Based on review of hospital documents, medical record review and interviews with hospital staff, the hospital failed to accept an appropriate transfer of an individual who required the specialized capabilities and facilities of the hospital. This occurred for four (Patients # 2, 3, 4 and 9) of four patient encounters reviewed from the hospital's ED (emergency department) Incoming Referral forms. Findings: ~Review of a hospital policy, titled, "Patient Transfer and EMTALA", approved 06/2015, documented, "...Recipient Hospital Responsibilities: 1. NRHS Facilities with specialized capabilities do not refuse a request for transfer of a patient requiring those capabilities if the facility has the capacity to treat the patient. 2. NRHS does not refuse a transfer request for any reason other than: a. Capability; or b. Capacity..." ~NRHS, privilege request form, entitled, " General Surgery/General Laser Surgery", requested and approved for Staff H and K documented "...I hereby request core General Surgery Privileges as follows: to correct or treat various conditions, illnesses, and injuries of the: abdomen and its contents; Also included within this core of privileges: complete care of the critically ill patients with underlying surgical conditions in the emergency department and intensive care unit..." ~The core privilege did not contain an age exclusion in the privileges for any of the physicians. This was confirmed by the Director of Legal and Regulatory Services on the morning of 08/25/2015. ~Hospital forms titled, "ED INCOMING REFERRAL", from May 2015 to August 2015 was reviewed by the surveyors. The following medical records were obtained from this list: 1. The medical record for Patient #2 was reviewed. The record documented on 07/01/2015 at 2:39 p.m., the [AGE] year old patient presented to Hospital P with complaints of abdominal pain. The patient received a medical screen examination (MSE) by a qualified medical person (QMP), complete blood count (CBC), basic metabolic profile (BMP) and a computerized tomography (CT) of the abdomen and pelvis with contrast. Based on the results of the diagnostic procedures and the examination of the QMP the patient was diagnosed with [DIAGNOSES REDACTED] ~ At 5:12 p.m. the ED physician called NRHS. At 5:30 p.m., NRHS returned the call to Hospital P. The medical record documented, "...surgeon will not op [operate] on anyone <18 y/o [years old]..." The patient transfer was denied by NRHS. ~Review of the on-call list for NRHS, documented Staff K was the on-call surgeon for 07/01/2015. ~An e-mail, concerning Patient #2, from the NRHS's Director of Legal and Regulatory Services to CMS, dated and timed 07/02/2015 at 11:02 a.m., documented, "...Now, we need your guidance on another potential EMTALA violation. It was reported late Wednesday evening that the on-call physician refused to accept a [AGE] year old patient with appendicitis from (hospital name omitted, Hospital P). His refusal was based on his practice of not performing surgery on anyone under 16 years of age. As you know, we are in the process or reviewing and updating our General Surgery Core Privileges Form so this issue is still a work in progress..." ~An e-mail,concerning Patient #2, from CMS to NRHS' Director of Legal and Regulatory Services, dated and timed, 08/03/2015 at 8:40 a.m., documented, "...If the on-call physician does not perform surgery on anyone under the age of 16 years (and the hospital can show that he has not performed surgery on anyone under 16) and refuses a transfer request for a 14- year old with appendicitis, is that an EMTALA violation? No, it will not be..." ~However, review of the, "Surgical Cases by Surgeon", for Staff K from 08/26/2014 through 08/26/2015, documented Staff K performed three laparoscopic appendectomies on patients from the ages of 8 to 16. With the most current laparoscopic appendectomy performed on 08/13/2015 on a [AGE] year old patient . ~Another e-mail ,concerning Patient #2 , between an NRHS surgeon, Staff J, and the Chief of the Executive Officer, (CEO), documented, "...On July 27, 2015 at 9:18 a.m., (staff name omitted, NRHS's CEO) wrote: Has the Surgery Dept addressed this re-occurring problem? With the addition of these two that now makes 4 potential EMTALA violations and we are due to report to CMS our corrective actions on #1 and #2 by 8/1/2015..." ~On the the morning of 08/25/2015, NRHS' Director of Legal and Regulatory Services was asked if she reported the above information to CMS. She stated, "No". 2. The medical record for Patient #3 was reviewed. The record documented on 05/31/2015 at 8:42 a.m., the patient presented to Hospital P with complaints of vomiting. The patient received a MSE by a QMP, CBC, comprehensive metabolic profile (CMP), Troponin, Creatine phosphokinase (CPK), acute abdominal series with chest, electrocardiogram (EKG), and a computerized tomography (CT) of the abdomen and pelvis without contrast. Based on the results of the diagnostic procedures and the examination of the QMP the patient was diagnosed with [DIAGNOSES REDACTED] ~The transfer request was denied by the on-call surgeon, Staff L, who has a certification from the American Board of Thoracic Surgery. The reason for denial was the procedure was not performed at NRHS. ~Review of the hospital's surgery log documented various types of hernia repairs performed at NRHS by Staff L. ~Patient # 3 was transferred to Hospital R where a para-esophageal hernia repair was performed without complications. 