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COLISEUM MEDICAL CENTERS 350 HOSPITAL DRIVE MACON, GA 31217 Sept. 26, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on reviews of medical records, " One Step " transfer center logs, Urology on-call schedules, Transfer Center Recording, bed census report, policies and procedures, interviews the facility failed to accept an appropriate transfer of an individual who required the specialized urological capabilities or facilities and the hospital had the capacity to treat one (#8) of 23 sampled patients. Refer to findings in Tag 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, " One Step " transfer center logs, Urology on-call schedules, Transfer Center Recording, bed census report, policies and procedures, interviews the facility failed to accept an appropriate transfer of an individual who required the specialized urological capabilities or facilities and the hospital had the capacity to treat one (#8) of 23 sampled patients.
Findings Include:
Review of facility policy entitled "Transfer Policy", approved by the Board of Trustees on March 31, 2014, revealed the purpose of the policy was "To define an efficient, EMTALA compliant, patient centric process for governing transfers. EMTALA shall govern all transfers of emergency department patients either to a Coliseum Hospital System (CHS) facility or from one. The section of the policy titled, " Transfers from an outside ED to a CHS Facility-1. Transfers into Coliseum Health System facility from an outside Emergency department shall be based solely on our capacity and capability. If it is clear that we lack capacity and capability, the emergency physician may decline the transfer. The administrator on call will be contacted by the One Step Transfer Center to review the appropriateness of the denial. 2. The Emergency physician is empowered to accept on behalf of the facility, but only after consultation with an appropriate specialist. These specialists do not have the authority to accept or decline a transfer from and outside Emergency Department ...4. During the consultation with the specialist, the Emergency physician will offer the specialist an opportunity to have a conference call with referring physician. The specialist will also be offered the option of having the patient directly admitted or received first into the emergency department. "
Patient #8 ' s medical record dated 9/12/2014 was reviewed. Review of the progress notes revealed that patient #8 arrived to the Veterans Administration (VA) hospital on [DATE] at 11:18 p.m. The patient was triaged as semi-urgent. Further review indicated part, " The chief complaint /Reason for visit bleeding from penis ... 94 y/o (year/old) presented alerted via w/c (wheelchair) with daughter at side. Pt ' s (patient ' s) daughter stated ...Today pt. has small soaked 2 briefs and under pads with bright red blood and urine. Further review revealed patient #8 had a " history of [DIAGNOSES REDACTED] found to be having hematuria ...but got worse last night ... Impression: Gross Hematuria ...Plan: Urology consult, Coliseum Dr. refused patient #8, revealing that they don ' t get paid by VA Medical Center and refused the patient instructing the ED to try VA first.
Review of the log of requests to transfer patients from other facilities to Coliseum Medical Center (CMC) from 04/01/14 through 09/24/14 revealed, on 09/12/14, the "One Step" transfer center log that CMC received a called regarding the possible transfer of a [AGE] year old man in need of Urology services, and CMC refused the transfer.

