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BAYFRONT HEALTH PORT CHARLOTTE 2500 HARBOR BLVD PORT CHARLOTTE, FL 33952 Oct. 9, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on reviews of medical records, state license, Transfer Center transcripts, Emergency Department logs, transfer logs, Emergency Service Back-up Physician Schedule (the on-call list), the facility ' s investigation report, General Rules & Regulations for Medical Staff, and interviews; the facility failed to accept a referral of an appropriate transfer from a hospital without obstetric (OB) services for 1 (Patient #10) of 10 identified transfers, out of a total of 29 medical records reviewed. The facility had the capacity and specialized capability to care for an OB patient. The failure to accept a transfer for specialized services may delay treatment to stabilize an emergency medical condition (EMC). Refer to findings at A-2411.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on reviews of medical records, state license, Transfer Center transcripts, Emergency Department logs, transfer logs, Emergency Service Back-up Physician Schedule (the on-call list), the facility ' s investigation report, General Rules & Regulations for Medical Staff, and interviews; the facility failed to accept a referral of an appropriate transfer from a hospital without obstetric (OB) services for 1 (Patient #10) of 10 identified transfers, out of a total of 29 medical records reviewed. The facility had the capacity and specialized capability to care for an OB patient. The failure to accept a transfer for specialized services may delay treatment to stabilize an emergency medical condition (EMC).

The findings include:

On 10/7/13, review of the Peace River Regional Medical Center's (PRRMC) license revealed a listing of specialized emergency services. The list included obstetrics (OB - services for pregnancy, post-natal/post-partum care and delivery). Review of Transferring Hospital #1's license revealed a listing of specialized emergency services. The list included gynecology (GYN - services for women and their reproductive system) but not OB.

Transcript of calls made by the HCA (Hospital Corporation of America) Transfer Center (TC) on behalf of Patient #10 was reviewed. The patient (pt.) had presented at Transferring Hospital #1 ' s Emergency Department (ED) on 8/23/13. The transcript documented:
"Call # Duration Summary"
5 - 3151 - 1353 Call initiated by (Transferring Hospital #1) requesting transport to Peace River for OB (name, RN) possible ruptured ectopic ([DIAGNOSES REDACTED] is a potential medical emergency in which the embryo implants outside the uterus).
0 - 1353 - 1356 TC agent calls Peace River to request ER (emergency room ) Doctor for transfer from (Transferring Hospital #1).
4 - 1356 - 1400 Unknown female comes onto the line requesting more info on pt., inquires if sending has no accepting physician, TC agent indicates that they are trying to facilitate an ED-to-ED transfer because (Transferring Hospital #1) does not have OB, female states that Peace River does not do ER-to-ER transfers. (Call disconnected).
6 - 1400 - 1403 TC reinitiates call to Peace River and speaks with (name) who transfers TC agent to ER. Unknown female in ER tells TC agent that she spoke to a representative at (Transferring Hospital #1) and gave them the information for the OB/GYN they needed to contact, TC agent asked who she spoke to at (Transferring Hospital #1) and Peace River indicated "a female, I'm not sure" Peace River advised TC agent "We do not take ER-to-ER transfers, it is an EMTALA (Emergency Medical Treatment and Labor Act) violation."
7 - 1403 - 1403 TC agent calls (name, RN) at (Transferring Hospital #1) who advised him that Peace River called them and provided OB/GYN contact information.
1 - 1418 - 1421 (Name, RN) calls TC requesting that pt. be transferred to (Accepting Hospital #3) to support ED-to-ED request.
2 - 1421 - 1422 HCA TC calls (Accepting Hospital #3) Transfer Center speaks with (name, Patient Intake Coordinator) in Pt. Placement regarding transfer of pt.
1 - 1422 - 1433 (Name), PA (Physician ' s Assistant) in conference with Dr. (name) for report on pt. PA confirms no OB or GYN at facility and connects Dr. (name) to Dr. (name). HCA TC confirms acceptance by Dr. (name) and request that RNs remain online for report. (Name, RN) instructs TC agent to call (advanced life support emergency medical services) for transport.
7 - 1434 - 1438 TC calls (name, Patient Intake Coordinator) in pt. placement transport to ED speaks w/(name, Multi-Skilled Tech) requesting ED CN (charge nurse) (name, CN) obtained direct # for report. (Name, CN) will advise NS (nursing supervisor) on transfer, gives # to NS for
4 - 1438 - 1441 TC speaks with (name) NS, to advise that patient was accepted into facility by Dr. (name). (Name, NS) advises that TC should call (Accepting Hospital #3)'s TC, requested # for (Transferring Hospital #1) for further info. on patient. Instructs agent to go ahead and set up transportation.
1 - 1441 - 1443 TC calls (name, Dispatcher) @ (advanced life support emergency medical services) to schedule transport (requested ALS (advanced life support)).
8 - 1443 - 1444 TC calls (Transferring Hospital #1) ER and speaks w/(name, RN) confirming accepting MD.
3 - 1453 - 1454 TC makes outbound call.
2 - 1510 - 1512 (Name, NS) from (Accepting Hospital #3) calls TC to advise that the patient was accepted in ER and was en-route.
1 - 1523 - 1526 Risk Mgr. at (Transferring Hospital #1) calls TC to inquire who was contacted on pt. and what transpired after contact. Risk Manager states that Dr. (Staff E) refused to take patient.

