The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

THOMAS HOSPITAL 750 MORPHY AVENUE FAIRHOPE, AL 36532 April 19, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews and review of Emergency Medical Services (EMS) Report, Trauma Communication Center Report, Medical Staff Bylaws and Rules and Regulations, Patient Identifier # (PI) # 27's registration information from Hospital # 1 and Hospital Number # 1's Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures, Hospital # 1 failed to:

A. Provide an appropriate medical screening examination for PI # 27, a patient involved in a Motor Vehicle Collision, who was transported from the scene of the accident to the Emergency Department (ED) at Hospital # 1 by EMS on 4/14/2013.


B. Provide stabilizing treatment to PI # 27.


C. Arrange, implement and document an appropriate transfer for PI # 27, a patient determined by the Emergency Department (ED) Physician at Hospital # 1 to need the services of a Level One Trauma Center not available at Hospital # 1, to Hospital # 2.


Hospital # 1's deficient practice effected PI # 27, one of 27 sampled patients who presented to Hospital # 1's Emergency Department and has the potential to effect all ED patients who present to Hospital # 1's ED for a Medical Screening Examination to determine if an Emergency Medical Condition exist, require stabilizing treatment, and / or require or request transfer from Hospital # 1 to another hospital.


Findings include:

PI # 27, was brought via ambulance to Hospital # 1's Emergency Department after a Motor Vehicle Collision on 4/14/2013. EMS personnel took the patient to Room 25. The Emergency Department Physician entered PI # 27's room and told EMS personnel the patient needed to be transported to Hospital # 2 because the patient needed Level One Trauma services not available at Hospital # 1. However, the physician failed to provide and document a Medical Screening Examination for the patient. The physician also failed to provide stabilizing treatment for PI # 27. The ED Physician also failed to provide an appropriate transfer of the patient, including failure to obtain permission from Hospital # 2, the receiving hospital, for the acceptance of PI # 27.



These citations are written as the result of the investigation of Complaint Number AL 835.

Please refer to findings at:

A-2406 / 489.24(r) and 489.24(c) - Medical Screening Examination;
A- 2407 / 489.24(d)(1-3) - Stabilizing Treatment and
A - 2409 / 489.24(e)(1-2) - Appropriate Transfer.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and review of Emergency Medical Services (EMS) Report, Report from the Trauma Communication Center (TCC), Medical Staff Bylaws and Rules and Regulations, Patient Identifier # (PI) # 27's registration information from Hospital # 1, and Hospital Number (#) 1's Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures, Hospital # 1 failed to provide an appropriate Medical Screening Examination for PI # 27, a patient involved in a Motor Vehicle Collision with a rollover requiring extraction from the automobile, who was transported via Emergency Medical Service (EMS) to Hospital # 1's Emergency Department (ED) at Hospital # 1 at 01:01 on 4/14/2013.

This deficient practice affected PI # 27, one of 27 sampled patients presenting to Hospital # 1's Emergency Department and had the potential to affect all patients who presented to Hospital # 1's ED requesting a Medical Screening Evaluation.

Findings include:

A review of the EMS report dated 4/14/2013 revealed EMS staff arrived on the scene of a "traffic accident" involving PI # 27, at 00:24 on 4/14/2013.


EMS Narrative:
C (Complaint): Possible Left Elbow Fracture/Shoulder Pain
Protocol: Trauma

The EMS narrative reveals, H (History): "Responding to...location for MVA (Motor Vehicle Accident) with unknown injury. Arrive on scene to find a...female sitting in the front seat of a (name of vehicle) that is on its side in the middle of Highway Number...Pt. (patient, PI # 27) was a restrained driver, no air bags were deployed. PI # 27 is CAO (Clear, Alert and Oriented) x 3. No LOC (loss of consciousness). PI # 27 is entrapped, but not pinned in the vehicle. EMS crew was able to remove the front windshield and PI # 27 stepped out herself. PI # 27 has PMS (Pulse, Motor, Sensory) x 4. No neuro deficits. PI # 27 had C-Spine managed and was placed on a Long Spine Board for Spinal Immobilization. PI # 27 is moved to the stretcher and loaded onto the ambulance. PI # 27 complains of left elbow pain and left shoulder pain. PI # 27's left great toenail is ripped partially off. PI # 27 has a small laceration above the left ear. PI # 27 has numerous small lacerations from glass. PI # 27 requests transport to (Hospital # 1) for evaluation and to prevent further decline in PI # 27's current condition."