Review of the "One Step" transfer center recording for 09/12/14 regarding patient #8 revealed the following:
Track 1 -- The "One Step" transfer center representative called CMC's emergency room and spoke with the emergency room Charge Nurse #7. The transfer center representative informed the nurse that a veteran's hospital physician wanted to talk with an emergency room physician about a possible transfer. CMC's emergency room physician #6 came on the line and was informed by the transfer center representative that the veteran's hospital physician wanted to discuss a possible transfer.
Track 2 -- The veteran's hospital physician reported he had a possible transfer. A [AGE] year old male with hematuria (blood in the urine) on and off for two (2) weeks, "but last night I was told he had clots coming out." The CMC emergency room physician #6 stated, hold on, before you go to far, is it urology you need? The veteran's hospital physician replied, yes. The CMC emergency room physician #6 asked the transfer center representative to get the on-call urologist on the line. The transfer center representative replied that the urologist on-call was physician #3.
Track 3 -- The transfer center representative contacted the on-call urologist #3 and informed the physician that he was on a recorded line. The transfer center representative informed the urologist #3 that the CMC emergency room physician had a possible transfer from the veteran's hospital and would like for "you to consult" regarding the possible transfer.
Track 4 -- The transfer center representative informed the CMC emergency room physician #6 and the veteran's hospital physician that the urologist #3 had joined the conference. The veteran's hospital physician stated the patient's name and age. The urologist #3 asks "is this a patient of mine?" The veteran's hospital physician replied, no. The urologist #3 stated, "OK, what is his issues?" The veteran's hospital physician replied, he has hematuria, our urologist has seen him here. He is [AGE] years old with a history of [DIAGNOSES REDACTED]. Our urologist put a foley catheter (tube inserted into the bladder to drain urine) but it started to clot because of the blood. The urologist #3 asked, was it a three (3) way irrigating catheter? The veteran's hospital physician replied, it was irrigated several times. The urologist #3 stated, no, was it a three (3) way catheter with an irrigation port? The veteran's hospital physician's response was no, no it was not. So, he (veteran's hospital urologist) advised us to send the patient out. The urologist #3 informed the veteran's hospital physician that the patient was a veteran's hospital patient and needed to be sent to a veteran's hospital. In addition, urologist #3 stated we do not accept veteran hospital transfers that do not meet Emergency Medical Treatment and Labor Act (EMTALA) requirements, and this does not meet EMTALA requirements. The veteran's hospital physician stated, OK. The urologist #3 stated, that's our policy of practice because we can't get paid. The veteran's hospital replied, OK. The Urologist #3 and then the veteran's hospital physician, retrospectively respond "OK". The Urologist #3 states Atlanta and Augusta veteran hospitals both have urology residency programs. The veteran's physician responds, ok. The Urologist #3 responds, " Alright " . The conversation ends with the veteran's hospital physician thanking urologist #3. "
Review of the September 2014 urology on-call calendar revealed physician #3 was on-call on 09/12/14. The facility had Urological capabilities and or facilities to provide the specialty care that patient #8 needed on 9/12/2014.

Review of CMC census report dated 09/12/2014 revealed that there were one-hundred-thirty (130) vacant hospital beds. Review of the census report dated 09/13/2014 revealed that there were one-hundred-fifty-five (155) vacant beds. The facility had the capacity to treat patient #8 on 9/12/2014.

Interviews were conducted on 09/25/14 at 5:30 p.m., and 9/26/2014 at 12:30 p.m. with Urologist/physician #3. Urologist #3 explained that on 09/12/14 he received a call from a physician who he thought was a doctor on the floor at the veteran's hospital. Urologist #3 stated the facility often got requests from the veteran's hospital requesting to transfer an inpatient to inpatient admission. The urologist #3 stated he thought the veteran's hospital physician was trying to transfer an inpatient because the veteran's hospital physician reported that the patient had been seen by the veteran's hospital urologist. Urologist #3 further explained that he thought the veteran's hospital physician had told him the patient had been at the veteran's hospital for two (2) days. Urologist #3 stated that he understood that the patient had been treated with a foley catheter by the veteran's hospital urologist. The urologist stated that was inadequate and that he had recommended a three (3) way irrigating catheter. In addition, the urologist #3 explained that he had been informed that the patient had [DIAGNOSES REDACTED] and that the patient would have been under the care of a urologist. The physician stated, "I don't feel that I should accept a patient if they are under the care of another urologist, because I am on for unassigned call." The physician #3 went on to say that hematuria was not an Emergency Medical Condition (EMC) and that it could be treated in any emergency room . The physician stated he was going to try and find out what had happened to patient #8. Urologist #3 stated that patients with gross hematuria can be treated with a three (3) way irrigation catheter and sent home to be followed as an outpatient. The facility failed to ensure that their transfer policy and procedure was followed as evidenced by failing to ensure that the emergency physician accepted patient#8 on 9/12/2014 on behalf of the facility after consulting with the on-call Urology specialist. According to the policy the specialist does not have the authority to decline a transfer from an outside emergency department. The hospital ' s failure to accept patient #8 on 9/12/2014 resulted in a delay in treatment for patient #8 identified emergency medical condition.

Interview on 09/26/14 at 10:45 a.m. with the Chief Medical Officer (CMO), who stated after listening to the transfer center recording that gross hematuria could be treated in any emergency room . The CMO added that he felt the treating urologist's information was missing from the recording.

An interview was conducted on 09/26/14 at 11:30 a.m. with the emergency room Nurse Manager (ERNM). The ERNM stated he had worked in five (5) Emergency Departments and that emergency room nurses could put in three (3) way catheters and do continuous bladder irrigation

The hospital failed to accept an appropriate transfer of an individual who required such specialized services of the on-call Urology specialist (#3) and facilities. The hospital also had the capacity to treat patient #8 on 9/12/2014.