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AU MEDICAL CENTER 1120 15TH STREET AUGUSTA, GA 30912 Feb. 20, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of the facility's Transfer Log, review of the Transfer Center's audio transcription, review of the facility's Census and Bed availability, and review of facility policy and procedure and staff interviews, the facility refused to accept from a referring hospital within the boundaries of the United States an appropriate transfer of individuals who required the specialized capabilities or facilities of the receiving hospital for two (2) patients (#s 17 and 18) from a referring hospital. Cross reference: Tag 2411 - Recipient Hospital Responsibilities
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the facility's Transfer Log, review of the Transfer Center's audio transcription, review of the facility's Census and Bed availability, and review of facility policy and procedure and staff interviews, the facility refused to accept from a referring hospital within the boundaries of the United States an appropriate transfer of individuals who required the specialized capabilities or facilities of the receiving hospital for two (2) patients (#s 17 and 18) from a referring hospital.

Findings include:

1. Review of patient #17's medical record from Washington County Regional Medical Center revealed =that the eighty-five (85) year old patient presented to the facility's emergency room via private vehicle with family members on December 3, 2017, at 9:18 PM with complaints of respiratory distress.

Triage was completed by an ER RN upon arrival, and assessed as an emergency severity index (ESI) 2- emergent. The RN noted that the patient was visiting from NY, and was oxygen dependent at 3 liter/minute via nasal canula, but had been without the oxygen since 11/23/2017. Patient #17 was alert and oriented with diminished breath sounds bilaterally, had nasal flaring and intercostal retractions (muscles suck in between the ribs) with breathing. An intravenous (IV) catheter was inserted for fluid and laboratory blood draws. Vital signs were: 97-113-17 114/58 oxygen saturation 75%.
The patient was placed on oxygen 3 liter/minute via nasal canula at 9:20 PM.
MD #7 performed an examination on Patient #17 at 9:25 PM, noting the patient had a history of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF)
Orders included laboratory studies, EKG, chest x-ray, heart monitor, pulse oximetry, indwelling urinary catheter, and medications.
At 10:25 PM, Solumedrol (anti-inflammatory) 125 mg was administered IV.
At 10:31 PM, the patient was on bi-pap (bi-level positive airway pressure)
At 10:33 PM, Lasix (diuretic) 40 mg was administered IV.
At 10:41 PM, an arterial blood gas was drawn and an EKG was performed
At 10:44 PM, the patient received a breathing treatment per respiratory therapy and was on a venti-mask (concentrated oxygen delivery mask) at 50% oxygen.
On 12/4/2017 at 12:52 AM, MD #7 intubated the patient, and he/she was placed on a ventilator
At 1:18 AM, the patient was started on a propofol drip for sedation.
At 1:56 AM, the RN noted that MD #7 was speaking to MD #4 over the phone for possible transfer.
At 2:00 AM, the RN noted the MD #4 was not accepting the patient.
At 3:04 AM, transport via air evacuation was declined due to weather conditions.
Patient #17 was transferred to [Name] of acute care hospital on [DATE] at 3:50 AM via ambulance. Vital signs were: 97.6-73-16 119/50 oxygen saturation 99% on the ventilator.

Review of the facility's Transfer Log revealed that on 12/4/2017 at 1:47 AM, MD #7 from [Name ] of referring Regional Medical Center's (Hospital A) ER telephoned AU Medical Center, requesting to transfer Patient #17 to their facility's pulmonology ICU due to the patient having respiratory distress which required placement of an endotracheal tube (rubber tube placed into the windpipe to assist breathing).

At 1:54 AM, the transfer center telephoned MD #3 at home, and a conference was conducted for MD #7 to present the case. At 2:05 AM, after discussion, MD #3 declined to accept patient for higher level of care.