EMS Narrative Continued:
"A (Assessment) by NREMT-P (Paramedic) AIRWAY - Patent and self maintained. BREATHING - Equal rise and fall with clear BBS (Bilateral Breath Sounds). RESPIRATIONS - 16/18. SPO2 (Saturation of Peripheral Oxygen) - 99% on room air. PI # 27 denies any difficulty breathing. Circulation - Bleeding is minimal and controlled with dressing and bandage. BP (Blood Pressure) - 115/86, P (Pulse) - 137. Cardiac Monitor shows Sinus Tachycardia. SKIN - Normal. No cyanosis. No diaphoresis.
HEENT (Head, Ears, Eyes, Nose & Throat) - Small laceration above the left ear. PERRL - Pupils Equal, Round, Reactive to Light, Accomodation. NECK - Normal. No JVD (Jugular Venous Distention). Trachea midline. CHEST - Normal. PI # 27 denies chest pain. ABDOMEN - Soft, non-tender. No rigidity. No masses...PI # 27 denies pain on palpation. EXTREMITIES - PMS (Pulse Motor Sensory) x 4. Equal grip strength...No neuro deficits. PI # 27 has a laceration with a deformity to the left elbow...complains of left shoulder pain. PI # 27 has good, intact distal pulses...Denies any neck or back pain, no pain on palpation...PI # 27 requests transport to (Hospital # 1) ER (emergency room ) for evaluation and to prevent further decline in PI # 27's current condition. PI # 27 entered into the TCC (Trauma Communications Center)..."

EMS Narrative Continued:
"Assessment. Cardiac Monitor, Pulse oximetry. Vital monitored in route.
IV - 18 gauge - left AC (Antecubital)...Normal Saline bolus then TKO (To Keep Open). Blood Glucose - 81. C-Spine managed. Spinal immobilization. PI # 27 treated for shock with blankets and fluids. Morphine 4 mg. (milligrams)/Ondansetron 4 mg. slow IVP (IV Push). Interventions: LOC and PMS re-assessed in route. PI # 27 transported in supine position and all safety precautions were taken."


There was no clinical information documented about PI # 27's presentation to Hospital # 1's Emergency Department on 4/14/2013. The only written information about PI # 27's ED visit was found in Hospital # 1's Admission/Registration System. (See next paragraph).

A review of Hospital # 1's Patient Admission Record dated 4/14/2013 (Time not documented) reveals PI # 27, "PI # 27 came in by ambulance. Dr. walked in and told EMS to take PI # 27 to Hospital # 2. PI # 27 was not treated here at Hospital # 1."


Interviews:

During a telephone interview at 7:32 PM on 4/18/2013, the Emergency Department (ED) Charge Nurse, Employee Identifier (EI ) # 3, reports she assigned PI # 27 to room number 25. The nurse said the ED Physician was already in room 25 with the patient and EMS staff when she entered the room. She heard the physician say the patient (PI # 27) was more critical than reported and they needed to go to Hospital # 2. The patient was crying and it "appeared" there were slivers of glass in PI # 27's leg. The Charge Nurse says she immediately notified the House Supervisor about the situation. The Charge Nurse says she was concerned Hospital # 1 did not receive any information from TCC (Trauma Communication Center). Later that evening, the nurse reports she received a call from the Regional Trauma Coordinator advising her about a possible EMTALA violation at Hospital # 1. The nurse says she relayed the information about the potential violation to the ED Physician. The surveyor asked the nurse about the physician's response and the Charge Nurse stated the physician was, "Surprised."

