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LIBERTY HOSPITAL 2525 GLENN HENDREN DR LIBERTY, MO 64069 May 19, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews and review of Emergency Department (ED) logs, Rules and Regulations of the Medical Staff, and Medical Records from other hospitals, the facility failed to accept one patient (#1), to be transferred for stabilizing treatment of an emergency medical condition (EMC) from an outside hospital ED. The patient required speciality care (orthopedics) that the transferring hospital (Hospital A) could not provide. Liberty Hospital had the capacity and capability to treat this patient's unstable EMC but the transfer was denied by the on-call orthopedic specialist. A total of 21 ED medical records were reviewed. The facility also failed to ensure that the Rules and Regulations of the Medical Staff delineated guidelines to physicians on acceptance of transfers. The facility's EMTALA policies and procedures also failed to delineate guidelines to physicians on acceptance of transfers. The facility census was 126. Please refer to A-2411 for details.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and policy review, Liberty Hospital failed to accept an appropriate transfer from another hospital's emergency department (Hospital A) for one patient (#1) of 21 Emergency Department (ED) records reviewed. This failure had the potential to cause harm by delaying stabilizing treatment to any emergent patient that required the specialized capabilities provided at Liberty Hospital. The ED average daily census was 92. The facility census was 126.

Findings included:

1. Record review of the facility's policies and procedures related to EMTALA showed no direction to staff to follow related to acceptance of transferred patients.

2. Record review of the facility's Medical Staff Rules and Regulations dated 11/2014, showed no direction for medical staff to follow related to acceptance of transferred patients.

3. Record review of Patient #1's ED (from referring Hospital A) visit dated 05/15/16 showed the following information:
- The patient presented to Hospital A's ED at 11:07 AM with complaints of right elbow injury status post fall.
- Record review of the radiology report dated 05/15/15 at 12:05 PM showed that the patient had a posterior (positioned at the end or behind) dislocation (bones of the arm moved out of place) of the elbow.
- ED physician note indicated that the patient had an elbow dislocation after falling on her right arm.
- Plan: Administer Intravenous (IV-needle placed into a vein to administer fluids or medications) sedation medications for reduction (put back into place) of the right dislocated elbow.
- Disposition: Transfer to Hospital B. After adequate analgesic (medications used to relieve pain) and sedation, attempt to reduce the dislocation using two different techniques failed. Discussed care with the on-call orthopedist (Staff G) at the closest hospital, Liberty, who declined to see the patient, stating that Hospital B had orthopedics that hold clinics at Hospital A. It was explained to the on-call orthopedic physician at Liberty Hospital that Hospital B did not provide emergency coverage for Hospital A and for this reason Liberty Hospital's on-call orthopedic physician was being called. The on-call orthopedic physician declined to see the patient. At 1:00 PM Hospital B was called and accepted the patient and she was transferred via EMS (emergency medical service).

During a telephone interview on 05/23/16 at 10:04 AM, Staff L, ED Physician (Hospital A) stated that:
- He was working in Hospital A's ED when Patient #1 (MDS) dated [DATE] with a dislocated elbow.
- He attempted to reduce (put the elbow back in place) the elbow using standards of practice with conscious sedation but was unable to get it back into place.
- The facility did not have orthopedic specialist available to cover on-call needs.
- A group of orthopedic physicians from Hospital B provide the facility with a clinic two days a week for scheduled outpatient services but did not provide on-call coverage.
- He contacted Liberty Hospital because they were the closest facility that provided on-call orthopedic specialty services (Hospital A is 12.7 miles from Liberty Hospital).
- When he called Liberty Hospital's ED, the triage nurse gave him the number for the on-call physician covering orthopedics and told him to call him directly.
- He called the on-call orthopedic physician, Staff G, who informed him that since the patient was not his, he did not have to see the patient.
- He confirmed with Staff G that he was on-call for the orthopedic group and Staff G confirmed that he was on-call coverage for orthopedics on 05/15/16.
- His colleagues reported that they have had the same experience with Staff G when he is on-call.
- Due to the urgency of possible nerve damage from the dislocated elbow he was seeking the nearest hospital with on-call orthopedic services.
- The patient was transported to Hospital B (50 miles away from Hospital A) by EMS.

