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COLISEUM MEDICAL CENTERS 350 HOSPITAL DRIVE MACON, GA 31217 March 19, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on reviews of the One Step transfer center logs and recordings, Medical Staff Bylaws, medical records, Medical Staff Rules and Regulations, current Medical Staff roster, MEC Meeting Minutes, facility policies, on-call physicians' schedules, on-call ED Directors' schedules, on-call AOC schedules, ED physician schedules, staff interviews, credential files, and observations, it was determined that the facility failed to ensure that effective policies were followed to ensure the acceptance of an appropriate transfer of an individual who required the specialty of General Surgery which was available at the time, and the hospital had the capacity to treat one (1) of twenty (20) sampled patients (#1). 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 the One Step transfer center logs and recordings, Medical Staff Bylaws, medical records,Medical Staff Rules and Regulations, current Medical Staff roster, MEC Meeting Minutes, facility policies, on-call physicians' schedules, on-call ED Directors' schedules, on-call AOC schedules, ED physician schedules, staff interviews, credential files, and it was determined that the facility failed to ensure that effective policies were followed to ensure the acceptance of an appropriate transfer of an individual who required the specialty of General Surgery which was available at the time, and the hospital had the capacity to treat one (1) of twenty (20) sampled patients (#1).


Findings include:

The log of requests to transfer patients from other facilities to CMC from 09/01/14 through 03/17/15 was reviewed. On 01/27/15, the "One Step" transfer center log revealed evidence that CMC received a called regarding the possible transfer of a [AGE] year old man. The log noted that the patient had intra-abdominal bleeding and that the transfer was not accepted because the facility did not have the capabilities / services were not available.

On 03/18/15 at 2:00 p.m., the "One Step" transfer center recording for 01/27/15 regarding patient #1 was reviewed. The recording revealed the following:
Track 1 at 12:16 a.m. -- The transferring facility's ED physician called One Step transfer center and informed the representative that she needed to talk to a surgeon. The ED physician informed the representative that she had a [AGE] year old black male. with probable intra-abdominal bleeding. The ED physician reported that the patient had a large hematoma, was hypotensive, and that the transferring facility did not have a surgeon on-call. The ED physician gave her call back number , and requested to be connected with CMC (Coliseum Medical Center) because the "Medical Center is on diversion".
-The transfer center representative asked if the physician wanted to be connected with the ED or the on-call surgeon.
-The transferring physician stated she wanted the on-call surgeon because the patient needed to go to the operating room.

Track 2 at 12:21 a.m. -- The transfer center representative pages the on-call surgeon (physician #1).

Track 3 at 12:28 a.m. -- The on-call surgeon (physician #1) calls the transfer center.

Track 4 at 12:29 a.m. -- The transfer center representative calls the transferring facility and asks for the ED physician.