During a telephone interview at 7:55 PM on 4/18/2013, the Emergency Department (ED) Admissions Assistant, Employee Identifier (EI ) # 2, stated she did a quick registration for PI # 27 when the patient arrived at Hospital # 1's ED on 4/14/2013. EI # 2 said she took the paperwork, walked into the room and heard the ED Physician and the paramedic talking. The paramedic explained PI # 27 was involved in a MVC prior to arrival and requested transport to Hospital # 1. The ED Physician said the patient was supposed to have been sent to Hospital # 2 because she had been entered in TCC (Trauma Communication Center). The ED Physician said she needs to go to Hospital # 2. The paramedics loaded the patient on the stretcher. The Admissions Assistant (EI # 2) said she heard the paramedic say the patient requested transport to Hospital # 1.

During an interview on 4/19/13 at 8:25 AM, the Emergency Department's (ED) Medical Director, EI # 4, was asked to report what he knew about the incident on 4/14/13 when PI # 27 was brought to the ED at Hospital # 1 by EMS and the ED Physician (EI # 1) directed the transfer of PI # 27 to Hospital # 2. The Medical Director stated all he knew about the incident was from information obtained from the ED Physician who was working when PI # 27 was brought to the ED. According to the Medical Director, TCC (Trauma Communication Center) told EMS to take PI # 27 to Hospital # 2, but the patient over-ruled and requested to come to Hospital # 1. A 30 minute extraction of the patient from the automobile was required and the patient (PI # 27) was intoxicated and screaming. These factors indicated the need for trauma services. The patient (PI # 27) was placed in the Trauma system.

The ED Medical Director (EI # 4) said the on duty ED Physician (EI # 3) at Hospital # 1 had already done an assessment and the patient (PI # 27) was in the TCC system. The ED Physician was in the room when PI # 27 arrived at Hospital # 1's ED. Because the patient (PI # 27) was stable and already entered in the TCC system, she was sent to Hospital # 2. According to the Medical Director, "Hospital # 1 does not have an in house Radiologist at night. After 11:00 PM, we use Telerad (Teleradiology). Tests get read, but it may take a while to get a report, verbal or written. If it had been me, I would have sent the patient (PI # 27) to Hospital # 2. Retrospectively, clerically, I would have documented something."
According to EI # 4, ED Medical Director, if a patient is in the TCC system, sending physicians do not call receiving physicians. TCC takes care of the telephone calls and locating the most appropriate hospital for the patient.
During an interview at 11:25 AM on 4/19/13, Hospital # 1's Radiology Manager, Employee Identifier # 5, stated the hospital has the capability to do x-rays and CT (Computerized Axial Tomography) scans. After 10:00 PM, teleradiology services are used and the results are sent to the ED via facsimile.

During an interview at 12:35 PM on 4/19/13 with the Emergency Department Physician (EI # 1), physician on duty at Hospital # 1 when PI #27 (MDS) dated [DATE], the surveyor asked the physician to describe the events relating to the patient. The ED Physician stated, "The patient (PI # 27) was involved in a severe motor vehicle crash (MVC) with rollover and extensive extraction from the automobile. The patient, PI # 27, was on a backboard, had a cervical collar and an arm deformity. PI # 27 requested to come to Hospital # 1, but the patient had the potential for multiple serious injuries as a result of the MVC. "I don't know what EMS was thinking about by bringing the patient (PI # 27) here (Hospital # 1), a patient with these type of injuries who was intoxicated and in pain." The ED Physician stated he questions the ability of the patient (PI # 27) to make this type of rational decision." According to the physician, the patient (PI # 27) needed to be at a Level 1 Trauma Center. The patient needed "head to toe" CT scans that would have taken too long at Hospital # 1 because of a longer response time for results related to the use of teleradiology. The ED Physician (EI # 1) said, "When I see people in the ED, I look at them. Does that person have life injury/limb injury? If you are here at night, a patient may have to have multiple CT scans, which are sent to who know where to be read. This takes a long time to send/read/send back. If PI # 27 had a ruptured spleen, aortic aneurysm, this patient needed to be at a Level One Trauma Center. I have to make the decision related to what is the best for the patient."

