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Based on the review of medical records, policies and procedures, Physician on-call lists, External/Transfer in/out forms, transfer out logs Social Security Act 1867- Examination and Treatment for Emergency Medical Conditions and Woman in Labor (EMTALA), and interviews, the facility failed to accept a transfer from a referring hospital an appropriate transfer of an individual with a certified emergency medical Condition and required such specialized services (Cardio-Thoracic Surgeon specialty) at the recipient hospital which had the capability and capacity to provide care for 1 of 20 sampled patients. The facility also failed to have an effective Recipient Hospital Responsibility policy and procedure to adequately address this EMTALA provision. Refer to the findings in Tag 2411.

Based on the review of medical records, policies and procedures, Physician on-call lists, External/Transfer in/out forms, transfer out logs Social Security Act 1867- Examination and Treatment for Emergency Medical Conditions and Woman in Labor (EMTALA ), and interviews, the facility failed to accept a transfer from a referring hospital an appropriate transfer of an individual with a certified emergency medical Condition and required such specialized services (Cardio-Thoracic Surgeon specialty) at the recipient hospital which had the capability and capacity to provide care for 1 of 20 sampled patients. The facility also failed to have an effective Recipient Hospital Responsibility policy and procedure to adequately address this EMTALA provision.

Findings include:

The medical record for patient #1 from the transferring hospital was reviewed. Review of the ED initial assessment form indicated that patient#1 a 63 year old arrived at the ED on 9/20/2013 at 8:34 am and was immediately triaged. The patient was triaged (in a hospital the practice of sorting emergency patients into categories for treatment) as " Priority: 3 Urgent. " The chief complaint was listed as Unresponsive or Unconscious. " Review of the History and Physical revealed in part, " Pt. (patient) was driving drove off the road ... patient strapped in and unconscious, rescue called and patient was transferred ...awake and following commands but not verbally ...mae (moves all extremities )x 4 ...symptoms are severe ...Physical Examination: Respiratory: Respiratory effort is mildly labored (abnormal respirations, increased effort to breathe). Lungs Sounds: Crackles noted in left base ...Neurologic: Alert and oriented to person, place and time ...DIAGNOSTIC TEST RESULTS: Radiology: Computerized Tomography Scan: Brain:- - Study done: Atrophy noted ...Positive aortic aneurysm with evidence of dissection ( a tear develops in the inner layer aortic , a large blood vessel branching off the heart. Blood surges through the tear into the middle layer of the aorta causing the inner and middle layer to separate (dissection)- a medical emergency). Aneurysm measures 10 cm (centimeters). Blood in the mediastinum and left pleural space. .. ED course and treatments: Note delay in transferring pt. secondary to multiple non-accepting locations. Clinical Impression: Dissecting Thoracic Aneurysm. Disposition: Critical Care Services ...pt. will be transferred to another acute care hospital ...Patient's condition represents a Certified medical emergency. " Review of the facility ' s Emergency Department transfer form for patient #1 revealed the patient was transferred via helicopter on 9/20/2013 at 12 noon. Further review indicated the reason for transfer was, " immediate access to specialized practitioner/equipment/monitoring Specifically: Cardio-Thoracic surgeon. "

The transferring hospital ER Transfer/Communication log for patient #1 was reviewed, the log was dated 9/20/2013. Review of the ER Transfer/Communication log specified in part, " Bethesda ...10:38 called Bethesda East Administrative supervisor (AS) - transferred to ED spoke with ED Unit coordinator, ...10:40 ED physician at Bethesda Hospital East (BHE) spoke with ED physician at transferring hospital TH) Dr. on-call (Cardio-vascular surgeon) -Assistant Nurse Manager/Charge Nurse of the ED (ANM/CN) BHE-ER will call on call Cardio Vascular surgeon and call right back. Need faxed CT report ....11:00 Spoke ...Nursing supervisor-needs adm (administration) approval don ' t send patient until talk c (with) AS CT report faxed to ANM/CN of ED at this time- Administrator of Bethesda Hospital East 11:13 refused ...told to leave message for Administrator of Bethesda Hospital East message left requested reason for refusal. ED physician at transferring hospital d/w (discussed with) on -call cardio-vascular surgeon- .... 11:15 DON Note: requested Administrator of Bethesda Hospital East to cback (call back). Review of the Emergency Department Additional Notes dated 9/20/2013 indicated that the transferring hospital called BHE, at 11:33 am " Called by (name of person at TH) to Bethesda to speak with the Administrator of Bethesda Hospital East re: Reason for refusal. " Further review specified that at 11:40 am , Bethesda (name of person at TH) spoke with nursing supervisor she does not know why.. was refusing. Administrator of Bethesda Hospital East is to call back ... with reason. "

