitalist D] called me and said a patient in [Hospital A] ingested chemicals and he had talked to his Attending H about accepting the transfer. I don't recall if [Hospitalist D] said he accepted the transfer. I told him if [Hospital A] was transferring the patient they should go to a tertiary care hospital because if...patient required emergency surgery, we could not perform that here." When asked if GI Specialist G performed surgery at Mercy, GI Specialist G stated, "I cannot do esophageal surgery, just upper and lower GI's. When asked if GI Specialist G knew the patient was in en route to Mercy GI Specialist G stated, "I was not aware the patient was en route. I would have gone to the ED and evaluated the patient and determined the appropriate level of care." When asked if GI Specialist G could have contacted a different GI Specialist to see the patient GI Specialist G stated, "[GI Specialist M] was on vacation. He cannot do GI esophageal surgery. I have never done surgery. I am an Endoscopist (A person trained to use the endoscope). Hospitalist D did talk with his Attending H and ICU (Intensive Care Unit) physician, Practitioner E. ICU physician E said he could care for the patient and his Attending H said to talk to me. I have not cared for any GI patients that have ingested chemicals. I do get patients with food impaction and it's rare for them... to be caustic (Burn or corrode organic tissue by chemical action) chemical ingestion, esophageal necrosis, or perforation. It would have delayed care if coming here and have to transfer to another hospital." When asked about GI complications, GI Specialist G stated, "Complications do not occur with all patients ingesting chemicals. This could happen suddenly. If no complications, we could care for these patients. If I knew the patient was already en route...would have patient come here and evaluate for proper care. If patient...still in sending hospital ED and I am consulted, I would refer to tertiary care due to complications...risks."
During an interview on 10/6/15 at 7:05 AM, the ED Medical Director at Mercy Medical Center North Iowa C stated "[Hospitalist D accepted transfer...talked to GI Specialist G...refused transfer. Hospitalist D] called sending hospital and refused transfer. If patient here and...did not see patient, this would be a refusal." The ED Medical Director C stated, "[GI Specialist G] gave an opinion, he could not care for the patient. If [Hospitalist D] accepted the patient...probably should have accepted transfer to evaluate the patient and decide if the patient could be cared for here or not." ED Medical Director C reported the patient would need to be evaluated and examined to make a correct determination if the hospital could provide care for the patient. ED Medical Director C stated, "We have had patients come into our ED that have ingested chemicals. If in severe distress...physician evaluates and calls the GI Specialist. If mild distress...call a Hospitalist. ED providers can incubate. Anesthesia can also do this. If...patient requires medical ICU we could admit and provide care. Significant ingestion burns would probably be transferred out. General surgery would complete the surgery if required. On our EMTALA committee, I instruct providers to see patients, evaluate, and determine the level of care."

During an interview on 10/6/15 at 11:05 AM, the ED Director, RN F reported a GI Specialist is expected to answer a page within 10 to 15 minutes and to respond to the ED in 50 minutes unless the GI Specialist is in the Operating Room. The ED physician manages the patient until the GI Specialist can respond to assess the patient. The ED Director, RN F reported if the GI Specialist is requested, the GI Specialist is expected to come to ED to evaluate the patient.