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Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to complete a physician certification regarding the medical benefits and risks of transfer. See deficiency A-2409-A.

2. The hospital failed to ensure the receiving hospital agreed to accept the transfer of the patient. See deficiency A-2409-B.

3. The hospital failed to ensure the transferring hospital sent to the receiving facility all medical records related to the patients' emergency condition. See deficiencyA-2409-C.

4. The hospital failed to ensure the transfer was through qualified personnel and transportation equipment. See deficiencyA-2409-D.

A. Based on document review and interview, it was determined that for 2 of 8 patients' (Pt. #1 and Pt. #8) clinical records reviewed for transfer, the hospital failed to complete a physician certification regarding the medical benefits and risks of transfer.

Findings include:

1. On 05/14/2024, the hospital's policy titled, "Transfer of the ED Patient" (revised 09/2021) was reviewed and required, "Due to various reasons, patients may require transfer to another hospital ... All transfers will be in accordance with ED EMTALA policy ... A decision may be made to transfer a patient if ... 4. The services needed by the patient are not available at (Hospital A) ... 1. Physician will determine the need for transfer and the appropriate transfer facility ... 7. The Transfer Form will be completed and signed by Emergency physician ..."

2. On 05/14/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 arrived at the Emergency Department (ED) escorted by Chicago Police Department (CPD) on 03/09/24 at 7:09 PM with Chief Complaint of Suicidal Ideation. The clinical record indicated that (Pt. #1) has a history of schizophrenia and bipolar disorder (type of mental disorder). A suicide risk assessment indicated (Pt. #1) was a high risk for suicide. The clinical record indicated that Pt. #1 was transferred to another hospital for inpatient psychiatric admission. The clinical record lacked a physician certification regarding the medical benefits and risks of transfer.

3. On 5/15/2024, the clinical record of Pt. #8 was reviewed. On 4/25/2024, Pt. #8 was brought to the ED due to schizoaffective disorder. On 4/26/2024, Pt. #8 was transferred to another hospital for inpatient psychiatric admission. The clinical record lacked a signed physician certification regarding the medical benefits and risks of transfer.

4. An interview was conducted with the ED Manager (E #3) on 05/15/2024 at approximately 10:30 AM. E #3 confirmed that the physician certification for transfer was not completed for Pt. #1 and Pt. #8.


B. Based on document review and interview, it was determined that for 1 of 8 (Pt. #1) patients requiring transfer for psychiatric treatment, the hospital failed to ensure the receiving hospital agreed to accept the transfer of the patient.

Findings include:

1. On 05/14/24, the hospital's policy titled, "Transfer of the ED Patient" (revised 09/2021) was reviewed and required, " ... All transfers will be in accordance with ED EMTALA policy ... 6. It has been confirmed that the receiving hospital has the space and personnel to receive the transfer and they agree to the transfer... 2. ED Physician will speak directly with the physician who will accept the transfer. 3. ED staff will contact accepting facility for available bed. 4. Nurse to Nurse report will be given prior to transfer."

2. On 05/14/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 arrived at the Emergency Department (ED) escorted by Chicago Police Department (CPD) on 03/09/24 at 7:09 PM with Chief Complaint of Suicidal Ideation. The clinical record indicated that (Pt. #1) has a history of schizophrenia and bipolar disorder. A suicide risk assessment indicated (Pt. #1) was a high risk for suicide. The clinical record indicated that Pt. #1 was transferred to another hospital for inpatient psychiatric admission. The clinical record lacked documentation that the ED staff contacted facilities for bed availability and acceptance of (Pt. #1).

3. On 05/15/2024 at 1:35 PM, an interview was conducted with a Crisis Worker (E #2). E #2 stated that normally the Crisis Worker evaluates patients after they are medically cleared to help determine if the patient requires admission. The Crisis Worker would discuss the findings with the ED physician and if the assessment determines that the patient requires to be admitted but we cannot admit here to closed unit, we call different hospitals for bed availability. Once the hospital accepts the patient, the Crisis Worker will notify the nurse and the physician. This is documented in the clinical record including the names of facilities that were contacted and whether there is availability or not. E #1 stated this was not done for Pt. #1 because E #2 did not complete an assessment.


