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Based on review of medical records, policies and procedures, Emergency Room (ER) on call Schedules, transfer logs, credentialing files, medical staff by-laws, EMTALA training and staff interviews the facility failed to accept from a transferring hospital an appropriate transfer of an individual who required the facility's orthopedic specialized capability and capacity to treat 1 of 20 (#1) sampled patients. Refer to A 2411

Based on review of medical records, policies and procedures, Emergency Room (ER) on -call schedules, transfer logs, credentialing files, medical staff by-laws, EMTALA training and staff interviews the facility failed to accept from a transferring hospital an appropriate transfer of an individual who required the facility's orthopedic specialized capability and capacity to treat 1 of 20 (#1) sampled patients.

The findings included:

Review of the current facility policy titled, "EMTALA--Transfer Policy Addendum" revealed that all requests for transfer into the facility will be directed to the nursing supervisor. All information will be documented in the transfer log. The process is as follows: the call is received from the transferring hospital to the nursing supervisor. The nursing supervisor will determine the specialty and determines if the service is available. The patient is then accepted or denied.

Patient #1's medical record from the transferring hospital was reviewed. Review of the Physician Documentation form dated 9/10/11 at 3 :57 p.m. revealed that patient #1 arrived to the ER at 3:48 p.m., in a private car, indicating in part, "fell 4 d (days) ago, hit Rt (right) face, arm, and Rt leg. Has pain and swell to Rt femur. No LOC (loss of consciousness)...Symptoms came on gradually and became progressively worse...Patient describes quality of symptoms as aching. Patient states symptoms are of mild severity." Documentation by the ER physician's review of the Radiology x- Ray report, indicated that patient #1 was diagnosed with an "Acute non-displaced intertrochanteric right hip fracture." The transferring hospital's ER/Transfer/Communication Log dated 9/10/11 at 5:16 p.m. was reviewed . Review of this log verified that Palms West Hospital was called and had spoken to the nursing supervisor on 9/10/2011. Further review indicated that at 5:38 p.m., Patient #1 was denied transfer to Palms West Hospital because, "No Ortho(Orthopedic) on call." Patient #1 was appropriately transferred to another facility and received the emergent care that was needed.

Review of the transfers log entry for patient #1 from 9/10/11 revealed that a transferring hospital requesting a transfer for orthopedic specialty for this patient with a hip fracture. Patient #1 was refused based on no Orthopedic surgeon on call who could complete the procedure. Review of the hospital's September 2011 ER on- call schedule revealed that on 9/10/11 there was an orthopedic surgeon on call who was credentialed to perform the procedure. The facility failed to ensure that specialized orthopedic services were provided that were within the capability and capacity of hospital for patient #1 on 9/10/2011, as this resulted in delay of treatment.

Interview on 9/15/11 at 9:15 am with the risk manager, quality manager and the nursing supervisor revealed that a Registered Nurse (RN) was training with the current nursing supervisor to be a nursing supervisor. She had worked in the facility for more than 20 years. The supervisor had been a nursing supervisor for 10 years and was a more than 20 year employee. The call came to the nursing office on 9/10/11 at 5:20 p.m. from the hospital requesting transfer of an orthopedic patient with a fractured hip in need of surgery. The supervisor and the trainee looked at the on call calendar for September and found an orthopedic surgeon on call. The physician on call specializes in complex hand surgeries, but is credentialed for core orthopedic procedures. The supervisor and the trainee were aware that the physician did hand surgery and they called the practice to ensure that there was a backup physician for the hip surgery. The answering service had the Advanced Registered Nurse Practitioner (ARNP) for the practice return the call. She informed the trainee that the on call physician only did hand surgeries and that they would have to call someone else. The transfer was refused by the nursing supervisor trainee in a call to the requesting hospital.
When the transfer log was reviewed the following day by the nursing management staff, they discovered that the patient was refused. Risk management and quality management investigated and spoke with the supervisor and the trainee. They reported that they (the supervisor and the trainee) had called the service of the practice to verify that the on call physician would come to the ER. The ARNP for the practice answered the call and stated that the physician was on call but only does hand surgery and occasionally an ankle if it is really simple. When the ARNP was asked who the backup surgeon was for the on call physician, they were told by the ARNP that there was no backup. The supervisors then refused the patient.

Review of the physician's credential file and interview with the medical staff manager on 9/15/11 at 10 am revealed that the orthopedic surgeon was initially credentialed on 10/27/97 for all orthopedic procedures and especially complex hand procedures. She was re-credentialed last on 8/2/10 for orthopedic core procedures and complex hand procedures. The physician conducts procedures on adults and children over the age of 8. The physician's medical license expires on 1/31/12. The physician's ARNP was credentialed by the facility to assist the physicians in the practice and as first assist in the Operating Room (OR). She has a current Florida license which expires on 4/30/13.

Review of the medical staff by laws and interview with the medical staff manager on 9/16/11 at 11 am revealed that the active staff physicians must take call in the ER. Between all of the physicians on the service the month must be covered daily.


Review of the EMTALA education revealed that on 4/24/09 and 9/3/10 the nursing supervisor trainee completed the facility's EMTALA training.

Interview with the nursing supervisor on 9/15/11 at 11:05 am revealed that she was aware that the nursing supervisor trainee had made the call to the orthopedic surgeon on call, and that the ARNP did not have the physician on call return the call.

Interview with the nursing supervisor trainee on 9/15/11 at 11:15 am revealed that when the call came in from the hospital requesting transfer, the required physician on call was identified. A call was placed to the answering service of the physician and they identified the ARNP as being the one to take the calls for the practice. The ARNP returned the call and told the trainee that the physician on call was unable to do hip surgery. The supervisor trainee did not ask for a backup surgeon. The ARNP did not offer a surgeon for backup and she did not have the physician on call return the facility's call.