Based on facility document review and staff interviews, the hospital failed to accept an individual from a referring hospital who required such specialized capabilities of the facility although it had the capacity and capability to treat the individual's emergency medical condition. Findings included: Facility based rules and regulations Policy Tech Ref #5832 entitled, "On Call Physician" stated in part, "EMERGENCY CARE SERVICES 4. There may be times when no listed or unlisted consultant is available for coverage. In those instances, the Emergency Department will arrange for transfer of those patients needing such services to a facility where the services are available, in accordance with EMTALA regulations, and established diversion protocols.5. [sic] In the event that an on-call physician should not be available, the following should be called in the respective order: a) Any physician in the applicable specialty if an emergent situation so requires; b) Medical Director of the Emergency Department; c) Chief of the applicable Section; d) Chief-elect of the Medical Staff; or e) Chief of the Medical Staff ... CALL RESPONSIBILITIES Revised 8/29/2015 1. EMERGENCY DEPARTMENT AND SERVICE CASES a. PARTICIPATION: All members of the Medical Staff ... shall be required to participate in the Emergency Department On Call Coverage Schedule. Revised 8/29/2015 b. CALL COVERAGE: Each service taking call shall make every effort to provide coverage twenty-four (24) hours a day throughout the year. For each specialty, each individual taking call will be expected to share call equally. Revised 8/29/2015 Emergency call will take place 24 hours a day, seven days a week. c. ON CALL SCHEDULE OF COVERAGE: Each on-call service will create and provide to the Medical Staff Office (MSO) a call coverage schedule ... "On-call" coverage shall be provided to the Emergency Department from the Active, Consulting and Provisional staffs in the following specialties and subspecialties: ... Gastroenterology [GI] ... Each Clinical Section shall be responsible for providing to the Medical Staff Office an accurate and current list of the on-call coverage ... d. DURATION OF ON CALL COVERAGE SCHEDULE: When a medical staff member is scheduled for a particular day/date for the Emergency Department On Call Coverage Schedule, he is on call from 7:00 a.m. the day of call until 7:00 a.m. the following morning. Revised 8/29/2015" Facility policy entitled, "Emergency Department: On-Call Specialist" stated in part, "Purpose: To define guidelines of on-call specialists in the Emergency Department (ED). I. Emergency Department Medical Coverage A. Emergency Department medical services are provided 24 hours per day ... C. The physicians are on-call for 24 hour periods beginning at 7 am. ...F. The Emergency Department physician or private physician requesting a specialist consult must talk directly to the specialist in order to receive the consult or follow up care." Review of the Transfer Center Reports revealed a call dated 6/10/18 regarding patient #2 that stated in part, "Diagnosis Notes: vomiting, upper abdominal pain, asking about a hydascan (? Sp) [HIDA scan an imaging procedure used to diagnose problems of the liver, gallbladder and bile ducts]/ any GI on call ... but ER advising that they do not take out of county pts ..." After the doc to doc [doctor to doctor], the doctors decided the patient could be handled outpatient. Review of the Transfer Center Reports revealed a call related to patient #1 dated 7/14/18 at 5:38 am that stated in part, "95 yr [year] old pt [patient] GI bleed, needing GI, in touch w/ ER [emergency room ], [Staff #1's name omitted] on call & in touch w/ MD [medical doctor], but MD stating "[they] cannot take care of all these pts, you called me last night", basically saying [they] could not accept this pt, [staff #9] made aware & [they] stated that if we had the capability to accept the pt & did not, that was an EMTALA violation ..." In an interview with staff #9 on the afternoon of 8/8/18, when asked about patient #1, staff #9 stated," I remember what happened ... I needed GI coverage. I don't remember what the exact issue was ... I called [the transfer center] and [staff #1] was covering for GI that day. The call center called me back and said '[staff #1] doesn't want to take any more patients today.' I said, 'you understand that's an EMTALA violation and I'm going to have to report it?' [The call center nurse] said, 'Go ahead and do what you need to do.' The GI doctor I never talked to her personally, [staff #12] was the nurse at the transfer center, the N.O.D. [nurse of the day] taking the phone call." Staff #9 was asked where the patient was transferred to for care. Staff #9 replied, "They [patient #1] had to go somewhere else because they [the receiving hospital] refused the transfer. Usually they are good about taking people up there... GI [services] has always been tricky there. Usually, if they refuse they are closed or have no coverage. [Staff #1] just doesn't feel like taking any patients. The nurse said [staff #1] does this all the time. I said it's a problem then." Staff #9 added regarding the individual who took the call at the transfer center, "I think that what [staff #12] said is [staff #1] doesn't take people from outside the area. I said, 'You're our closest and that how's referrals work.'" In an interview with staff #1 on the morning of 8/9/18, when asked if they remember the situation with