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Based on documents review, record review and interviews the facility [Facility A] failed to ensure one of 21 sampled patients (Patient 100) received medical stabilizing treatment before being transfer to a psychiatric facility [Facility B] where patient was determined to be unstable to be admitted necessitating patient to be transfer by (911) emergency medical system (EMS) services to [Facility C] an acute hospital emergency department (ED) within an hour and 35 minutes from arrival to facility [Facility B].

This failure resulted in patient being transfer to the ED [Facility C] where he received medical treatment to stabilize the patient's medical condition. Subsequently patient was intubated (the insertion of a tube into the lungs to provide artificial ventilation) and admitted to the intensive care unit for several days.

Findings:

The facility's policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Patient Transfer to Another Facility, dated 10/21, indicated "It is the policy to assure that any individual presenting for care and treatment of a potential medical emergency will receive emergency services and care which means screening and treatment as required within the capabilities of the facility to stabilize the medical condition. Examination, evaluation and treatment shall include any necessary consultation with specialty physicians qualified to render treatment necessary to stabilize the patient."

A record review for Patient 100 was conducted on 4/7/22 and 5/5/22. The ED triage noted dated 2/26/22 at 8:35 p.m., indicated Patient 100 was "brought in by EMS after having anxiety, patient having tangential speech and difficult to reorient ..." Blood pressure 156/129.

The ED provider note, dated 2/26/22 at 10:31 p.m., indicated patient was seen in the ED for anxiety. This is a 55-year-old gentleman with history of methamphetamine abuse, noncompliance, CHF, with EF of 10-15% who is frequently in the ED with chest pain, shortness of breath, altered mental status secondary to intoxication who presents after 911 was activated because he was acting bizarrely outside a convenience store. He denied chest pain and shortness of breath when he initially showed up, however he started screaming about shortness of breath over an hour into his visit. According to this ED providers note BUN 35, Creatinine 1.5, troponin 0.013, and abnormal EKG. Patient eloped from the ED.

The nursing general note, dated 2/26/22 at 10:20 p.m., indicated "0022H Patient seen up in his wheelchair stating "I'm leaving. 0023H Patient eloped headed to the exit door ..."

The chest X-ray report, dated 2/26/22, indicated "mild residual venous congestion."

The ED triage note, dated 2/27/22 at 2:00 p.m., indicated patient brought in by police department (PD) due to gravely disabled and unable to answer due to physical or mental condition. B/P 176/122.

The ED provider (MD 1) note, dated 2/27/22 at 2:54 p.m., indicated on today's visit patient is acting bizarrely, the police department pick him up, activated the crisis and recovery emergency services (CARES) team for gravely disabled who plan to assess him here in the ED. CARES provides 24/7 crisis support for children and adults for mental health and alcohol and drug emergencies, consolidating intake, mobile crisis response and access to service. According to this ED provider's note Creatinine 1.5, troponin 0.011, and abnormal EKG.

A lab report dated 2/25/22 at 6:54 a.m., indicated a brain or B-type natriuretic peptide (BNP) of 3020.

Crisis team personnel evaluated patient and place him on a 5150 (72 hour hold) for gravely disable on 2/27/22 at 5:49 p.m.

Patient 100 stayed in the ED from 2/27/22 until 3/2/22. Treatment included bloodwork, medications such as Ativan, Clonidine, Carvedilol, Lasix, Zyprexa, Nicotine patch and ultrasound of scrotum.

ED Nurse Note, dated 2/28/22 at 1:00 a.m., indicated at 6:30 a.m., patient saturation dropped to 76% picked up but not sustainable then patient was placed on oxygen 2 liters nasal cannula and placed on pulse oximeter sensor. ED [physician's name] (MD 2) at bedside. However, there is no documentation from the ED physician regarding this incident and how was this going to be managed. Also, no physician order for oxygen was located in the record.

During an interview with MD 2 on 5/4/22 at 3:30 p.m., and 6/14/22 at 11:06 a.m., MD 2 was asked if there was any documentation and orders for interventions regarding the patient's low saturation on 2/28/22 event and need for oxygen for this patient. MD 2 reported "this low saturation event was not real, this happens with this patient, if the patient had a true hypoxia event, then it would warrant a note or documentation."

ED Nurse Note, dated 3/1/22 at 7:56 a.m., indicated patient "has been urinating and defecating on self, ripped off oxygen 02, monitor equipment, yelling out ..., awaiting placement."