Review of the Transfer Center Audio Transcription from 12/4/2017 revealed:
Hello, MD #3. Hi, this is ----- calling from the transfer center at Augusta University. I have a doctor down in (Hospital 'A') that wants to transfer a critical patient here, respiratory distress and is intubated. Okay, its MD #7, you want me to get him/her on the line for you now? Okay, hold on just a minute.
MD #3 Call hold

Transfer center: MD #3, MD #7 is on the line.
MD #7: Hey MD #3. I've got an [AGE]-year-old named (Patient #17) came to our facility complaining of shortness of breath for several days. Turns out he/she came down from New York to here on the 23 rd of November and left his/her oxygen at home. He/She's always on 3 liters and some type of way we never got a real good answer it was left at home. So he/she was in respiratory distress when he/she got here. Had his/her blood pressure (what was his/her initial blood pressure) 114/58. Respirations were 31 and labored, pulse was 70, he/she was sat-ing 91%. When we put his/her on 2 liters when he/she got here. I got an initial blood gas on his/her and the pH was 7.31 the CO2 was 71, oxygen was 38 and he/she was sat-ing 72.1%. saturation-the level of oxygen found in a persons blood normal range- between 95-100 %) Gave him/her a couple of treatments of some Lasix (diuretic) and on physical exam he/she was had diminished breath sounds in both lungs and he/she had some wheezing bilaterally. The second blood gas after duo-neb twice, the pH was 7.17, no I'm sorry that's the 3rd blood gas. The second one the pH was 7.21, CO2 was 99, so it had gone up from 71 to 99, the O2 was incalculable. He/she was sat-ing 88.7. So I went ahead and put him/her on BiPAP and got another blood gas about 30 minutes later and the pH was 7.17, CO2 was 108, the O2 was 72, he/she was sat-ing 93.8 so I went ahead an intubated his/her and the sats are now 100 but we got him/her on propofol (general anesthetic) drip and that's why I'm calling you, he/she's on a ventilator.
MD #3: So, what do you want me to do?
MD #7: Well, we don't have ICU here so I was hoping you could take him/her and put him/her in ICU.
MD #3: But, what then?
MD #7: Hum?
MD #3: What, what after that?
MD #7: Well, once he/she gets better, I guess extubate him/her and you know, give him/her 3 liters of O2 and let him/her go home provided everything is okay.
MD #3: I don't know, man it's pretty. I'm not going to accept him/her now, I'll talk to you later today. I'm not going to take him/her.
MD #7: Why not? What's the problem?
MD #3: It's 2:00 AM in the morning, dude. So, no.
MD #7: Wait a minute, wait a minute, whooo, whooo, whooo, whooo I'm not dude. Listen to me.
MD #3: Out here
MD #7: Listen to me
MD #3 call ended

Review of the facility's Census and Bed Availability as provided by the Director of Inpatient Nursing on 2/20/2018 at 4:00 PM revealed that on 12/4/17 at 1:47 AM, the twenty-four (24) bed pulmonary ICU had twenty-three (23) patients and was staffed for twenty-four (24) patients. At 7:00 AM, the unit continued to have twenty-three (23) patients and was staffed for twenty-four (24) patients.

Interview with MD #3 on 2/20/2018 at 1:04 PM in the conference room revealed that he/she was a certified critical care pulmonologist, and had been on staff at the facility since the year 2000. The MD stated that he/she was aware of EMTALA, and believed it had been reviewed in staff meetings once or twice. MD #3 recalled the incident involving Patient #17, stating that he/she had worked at the facility for a long time, and something like this had never happened before. He/she added that he/she felt very badly and regretted that it had happened. The MD explained that he/she had been on call since 5:00 PM that Friday through that Monday morning, and it had been a very busy weekend. He/she also stated that he/she was not at his/her best during the transfer telephone call; and, had experienced difficulty hearing, listening, and communicating. The MD further stated that he/she believed he/she had missed something when he/she received the call and had not realized that Patient #17 was an ER patient. MD #3 stated that he/she did not intend to refuse the patient, and believed he/she had said something about "call me back". MD #3 stated further that the patient was intubated, and he/she thought the patient was stable on the ventilator (breathing machine), and could wait. The MD stated that looking back, he/she realized that that was not a good reason not to take the patient, and, that the correct answer should have been "sure, send the patient" - which he/she had done a thousand times. MD added that he/she had subsequently appeared before the Credentialing Committee regarding the incident.