patient #1, staff #1 stated, "No, I don't." When asked to describe how they are contacted when scheduled as GI on-call. Staff #1 replied, "Sometimes the transfer center calls us from different places. I'm at home. They call you and present the case and see if it's one I'm interested in taking or capable of taking. They present the case. If it's a bleeder like this, I tell them to bring them to ER so that it's safer that way." Staff #1 continued, "On top of my mind I don't remember [the transferring hospital] calling me. This is what I usually talk to the doc to on the opposite side asking what kind of bleed is it. How stable is he? Is he stable enough to come here? Is their transportation good?" Adding, "The bleeders I usually don't accept as a direct patient, usually a hospitalist is involved with it and me. Usually there is a call with the ED doc, me and the people from the other side [transferring facility]." Staff #1 was asked if the location of the transferring facility affects acceptance at the facility. Staff #1 replied, "Usually doesn't affect it, usually [other hospitals] call ... each clinical situation is different. We usually don't say no; I ask the transfer center what the situation is when it comes to other hospitals. [Other hospitals] are close with no GI. [Transferring hospital] I'm not familiar with that hospital and how far it is. I'll ask someone else how far we are from that place; they might need to go to a closer hospital based on the bleeder. If a hospital is closer and they can go faster there. [A hospital close by] is closer with 3 GI doctors. We tell the hospital the other place is closer; it will help the patient. The sooner the patient comes to the hospital the sooner they can be helped ... If we are closer to that hospital, we take it ... Sometimes [receiving hospital] tell you this is friendly hospital, they don't have GI so we take these patients. It depends which hospital is closer when it comes to GI bleeding. If a bleeder, they need attention right away, they need to go to the closest hospital. If your hemoglobin is 3 you need to transfuse, you can't just transfer the patient." Regarding patient #1, staff #1 stated, "I don't remember this. If I remembered, I would have told you. I don't even know if I was called or not." Staff #1 was informed according to the on-call schedule they were on-call that day and the day prior. Staff #1 said, "Sometimes, I do ask them to treat at the closer hospital. If [another hospital] is closer, I say see if they're available if they're closer than us. We don't pick and choose. Depends what the other doctor is presenting us." In an interview with staff #1 on the afternoon of 8/9/18, staff #1 stated, "Sometimes we have our ER patients, consults, CCU [critical care unit], ICU [intensive care unit], and we don't have enough time to handle an emergency, is another scenario. Sometimes we're too busy to accept another patient. Sometimes you really don't have time to get to another case. You can't cover all of west Texas. Being GI here, you might get calls from several different people, you do as much as you can. Sometimes you don't have time if you're already handling another person." When asked if they had received any EMTALA training, staff #1 replied, "During residency and fell owship. We're kinda told no you can't refuse, use your judgement as much as you can." Staff #1 was shown the transfer center note for July 14, 2018 regarding their declining the transfer of patient #1. Staff #1 replied, "Yeah. I don't remember this that like I said. I don't remember the call exactly ... There can be situation like this I'm already doing something else or talking to some else, that you can't get to the emergency." They did not state that they had any emergency situations on the date in question. Staff #1 added, "Sometimes we tell the patients if we're already busy in our hospital, 'We can't cover all of west Texas you have call someone else.' With all ICU, ER patient, I'll tell them I can't take care of the patient. When I came here a senior doctor told me that you can't cover all of west Texas. You get calls from so many different people. Suppose I get call from 2-3 emergencies. If I take one patient and start to take other patient, its overwhelming, if you take another patient and you can't handle it." Although the facility had the capacity and capabilities of providing specialized GI services to patient #1, the facility failed to accept the transfer of the individual. The receiving hospital also failed to train their staff regarding EMTALA requirements. In an interview with staff #5 [a transfer call center operator] on the afternoon of 8/9/18, when asked if they received any EMTALA training, staff #5 replied, "I came from the ED where I had training in EMTALA there before I moved here." When asked staff #6 [a transfer call center operator], if they received any EMTALA training, staff #6 stated, "Excuse me? What's that?" When defined EMTALA, they stated, "No." In an interview with staff #7, the staff development manager, on the afternoon of 8/9/18, staff #7 stated, "ER nurses get EMTALA training." When asked about other staff throughout the hospital, staff #7 stated, "There is no formal EMTALA training." Staff member #12, who received the call on July 14, 2018, failed to report the EMTALA violation through the necessary channels. When asked for EMTALA policies and procedures, staff #2 was unable to provide any specific policies.