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Based on interviews with hospital staff, and the review of hospital policies and procedures and guidelines, it was determined that the hospital failed to ensure the implementation of its Emergency Department (ED) and Emergency Medical Treatment and Active Labor Act (EMTALA) policies and procedures related to the acceptance of transfers from referring hospitals.

Findings include:

During an interview with the Director of Quality Resources on 06/15/2011 at 1100 he/she indicated the hospital used to have an ED transfer line for managing incoming transfer calls. He/she said the transfer line was discontinued prior to 05/27/2011, and he/she did not know when it was discontinued. He/she said that the transfer line was not in place when the hospital failed to accept the transfer of an individual with an emergency medical condition from a referring hospital on 05/28/2011. He/she said the hospital failed to maintain the ED transfer line as directed by the hospital's EMTALA policy and procedures. He/she also said the hospital has no consistent process for documenting requests for EMTALA related transfers from referring hospitals as required by the hospital's EMTALA policy and procedures.

Based on the review of medical records, documentation and interviews with hospital staff, it was determined that PMMC with specialized capabilities failed to accept from a referring hospital an individual with an emergency medical condition who required the specialized capabilities of the hospital's on call trauma surgeon and subspecialty services.

Findings include:

Medical record #27 was reviewed. Documentation reflects that Patient #27 presented by ambulance to Hospital 2 at 2335 on 05/27/2011. The Emergency Department (ED) final physician's report reflects the following documentation: "[He/she] states [he/she] was 'minding my own business' when some people walked up to [him/her] and started beating [him/her] up with a baseball bat. 911 was called. Paramedics found [him/her] on the scene to have some lacerations to [his/her] face and deformity about the left arm, and [he/she] was placed in a cervical collar and a backboard, and they brought [him/her] to the emergency department for further evaluation." Review of the documentation reflected that a physician conducted a history and physical exam of the patient and a secondary examination of the head. The secondary examination reflected that the patient had "significant swelling about the eyes bilaterally, developing some bruising underneath the right eye...a laceration to the left cheek that is approximately 2 cm in length...significant laceration through the entire length of the upper lip just to the left of the midline...abrasions and lacerations to the inner aspect of the lower lip...tender to palpation over the bones of the midface...tender to palpation over the nasal bone, and there is crepitus appreciated there... multiple fractured teeth...significant deformity of the left elbow with a small laceration to the posterior most aspect of the elbow..."

Review of the documentation revealed that x-rays and CT scans were completed and the patient had multiple facial fractures, a fracture of the ulna, and a dislocated radius. The record reflected "This patient is clearly a multiple trauma. [He/she] was made a modified trauma. I believed that [he/she] needed to be admitted to a trauma surgeon so that [he/she] could get appropriate subspecialty care including but not limited to possibly ophthalmology for [his/her] orbital wall fractures, and orthopedic surgery for [his/her] open fractures, ENT or oral maxillofacial surgery for the rest of [his/her] facial fractures, and orthopedic surgery for [his/her] open fracture dislocation of the elbow. I spoke with our surgeon here, who felt that [he/she] might not be appropriate to keep here secondary to the fact that [he/she] likely does need oral maxillofacial surgery, which I entirely agree with, and so the next closest facility would be [Hospital 3] where they do have ear, nose, throat, ophthalmology, oral maxillofacial surgery as well as orthopedic surgery." Review of the documentation revealed that the patient was not transferred to Hospital 3, and that the on call physician "would not be accepting the patient because [he/she] felt like the patient only needed subspecialty care and not [his/hers]." Review of the patient transfer form documentation reflected the patient was subsequently transferred to Hospital 4 after communication with the on call trauma physician at that hospital on 05/28/2011 at 0320.

Review of the documentation on the patient transfer form reflected "Risk of NOT Transferring...same level of service/treatment available is not offered at this hospital may negatively impact outcomes."

The TRCH ED physician was interviewed at 1045 on 06/23/2011. The physician confirmed that he/she treated Patient #27 at Hospital 2. The physician reported that Patient #27 was a "poly trauma patient" with multiple facial injuries and required "several subspecialties," including possible oral maxillofacial surgery for the repair of those injuries. confirmed that he/she arranged for contact with Hospital 3 through an ED nurse in order to arrange a transfer of Patient #27 to that hospital. The nurse reported to Physician L that Hospital 3 was "not on call for trauma patients" and that Hospital 1 was on call for trauma patients. Physician L reported that the nurse contacted Hospital 1 in order to arrange contact with the trauma on call physician. Physician L reported that the charge nurse from Hospital 1 contacted the nurse at Hospital 2 and informed him/her that the trauma physician refused to accept the transfer of Patient #27. Physician L confirmed that the medical record documentation for Patient #27 failed to reflect the correct sequence of events surrounding Patient #27's transfer and the refusal of Hospital 1 to accept Patient #27.

