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BANNER-UNIVERSITY MEDICAL CENTER SOUTH CAMPUS 2800 EAST AJO WAY TUCSON, AZ 85713 Jan. 6, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of clinical records, review of policies and procedures/documentation and staff interviews, it was determined the hospital failed to enforce compliance with all requirements of 489.24 including the responsibilities of a recipient hospital. The Hospital refused to accept a request for an appropriate transfer of Patient #1 with emergent medical and psychiatric conditions when they had the capacity and capability to do so as evidenced by:

A2411 489.24(f): Recipient Hospital Responsibilities

The cumulative effect of this system process resulted in non compliance with the Special responsibilities of Medicare hospitals in emergency cases.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records, review of policies and procedures/documentation and staff interviews, it was determined the hospital failed to accept a request for an appropriate transfer of Patient #1 with emergent medical and psychiatric conditions when they had the capacity and capability to do so.

Findings include:

University Physicians Healthcare (UPH) Hospital at Kino (Hospital #1), is a short term acute care hospital with an in-patient bed capacity of 197 as follows: 13 ICU/CCU beds; 103 Medical/Surgical beds; and 81 Psychiatric beds.

The Hospital's policy and procedure # ADM-130 on the subject of "Compliance with the Emergency Medical Treatment and Labor ACT (EMTALA) included: "6.0 Acceptance of Patient Transfers...6.1 General-UPH HOSPITAL will accept an appropriate transfer of a patient from another hospital's emergency department (EMTALA) (doesn't apply to inpatients) with an unstabilized emergency medical condition who requires specialized capabilities or facilities if UPH HOSPITAL has the capacity, and the transfer is in the best interest of the patient. The treating physician's decision at the other (sending) hospital is determinative as to whether his or her patient has an emergency medical condition requiring a higher level of care than the sending hospital can provide." This policy and procedure also included the following: "16.0 Training - All UPH HOSPITAL staff, members of the UPH HOSPITAL Medical Staff and residents & interns, as appropriate, will receive EMTALA training. The content of the training will be consistent with their level of responsibility for EMTALA compliance."

A review of Patient #1's clinical record from Hospital #2 revealed he was taken by Emergency Services Personnel (EMS) to Hospital #2's Emergency Department (ED) on 9/26/2010 at 10 a.m. Upon arrival to the ED, the patient was immediately triaged by a Registered Nurse and received a medical screening examination by the ED physician, Physician #2. After tests and studies were completed, Physician #1 diagnosed the patient with the following: (1) Diarrhea[DIAGNOSES REDACTED]icile; (2) Hypotension; (3) Renal insufficiency; (4) Alcoholism/Intoxication; (5) Elevated Ammonia Level; (6) Depression (with) SI (suicidal ideation). Physician #1's documentation included "Pt. angry, anxious, depressed, actively suicidal (with) plan to OD (overdose) on pills. Likely (with) untreated [DIAGNOSES REDACTED]icile diarrhea...confounded by alcoholism/MH (mental health) issues." The ED physician documented in the Emergency Physician Record Progress Notes on 9/26/2010 at 1:45 p.m.: "I do not have on call GI, renal, psychiatric services @ (initials of Hospital #2)...He requests transfer to (initials of Hospital #3) as they have his records...No beds @ (initials of Hospital #3). Dr. (Physician #1) at (name of Hospital #1) refuses to accept as he believes we have the capability to care for pt @ (initials of Hospital #2) even though I have discussed this situation (with) him repeatedly in detail...."

Hospital #2 then contacted Hospital #4 who had the specialized capabilities of both medical/ surgical and psychiatry, and Hospital #4 agreed to receive Patient #1 in transfer. The initial nursing note at Hospital #4 was dated 9/27/10 at 1:30 a.m., and included: "Pt rec'd (received) from (Hospital #2) at 2203 (10:03 p.m.). This writer assessed his reports of SI/HI. Pt states 'I'd rather die than have this diarrhea' & 'I'm going to kill these doctors if they can't find out what's wrong with me.' Pt contracts for safety...."

