HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to ensure that the acceptance of emergent [emergency department (ED) to ED] transfer requests were not delayed in order to inquire about the individual's method of payment or insurance status. (A- 2408)

Based on document review and interview, it was determined that for 1 of 5 patients (Pts. #2) inbound emergency transfer records reviewed, the hospital failed to ensure that the acceptance of emergent [emergency department (ED) to ED] transfer requests were not delayed in order to inquire about the individual's method of payment or insurance status, as required.

Findings include:

1. On 10/9/2024, the Hospital's Transfer Center Training Manual/EMTALA Policy (Revised 9/2011) was reviewed. The training manual/EMTALA policy indicated, " ... A. Transfers to [this Hospital] ... 2. If the transferring physician indicates that the patient is (a) medically unstable, (b) experiencing an emergency medical condition, and (c) that the patient requires the specialized capabilities of [this Hospital], the [Hospital's] attending physician shall contact the transfer center. [This Hospital] may not refuse to accept from a transferring hospital an appropriate transfer of an individual with an unstabilized emergency medical condition who requires such specialized capabilities if [Hospital] has the capacity to treat the individual... If capacity is available, the transfer center shall make appropriate arrangements for transfer of the patient without inquiry into whether the patient has the financial resources to pay for such care... Transfer center protocol ... Transfer Center RN: Confirm location of patient ... Emergency department - EMTALA applies..."

2. On 10/9/2024, the transfer center at receiving hospital record for Pt. #2 from 7/29/2023 was reviewed. The record included, "Reason for transfer need for hand surgery evaluation, they have no hand surgery ...ICU [intensive care unit] level of care needed ... Referring Provider: [Physician at Referring Hospital Emergency Room] ..." The record indicated that the transfer request for Pt. #2 was made on 7/29/2023 at 9:16 AM and transfer type was selected as "Inpatient Transfer" for higher level of care, instead of an emergency or EMTALA transfer. The record indicated that 3 approvals were required including: Physician acceptance, financial approval, and capacity approval, as opposed to only requiring physician acceptance in emergent cases.
The transfer center/notes at receiving hospital timeline documentation indicated the following:
- "9:16 AM - Request began - ICU Level of care needed.
- 9:38 AM - transfer type sent to Inpatient Transfer by [E#9 - Patient Logistics Nurse]
- 9:40 AM - [MD#9 - Hand Surgeon] - paged plastics-hand
- 9:42 AM - call from [MD#9] - if MICU [Medical Intensive Care Unit] accepts they will be happy to do an evaluation of the hand. But is concerned that there may be what is outwardly apparent.
- 9:46 AM - Call from [MD#8 - Pulmonary/Critical Care Fellow]
- 11:09 AM - call to [Transferring ED Physician] - Dr to Dr complete - entered by [E#9]
- 11:12 AM - call from [MD#2-Intensivist/Attending Physician]. [MD#2] approved transfer for Medical Intensive Care Service
- 7/31/2023 - 11:32 AM ... Per OPS (payor source), pt. is financially not admissible. Called to OSH [outside hospital] to notify, pt. expired."

3. On 10/9/2024 at approximately 11:00 AM, the hospital provided an email from Pt. #2's ED physician at transferring/outside hospital, dated 7/31/2023, which was addressed to the Director of Patient Logistics (E#8). The email included the following: " ...Upon contacting the transfer center, I was initially told that as we have an ICU at [transferring hospital], the patient should be admitted to our ICU and then could be potentially transferred from there, which is highly atypical for the transfer process for a higher level of care. I explained that I felt this patient needed more emergent transfer particularly for surgical evaluation ... This response is unacceptable coming from someone who is not themselves a hand surgeon nor would in any way, shape or form be involved in this patient's clinical care. I again emphasized the importance of surgical evaluation for this patient for potential source control of [Pt. #2's] sepsis. I was eventually begrudgingly transferred to the ICU fellow who accepted the patient stating they would like [Pt. #2] prioritized for immediate transfer. When I stated I would start arranging transportation, the transfer center informed me that the patient could not be transferred until his insurance information had been run. This, as I'm sure you are aware, is a significant EMTALA violation. I called the transfer center back to attempt to explain the illegality of delaying patient's transfer due to insurance reasons, only to be told that the patient was not yet accepted. This confused me as I had just spoken with an accepting physician. I was then told that no ICU beds were available ..."

4. The clinical record for Pt. #2 from the transferring hospital was reviewed on 10/9/2024. The record indicated that on 7/29/2023 at approximately 7:58 AM, Pt.#2 presented to the ED at [transferring hospital] for evaluation of shortness of breath. The record indicated that Pt.#2 had a wound to the left hand with some bone exposed. The record included a differential diagnosis of bacteremia [bacteria in the blood], septic shock and osteomyelitis [bone infection] of the left hand. A request to transfer Pt.#2 to the receiving hospital was made on 7/29/2023 by transferring hospital ED physician, and Pt #2 was accepted, but no ICU beds were available at that time. The clinical record did not indicate that Pt #2's emergency medical condition was stabilized. Pt.#2 coded (required cardiopulmonary resuscitation - CPR) at 11:19 AM and again on 12:25 PM. Pt. #2 was pronounced dead/expired at 12:32 PM on 7/29/2023 in the ED.