The surveyor asked the ED Physician (EI # 1) if he medically screened the patient (PI # 27). The ED Physician at Hospital # 1 stated, "This is what is interesting. I can tell you this. I can tell a lot about a patient in about 5 seconds. I saw this lady (PI # 27). I can describe this patient in detail. Do I have a written note? No. She (PI # 27) had a C-collar, back board, and her toenail was ripped off. Arm was bandaged. Bruising on the abdomen. I still remember the patient. She (PI # 27) was screaming all the way down the hall and out the doors. I am guilty of not writing a note or making a call to the hospital to let them know she was coming."

The ED Physician (EI # 1) said, "My understanding is that a phone call was made from TCC (Trauma Communication Center) to a nurse at (Hospital # 1) prior to the patient's arrival. I didn't call the hospital (Hospital # 2) to let them know because she (PI # 27) was in the system (TCC). Usually when we get a trauma that should have gone somewhere else, it's because of the skill of the EMS and we call TCC and send them (patient) somewhere else."

The facility failed to ensure a Medical Screening Exam was provided for PI # 27 on 4/14/13.

Review of EMTALA Policy (Hospital # 1):
Policy Title: Medical Screening Examination
Review Date 4/2013:

Purpose: To establish who provides appropriate medical screening exams on all patients presenting to Thomas Hospital property or the Emergency Department.

Policy: Every patient presenting to Thomas Hospital property or Emergency Department seeking medical treatment, regardless of his/her financial or insurance status, will be given an appropriate medical screening examination within the hospital's capability to determine whether an emergency medical condition exists.

Emergency medical conditions are those manifesting themselves by acute symptoms of sufficient severity including pain, psychiatric disturbances, symptoms of substance abuse, and/or women in labor such that the absence of immediate medical attention could reasonably be expected to result in:
1) Placing the health of the individual in serious jeopardy;
2) Placing the health of a pregnant woman or her unborn child in serious jeopardy;
3) Serious impairment to any bodily functions;
4) Serious dysfunction of any body organ or part.

The use of ancillary services may be required to determine whether or not an emergency medical condition exists.

1. A physician or a mid-level practitioner will conduct a medical screening examination that will include pertinent information and assessment related to the presenting symptoms ...

Hospital # 1's Medical Staff Rules and Regulations, 12/2011:

... D. Emergency Services

1. An appropriate medical records shall be kept for every patient receiving emergency services in the Emergency Department, and be incorporated in the patient's hospitalization record, if such exists. The record shall include:
... b. information concerning the time of the patient's arrival, means of arrival and by whom transported.
c. pertinent history of the injury or illness including details relative to first aid or emergency care given the patient prior to his/her arrival at the Hospital ...
f. treatment given.
g. condition of the patient on discharge or transfer.
h. final disposition, including instruction given to the patient and/or family, relative to necessary follow-up care.

2. Each patient's medical record shall be signed by the practitioner in attendance who is responsible for its clinical accuracy...

A review of Alabama's Trauma and Health System, obtained from the Alabama Department of Public Health's website: www.adph.org.ats reveals, "...This network of care is designed to get seriously injured people to a place with the right resources as quickly as possible..."

Alabama Trauma Communication Center (ATCC):
"Trauma system patient routing will be done by a single high-tech communication center (Alabama Trauma Communication Center - ATCC) that monitors the resources of every trauma center and coordinates patient transport to the appropriate ready trauma center. The ATCC can also facilitate transfer of patients that must be stabilized locally before transfer to definitive care..."

The facility failed to ensure that their policy and procedures were followed as related to conducting a Medical Screening Exam to determine if an emergency medical condition existed for PI # 27 on 4/14/13.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on interviews and review of Emergency Medical Services (EMS) Report, Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures, Medical Staff Rules and Regulations and Patient Identifier # (PI) # 27's registration information from Hospital # 1, Medical Record from Hospital #2, Hospital # 1 failed to provide stabilizing treatment to Patient Identifier (PI) # 27, a patient who presented to Hospital # 1's ED (Emergency Department) status post a Motor Vehicle Collision (MVC) requiring extraction from the automobile, at 01:01 on 4/14/2013. The facility also failed to have a policy and procedure in place at the time of the incident as it relates to stabilizing treatment of an emergency medical condition.

This deficient practice affected PI # 27, one of 27 sampled ED patients, but has the potential to affect all patients who present to Hospital # 1's emergency Department and require stabilizing treatment of an Emergency Medical Condition identified during a Medical Screening Examination.