During an interview on 05/19/16 at 10:40 AM, Staff G, Physician, Orthopedics, stated that:
- He was a general orthopedic physician capable and within his scope of practice to handle a dislocated elbow.
- He was on-call for orthopedics on 05/15/16 and did receive a call from Hospital A regarding a patient with a dislocated elbow.
- He asked Staff L, ED Physician, from Hospital A if they had orthopedic services that came during the week.
- He has never refused to see a patient from a facility that he provided services to.
- He asked Staff L if Hospital A had orthopedic services and Staff L asked him again if he was refusing to see the patient. Staff G stated that he did not refuse to see the patient.

4. Record review of Staff G's (Liberty Hospital Orthopedic Physician) written statement dated 05/23/16 showed the following information:
- A physician from Hospital A (Staff L) contacted him on Sunday, May 15, 2016, asking if it was ok to send an elbow dislocation.
- He was at the hospital doing numerous cases in the OR (operating room) and available.
- He asked Staff L if he had contacted the orthopedic physicians that normally come to Hospital B to see the patient and Staff L responded that none of them were on-call.
- Staff L asked him if he planned to accept the patient and in turn, he asked Staff L if he was going to contact one of the orthopedic physicians that are on staff at Hospital A. Staff L simply stated "thank you" and hung up the phone.
- He did not have any issues ever in accepting transfers from other hospitals that have no orthopedic coverage available.

During an interview on 05/19/16 at 10:00 AM, Staff D, Physician, ED Medical Director at Liberty Hospital stated that:
- If the hospital (Liberty Hospital) had the capability then staff needed to assess and treat patients that present.
- To accept a transferred patient would be dependant on if the facility had capability and capacity at the time of the request.
- He expected physicians on-call to discuss with the referring facility the case being referred to ensure that the facility can accept the patient based on current capability and capacity. The decision to accept the transferred patient would be made after discussion with the referring physician.
- He received EMTALA training/education on a yearly basis through competency requirements.
- To his knowledge there had not been any issues with physicians on-call accepting referrals.
- He would be aware of any denials of acceptance of transfers and he would do an investigation and review why the patient was not seen.
- The ED worked hard with on-call specialist and multiple divisions of the facility work with referral facilities to allow for ease of a requested transfer.

During an interview on 05/19/16 at 10:25 AM, Staff E, Physician, Medical Staff President at Liberty Hospital stated that:
- If the facility can provide a higher level of care they expect the on-call physician to see/consult with the referral facility.
- If the facility is unable to meet the referral's request then an explanation of why needs to be given.
- There had not been any trends or issues of on-call physicians not seeing a patient when requested by a referring facility.

During an interview on 05/19/16 at 11:45 AM, Staff H, Chief Executive Officer (CEO) at Liberty Hospital stated that:
- He expected on-call physicians to be available for patients that either present to the facility and/or are referred according to the facility's capability and capacity.
- He expected services to be provided to the patient to meet their needs if the facility can.
- He denied any issues with on-call physicians being available for either consult or coming into see a patient.
- He expected the medical staff to follow the facility's Medical Staff Rules and Regulations and Medical Staff ByLaws.

During an interview on 05/19/16 at 2:40 PM, Staff K, Registered Nurse (RN), ED Nurse Manager at Liberty Hospital stated that she expected ED staff to know what EMTALA was and what their role was. Staff K stated that EMTALA training/education was provided upon hire, yearly and on-going as needed. Staff K stated that she expected ED staff to follow the facility's policies, procedures and protocols related to EMTALA.

5. Record review of Hospital A's on-call schedule dated 05/15/16 showed that no on-call services were provided/available for orthopedics. The on-call schedule for the month showed no on-call services were provided/available for orthopedics.

During an interview on 05/23/16 at 10:46 AM, Staff M, RN, Director of Nursing (DON) for Hospital A stated that the facility did not have any on-call specialist including orthopedics. Staff M stated that primary care physicians share on-call duties for the facility.