3. The medical record for Patient # 4 was reviewed. The record documented on 06/18/2015 at 11:57 a.m. the patient presented to the ED at Hospital O. The patient presented to the ED after a routine primary care physician (PCP) visit at which time the patient developed vomiting and some chest pain. The patient received a MSE by Staff T chest x-ray, CBC, CMP, Creatine Kinase-MB (CK-MB) Troponin, Prothrombin time (PT), amylase, lipase and EKG. Based on the results of the diagnostic procedures and the examination by Staff T the patient was diagnosed with [DIAGNOSES REDACTED]. DW (physician name omitted, Staff G [ED physician at NRHS]), pt not having acute [DIAGNOSES REDACTED], will be appropriate to rule out acute coronary event here and consult surgeon after..." The patient was not transferred to NRHS. The patient was admitted to Hospital O. ~In an interview with Staff T on 09/01/2015 at 8:44 a.m., Staff T confirmed what was written in Patients #4 medical record. Staff T stated during consultation with the patient's PCP, the PCP stated Patient #4 had gallbladder problems in the past. ~ Review of a NRHS form titled, "ED INCOMING REFERRAL," dated 06/18/2015 for Patient # 4, documented, "...No need for T[transfer], pt [patient] can be r/o [rule out] there ... " 4. The medical record for Patient #9 was reviewed. The medical record documented on 05/16/2015 at 7:40 a.m. the patient presented to the ED at Hospital O. The patient presented with complaints of bleeding from a stoma. The patient received a MSE by a QMP, CBC, CMP, EKG, and CT of the abdomen and pelvis with contrast. Based on the results of the diagnostic procedures and the examination of the QMP the patient's clinical impression was traumatic abdominal pain and traumatic bleeding from colostomy. The medical documented, "...NRH(Norman Regional Health System) refused patient so they are going to call (hospital name omitted, Hospital Q). ~A NRHS form titled, "ED INCOMING REFERRAL/ TRANSFER FORM", dated 05/16/2015, documented, "...I spoke with (physician name omitted, Staff L) who recommended higher level of care and did not wish to accept..." ~The Trauma Referral Center (TReC) report for the Patient # 9 documented, "...TReC spoke with (physician name omitted) regarding the pt. (Physician name omitted) spoke with (physician name omitted, Staff L) regarding accepting the PT [patient]. and (physician name omitted, Staff L) declined to accept the PT. Based on the possibility the PT could need a higher level of care..." ~ Patient #9 was transferred the ED at Hospital Q. At Hospital Q the patient received a MSE by the QMP. The QMP consulted with the surgeon. No surgery was performed and the patient was discharged home.

Based on review of hospital documents, medical records and physician credentialing files and interviews with hospital staff, the hospital failed to enforce policies and procedures to ensure compliance with the requirements of 42 CFR 489.24. The hospital failed to enforce its policy and procedure concerning appropriate transfer of patients. Findings: 1. Norman Regional Health System (NRHS) policies and procedures concerning EMTALA were reviewed on 03/23-03/25/15. a. NRHS, policy and procedure, entitled, "Patient Transfer and EMTALA", effective 04/2014, documented, " ...Patients receive stabilizing treatment within the capability and capacity of NRHS to ensure: a. The EMC is removed; or b. The patient is stable for transfer...." b. NRHS, policy and procedure, entitled, " Transfer of Patient to Another Acute Care Facility", effective 01/28/15, documented, "...To procure specialized care at Norman Regional Health System (NRHS), or because NRHS does not have the capacity to care for the patient (bed space, equipment, personnel) or to accommodate Patient request to transfer to another acute car facility (i.e. O U Medical Center)..." 2. NRHS, privilege request form, entitled, " General Surgery/General Laser Surgery", requested and approved for Staff N on 04/23/13, documented "...I hereby request core General Surgery Privileges as follows: to correct or treat various conditions, illnesses, and injuries of the : abdomen and its contents; Also included within this core of privileges: complete care of the critically ill patients with underlying surgical conditions in the emergency department and intensive are unit..."There was exclusion to age in the privileges for Staff N. This was confirmed by Staff V the credential specialist. 3. Review of the on-call emergency department (ED) schedule for the month of December 2014, documented Staff N was the on-call surgeon on 12/26/14 from 7:00 am until 11:59 pm. 4. Review of the medical record for Patient #8, documented on 12/26/14 at 11:27 am Patient #8, a 4 year old female, presented to the Porter ED, with a three-day complaint of abdominal pain and decrease in oral intake. The patient diagnosed with acute appendicitis. 5. There was no documentation of Staff N consulting or evaluating Patient #8.

