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Based on record review, staff interview, review of medical staff rules and regulations and review of facility policies related to EMTALA (Emergency Medical Treatment and Labor Act), the facility failed to ensure staff followed the policies related to stabilizing an individual's emergency within it's capabilities. Review of 1 (Patient # 4) of 31 sampled medical records from 11/10/10 to 3/29/11 found the facility inappropriately transferred a patient prior to stabilizing the emergency. The facility had a physician or Advanced Practice Registered Nurse (APRN) on call for nephrology available on the date of transfer. Review of the facility provided list of services includes "Renal Dialysis (Acute Inpatient) provided by arrangement or agreement".

Findings are:

A. Record review of facility policy titled "Emergency Medical Screening (EMTALA)" 500.1.12 dated 8/96 states that "If the Medical Screening Examination reveals that the patient has an emergency medical condition, Regional West Medical Center shall provide either: 1) Within the capabilities of the staff and facilities available at Regional West Medical Center for further examination and treatment as required to stabilize the medical condition; or 2) Appropriate transfer to another medical facility."

B. Review of the facility "Medical Staff Rules and Regulations" dated 3/23/09 revealed under Section 7 titled "Transfer of Patients: (a) Patients shall be admitted for the treatment of any and all conditions and diseases for which the hospital has facilities and personnel."

C. Review of the facility provided information for the list of services provided by the facility on 4/14/11 included "Renal Dialysis (Acute Inpatient) provided by arrangement or agreement". The facility has a contract with a provider for inpatient renal dialysis services.

D. Interview with the facility Director of Risk Management on 4/14/11 at 9:45 AM revealed that the hospital "is firm that we will not be providing dialysis services to [Patient 4] secondary to a restraining order for [Physician "A" and APRN "B"] regarding [Patient 4]." Physician "A" and APRN "B" are the only 2 medical staff who can order renal dialysis services at the hospital. Prior to the "Harassment Protection Order" effective 10/13/10 the hospital was providing inpatient hemodialysis services to Patient 4 on an emergent basis.

E. Review of the Emergency Department (ED) "Weekly On Call List" from 10/14/10- 4/13/11 identified Physician "A" and APRN "B" take call for nephrology services. When APRN "B" is on call Physician "A" is listed as second on call staff.

F. Record review revealed that on 2/22/11 the hospital inappropriately transferred Patient 4 with an unstable emergency medical condition, to another acute care facility [Hospital "B"] located 200 miles away for the provision of hemodialysis services, a service that the hospital had capability to provide. Refer to tag A 2407 for further details.

Based on review of the receiving hospital medical record, medical staff rules and regulations, facility policies related to EMTALA (Emergency Medical Treatment and Labor Act) and staff interviews, the facility inappropriately transferred Patient 4 from the Emergency Department with an Emergency Medical Condition they had the capability to stabilize. The facility had a Physician or Advanced Practice Registered Nurse (APRN) on call for dialysis on the date of transfer. Review of it's list of services revealed the hospital provided "Renal Dialysis (Acute Inpatient) by arrangement or agreement." The total sample of 31 records from 11/10/10 to 3/29/11 were selected for review. Findings are:

A. Review of facility policy titled "Emergency Medical Screening (EMTALA)" 500.1.12 dated 8/96 states that "If the Medical Screening Examination reveals that the patient has an emergency medical condition, Regional West Medical Center shall provide either: 1) Within the capabilities of the staff and facilities available at Regional West Medical Center for further examination and treatment as required to stabilize the medical condition; or 2) Appropriate transfer to another medical facility."

B. Review of the facility "Medical Staff Rules and Regulations" dated 3/23/09 revealed under Section 7 titled "Transfer of Patients: (a) Patients shall be admitted for the treatment of any and all conditions and diseases for which the hospital has facilities and personnel."

C. Review of the hospital's list of services provided on 4/14/11, included "Renal Dialysis (Acute Inpatient) provided by arrangement or agreement." The facility has a contract with a provider for inpatient renal dialysis services.