Track 5 at 12:30 a.m. -- Physician to physician conference:
-The transferring ED physician reports that she has a [AGE] year old black male with abdominal pain that has not felt well for four (4) days, that the patient is a bad diabetic and that she at first thought the patient was in Diabetic Ketoacidosis (DKA) because the patient's blood sugar had been over 400 (normal range 60-110), his hemoglobin looks good, and the first blood pressure was 130/50 then it dropped. The patient has a very tender abdomen, the CT was done without contrast because the patient was vomiting and his renal functions are bad, the CT revealed a huge intraluminal and epigastric region (upper middle region of the abdomen) hematoma that the Radiologist said was about 15 centimeters (cm) and related to the intestines, no free air was seen. The patient has received three (3) liters of fluid, I'm hanging some blood, type and cross matching the patient because his blood pressure is 90/50 after three (3) liters of fluid and he is on Levophed (used to treat low blood pressure). We've got his blood sugar down but we do not have a surgeon.
-CMC's on-call surgeon (physician #1) states, is this just in the day time, stuff like this gets transferred out in the middle of the night. We get everything during the middle of the morning. Is he throwing up blood? I don't understand.
-The transferring ED physician states no he is not throwing up blood. I'm confused too! I'm getting ready to do a rectal exam, he fell today, but he denies trauma and he's been hurting for a few days. His first hemoglobin (Hgb) was 13 and his hematocrit (Hct) was 42. He bottomed out.
-CMC's on-call surgeon (physician #1) asked what is it now?
-The transferring ED physician states I'm getting ready to repeat it now, I'm gonna hang some blood because of the low blood pressure after receiving four (4) liters of fluids and Levophed. I thought I'd hang negative blood in the mean time, he's had all that saline and probably needs some blood. -CMC's on-call surgeon (physician #1) states, why the acute drop if this has been going on for several days?
-The transferring ED physician replies, that's what I don't understand. I'm stumped, when I got the CT back I was thinking DKA he has a history of pancreatitis, his abdomen is tenderer, the first blood pressure was ok, then it dropped, the platelet count is good. Then I got the CT report, he doesn't drink.
-CMC's on-call surgeon (physician #1) ask the ED physician to read her the CT report and states it's gotta be trauma you just don't develop.
-The transferring ED physician interrupts and says, I agree! The CT report revealed a large heterogenous round collection within the left upper abdomen most consistent with a hematoma. It measures 9 cm x 15 cm x 12 cm. Soft tissue fat stranding around the collection, most likely hemorrhage. The spleen, adrenal gland, and left kidney are separate from this collection of fluid. No pneumoperitoneum, no other free fluid in the pelvis. The patient swears he has had no trauma. It just does not make sense.
-CMC's on-call surgeon (physician #1) says I don't understand, it's gotta be a spleen injury.
-The transferring ED physician states you can clearly see the spleen and kidney, but they did the CT without contrast.
-CMC's on-call surgeon (physician #1) states, something has to be bleeding, it's gonna be a trauma and we are not a trauma center.
-The transferring ED physician reports that the Medical Center is on diversion.
-CMC's on-call surgeon (physician #1) states the patient needs to go to a trauma facility, nothing just spontaneously bleeds.
-The transferring ED physician says that she agrees with the surgeon but that the Medical Center is on diversion.
-CMC's on-call surgeon (physician #1) states the patient needs trauma treatment, that nothing free bleeds in the abdomen. He's gonna get here and we are not a trauma facility. Where is another trauma facility?
-The transferring ED physician replies I don't know. I've called the helicopter for transport.
-The transfer center representative asks if (Hospital #3 and Hospital #4) are trauma centers.
-CMC's on-call surgeon (physician #1) states (Hospital #3) is not, but (Hospital #4) is a trauma center.
-The transfer center asks the transferring ED physician is she wants to be connected with Hospital #4) and the physician replies "Yes".
-CMC's on-call surgeon (physician #1) states if you can get him there by copter, if not call me back. I'm afraid it's gonna be trauma.
-The transferring ED physician replies, yes. Thank you for your help.

Track 6 at 12:37 a.m.-- The transfer center connects the transferring ED physician with (Hospital #4).

Track 7 at 12:37 a.m. -- (Hospital #4) is connected.

Track 8 at 12:38 a.m. --(Hospital #4) bed control and the transferring ED physician are connected.

Track 9 at 12:53 a.m. -- The transferring ED physician calls the transfer center and ask to speak with CMC's on-call surgeon (physician #1), stating the Medical Center refused to take the patient because they did not consider the patient a trauma and that she was trying Augusta.

Track 10 at 12:56 a.m. -- CMC's on-call surgeon (physician #1) was paged.

Track 11 at 1:31 a.m. -- CMC's on-call surgeon (physician #1) called the transfer center and waits to be connected with the transferring ED physician.

Track 12 at 1:32 a.m. -- The transferring ED physician is called.

Track 13 at 12:30 a.m. -- The transferring ED physician thanks CMC's on-call surgeon (physician #1) for returning her call, and informs the surgeon that the patient is being transferred to (Hospital #4) because the Medical Center is on diversion and refused to take the patient because they did not consider him a trauma patient.
-CMC's on-call surgeon (physician #1) states, after I hung up I wondered what about an aneurysm. Do you think he might have a dissecting aneurysm?
-The transferring ED physician replies, he has hypertension, I guess it's possible because the CT was done without contrast. But, (Hospital #4) has accepted him and the helicopter is here. I appreciate your help.
-CMC's on-call surgeon (physician #1) says again, something is not adding up. I don't know.
-The transferring ED physician replies, I agree. Ok, thank you.

