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Based on record review and interview, facility failed to ensure appropriate documentation was completed for 1 of 3 patients (Patient #32) who were transferred to another facility in a total sample of 22 Emergency Department medical records reviewed.

Findings include:

The facility failed to complete the appropriate documentation for 1 of 3 patients who were transferred to another facility. See Tag A-2409.

Based on record review and interview the facility failed to follow their policy to ensure that appropriate documentation was completed for 1 of 3 patients (Patient #32) who were transferred to another facility in a total sample of 22 Emergency Department (ED) medical records reviewed.

Findings Include:

A review of the facility policy titled, "Emergency Medical and Treatment (EMTALA), AW", last reviewed 07/28/2020, revealed: "...Transfers 1. If a patient is stabilized (meaning that no material deterioration of the condition is likely, within reasonable medical probability to result from or occur during transfer) the patient may be transferred...3. In addition, the transfer must be an "appropriate transfer." An appropriate transfer is a transfer in which: a. The hospital provides the medical treatment within its capabilities that will minimize the risks to the individual's health...b. Sending Documentation. The physician or Qualified Medical Person shall complete the "TRANSFER FORM" prior to transfer..."

Patient #32 was admitted to the facility's ED on 06/25/2022 at 1:55 PM with arrival complaint of "CHEST PAINS WORSE TODAY", and had diagnoses that included "Acute ST elevation myocardial infarction (STEMI), unspecified artery (HCC)." Patient was transferred via ambulance to another facility's cath (catheterization) lab on 06/25/2022 at 3:10 PM.

Patient #32's ED Physician BB's assessment, completed on 06/25/2022 at 2:31 PM, revealed, "HPI [history of present illness]...presenting with chest pain. Upon arrival, EKG [electrocardiogram] noted to be showing acute STEMI [heart attack]...IMPRESSION and PLAN...As there is no cardiac cath available here, discussed case with [Accepting Physician Name] in Milwaukee. Agreeable with plan for heparinization [anticoagulation], will transfer patient to walkie [Milwaukee] for further care. I updated the patient on [his/her] condition, discussed need for transfer. [He/she] was in agreement. Patient started on heparin infusion as well, transferred to Milwaukee for further care...DISPOSITION ED Disposition: Transfer to Another facility Condition: Stable..."

A review of Patient #32's medical record revealed that there was no Transfer Form found in Patient #32's medical record per facility policy.

During an interview on 08/02/2022 at 10:11 AM with ED Manager H, when asked if there should have been EMTALA transfer paperwork completed for Patient #32, Manager H stated "Yes, I would expect there to be EMTALA paperwork completed for a transfer."

During an interview on 08/02/2022 at 11:47 AM with ED Registered Nurse (RN) X, when asked if there is paperwork completed for transfers, RN X stated "We fill out sheets regarding transfers from one facility to the next, this is done on every patient."