D. Interview with the facility Director of Risk Management on 4/14/11 at 9:45 AM revealed that the hospital "is firm that we will not be providing dialysis services to [Patient 4] secondary to a restraining order for [Physician "A" and APRN "B"] regarding [Patient 4]." Physician "A" and APRN "B" are the only 2 medical staff who can order renal dialysis services at the hospital. Prior to the "Harassment Protection Order" effective 10/13/10 the hospital was providing inpatient hemodialysis services to Patient 4 on an emergent basis and an outpatient basis.

E. Review of the Emergency Department (ED) "Weekly On Call List" from 10/14/10- 4/13/11 identified Physician "A" and APRN "B" take call for nephrology services. When APRN "B" is on call Physician "A" is listed as second on call staff.

F. Review of Patient 4's medical record revealed the patient came to the ED on 2/22/11 at 6:20 PM. Patient 4 requested dialysis and pain medication for abdominal pain he rated a "9" (severe) on a scale of 1-10. ED Physician "G", Resident Physician "H" and ED Physician "F" examined Patient 4 and ordered an ECG (heart tracing), lab testing, a chest x-ray, and blood glucose monitoring. Documentation revealed Patient 4 had abnormal lab results which included a critically elevated potassium level of 6.4, an elevated blood urea nitrogen of 107, and an elevated creatinine of 11.7 (blood tests that measure kidney function). The chest x-ray showed mild cardiomegaly (abnormal enlargement of the heart). Further documentation revealed Patient 4 was unsure when he was last dialyzed. The ED Physician's exam revealed the patient had distended jugular veins, non labored respirations with wheezing throughout, abdominal tenderness in the epigastric area (upper region of abdomen), and swelling in the lower extremities (symptoms of excess body fluid). Vital signs showed Patient 4 had a severely elevated blood pressure (BP) of 203/123. The ED Physician ordered a dose of Lasix (medication that reduces swelling and fluid retention) and transfer to Hospital "B" for dialysis. The ED weekly on call list identified Physician "A" on call for dialysis. The record fails to indicate Physician "A" was called about this patient. At 7:00 PM Physician "F" took over Patient 4's care and ordered an intravenous catheter (IV) to administer a pain medication directly into the vein at 7:43 PM; Nitroglycerin 0.4 mg at 7:39 PM for complaints of chest pain; Lasix 80 mg IV at 7:25 PM; 10 Units Regular insulin at 7:40 PM IV; D (Dextrose) 50% in 50 ml [sterile] water solution at 7:40 PM and 8:40 PM and D 10% 1000 ml for ongoing IV infusion at 9:32 PM to treat Patient 4's critically low blood sugar levels. Monitoring of Patient # 4's blood sugar showed he had a critically low blood sugar (24) at 8:38 PM, and (29) at 9:22 PM. The patient's blood pressure remained significantly elevated, at 8:25 PM blood pressure was 188/120. Interview with Physician "G" who is the ED Medical Director on 4/14/11 at 8:15 AM revealed Patient 4 does not tolerate insulin treatment for an elevated potassium. Review of the "Consent To Transfer Form" dated 2/22/11 revealed the risks for transfer included "Fall, Deterioration in condition." The documented reason for transfer was "specialized care." The ED physician signed the transfer form and ordered transport to Hospital "B" by an ambulance with advanced cardiac life support capabilities. Patient 4 left the ED at 9:15 PM with an untreated significantly elevated blood pressure 248/141. Review of the ambulance transport report dated 2/22/11 revealed Patient 4's blood glucose levels continued to fluctuate (at 10:50 PM glucose level critically low at 46, at 11:05 PM glucose level normal at 106, at 11:35 PM glucose low at 61, at 00:15 AM blood glucose 90, and at 00:45 AM blood glucose 108). The ambulance arrived at Hospital "B" at 1:15 AM on 2/23/1. Review of Hospital "B's " medical record revealed Patient 4 was transferred for "emergent dialysis", that Patient 4 had end-stage renal disease complicated by severe, life-threatening hyperkalemia (elevated potassium) and volume overload.