Findings include:

A review of the EMS Narrative, dated 4/14/2013, (arrival time not documented) reveals, "PI # 27 transported to Hospital # 1...Taken to room # 25. ED Physician (Employee Identifier, EI #1) came into the room and stated that this patient (PI # 27) needs to go to (Name of Hospital # 2). EI # 1 states that PI # 27 would have to be scanned and x-rayed and Hospital # 1 could not do that...."

A review of Hospital # 1's Patient ED Registration/Admission Record dated 4/14/2013 (Time not documented) reveals PI # 27, "PI # 27 came in by ambulance. Dr. walked in and told EMS to take PI # 27 to Hospital # 2.
PI # 27 was not treated here at Hospital # 1."

Review of PI # 27's medical record from Hospital # 2 revealed the following:

Medical Screening/Nursing Assessment revealed the patient arrived in Hospital # 2's Emergency Department on 4/14/13 at 01:45 (1:45 AM) with the Chief Complaint of MVC (Motor vehicle collision) via ambulance with reports of MVC rollover landing on it side.. PI # 27's vital signs were as follows: Blood pressure 128/85, pulse 92, respirations 20. The patient was alert and oriented times 3, but drowsy, responded to verbal stimuli and had slurred speech. PI # 27 had left arm pain rated 10 on 0 to 10 scale (0 = no pain and a 10 = extreme pain) and the patient's abdomen was distended with diffuse tenderness. PI # 27 admits to ETOH (alcohol) consumption.

Review of the Trauma History & Physical from Hospital # 2 revealed the physician documented the patient had splenic infarct (is a condition in which oxygen supply to the spleen is interrupted, leading to partial infarction (tissue death due to oxygen shortage) in the organ(spleen) and possible splenic grade 1 laceration. Assessment/Plan was to admit the patient to STICU (Surgical Trauma Intensive Care Unit- special department of a hospital that provides care for patients with the most severe and life threatening illnesses) for serial labs every 4 hours for 12 hours.


Review of the Discharge Summary from Hospital # 2 revealed PI # 27 was admitted to the intensive care unit for monitoring. PI # 27's Principal Diagnosis was Status post motor vehicle collision with small splenic grade 1 liver laceration (some form of trauma sustained to the liver). PI # 27's hospital course revealed the patient was "... originally at (Hospital # 1) and was transferred to (Hospital # 2) under stable conditions. Upon arrival, the patient was GCS (Glasgow Coma Scale is an objective way of recording the conscious state of a person, 14-15 fully awake person.) of 14 and hemodynamically stable..." PI # 27 was discharged from Hospital # 2 on 4/15/13 in good condition.


During the entrance conference on 4/17/13, a list of items needed for the survey, was given to hospital staff by the surveyor. Included on the list was All EMTALA Policies and Procedures. The surveyors reviewed the policies and procedures, but no policy was found that addressed stabilization and treatment of a patient after provision of a Medical Screening Examination. However, following a second request for all EMTALA policies and procedures, information regarding stabilizing treatment was found in a copy of EMTALA education provided to ED physicians and ED staff after 4/14/13.

During a telephone interview at 7:32 PM on 4/18/2013, the Emergency Department (ED) Charge Nurse, Employee Identifier (EI ) # 3, reports she assigned PI # 27 to room number 25. The nurse said the ED Physician was already in room 25 when she entered. The Charge Nurse stated she heard the ED Physician say the patient (PI # 27) was more critical than reported and needed to go to Hospital # 2.

During an interview at 11:25 AM on 4/19/13, Hospital # 1's Radiology Manager, Employee Identifier # 5, stated the hospital has the capability to do x-rays and CT (Computerized Axial Tomography) scans. After 10:00 PM, teleradiology services are used and the results are sent to the ED via facsimile.