Further documentation in the patient's clinical records at Hospital #4 included the physician's dictated History and Physical dated 9/26/2010 at 11:27 p.m., as follows: "CURRENT MEDICINES: Include: 1. Haldol (antipsychotic)...2. Celexa (antidepressant)...3. Remeron (antidepressant)...4. Abilify (antipsychotic)...GENERAL PHYSICAL EXAMINATION:...He is voicing active suicidal ideation...ASSESSMENT: 1. Sever chronic diarrhea for the last one month. 2. Acute renal failure, suspect prerenal failure secondary to underlying diarrhea. 3. Major depression with active suicidal and homicidal ideation. 4. Hyponatremia. 5. [DIAGNOSES REDACTED]. 6. Alcohol abuse disorder. 7. Suspected [DIAGNOSES REDACTED]. 8. Diabetes mellitus Type II. 9. COPD. 10. Chronic pain." The patient was admitted to Hospital #4 with a 1:1 sitter related to his active SI/HI.

A psychiatric evaluation/consultation was performed at Hospital #4 on 9/27/2010, and the psychiatrist's documentation included: "...The patient appears to be a reliable historian. The patient reports that he is tired, that he has been in and out of the hospital. This is his fourth admission secondary to having significant issues with diarrhea and having a long history of depression that he has been struggling with increase in suicidal thoughts because he is 'tired of feel sick'...The patient reports that he is tired of having this chronic diarrhea and not getting better. According to the patient, he is court ordered and he takes his medications, but he is not sure if the medication has been helpful. He currently acknowledged feeling suicidal, 'I wish I was dead'. He has no plan and no intent and contracted for safety. He is not homicidal, but according to the chart, he has been homicidal before in the past...PAST PSYCHIATRIC HISTORY: Patient has multiple psych hospitalization s. He has multiple suicide attempts...He is court-ordered, and he has had homicidal ideation towards police, and this is usually when he intoxicated (sic)...MENTAL STATUS EXAMINATION: The patient was actually seen at his bedside. He has a sitter...He is alert, he is oriented x 3...He is currently suicidal, 'I just can't live like this anymore. I can't take the pain.' He is not homicidal. He contracted for safety, although he did acknowledge that he has felt homicidal in the past. He remains hopeless, but is agreeable to treatment...." Documentation in the patient's clinical record at Hospital #4 revealed he was discharged on [DATE], after his medical and psychiatric conditions were stabilized.

A telephone interview was conducted on 01/05/2011 at 1:30 p.m. with Physician #1 at UPH Hospital, who received the call from Physician #2 at Hospital #2 requesting transfer on 9/26/2010. Physician #1 was able to recall the conversation and reported he was told by Physician #2 that the patient had "a known case of[DIAGNOSES REDACTED]" with diarrhea, the patient was hypotensive and had psychiatric issues, and Physician #2 requested transfer of the patient to UPH Hospital for both GI (gastrointestinal) and psychiatric consults. Physician #1 reported Hospital #2 did not have those specialties on call on that day, a Sunday, but that Hospital #2 did have those specialities available Monday through Friday. Physician #1 reported telling Physician #2 that they (Hospital #2) could admit and treat the patient there. Physician #1 stated "the patient did not need a GI consult right away," and "he was not medically stable for a psych eval." Physician #1 was asked by the surveyor during the telephone interview if Physician #2 agreed with that plan, and Physician #1 responded that he would call another hospital.

