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Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to fulfill transfer requirements for 5 patients (P-11, 12, 16, 21, 30) of 5 patients reviewed for transfer, resulting in the potential for less than optimal outcomes for all patients requiring transfer to another facility from the emergency department. Findings include:

See tag 2409: Failure to fulfill transfer requirements.

Based on record review and interview, the facility failed to have transfer documents present and/or designate resources needed during transfer for 5 (#11, 12, 16, 21, 30) of 5 patients reviewed for transfer according to facility policy resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include:

Review of the medical record for P-11 revealed he was a 5-year-old male who presented to the ED 5/17/2024 at 1512 and was diagnosed with febrile hyperbilirubinemia. Physician note indicated patient needed to go to a Children's hospital ICU and was at high risk for decompensation. It was determined flight transport was required. Review of the EMTALA (emergency medical treatment and labor act) transfer form revealed section 4, "Mode/Support During Transfer as Determined by Physician" was left blank. A form titled "Physician Medical Necessity Statement Supporting Ambulance Transport" was present which indicated the date, patient name, sending physician, sending and receiving facility, the need for cardiac monitoring or IV (intravenous) maintenance, and the reason for transfer. Following the above listed information was a statement reading as follows: "In my professional opinion, this patient requires transport by ambulance and should not be transported by other means. The patient's condition is such that transportation by medically trained personnel is required. I certify that the above information is true and correct based on my evaluation of this patient, to the best of my knowledge. I understand that this information will be used by the Centers for Medicare and Medicaid and/or its agents to support the determination of medical necessity for ambulance services." Under the statement were listed options, physician, physician assistant, nurse practitioner, registered nurse, and discharge planner. The line for registered nurse (RN) was marked and the printed name and signature of the nurse was present with her credentials and the date. No time of signature was present. There was no acknowledgement or signature present by a physician or provider.

Review of the medical record for P-12 revealed she was a 9-year-old female who presented to the ED on 5/17/2024 at 2128 and was diagnosed with status asthmaticus. Review of the EMTALA transfer form revealed section 4, "Mode/Support During Transfer as Determined by Physician" was left blank. The "Physician Medical Necessity Statement Supporting Ambulance Transport" was present and was found to have been completed and signed by the RN. No acknowledgement or signature was present by the physician or provider. Physician note indicated the patient needed a pediatric ICU and that the patient required continuous nebulizers during transport.

Review of the medical record for P-16 revealed she was a 41-year-old female who presented to the ED on 6/2/2024 at 2043 and was diagnosed with a food bolus impaction. No transfer documents or evidence of transferred records were found. Review of physician documentation on 6/3/2024 at 1250 stated, "Spoke to Dr. (physician name) at (accepting facility name) who accepted patient for transfer. Patient is stable. She will go via private vehicle to be driven by her husband."

On 10/1/2024 at 1500, Emergency Department Clinical Director Staff B, who was present during chart review, was queried as to why there were no transfer documents present to which he stated it was because the patient had been sent by private car. The facility failed to identify P-16 as a transfer and follow EMTALA transfer requirements.

Review of the medical record for P-21 revealed she was a 42-year-old female who presented to the ED on 6/11/2024 at 1137 and was diagnosed with being bipolar. Physician note indicated the patient had a petition and certification stating she had unresolved psychiatric symptoms and required inpatient psychiatric care. Review of the EMTALA transfer form revealed section 4, "Mode/Support During Transfer as Determined by Physician" was left blank. The "Physician Medical Necessity Statement Supporting Ambulance Transport" was present and was found to have been completed and signed by the RN. No acknowledgement or signature was present by the physician or provider.

Review of the medical record for P-30 revealed she was a 40-year-old female who presented to the ED on 8/13/2024 at 1557 and was diagnosed with a post-operative abscess. Physician note indicated the patient was having post op surgical complications and needed to see specialist surgeon at another facility. It was determined flight transportation would be needed due to delays in ground transportation. The EMTALA transfer form was not present in the medical record. Discharge information revealed she was being transferred to another acute care facility and P-25 left the ED 8/13/2024 at 2023. Physician documentation dated 8/13/2024 at 1631 stated, "I did discuss the case with Dr. (physician name) from Urology in Traverse City Michigan at (hospital name)...He is accepted (sic) the patient in transfer...Patient has been accepted by Dr. (physician name) in the ER (emergency room) at (hospital name). Working on arranging transfer now." The "Physician Medical Necessity Statement Supporting Ambulance Transport" was present and was found to have been completed and signed by the RN. No acknowledgement or signature was present by the physician or provider.

Review of patient transfer form did not have a way for providers to note if the patient was stable or unstable. Review of documentation revealed no physician certification statements regarding transfer details and no clear indication if patient was stable or unstable upon transfer.

Facility policy #14334383 titled "EMTALA Transfers To Other Acute Care Facilities 100-210" last revised 9/2023 states, "EMTALA forms are required when transferring a patient to another acute care facility....The transfer from (hospital name) will be affected through qualified personnel and equipment. The patient's attending physician has the responsibility to determine the appropriate mode of transportation (air or ground), equipment, and attendants needed for the transfer. Completion of the EMTALA Transfer Record is required (TR-0015)...The attending physician must complete the Physician Medical Necessity Statement Supporting Ambulance Transport form (EMS-0001)."