During an interview with the Emergency Department Physician (EI # 1) at Hospital # 1 on 4/19/13 at 12:35 PM, the physician verified PI # 27 was brought to Hospital # 1's Emergency Department (ED) on 4/14/13 by Emergency Medical Services (EMS). The ED Physician stated the patient (PI # 27) was involved in a severe motor vehicle crash (MVC) with rollover requiring extensive extraction from the automobile..."the patient (PI # 27) needed to be at a Level 1 Trauma Center...CT scans that would have taken too long at Hospital...If PI # 27 had a ruptured spleen, aortic aneurysm, this patient needed to be at a Level One Trauma Center... I am guilty of not writing a note... " The facility failed to provide stabilizing treatment to PI # 27 on 4/14/13. The facility also failed to have in place a policy and procedure as it relates to providing further medical examination and treatment to stabilize the medical condition.

Hospital # 1's Medical Staff Rules and Regulations, December 2011:
... D. Emergency Services
1. An appropriate medical records shall be kept for every patient receiving emergency services in the Emergency Department, and be incorporated in the patient's hospitalization record, if such exists. The record shall include:
... b. information concerning the time of the patient's arrival, means of arrival and by whom transported.
c. pertinent history of the injury or illness including details relative to first aid or emergency care given the patient prior to his/her arrival at the Hospital ...
f. treatment given.
g. condition of the patient on discharge or transfer.
h. final disposition, including instruction given to the patient and/or family, relative to necessary follow-up care...
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on interviews, review of hospital Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures, Emergency Medical Services (EMS) Report and the Report from the Trauma Communication Center, Hospital # 1 failed to follow their EMTALA policy and procedures as it relates to an appropriate transfer of PI # 27, a patient involved in a MVC (Motor Vehicle Collision), determined by the Emergency Department (ED) Physician at Hospital # 1 on 4/14/13 to need the services of a Level One Trauma Center not available at Hospital # 1, to Hospital # 2.

This deficient practice effected Patient Identifier (PI) # 27, one of 27 sampled patients who presented to Hospital # 1's Emergency Department, but has the potential to effect all ED patients requiring or requesting transfer from Hospital # 1 to another hospital.


Findings include:

A review of the EMS report dated 4/14/2013 revealed EMS staff arrived on the scene of a "traffic accident" involving PI # 27, at 00:24 on 4/14/2013.

EMS Narrative:
C (Complaint): Possible Left Elbow Fracture/Shoulder Pain
Protocol: Trauma


EMS Narrative Continued:
"PI # 27 transported to Hospital # 1 without incident...Taken to room # 25. ED Physician (Employee Identifier, EI #1) came into the room and stated that this patient (PI # 27) needs to go to (Name of Hospital # 2). EI # 1 states that PI # 27 would have to be scanned and x-rayed and Hospital # 1 could not do that. Paramedic states that PI # 27 requested transport to Hospital # 1 and then asked the Dr., 'So you are saying we should take PI # 27 to (Name of Hospital # 2)?' Dr. (Name of ED Physician / EI # 1 at Hospital # 1) said, 'Yes.' Paramedic contacted the (Name of EMS Company) Supervisor and explained the situation. Pt.(PI # 27) was taken back to the ambulance and transported to (Hospital # 2), extending transport time by 43 minutes...Report and paperwork given to Registered Nurse (RN's name) on duty..." The facility failed to request a transfer to Hospital # 2 from Hospital # 1. There was no documentation of a transfer form with informed consent for transfer.

A review of the ATCC (Alabama Trauma Communication Center) report, dated 4/14/2013 reveals, "Possible issues: Patient transport designation issues. (Name of Ambulance Company & Ambulance Number) transported a ...yo (year old) female MVC (Motor Vehicle Collision) to Hospital # 1 per patient request...patient with deformity to left elbow and shoulder pain. (Ambulance Number) arrived Hospital # 1 at 01:01 and took patient to rm. (room) 25. The ED Physician (EI # 1) told (name of ambulance crew) the patient needed to be transported to Hospital # 2 where upon the ...crew has to reload the patient and leave Hospital # 1 for Hospital # 2. The ED Physician (EI # 1) did not contact TCC for a trauma transfer, Hospital # 2 reported ED Physician (EI # 1 at Hospital # 1) did not contact them (Hospital # 2) for a transfer."