Review of the Medical Staff Bylaws, revised 09/24/12, revealed in section 4.3.3. Obligations of Active Staff, "Each member of the Active Staff shall...accept emergency on-call coverage for emergency care services within his/her Medical Staff Division as specified by the requirements of the assigned Medical Staff Division.

Review of the Medical Staff Rules and Regulations, revised 09/24/12, revealed under Emergency Services, section B. 1. Appointees of the staff shall accept responsibility for Emergency Center call as established by the respective division and in accordance with Emergency Center policies.

Review of the facility's current Medical Staff roster revealed physician #1's specialty was General Surgery and that the physician was categorized as an Active Medical Staff member.

Review of the Medical Executive Committee (MEC) Meeting Minutes from 02/01/14 through 03/17/15 revealed the following:
-02/19/14 A subcommittee met to draft a revised transfer policy to establish a strong clinical hand-off of patients to and or from Coliseum Health System facilities. D. 1. was revised to state, notify the appropriate on-call physician / specialist, rather than will notify the physician on-call.
-03/19/14 Revision to a sister facility's MEC, was approved, and was to go to the Board of Trustees on 03/24/14.
-11/19/14 The facility's corporate regulatory attorney and a sister facility's MEC members were given copies of the 03/24/14 approved Transfer policy. EMTALA (Emergency Medical Treatment and Labor Act) training was offered to "relevant Medical Staff", with emphasis on documentation, appropriate transfers, on-call physician obligations, and potential liability for non-compliance for the hospital and Medical Staff.
-12/12/14 Transfer policy addendum; ED physicians call the on-call specialist after the transfer has been accepted. The MEC approved the Transfer policy and addendum. Administration scheduled EMTALA training with Legal Counsel in the near future.
-1/14/15 EMTALA training scheduled 02/11/15.
-2/11/15 Transfer policy approved, physician / qualified medical personnel certificate signed timely. Previous EMTALA survey (September 2014) physician's (Urologist) EMTALA training was discussed by the MEC.



The medical record for Patient #1 from the transferring hospital was reviewed. The medical record indicated that Patient #1 was brought in by the Emergency Medical Service ambulance on 1/26/2015. Further review revealed in part, "History of Present illness...Time seen by MD (medical doctor) (MSE-medical screening examination) :19:54 (7.54 p.m.)...presents to the ED (Emergency Department) complaining of "EMS states BS (Blood sugar ) 540". Not feeling well for several days. Did not take afternoon insulin. Hx (History )of pancreatitis (Inflammation of the Pancreas). Duration of episode: days (3) Progression: Constant getting worse Severity:severe Quality ; Cramping Location of Pain/injury: Abdomen. .. Preliminary Radiology Report 1/26/2015....Clinical History /Indicator for Exam: Diffuse Abdominal Pain...IMPRESSION: Large Hematoma within the left upper abdomen, most likely associated with bowel ...an underlying neoplasm is also a consideration... Addendum:Also attempted to transfer patient to Coliseum, surgeon (Physician #1)felt injury secondary to trauma...Patient accepted to Hospital #4 pt (patient) flown to trauma and wanted me to try other locations Augusta and Atlanta...Addendum discharge diagnosis Intra-Abdominal Hemorrhage (bleeding in the abdomen) with hypovolemic shock (shock due to decrease in blood volume from bleeding)."...Departure Information...Departure date/Time: 01/27/15-0213...Condition: Critical."


Review of facility policy entitled "EMTALA - Georgia Transfer Policy", number CHS.EM.006, dated 03/01/13, 3. Authority to Accept a Transfer. The Emergency Physician and the Hospital CEO (Chief Executive Officer) or designee, such as the Administrator on Call ("AOC") or the House Supervisor, are the ONLY individuals authorized to accept or refuse the transfer of an individual from another facility on behalf of the receiving hospital. The facility failed to ensure that there transfer policy and procedure was followed as evidenced by failing to ensure that the AOC or the ED physician accepted or refused patient #1 on 1/26/2015. .. Physical Exam(Examination):...ABD (abdomen)L soft..tenderness (diffuse-throughout the abdomen).