The medical record from the Transferring Hospital #1 was reviewed. The medical record review revealed Patient #10, a [AGE] year old (MDS) dated [DATE]. Review of the section titled HPI (history of present illness) indicated in part, " Complaint " : abdominal pain, pt. is 6 weeks pregnant, was seen at the Health depart. (department) to confirm; c/o (complain/of) abd (abdominal) pain x 1 week, denies vaginal bleeding or discharge. " ... Review of Systems ...Gastrointestinal: abdominal pain ...Phys(physical) Exam (examination) ... Abdomen: soft, tenderness ... Ultrasound-Pelvic Ultrasound, transvaginal 08/23 1259 ... Report Impression ... Patient has ectopic gestation in the left adnexa with fetal pole and heartbeat. A Second gestation sac is seen within the uterus also with a fetal pole and heartbeat ... Disposition-Abdominal Pain- ... Primary Impression: [DIAGNOSES REDACTED] -Additional Impressions: Intrauterine Pregnancy Pelvic pain ... Disposition: discharged to ... (Accepting Hospital #3). "

The medical record from Hospital #3 was also reviewed. Review of the record revealed in part, " DOS (date of service): 8/23/2013 15:55 ... Historian: Patient. Further history obtained from EMS personnel and prehospital care records. Chief complaint: Abdominal Pain. History of Present illness: (17 y/o g (girl) ... at 6 wks (weeks) by lmp (last menstrual period) 7/14/2013 transferred from hospital #1 for r.o. (rule out) ectopic pt. has 2 d. (day) h/o (history /of) llg (left lower quadrant-abdomen) pain. Us (ultra sound) at (Transferring Hospital #1) demonst (demonstrates) iup (intrauterine pregnancy) with fhr (feta heart rate) at 109 and 2 complex mass/ectopic of left adnexa ... no gyn (gynecologist) care as yet ... Interventions: IV fluids ... Consult: OB physician at bedside at time of arrival to (Accepting Hospital #3) ... relevant patient information and plan of care reviewed ... Clinical impression/Problem List threatened ab (abortion) vs heteroectopic -( abnormal tissue occurring in an abnormal anatomic location ). "

On 10/7/13, review of the facility ' s ED log and transfer logs failed to find the request for transfer for Patient #10 for OB services.

On 10/7/13, review of the facility's Emergency Service Back-up Physician Schedule (the on-call list) for August 2013 revealed on Friday 8/23/13, Dr. (Staff A) was on call for OB. Dr. (Staff D) was listed as on call for medicine for that date.

In an interview on 10/9/13 at 2:10 p.m., the Assistant Chief Nursing Officer explained the on-call list for ED is same as on-call for list for the hospital.

In an interview 10/9/13 at 2:48 p.m., Administrative Representative (a supervisor) Staff B said, "I didn't realize it was an ER-to-ER admit. Someone said it was a direct admit. Dr. (Staff A) would have been the doctor that would be asked to accept a direct admit. They (Transferring Hospital #1 ' s TC) called the ER and they (the ER) gave Dr. (Staff C's) number."

Review of the facility's General Rules & Regulations for Medical Staff revealed on page G-6: "In the event that a particular specialty is not available (i.e., cardiology, pulmonary, hand, dermatology, dental), or the on-call physician cannot respond because of circumstances beyond the physician's control, the patient's primary care physician will be contacted to render a decision or to consult with another physician on staff. In the event the patient does not have a primary care physician, the physician on medicine call will be contacted."

Review of the facility's investigation of the incident found no evidence the correct on-call OB physician (Staff A), the patient's primary care physician, or the on-call medicine physician (Staff D) was called.

Review of the facility's investigation of the events related to the request for transfer of Patient #10 revealed interviews with two (2) ED physicians on 9/12/13. "Both physicians stated that: (a) they would not accept that ED patient transfer request because EMTALA prohibits them as they are considered 'lateral transfer', and (b) the only way to accept such Emergency Department patient transfer request would be to already have a PRRMC admitting physician..."

In an interview during the emergency access investigation of 9/24/13 at 11:00 a.m., the Chief Medical Officer (CMO) said he "met with the ED physicians to correct their interpretation of the regulations for EMTALA. The physician's group was under the interpretation of the regulations that no ED-to-ED transfers are acceptable under EMTALA regulations."

In an interview on 10/9/13 at 3:32 p.m., the Chief Nursing Officer (CNO) explained the actions taken since refusing the transfer of Patient #10. She said, "We've educated the CEO (Chief Executive Officer), the CMO, Medical Director of the ED about EMTALA and ED-to-ED transfers. It is understood they absolutely accept ED-to-ED transfers. The Medical Director met with his staff and informed them they accept ED-to-ED transfers. And (name), the ED Nursing Director has educated her staff. We have a log: it has date; facility and caller; accepting MD; patient name; date of birth; diagnosis; accept/not reason and house supervisor (AR- Administrative Representative) notified."

Peace River Regional Medical Center failed to accept an appropriate transfer of patient #10 on August 23, 2013, who required such specialized capabilities (obstetrics). Peace River Regional Medical Center had the capability and capacity on 8/23/2013 to treat patient #10.