During an interview with the Emergency Department Physician (EI # 1) at Hospital # 1 on 4/19/13 at 12:35 PM, the physician confirmed Patient Identifier (PI) # 27, was brought to Hospital # 1's Emergency Department (ED) at Hospital # 1 on 4/14/13 at 01:01 AM by EMS. The ED Physician stated the patient (PI # 27) was involved in a severe motor vehicle crash (MVC) with rollover and extensive extraction from the automobile.

The surveyor asked the ED Physician (EI # 1) if he medically screened the patient (PI # 27). The ED Physician at Hospital # 1 stated, "...I can tell a lot about a patient in about 5 seconds. I saw this lady (PI # 27). I can describe this patient in detail. Do I have a written note? No...The patient needed to be at a level Trauma 1 Center. I am guilty of not writing a note or making a call to the hospital to let them know she was coming."

A review of PI # 27's ED medical record from Hospital # 2 reveals the patient arrived at Hospital # 2 via EMS at 01:45 on 4/14/2013.


EMTALA Policy and Procedure Review (Hospital # 1):

Transfer of Patients: COBRA/EMTALA
Effective Date: 5/9/2005

Policy: A patient may be transferred to another acute/specialty facility if:

1. If that facility has the capability and capacity to care for a patient in a manner which Thomas Hospital is unable to provide.

2. And/or if a receiving physician at another facility has privileges to care for a patient in a manner which is not available at (Hospital # 1) and will accept care of the patient.

3. The physician will determine that the patient is medically stable stable for transferred or that the benefits of transfer outweigh the risks.

4. All patients being transferred...will have the appropriate arrangements made and forms completed to provide informed continuous patient care.

5. All patients transferred will be transferred by appropriate medical vehicle with physician orders for appropriated attendant personnel...

6. Copies of appropriate medical records, tests...must be sent with the patient...


Procedure: The following procedures will be followed upon the decision to transfer a patient to another healthcare facility.

1. The attending, consulting, or emergency department physician will have the responsibility to initiate physician-to-physician contact at the receiving facility and obtain consent to accept the patient ...
3. The physician will sign the Physicians Summary of Risks and Benefits for Transfer to Acute Care/Specialty Facility prior to the patient transfer...

A. The form must be filled out completely with specific risks and benefits that have been discussed with the patient and/or family. These cannot be generalized terms i.e. " specialized care "

B. The physician must check whether the patient has requested the transfer, or that the medical benefits of the patient ' s transfer outweigh the risks involved.

C. The physician must sign the form and specify transport vehicle, personnel and/or medical orders ...

Documentation: The patient's medical record will record that the patient was transferred and the facility to which the patient was transferred... "



A review of the ATCC (Alabama Trauma Communication Center) report, dated 4/14/2013 reveals, "Possible issues: Patient transport designation issues. (Name of Ambulance Company & Ambulance Number) transported a ...yo (year old) female MVC (Motor Vehicle Collision) to Hospital # 1 per patient request...Patient with deformity to left elbow and shoulder pain. (Ambulance Number) arrived Hospital # 1 at 01:01 and took patient to rm. (room) 25. The ED Physician (EI # 1) told (name of ambulance crew) the patient needed to be transported to Hospital # 2 where upon the ...crew has to reload the patient and leave Hospital # 1 for Hospital # 2. The ED Physician (EI # 1) did not contact TCC for a trauma transfer, Hospital # 2 reported ED Physician (EI # 1 at Hospital # 1) did not contact them (Hospital # 2) for a transfer."


Hospital # 1 failed to follow their EMTALA policy and procedures as it relates to the appropriate transfer of PI # 27 on 4/14/13 to Hospital # 2, in that Hospital # 1 failed to:

1. Provide an appropriate medical screening exam and stabilizing treatment, which the facility had the capacity and capability to perform.

2. Arrange for a receiving physician at Hospital # 2 to accept care of PI # 27.

3. Provide and complete informed consent for transfer forms for PI # 27.

4. Supply Hospital # 2 a copy of the medical record information for PI # 27.


PI # 27 was inappropriately transferred from Hospital # 1 to Hospital # 2 on 4/14/13 due to Hospital # 1's failure to provide an appropriate medical screening exam and stabilizing treatment, which the facility had the capacity and capability to perform.