The medical record from Hospital F (where patient #1 was finally accepted) was reviewed. Review of the medical record revealed that patient #1 arrived at the hospital on 9/20/2013 at 1:14 p.m. Patient #1 received a medical screening examination and was admitted to the operating room.


BHE maintains a binder which contains information of requests to Transfer in a patient with an emergency medical condition. This information is documented on the Hospital External/ Transfer In/ Out Form. A review of the Transfer In form dated, 9/20/13 at 11:10 a.m., for Patient # 1 revealed the following:
? Reason for transfer: cardiothoracic surgeon
? Diagnosis: old aneurysm
? Final Disposition: Denied per Administrator of Bethesda Hospital East 11:10am
? Description of disposition: Per Administrator patient was denied at Hospital A, B, C, D, per the requesting hospital. Spoke with Transferring RN in ER. We are not the closest facility to transfer to. DON, leaking triple A (aneurysm) now. Hospital D surgeon declined no capacity. Called Hospital E, F, G. Hospital F will take patient at 11:50 am. Administrator of Bethesda Hospital East notified. On 10/2/13 at 11:21 AM an interview was conducted with the Administrator noted on the Transfer Form as refusing the request to transfer Patient #1 to Bethesda Hospital East. He stated, "I did not have the opportunity to research our capacity before an alternative was identified. He stated, "I did not deny acceptance of the patient, I was contacted at 11:10 AM. I do not recall speaking to anyone at that hospital. I was left a message to call, but I was in a meeting and they found another place before I got back to them." The facility failed to accept patient #1 with an identified EMC on 9/20/2013 an appropriate transfer, who required the specialized services of the cardiovascular surgeon and the hospital had capability and capacity to provide the care.

A review of the Policy for Transfer of Patients to and from Bethesda Hospital, updated 12/31/12 reveals the following pertinent entries in part: " I. General Information
Regulation provides for a concise reference to expedite the process of patient transfers including necessary criteria to be followed concerning the health and safety of the patient. .. III. Policy . . . B. Bethesda Memorial Hospital will provide emergency services or care (under EMTALA guidelines). .. C. Patients will be accepted for care only where Bethesda Memorial Hospital is the closest facility with service capability for patients that fall under the EMTALA guidelines. The facility failed to have an effective policy as it relates to accepting an appropriate transfer of an individual with an EMC when the facility has capability and capacity. According to the Social Security Act 1867- Examination and Treatment for Emergency Medical Conditions and Woman in Labor (EMTALA ), " 489.24 (f) Recipient Hospital Responsibilities .... A participating hospital that has specialized capability and capacity ... may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has capacity to treat the individual. " On 9/20/2013 patient #1 was within the boundaries of the United States and Bethesda Hospital East had capability and capacity (level of care personnel can provide within scope of profession - Cardio-vascular surgeon, physical space, equipment, supplies, and specialized services, i.e., surgery, intensive care).


Review of the Operations Regulation No .1107 pages 5 of 9 indicated in part, " C. Transfers in to Bethesda Hospital Emergency Department meeting Emergency Medical Condition Criteria under EMTALA guidelines.

1. When a call is received from an outside Emergency department for an emergency transfer, the call will be directed to the ED ANM/Charge Nurse; 2. ANM/Charge Nurse. Will check the Physician on-call list to determine if the Physician specialist required is on call today; 3. The ED Assistant Nurse Manager/Charge Nurse will contact Patient Placement, or Administrative Supervisor if after hours, to determine service capacity and for patient transfer authorization; 4. Once the transfer authorization approval is obtained the ED ANM/Charge Nurse will contact the facility requesting the transfer so the transferring ED physician can call report to Bethesda ED physician ...5. When the transfer has been accepted, a courtesy call will be placed by the ED to the specialist on call to notify him/her of the transfer. " The facility failed to ensure that this policy was followed as evidenced by there is no indication that the Administrator has to be notified to make a decision to ACCEPT OR DENY a patient with an identified EMC coming from a transferring hospital.