5. On 10/9/2024, the personnel file of E#9 (Patient Logistics Nurse) was reviewed. E#9's personnel file included an email dated 8/10/2023 at 3:03 PM, which indicated that the Manager of Patient Logistics (E#16) discussed with E#9 regarding follow up to a potential violation on 7/29/2023. The email included that when an outside hospital ED is asking for a higher level of care transfer, to not make it appear that an ED to ED transfer is pending insurance clearance, and that EMTALA transfers should be doctor to doctor.

6. An interview was conducted with the Medical Director of the Adult ED (MD#1) on 10/07/2024, at approximately 11:40 AM. MD#1 stated MD#1 stated that sometimes they receive transfer requests from other hospitals. MD#1 stated that if it is ED to ED, an ED physician will be the accepting physician, if it's ED to inpatient or inpatient-to-inpatient transfer, the accepting physician will be the attending on the unit they are requesting transfer to. MD#1 stated that they pretty much accept most transfer requests since the Hospital has a lot of specialty services that other hospitals don't have. MD#1 stated that they do not check for insurance when an ED-to-ED transfer is requested.

7. On 10/8/2024 at approximately 10:35 AM and on 10/9/2024 at approximately 10:11 AM, interviews were conducted with the Director of Patient Logistics (E#8). E#8 stated that when a transfer request comes in for an ED-to-ED transfer, no insurance verification is done. E#8 stated that when a patient is accepted but there is no bed availability, the patient is then placed on a holding list, which is typically updated daily. E#8 stated that in some instances, an ED-to-ED or ED-to-inpatient transfer is declined based on capacity, the transferring facility is then informed. E#8 stated that for inpatient transfers 3 approvals are required to be completed before a patient will be accepted which includes physician acceptance, financial (insurance) approval, and capacity approval. E#8 demonstrated on the computer that 3 icons that represent these approvals need to turn green for the patient to be accepted. E#8 stated that for emergent transfers [ED-to-ED], only the physician acceptance is required; financial approval is not required, and insurance verification is not done. E#8 stated that capacity approval means that the patient has been accepted but is awaiting bed availability. E#8 stated that E#8 does not recall any complaints/grievance filed in relation to the transfer of Pt. #2. E#8 stated that although Pt. #2's transfer request was put in as an inpatient transfer, E#8 stated that insurance verification should not have been done. E#8 stated that Pt. #2's case should have been marked or noted as an EMTALA transfer.

8. On 10/8/2024 at approximately 1:05 PM, an interview was conducted with the Patient Logistics RN (E#9). E#9 stated that no insurance verification is done for emergent cases. E#9 stated that Pt.#2 was from [transferring hospital] and was intubated, septic and on vasopressors (a class of drugs that constrict blood vessels to increase blood pressure in people with low blood pressure or shock). E#9 stated that Pt.#2 was accepted but there were no beds available at that time. E#9 stated that Pt. #2's insurance was not verified.

9. An interview was conducted with the Director of Regulatory Compliance (E#1) on 10/09/2024, at approximately 11:00 AM. E#1 stated that they were just informed last night [10/08/2024] around 9:00 PM, that the Transfer Center had received an email on 07/31/2023 with a complaint from an ED physician from an outside hospital regarding the transfer request made for Pt. #2. E#1 stated that it was very detailed in explaining the conversation between the referring ED physician and the Transfer Center staff (identified as E#9). E#1 stated that they spoke with E#9 and the Director of Patient Logistics (E#8) last night regarding the email and based on their response, E#1 stated that it appeared that there was an EMTALA violation. E#1 stated that there was documentation in E#9's personnel file indicating that there was a discussion between E#9 and the Manager (E#16) regarding the complaint which occurred shortly after receiving the email back in 2023; however, the concern was never escalated up to Risk or higher management. E#1 stated that based on the notes from their discussion, it seemed that there was an issue with insurance being mentioned. E#1 stated that for ED to ED transfers, insurance should not be reviewed or requested at all, and that the transfer request should have been accepted. E#1 stated that they will be doing a gap analysis (thorough review) of the transfer center process and at this time were not aware of any other incidents where insurance was asked for emergency transfers. On 10/10/2024, at approximately 11:00 AM, E#1 stated that in Pt. #2's case, it was considered a "Just Say Yes" transfer, which means even if they didn't have an ICU bed available at the time, they would have accepted the patient to transfer to the ED. E#1 stated that they should just let the referring hospital know that they have no beds at the time but can still send the patient to the ED. E#1 stated that typically they wouldn't deny ED-to-ED transfers unless they were on bypass, which they were not at the time Pt. #2's request came in.