The trauma physician was interviewed at 0930 on 06/16/2011. He/she said that he/she received a call at 0200 on 05/28/2011 from the nursing supervisor from PMMC requesting the transfer of a patient with facial fractures. The physician reported that the patient did not have multi-system issues and "getting hit in the face is a traumatic event, a single system injury." He/she reported that he/she did not think the patient was a trauma case; he/she did not refuse a trauma transfer patient because the patient did not have a multi-system trauma; and he/she told the nurse he/she would be willing to "consult" for the patient. The physician said "They should've called an ENT" and "At that time in the morning, I'm not too curious." The physician said that he/she had not received specific training from the hospital regarding EMTALA requirements or the hospital's ED transfer process and reported "Just general knowledge. No specific training. I know for trauma transfers, if there's capability and services, you take them, that's it." The physician said that trauma transfers needing a specialist should include a physician to physician contact.

The director of quality resources was interviewed on 06/15/2011 at 1100. He/she said the on all trauma physician at PMMC, refused to accept the transfer of Patient #27 who required trauma and specialty care. He/she also reported the physician was responsible for accepting the patient and said that he/she did not. The director of quality resources also confirmed that the trauma physician was on call for trauma services on 05/27/2011.

The director of quality resources received information about the EMTALA complaint from PMMC ED staff on 06/01/2011. Staff at Three Rivers Community Hospital had reported the complaint to the PMMC ED medical diretor, and this prompted an investigation. the director of qualit resources that he/she had investigated the complaint and identified multiple factors that resulted in PMMC's failure to accept an appropriate transfer: He/she reported a significant turnover in ED management staff over the past approximately 18 to 24 months, including the ED medical director and ED manager positions; a lack of support of ED processes during those staff changes; a reduction in "house supervisor" hours; and failure to orient new ED staff, including the medical director and managers, regarding EMTALA requirements.

The ED relief charge nurse was interviewed on 06/16/2011 at 0950. He/she reported that the house supervisor transferred a call from a nurse at TRCH to the ED; he/she received the call; and the caller said "We need a trauma surgeon." The nurse then called the on call trauma surgeon, informed him/her that TRCH requested to transfer a trauma patient with facial fractures who had been beaten with a bat. The trauma surgeon said he/she would not accept the patient because he/she would have to call in an oral surgeon, and that he/she would only be able to consult. The nurse asked the trauma surgeon "Do you want me to call back and tell them you're not accepting?" The trauma surgeon said "Yes." The nurse said the trauma surgeon was "a little short. He/she did not hang up on me, but I wasn't able to finish telling him/her about the (patient's) broken arm." He/she confirmed that he/she had received no training regarding the policy and procedure for ED to ED transfers.

The RN risk manager was interviewed on 06/16/2011 at 0745. The RN reported that he/she received a call from the charge nurse at Hospital 2 requesting a trauma physician for Patient #27. He/she confirmed that he/she told the caller that the hospital had capacity and capability, accepted the patient, and transferred the call to the ED charge nurse. Approximately an hour later the RN informed the RN that he/she had spoken to the trauma surgeon; the trauma surgeon informed the ED charge nurse that Patient #27 needed an OMS specialist; the trauma surgeion said he/she would only accept the patient if an ENT or OMS physician was arranged. Person D reported that he/she was surprised that ED charge nurse spoke to the trauma surgeon because communication for transferring patients is normally physician to physician. He/she said the normal process is for the hospital to give the transferring hospital the on call physician's phone number in order to facilitate the communication between the two physicians.

The RN reported that the point of contact for trauma transfers is the trauma physician, and the trauma physician is responsible for contacting other specialists as needed. He/she said that PMMC had capacity, that the trauma surgeon was on call, and that the hospital had ENT availability when TRCH requested the transfer of Patient #27 on 05/28/2011.

The RN reported that the ED transfer line was discontinued sometime between 10/2009 and 08/2010. He/she left the hospital for that ten month period. He/she reported that the transfer line was in place when he/she left 10/2009, and was discontinued when he/she returned in 08/2010.

The review of the emergency services backup schedule documentation for the month of 05/2011 reflected that Physician 3 was the trauma physician scheduled on 05/27/2011. The documentation also reflected ENT specialty backup coverage for the week of 05/23/11 through 05/29/11.