The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on record review and interview, the hospital failed to ensure acceptance from a referring hospital an appropriate transfer of an individual who required specialized capabilities or facilities for one (Patient #21) of 21 patients.

This failed practice has the likelihood to result in patients receiving delayed evaluation and treatment and an increased risk for adverse health outcomes.

Review of a policy titled "Ascension Emergency Medical Treatment and Active Labor Act (EMTALA) PolicyStatID: 55" read in part, "Procedure to Accept Patients from Another Facility: EMTALA provides that a hospital with specialized capabilities or facilities may not refuse to accept an appropriate transfer of an emergency department or observation patient if the hospital has the capability and capacity to treat the individual ...The St. John Transfer Center at SJMC and the designated representative for ...Jane Phillips Medical Center (JPMC) ...will ...accept transfers from outside facilities ensuring the capacity and capability to care for the patient is available ...All requests for transfers must be directed to the transfer center for SJMC and the designated representative for all other hospitals."

Review of a policy titled "Ascension Patient Transfers PolicyStatID: 54" read in part, "Transfer from outside facilities to ASJJP [Ascension St John Jane Phillips] will be accepted and occur if the capacity and capability to care for the patient is available. The House Supervisor will facilitate and coordinate transfers following EMTALA guidelines ...Patients determined by the referring medical provider to have an emergency medical condition will be accepted for transfer to ASJJP provided the needed resources and personnel are available at the time of transfer."


Patient #21

Review of an internal document dated 02/02/21 at 4:21 PM documented the summarization of recorded transfer center phone call conversations for Case 119-0036 and showed they occurred on 01/19/21 between approximately 5:46 PM and 7:10 PM.

Review of a recorded phone call " 119-0036JPMC2.wav" between the referring hospital physician, Staff J and Staff Q showed the referring hospital physician state at approximately the 3:55 minute mark, " ...from my standpoint she needs a transfer ...because she has an elevated troponin."

Review of a recorded phone call " 119-0036JPMC6.wav" between the referring hospital physician, Staff J, Staff P and Staff R showed Staff J state at approximately the 5:32 minute mark, "Your request to transfer the patient for something that can be followed outpatient, I don't think is necessary." At approximately the 6:59 minute mark, Staff J stated, "No I'm not going to accept that transfer. There's no need to transfer."

Review of the 01/19/21 night House Supervisor Report Brain Sheet showed 1-2 beds available on 10 Tower.

On 02/04/21 from 12:41 PM to 1:01 PM, Staff A stated:
1. The transfer request for Patient #21 should not have been declined as the facility had capability and capacity on the night of 01/19/21.
2. If a facility has capability and capacity, it is responsible to accept patient transfers.
3. Physician's opinion should not matter in accepting a patient transfer.

On 02/04/21 from 1:15 PM to 1:42 PM, Staff O stated:
1. Capability and capacity were determined by House Supervisors because they were bed control. Criteria for capability and capacity were clinical needs of patients and staff available to care for them.
2. Patients with elevated troponin levels would likely go to 10 Tower. At shift change on the night of 01/19/21, there appeared to be one 10 Tower bed available.