Review of the facility's On Call List dated 4/01/13 to present revealed that on 9/20/13 the facility had a Cardiovascular Surgeon on call.


During interviews, on 10/2/13 at 11:45AM, the surveyor conducted interviews with 2 ER physicians, the Charge Nurse and a Nurse regarding their responsibilities when they receive a request from another acute care provider to transfer a patient who has an emergency medical condition, for emergency care and services. The ER physician's both stated they do not speak to the referring ED until after Bethesda Hospital East Administrative approval for the transfer has been obtained. The Charge Nurse stated: if she receives a call regarding a request to transfer a patient in, she immediately transfers the call to the Nursing Supervisor (Administrative Supervisor) who handles the request; "A patient will not be accepted for transfer in until Administration has approved the transfer. If the transfer is approved, she will then notify the ED Physician and he will speak to the ED physician at the transferring ED. A call is then made to the specialist on call to notify him that a transfer is coming to the ED."

The Director of the ER was asked to describe the policy for transfers in and out of the ED. He stated the Charge Nurse makes the call and arranges transports out of the ED to another ED. This information is maintained on a Log, of all patients who are Transferred Out of the facility, by the Charge Nurse for that particular shift. Review of the Transfer Log (out) for the past six months did not disclose any requests to transfer patient #1 or any other patients from an outside ED to Bethesda Hospital East Hospital. When asked why both transfers out and transfers in are not included in the Transfer Log, he stated all requests to transfer patients into the facility ED are handled by the Administrative Nursing Supervisor. They keep a binder with the requests, however it is not maintained in a Log format, nor in the ED.



An interview was conducted with the Nursing Administrative Supervisor, on 10/2/13 at 11:30 am. The Supervisor stated the call from the transferring hospital was transferred to her from the ED Charge Nurse. She stated, "I asked for the face sheet. I called the ER staff at the transferring Hospital to get the name of the ER physician to have the two ED doc's talk to each other. That hospital is far away and we were not the closest. There is a policy on mileage, you go to the closest. I spoke to the Administrator and discussed it with him. He asked if they (the
transferring hospital) had called any other facilities; they said he was stable. Through the whole thing we had multiple conversations." "At 11:10 AM, it was denied based on the fact that we did not have all the information. I documented that the patient was going to Hospital F at 11:50 AM. We no longer needed to evaluate the case." When the surveyor asked why the check box for "denied " is marked with the name of the Administrator, and the time, the Supervisor stated, there is only an option top " accept or deny " so she checked off denied. When the surveyor asked why all Transfers out of the facility are handled by the ED Assistant Nurse Manager/Charge Nurse but all requests to Transfer Into the facility are handled by the Assistant Administrator/ Supervisor, the Supervisor stated, "because we have to get authorization before we can accept a patient." She then confirmed that the ER Charge Nurse handles all requests to transfer patients out, and maintains the Transfer Log Out, but that the Administrative Nursing Supervisors who handles request for transfer in do not maintain a log of patients who request to be transferred into the facility.

The Surveyor placed a phone call to the Cardiovascular Surgeon on 10/02/13 at 2:22 PM and left a message. The surgeon returned the call, and when asked if he recalled being contacted on 9/20/13 regarding the request to transfer Patient #1 in to Bethesda Hospital East, he denied receiving such a call. Subsequent to this phone conversation, the surgeon called the surveyor back approximately 10 minutes later, and stated that he asked his office manager and she recalled that the A.R.N.P. had handled such a call, but he did not know what the call was about. The Cardiovascular Surgeon and the A.R.N.P. are employees and maintain an office inside the hospital proper.

