FILE: 11-005
DATE: February 17, 2011
STATE: California
TAG: A2411
TITLE: Recipient Hospital Responsibilities
ALLEGED VIOLATION:
Based on interview and record review, the facility did not accept an appropriate transfer of a patient with an emergency medical condition even though the facility had the specialized capabilities, which included an ENT (Ear, Nose, Throat) physician on call, to treat the patient (Patient 1). The facility also failed to maintain a complete and accurate transfer log as required by its policy.
… A review of Patient 1’s record from the transferring facility disclosed that Physician A called the facility on 1/22/11 at 11:30 am, and was given the name and number of Physician D. The following was documented at 11:35 am in Physician A’s ED note, “discussed with Physician D, doesn’t take transfers.” Physician A then made arrangements to transfer Patient 1 to another facility. A review of Patient 1’s
records from that facility disclosed that Patient 1 arrived in their ED at 1:35 pm and was transferred to the Operating Room at 3 pm.… The facility’s policy titled, EMTALA – Patient Transfer, dated 8/09, was reviewed on 2/3/11. It read as follows: The facility will maintain a log of the inquiries and subsequent disposition for all requested patient transfers from other hospitals. This request for transfer log will include:
• name of hospital requesting transfer, time of request, name of individual requesting transfer, name of individual receiving request, patient
• name, patient condition, reason for transfer, disposition of transfer (accept or refuse) and if refused, reason for refusal.A blank copy of the facility’s transfer communication form was provided on 2/15/11. This form contained spaces in which to insert the information required by the facility’s policy. The following was written at the bottom: If transfer must be denied: dictate a note giving details of why the transfer had to be denied, make specialist aware that they should do the same it they cannot accept the patient.
The transfer communication forms for 1/22/11 were reviewed and Patient 1’s name was not on the list. On 2/3/11 at 3:35 pm, Administrative Staff F and Physician C, the medical director of the ED, confirmed that they also could not find a transfer communication form for Patient 1.
…During a subsequent interview on 2/8/11 at 9:05 am, Physician A stated he was positive that Physician B did not offer to accept Patient 1 into the ED during their conversations.
During a subsequent interview on 2/15/11 at 4:55 pm, Physician B stated that he told Physician A he would accept Patient 1 during both the initial call and the second call. He again confirmed that he had completed the top half of the facility transfer communication form but did not know what happened to it.
COMMENT: CMS places a heavy burden of documentation on each facility. In this case, lack of documentation may not prove which version is accurate, but it is enough to prove a failure to document, which is enough for CMS to issue a citation.
NOTE: Citations issued by CMS for EMTALA violations are allegations that have not been proven in any court and the information is presented here in summary format for educational purposes only to demonstrate the circumstances which in the view of CMS constitute EMTALA violations. Identifying information is removed to focus on the allegation without prejudicing the facility.