Interview with the Interim Chief Medical Officer (CMO) on 2/20/2018 at 5:00 PM in the conference room regarding recipient hospital responsibilities revealed that the expectation is that the facility accepts appropriate transfers when they have the capacity and capability to care for the patient. An appropriate transfer is for an increased level of care or when the facility is relatively more capable of caring for the patient. The Interim CMO stated that he/she became aware of the incident involving Patient #17 the following morning, adding that the patient should have been accepted. He/she explained that the facility did make an attempt to accept the patient, but by then, the requesting facility had transferred the patient elsewhere. The Interim CMO also stated that their facility had immediately reviewed the audio, and noted the involved MD, his/her chairman, and the Credentialing Committee in an effort to investigate the incident. The outgoing CMO had also met with MD #3.

2. Review of the facility's Transfer Log revealed that on 12/2/2017 at 1:53 AM, MD #10, a cardiologist from [Name ] Regional Medical Center (Referring Hospital), requested to transfer patient #18 for cardiology ICU due to having no ICU beds at their facility. At 1:59 AM, MD #4 (at AU Medical Center ) declined to take patient, stating that he felt the patient could be managed at the referring hospital.

Review of the Transfer Center Audio Transcription revealed:
Fourth call
MD #4: Hello,
Transfer center: Hello MD #4?
MD #4: Yes?
Transfer center: This is ----- from AU Transfer Center. Sorry to bother you so late. I just received a call from MD #10 from Meadows Hospital in Vidalia. They have an acute patient they want to send over to us. Um the patient is an acute decompensating CHF respiratory arrest, on a heparin (medication to treat or prevent blood clots) drip, dobutamine (medication used to increase heart output) drip and a balloon pump (mechanical device inserted into the heart to assist pumping function) and ventilator (vent-machine to assist with breathing).
MD #4: Why would they send him/her if they have him/her on all of that, why would they send him/her here?
Transfer center: a higher level of care. They cant manage the patient there.
MD #4: If they have a balloon pump in him/her and all of that, they can.
Transfer center: They say they cannot manage him/her there. It's a real small community hospital in Vidalia.
MD #4: Well they can't have a balloon pump in ....ok , just connect me with them.
Transfer center: Ok hold on let me connect you with them.
Fifth Call:
Transfer center: MD #10?
MD #10: Yes
Debra: I have MD #4 on the line, OK
MD #10: OK. Thanks
MD #4: Hello.
MD #10: Hello. Sorry to wake you this evening. This is MD #10, I'm Cardiology, down here in Vidalia. We have an [AGE] year old (patient) come in with acute congestive heart failure (CHF), also complaining of some chest pain, but not having STEMI (heart attack with ST-segment elevation on the EKG). We actually accepted him/her on transfer from one of the local hospitals. He/she crumpled on the way. Needed fluid resuscitation, was bagged. Lost his/her pulse. Got here, ER physician stepped in and intubated him/her and started him/her on Levophed (constricts blood vessels). He/she was actually talking when he/she when he/she got here. So he/she was awake. Intubated, (on) Levophed, and we were having trouble with blood pressure. There wasn't really time to evaluate urine output. And so Family was coming in. One family member was from Augusta, the other is an Oncologist from SC. And they really wanted to support him/her until they could figure out what to do. So we put a balloon pump in him/her. His/her hemodynamics have improved tremendously. Mean arterial pressure about 70. Augmented pressures about 110-120. Levophed down to about 4 mics. And he/she is waking up. Unfortunately, we have no beds . . . to keep this (patient). And so with one brother in Augusta, they asked that we call you guys to see if somebody who we might be able to send up to.
MD #4: Yea. Seems a little bit odd to me that you put in an intra-aortic balloon in and you want to transfer him/her. . .
MD #10: It really looks like he/she was going to crump and die.
MD #4: Yea, but I mean, ya'll were able to take care of him/her there.
MD #10: We don't have any beds. We, There ' s nowhere to go.
MD #4: You did all this in the ER?
MD #10: Well, the ER is right next to the Cath Lab. And so they called me in to evaluate these folks. You see them. And I didn't really ask if there's a bed because I don't think I've ever encountered . . . .
MD #4: That, that doesn't make sense to me to transfer a (patient) that far. Because if you've done all that I think you all can take care of him/her there.
MD #10: So we really haven't done anything else in terms of cathing him/her or looking for reversible causes at this point because he/she wasn't in a STEMI. And I really felt I might make things worse if we start shooting coronary arteries, and trying to fix things when he/she's not having a STEMI. It's really an acute decompensated CHF.
MD #4: Umm.
MD #10: That's all I've got. And I did look at, do a bedside echocardiogram (ultrasound of the heart) just looking at left ventricular (LV) function. Heart function is about 25%, so that's why I went towards the balloon pump. He/she was already on Levophed when I knew his/her pump was bad. And I don't know what the long-term, let's say what the medium-term outcome is. Long-term, he/she's [AGE] years old.
MD #4: Yea, I can't understand transferring an [AGE]-year-old if you have all the capability there. I think ya'll should take care of him/her.
MD #10: I think we should too, I just don ' t have a bed. That's the issue. It's not that we can't take care of him/her, it's just there's no bed to put him/her in. The place is locked up. I've, and this has never happened in 5 years. This has never happened where they send . . . . we have no beds. As part of the certificate of need (CON) for the whole STEMI piece. We have to take everybody. So at least in the past, there have been, I think, two infarcts that came in and gotten fixed. But then I say, there's no room in the inn. There's nowhere to go, but we can't turn them down.
MD #4: Yea, I don't, I don't, I can't, I can't . . . something about that doesn't make sense to me. I think you should take care for him/her there. If you're capable of doing all that, that, doesn't make sense to transfer an [AGE] year old (patient) with a balloon pump to another hospital. I mean, if you've done all that, I think you need to keep, take care of him/her.
MD #10: OK. Well, I appreciate your time, I'm sorry to have awoken . . .
MD #4: OK, OK. Hangs up.