ED Nurse Note, dated 3/1/22 at 8:12 p.m., indicated at 7:15 p.m., patient on room air...at 8:00 p.m., he claims intermittent shortness of breath. At 9:53 p.m., indicated patient noted reaching for his wheelchair, but weak to get self up to it (W/C). He started trying to get up but then went to lay back in the foam (floor).

Review of the vital sign flowsheet indicated on 3/1/22 at 8:25 p.m., patient's saturating was 91% with supplemental oxygen.

The Nursing Transfer Note, dated 3/2/22 at 2:28 p.m., indicated patient was transfer to the psychiatric facility [Facility B].

During a review of the ED provider (MD 1) note, dated 2/27/22 at 2:54 p.m., and concurrent interview with MD 1 on 4/7/22 at 5:10 p.m., MD 1 confirmed this was his ED note. MD 1 reported seeing Patient 100 on 2/27/22 initially and on 3/2/22 before patient was transferred to the psychiatric facility. MD 1 was made aware that according to record review the patient oxygen saturation had dropped requiring oxygen while in the ED. MD 1 stated "That I don't know. This patient would get anxious and scream at times, he will have these episodes at times but no he did not needed oxygen." MD 1 was asked if he evaluated this patient on 3/2/22 and if patient was stable to be transfer to the psychiatric facility. MD 1 stated "I did assess patient and he was medically clear or stable, he had been since 2/27/22." MD 1 was asked where the provider's note was indicating patient was stable to be transfer to the psychiatric facility. MD 1 stated "I probably did not do one, if is not in his record then I did not do one." The Patient Transfer to Another Facility document, dated 3/2/22, was reviewed with MD 1. MD 1 confirmed his signature on this document and acknowledged not indicating on the document whether this patient was stable for transfer.

During a record review of Patient 100 and concurrent interview with the quality data analyst (QDA) on 4/7/22 at 12:30 p.m., the QDA was asked to provide all ED providers notes for the visit from 2/27/22 to 3/2/22. QDA only provided ED provider note dated 2/27/22. QDA stated "There are no more ED MDs (providers) notes. I am sure of this."

During a record review of Patient 100 and concurrent interview with chief nurse officer (CNO) on 4/7/22 at 3:05 p.m., CNO acknowledged and confirmed there was no providers note in the record indicating patient was medically stable to be transfer to the psychiatric facility [Facility B].

During a review of the Receiving Facility B document titled, " Nursing Assessment, dated 3/2/22 at 3:55 p.m., indicated "patient arrives on the wheelchair, lethargic, awake, alert, oriented X 1 (person). It is obvious patient is short of breath. Oxygen saturation between 88% on room air and 93%, audibly panting and short of breath at rest while sitting.

The [Facility's Name] Admission/Discharge Combined Report, dated 3/2/22 at 4:41 p.m., the psychiatrist indicated "Patience chief complaint was "I cannot breathe. I feel miserable". The face-to-face evaluation patient was poorly able to cooperate with intake, patient was a blurb, struggling for air, making deep gas intermittently between questions... patient had 02 saturation that was fluctuating as slow as high 70s to low 90s. Patient was oriented to self. He appeared delirious possibly secondary to presumed hypoxia. After discussion with the internist determine best the patient be sent to medical hospital for further stabilization. Patient did not receive any medications while on the unit. Physically patient appeared to be decompensating as noted by low oxygen saturation and requiring medical attention. Patient was sent out to the emergency department not medically stable for [Facility's name]."

The Daily Flow Sheet, dated 3/2/22 indicated at 4:50 p.m., patient was transported by EMS to a hospital ED [Facility C].

During a review of the Receiving Facility C document titled,Facility C, ED MD Note, dated 3/2/22 at 5:43 p.m., indicated "[Patient's Name] is a 55 y.o. male, history of psychiatric disorder, possible anxiety, sent to [Facility A] on a 5150 hold. Patient was seen there ... and was sent to the [Facility B] for further psychiatric evaluation. At the psychiatric facility, patient was found to be hypoxic and was reporting some shortness of breath, so they sent him to the hospital for evaluation. Notably, patient had been hypoxic at [Facility A] as well. ED MD note at 6:47 p.m., indicated Patient was re-evaluated. "He was continued to have episodes of apnea where he would desaturate into the 70s unable to reverse with painful stimulation. Unable to safely transfer patient to CT scanner secondary to apneic episodes. As a result, patient was intubated for airway control, and ventilation. Patient had received 2 doses of Narcan without any effect."

Subsequently, Patient 100 was admitted to the critical care for further treatment of his medical condition.