C. Based on document review and interview, it was determined that for 2 of 8 (Pt. #1 and Pt. #5) patients requiring transfer for psychiatric treatment, the hospital failed to ensure the transferring hospital sent to the receiving facility all medical records related to the patients' emergency condition.

Findings included:

1. On 05/14/24, the hospital's policy titled, "Transfer of the ED Patient" (revised 09/2021) was reviewed and required, " ... All transfers will be in accordance with ED EMTALA policy ... 6. A copy of the patient chart, including all lab and imaging data is to accompany patient ..."

2. On 05/14/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 arrived at the Emergency Department (ED) escorted by Chicago Police Department (CPD) on 03/09/24 at 7:09 PM with Chief Complaint of Suicidal Ideation. The clinical record indicated that (Pt. #1) has a history of schizophrenia and bipolar disorder. A suicide risk assessment indicated (Pt. #1) was a high risk for suicide. The clinical record indicated that Pt. #1 was transferred to another hospital for inpatient psychiatric admission. The clinical record lacked documentation that copies of pertinent medical records were sent to the receiving hospital.

3. On 5/16/2024, the clinical record of Pt. #5 was reviewed. On 5/06/2024, Pt. #5 was brought to the hospital's ED due to suicidal ideation and psychiatric evaluation. On 5/07/2024, Pt. #5 was transferred to another hospital for inpatient psychiatric admission. The clinical record lacked documentation that copies of all pertinent medical records were sent to the receiving hospital.

4. An interview was conducted with the ED Manager (E #3) on 05/15/2024 at approximately 10:30 AM. E #3 confirmed that the clinical records for (Pt. #1 and Pt. #5) lacked documentation that medical records were sent to the receiving hospital.


D. Based on document review and interview, it was determined that for 1 of 8 (Pt. #1) patients requiring transfer for psychiatric treatment, the hospital failed to ensure the transfer was through qualified personnel and transportation equipment.

Findings include:

1. On 05/14/24, the hospital's policy titled, "Transfer of the ED Patient" (revised 09/2021) was reviewed and required, " ... All transfers will be in accordance with ED EMTALA policy ... 5. ...primary nurse will arrange for transfer with appropriate level of support and appropriate equipment."

2. On 05/14/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 arrived at the Emergency Department (ED) escorted by Chicago Police Department (CPD) on 03/09/24 at 7:09 PM with a Chief Complaint of Suicidal Ideation. The clinical record indicated that (Pt. #1) has a history of schizophrenia and bipolar disorder. A suicide risk assessment indicated (Pt. #1) was a high risk for suicide. The clinical record included the following:

-A Nurse's (E #4) note dated 03/09/24 at 11:53 PM, "(Pt. #1) being discharged back to CPD. (Pt. #1) given discharge instructions. (Pt. #1) discharged to CPD. Name of Transporting Ambulance: Left with Chicago Police Department."

-An "Arrestee Medical Clearance Report" (completed and signed by MD #1) dated 03/09/24 at 11:28 PM, "Name of Examining Physician (name of MD #1) ... I have examined the arrestee and find him/her in need of hospitalization. Female psych unit at (Hospital A) is undergoing renovation. CPD to transport (Pt. #1) to another psych facility (Hospital B)."

-A "Police Release Form", dated 03/09/24 at 11:30 PM, "(Pt. #1) has been examined at (Hospital A) ED and has been: Treated & Released."

3. On 05/15/24 at 12:45 PM, an interview was conducted with the ED Physician (MD#1). MD #1 stated that MD #1 did not recall (Pt. #1) stating they were suicidal. However, MD #1 recalls that (Pt. #1) was aggressive and smelled of alcohol and was banging (Pt. #1's) head on window (triage area). (Pt. #1) required to be transferred due to the female psychiatric unit at (Hospital A) was not available. MD #1 stated that it is not appropriate to transfer psychiatric patients or patients with suicidal ideation via Chicago Police Department. Patients requiring transfer should be transferred via ambulance with appropriate personnel and equipment. This (Pt. #1) was not transferred via ambulance, (Pt. #1) was transported by the Police Officers.