Review of the facility's Census and Bed Availability as provided by the Director of Inpatient Nursing 2/20/2018 at 4:00 PM revealed that on 12/2/17 at 1:53 AM the seven (7) bed cardiology ICU had five (5) patients and was staffed for seven (7) patients. At 7:00 AM the cardiology ICU had six (6) patients and was staffed for seven (7) patients.

Interview with MD #4 on 2/20/2018 at 12:32 PM in the conference room revealed that he/she had been on staff at the facility as a cardiologist since 2002. The MD stated that he/she was aware of EMTALA regulations, but had not been formally trained. MD #4 stated that he/she was on-call approximately once every ten to twelve (10-12) days, or more if other staff were on vacation. The MD recalled the situation involving patient #18, stating that he/she believed that it was too dangerous to transfer the patient since he/she had an intra-aortic balloon pump in and was on a ventilator. The MD explained that the facility had resuscitated the patient well, the patient was on Levophed, and was starting to wake up. MD #4 continued on stating that the facility had full capability to take care of the patient, but did not have a bed in the desired location. The MD stated that he/she believed transferring the patient would have placed him/her at incredible risk due to the patient's condition, age, balloon pump, ventilator, and approximate travel time of two (2) hours.

Review of facility Policy 2.03, Emergency Medical Treatment and Labor Act (EMTALA), effective July 1, 2000, revised April 11, 2005, reviewed 3/1/2011, page 7, revealed:
Duty to Accept Appropriate Transfers (nondiscrimination)
Hospitals that have specialized capabilities or facilities (such as burn units, shock-trauma units, NICUs, etc.) that are not available at the transferring facility must accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual.
Capacity defined: The number of patients; the staffing levels or the amount of equipment on the hospital's premises does not necessarily determine the capacity of the hospital to care for additional patients. If a hospital generally accommodates additional patients by transferring patients to other units, calling in additional staff, borrowing equipment from other facilities, etc. it has demonstrated the ability to provide services to patients in excess of its occupancy limit.


The facility failed to ensure that their policy and procedure was followed as evidenced by failing to accept appropriate transfers of Patient #17 on 12/3/2017 and Patient #18 on 12/2/2017 who required the specialized capabilities of Pulmonary and Cardiac services . The hospital also had the capacity and facilities to treat Patient #17 and Patient #18.