Based on review of the hospital's emergency department (ED) log, policies and procedures, and interviews with hospital staff, the hospital failed to maintain a central log entry for each individual who presents seeking treatment and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged . In six of six months (September 2014 through March 20,2015) the emergency services log entries for patients was not complete. Findings: Norman Regional Health System (NRHS), policy and procedure, entitled, "Patient Transfer and EMTALA", effective 04/2014 documented, " ...The Emergency Medical Care Log includes: (1) Includes: (a) Patient identification; (b) Date of service; (c) Medical complaint; (d) Provider name; and (e) Patient disposition;..." Norman Regional Health System (NRHS) is an acute care hospital with two campus locations, both in Norman, Oklahoma, for inpatient care, including an ED at both facilities. The hospital also has a third ED located in Moore, Oklahoma. 1. The ED logs from all three hospitals were reviewed from 09/01/14 through 03/20/15. According to statistics submitted by the hospital, all three logs under review contained 53,321 entries for the time period. One hundred and twenty-six (126) of the entires did not contain dispositions for the patients. Porter: a. September 2014: seven (7) patients did not have a disposition documented. b. October 2014: six (6) patients did not have a disposition documented. c. November 2014: four (4) patients did not have a disposition documented. d. December 2014: two (2) patients did not have a disposition documented. e. January 2015: seven (7) patients did not have a disposition documented. f. February 2015: twenty-five (25) patients did not have a disposition documented. g. March 1 - 20, 2015: seven (7) patients did not have a disposition documented. Moore: a. September 2014: three (3) patients did not have a disposition documented. b. October 2014: one (1) patient did not have a disposition documented. c. January 2015: four (4) patients did not have a disposition documented. d. February 2015: five (5) patients did not have a disposition documented. e. March 1 - 20, 2015: two (2) patients did not have a disposition documented. Healthplex: a. September 2014: six (6) patients did not have a disposition documented. b. October 2014: three (3) patients did not have a disposition documented. c. November 2014: five (5) patients did not have a disposition documented. d. December 2014: seven (7) patients did not have a disposition documented. e. January 2015: six (6) patients did not have a disposition documented. f. February 2015: fifteen (15) patients did not have a disposition documented. g. March 1 - 20, 2015: eleven (11) patients did not have a disposition documented. 2. The above information was presented in the exit interview with the administrative staff.

Based on review of hospital documents, medical records and interviews with hospital staff, the hospital failed to effect appropriate transfers. In one (Record #8) of two records reviewed for the last six months, of patients who were transferred to another facility, the hospital did not execute a proper transfer. The hospital transferred a patient that they had the capability and capacity to treat. Findings: 1. Review of the hospital policies and procedures documented: Norman Regional Health System (NRHS), policy and procedure, entitled, "Patient Transfer and EMTALA", effective 04/2014 documented, "...Patients receive stabilizing treatment within the capability and capacity of NRHS to ensure: a. The EMC is removed; or b. The patient is stable for transfer...." 2. Review of the on-call emergency department (ED) schedule for the month of December 2014, documented Staff N was the on-call surgeon on 12/26/14 from 7:00 am until 11:59 pm. 3. During medical record review in the morning of 03/25/15, Staff E and Staff D both stated the hospital does not perform pediatric surgery at either of the inpatient locations (Porter and Healthplex). 4. NRHS, privilege request form, entitled, "General Surgery/General Laser Surgery", requested and approved for Staff N on 04/23/13, documented "...I hereby request core General Surgery Privileges as follows: to correct or treat various conditions, illnesses, and injuries of the: abdomen and its contents. Also included within this core of privileges: complete care of the critically ill patients with underlying surgical conditions in the emergency department and intensive are unit..." Staff N's credential file did not contain specifications or exclusions to the treatment that would be provided, including the specifications of the age of patients. 5. Review of the medical record for Patient #8, documented on 12/26/14 at 11:27 am Patient #8, a 4 year old female, presented to the Porter ED, with a three-day complaint of abdominal pain and decrease in oral intake. The patient received a medical screen examination (MSE) by a qualified medical person (QMP), complete blood count (CBC), basic metabolic profile (BMP),urine analysis (UA), lipase and a computerized tomography (CT scan) of the abdomen and pelvis. Based on the results of the diagnostic procedures and the examination of the QMP the patient was diagnosed with acute appendicitis. a. The QMP documented a physician at another acute care facility was consulted and agreed to accept the patient. Patient #8 was transferred to accepting facility via ambulance. b. The medical record did not document whether the on-call surgeon Staff N, had been consulted. c. The medical record did not contain evidence the patient or the patient's family requested to be transferred to another acute care facility.