A telephone interview was conducted on 01/05/2011 at 2:30 p.m. with Physician #2. Also present with Physician #2 were Hospital #2's Medical Director, Nurse Director of the ED, and the Hospital's Chief Nursing Officer. During the interview, Physician #2 was asked how long he had been an ED physician, and he responded, "between 17 and 18 years." Physician #2 recalled the conversation with Physician #1 on 9/26/2010. Physician #2 stated that after evaluating Patient #1, "It was clear he had medical and psych needs." Physician #2 reported Hospital #2 specializes in the care and treatment of heart and vascular disorders and do not have the capacity and capability to admit and treat patients with acute gastrointestinal and psychiatric needs. Hospital #2 initiated the process for an appropriate transfer of Patient #1 to a hospital for a higher level of care, specifically, gastrointestinal and psychiatric. Hospital #3 was contacted and responded that they did not have bed availability, however, Hospital #3 reported they contacted Hospital #1 who reported they did have a bed available. Hospital #2 was transferred telephonically to Hospital #1 and told to page Physician #1 which was done. Physician #1 responded to the page at which time Physician #2 discussed Patient #1's situation with him. Physician #2's response was, "You can take care of that there." Physician #2 stated he repeatedly explained the medical and psychiatric needs of the patient and why Hospital #2 did not have the capability of admitting and caring for his needs. Physician #2 reported he even asked Physician #1 if he would check with his supervisor at UPH Hospital and call him back. Physician #2 stated Physician #1 called back a short time later and again refused to accept the patient. At that time the surveyor requested clarification of Hospital #2's scope of services. The Chief Nursing Officer stated Hospital #2 is licensed as a "general" hospital but specializes in the care and treatment of heart and vascular disorders. The Chief Nursing Officer reported the hospital does have "consultative" specialty services available such as psychiatry and gastrointestinal to patients admitted with primary diagnoses of [DIAGNOSES REDACTED]

A review of Department's licensing file revealed Hospital #2 is a short term acute care hospital licensed for a total of 60 beds as follows: 14 ICU beds; and 46 Medical/Surgical beds. Hospital #2 specializes in the care and treatment of patients with heart and/or vascular conditions. A review of Hospital #2's ED specialty on-call schedules for 9/26/2010, confirmed the only physicians on call were for the specialties of cardiothoracic surgery, cardiology, and vascular surgery.

A review of UPH Hospital's House Supervisor call log revealed an entry dated 9-26-10 at "1300" (1 p.m.). The entry included: "...y.o. male, C.diff, Dehydration, from (name of Hospital #2). Med (name of Physician #1) refuse to accept the pt." A review of UPH Hospital's Census Detail by Nursing Station for 9/26/2010 revealed a total in-patient census of 97 with both medical/surgical and psychiatric beds available.

A review of Physician #1's credential file revealed an original appointment date of 08/27/2008 and a reappointment date of 02/01/2010 as Active Staff in the Department of Medicine, Internal Medicine. There was no specific documentation in the file that Physician #1 had training in the hospital's policies and procedures for EMTALA. The Director of Medical Staff Services stated during an interview on 01/06/2011, that EMTALA training is made available to all physicians, however, it is not mandatory.

The Director of Emergency Services stated during an interview on 01/05/2011, that she received a telephone call from Hospital #2 after 9/26/2010, requesting review and discussion of why UPH Hospital would not accept Patient #1. The Director of Emergency Services stated she followed up with Physician #1 and because Physician #2 requested a "direct admit" of Patient #1, EMTALA regulations did not apply and UPH Hospital had no obligation to accept the patient. The Director of Emergency Services reported no further action was taken because there was no EMTALA violation.

The Interim Chief Executive Officer (CEO) at UPH Hospital stated on 01/05/2011, that she had been made aware of the incident involving Patient #1 on 9/26/2010 and had, in fact, discussed it with the CEO at Hospital #2. The Interim CEO repeatedly told the surveyor that it was clear there was no EMTALA violation because the patient did not go through their ED and because it was a "lateral transfer" and that UPH Hospital "has the right to refuse any time we want." The CEO further stated Hospital #2 had the capacity and capability of admitting and treating Patient #1.

Physician #1 at UPH Hospital (recipient hospital) refused to accept the patient in transfer even though the hospital had the capacity and capability of providing the specialized needs of the patient.