That afternoon (10/02/2013) at 4:03 PM, the surveyor conducted an interview with the Cardiovascular A.R.N.P. who stated, "I got a message from our office manager that there was a potential transfer and they wanted to know if the surgeon would accept the transfer. The office manager had written the message down. I wasn't in the office at the time the message came in; they had just gotten off the phone. When asked who called the office manager, he stated, "K....", and said I was in the hospital and walked into the office and the office manager asked me this. I asked what it pertains to. The office manager handed me a slip of paper with the phone number on it. She stated it is about an aortic bleed. I asked where in the aorta is the bleed, abdominal, thoracic, where specifically." We needed more information. "I said that maybe we should call this K.... back and I can have Dr. B... talk to the physician or myself. It was relayed to our office," "not to mind the message as the patient was going somewhere else." That was the last I heard of it. Nobody sent us a FAX or any other clinical information. I do not know who K.... is or from what ER she is from. "I have never dealt with a phone call about a transfer before."

On 10/3/13 at 10:05 am, an interview was conducted with the Cardiovascular Service Office Manager. Who was asked about the call placed to her office on 9/20/13 regarding patient #1. She stated, I remember speaking to C....., she wanted to speak with the Cardiovascular surgeon. "I told her he was scrubbed in on a case." I asked her what it was in regards to and she said she wasn't sure and put me on hold. She said she would call me back and hung up. The A.R.N.P. came in and I gave him the message. We were going to wait on her to call back. She said it had to do with a thoracic bleed. She did call back, but said to disregard the call. She said the Hospital had denied the case. She didn't say who she had spoken to. "

On 10/3/13 at 10:18 am, a call was placed to the Bethesda Hospital East ED Physician on duty on 9/20/13. He was asked if he is aware of a request to transfer patient #1 who had a bleeding aneurysm in to the facility. He stated, that he got a call from the facility as they had asked to speak to the ED physician. "I asked what the call was for. I told him, I should not speak to him until after Administration approves the transfer, that is our procedure." I told him, "I need to speak to him if Administration ok's the case. I told him, I would transfer the call to Administration. I never spoke to any doctor at that facility, but the Nurse did, and she called the Cardiovascular Surgeon regarding the CT report which was sent to our FAX. I know that I am not supposed to get involved until our Administration has approved the transfer."

At 1258 PM, the surveyor conducted a telephone interview with the Assistant Nurse Manager/ Charge Nurse who was on duty on 9/20/13. The Assistant Nurse Manager/Charge Nurse stated, she vaguely recalled a phone call requesting to transfer an aneurysm patient in. She said, they offered to send the CT results, and when it came in, I gave it the ED Director. I was told by the Nursing Supervisor that the hospital was not accepting the transfer." The surveyor asked, what was the name of the individual who asked about the CT. She stated, I spoke to the Cardiovascular Surgeon on call and he requested it. I don't remember if it was Dr. A or Dr. B. He wanted to know if the aneurysm was ascending or descending. So, we asked for the CT results which they sent over and I gave it to the ED Director.

At 1:07PM on 10/02/13, the Assistant Nurse Manager/ Charge Nurse called the surveyor back, and stated, "the ED physician asked her to see who the cardiovascular surgeon was on call. She called the surgeon to verify that he was on call. The ED Physician asked her to call back the requesting hospital and they asked if the hospital (Bethesda) wanted the report."

The ED Director was then interviewed on 10/02/2013 at approximately 1:30 PM and was asked if the copy of Patient # 1's CT report had been given to him. He stated, the Assistant Nurse Manager/Charge Nurse handed him the report and told him the transferring hospital had sent the report, but the transfer was denied. She didn't know what to do with the CT report and was turning it over to him. The ED Director provided the Surveyor with the report which he had kept in his office. He stated, he did not know what to do with the report since the patient wasn't accepted. Review of the CT of the Thorax revealed, it was Faxed to the Hospital on 9/20/13 at 11:10 AM to the attention of the Administrative/Charge Nurse.

The Assistant Chief Nursing Officer confirmed that the facility had the service capability to accept the transfer of Patient # 1 on 9/20/13, but did not follow the designated transfer procedure and EMTALA guideline. He confirmed, the documentation on the Transfer in/ Transfer Out form documented the refusal to accept the patient at 11:10 am on 9/20/13.

Review of the credential files for the sampled ED physicians, the cardiovascular surgeon and the involved ARNP revealed, no evidence of EMTALA Requirement training. Upon inquiry, the Chief Nursing Officer stated, the ED physicians conducted their own training for EMTALA, but no record of the training is maintained by the hospital.