Review of the on-call schedules for January 2015 revealed physician #1 was on-call for General Surgery on 01/26/15 from 7:00 a.m. until 1/27/15 at 7:00 a.m. The facility also had an ED Director and an AOC on call during this time. The ED physicians' schedules were reviewed from 12/01/14 through 02/28/15, there was evidence of 24 hours a day physician coverage.

During an interview on at 3:45 p.m., physician #1 confirmed that she received a call from the transferring ED physician on 01/27/15 requesting to transfer a patient with a large hematoma / intra-abdominal bleed. The physician stated she had not reviewed the tapes, but did remember the episode. She stated that when she was informed the patient had a big intra-abdominal hematoma her concern was that the bleeding was not in an organ. Physician #1 said that she was concerned that the patient had trauma of the spleen or an organ injury. The transferring ED physician agreed that it was possibly trauma and that she would check with Hospital #3 or Hospital #4. It was a mutual agreement. The ED physician called me back and told me the Medical Center was on diversion. I asked if it was possibly an aneurysm, I was going to suggest that I bring in the vascular surgeon, but the transferring physician said never mind (Hospital #4) has accepted the patient. At no time did I refuse to accept this patient. I was trying to accept him when she told me he was going elsewhere.

During an interview on 03/19/15 at 11:00 a.m. with the Ethics and Compliance Officer, the Officer explained that she gets an email every morning from the transfer center listing any requests for transfers that were not accepted. The Officer stated she started monitoring the requests for transfers in January 2015 and that she reviews any requested transfers that were not accepted. The Officer stated that when she reviewed the call from 01/27/15 regarding patient #1 she was not sure whether it was a possible EMTALA because the physician had not refused the patient but that the facility reported the incidence just to be on the safe side. She went on to say that the two physicians had discussed that the patient might have had some type of trauma or injury. The officer added that the transferring physician had contacted a helicopter for transport and that CMC does not have a helipad. The Officer stated the Chief Operating Officer initiated an investigation on 01/28/15 which included the facility and the transfer center. The Officer said that the Chief Medical Officer met with physician #1 on 02/02/15 and again on 02/03/15 to discuss the incidence and the facility's transfer policy. The Officer explained that the facility's transfer policy had been sent to CMS (Centers for Medicare and Medicaid Services) as part of their action plain related to the EMTALA investigation in September 2014. The Officer presented evidence that physician #1 attended EMTALA training on 02/11/15 and also reviewed the transfer policy at that time. The Officer explained the EMTALA training had been presented by the facility's corporate attorney and a private attorney who specializes in EMTALA law. The Officer stated physician #1's actions were reported to the Peer Review Committee, the Chief of Staff, and the Chief Medical Officer and that the final actions were still pending. The Officer said the Chief Executive Officer, the Chief of Staff, and the Board of Trustees were notified of the event on 02/02/15. The Officer stated once we found out the transfer center was calling on-call physicians directly and were bypassing the facility's ED physicians the Transfer Center Supervisor sent an email out to all transfer center staff. A copy of the email confirmed that 02/03/15 the Transfer Center Supervisor sent an email to all transfer center staff alerting them that "Transfer requests are to be connected to the ED physicians only." This also contained information on the process for contacting the AOC as needed. The Officer provided a copy of the quality monitoring tool she was using to monitor transfer requests that were not accepted. There were no regulatory issues identified with these transfers.

Review of three (3) credential files revealed physicians # 1, and 3 completed EMTALA training on 02/11/15. Physician #2 the Chief Medical Officer did not perform patient care and was not required to complete EMTALA training.

The facility failed to accept an appropriate transfer of Patient #1 on 1/26/2015 who required such specialized capabilities (General Surgeon) or facilities, and Coliseum Medical Centers had the capacity to treat patient #1.