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2. During an interview on 5/4/22, at 12:15 p.m., with licensed nurse (LN 2), LN 2 verbalized when a patient comes in on a 5150 hold need to treat the patient medically then call the CARES team (Crisis and Recovery Emergency Services-A County department for behavioral wellness) to coordinate what needs to be done to place the patient at a psychiatric facility. LN 2 verbalized when patient arrives in triage get an assessment, draw labs, take away belongings for safety, put them in a gown, and once evaluated, call CARES. LN 2 verbalized once patient is evaluated by CARES, and the patient has placement at the psychiatric facility, then AMR ambulance is called for transport. LN 2 verbalized the ER physician reviews labs and if results are normal, and the patient is physically fine, then the ER physician clears the patient medically. LN 2 verbalized the ER physician will verbally tell us the patient is medically cleared and should be writing a physician note. When asked about the ER physicians changing shifts, and when the oncoming physician takes over the patient, does the oncoming physician reassess the patient, LN 2 stated, "I do not know, but I reassess a patient when I come on shift." LN 2 verbalized nurses chart notes each shift but did not know if the physicians chart each shift.

During a phone interview on 5/4/22, at 3:30 p.m., with the ER physician (MD 2), MD 2 verbalized was familiar with EMTALA (Emergency Medical Treatment and Labor Act) regulations. MD 2 verbalized having annual competencies for EMTALA. MD 2 verbalized when a patient comes to the ER needs an MSE (medical screening exam)needs to be done prior to any transfer to a higher level of care. When asked about Patient 100, MD 2 verbalized has seen Patient 100 in the ER 40 times, and stated "I know him, he comes to the ER all the time." The ER note dated 2/27/22 at 6:30 pm, was read to MD 2. The ER note indicated re-evaluating Patient 100, oxygen saturation 76%, on oxygen. MD 2 verbalized this is a frequent event with Patient 100. Informed MD 2 there was no physician order for the oxygen administration and no documentation in a physician note. MD 2 stated, " If it is a true hypoxic event, then yes I would write a note." MD 2 verbalized placing oxygen on a patient is common nursing practice and nurses can do that with out an order. MD 2 verbalized when a patients oxygen saturation decreases and nurses give oxygen to improve the oxygen saturation, it does not warrant an order, it is in nursing scope of practice. MD 2 verbalized if oxygen is needed for a longer period of time and the patient is truly hypoxic, then it warrants some kind of documentation. MD 2 verbalized if a patient needs oxygen longer than an hour then yes, would reevaluate the patient and document.

During an interview on 5/6/22, at 8:32 a.m., with the ER physician (MD 3), MD 3 verbalized has annual competencies for EMTALA. When asked about Patient 100, MD 2 verbalized Patient comes to the ER frequently and was in the ER last week. MD 3 verbalized remembering Patient 100 sitting on the floor, resisting exams, and these behaviors were his norm. MD 3 verbalized Patient 100 has chronic cardiac and respiratory disease and does drugs, and stated, "He does not look good." MD 3 verbalized Patient 100 is a difficult patient with severe underlying conditions and is non-compliant. MD 3 verbalized Patient 100 was placed on a 5150 hold to determine his underlying medical problem and figure out if a medical condition is making him act this way. MD 3 verbalized if a medical condition was going on would try to medically treat that condition and stabilize. MD 3 verbalized Patient 100 has chronic condition and medical clearance has been going on. When asked what is necessary for medical clearance, MD 3 verbalized it depends on patient history and presentation, lab work, and physical examination. MD 3 verbalized would get labs, a basic panel for a baseline. MD 3 verbalized once labs are reviewed, and patient is medically stable, then would transfer patient out. When asked should a medical clearance be documented before the patient is sent out, MD 3 stated, "Yes I would say that."

Based on documents review, record review and interviews the facility failed to ensure 13 of 21 sampled patients (Patient 100) had an appropriate transfer to another facility and as per their policy and procedure.

These inappropriate transfers place patients at risk of negative outcome and/or possible injury.

Findings:

The facility's policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Patient Transfer to Another Facility, dated 10/21, In the Transfer Of Patient Without An Emergency Medical Condition part indicated "After emergency services in care, as described above, have been provided, the patient may be transferred for a non-medical reason only when the following conditions have been met: 1. Patient is stabilized and the transfer will not jeopardize or harm the patient within reasonable medical probability. 2. The transferring physician has notified a physician at the receiving hospital and has obtained both the physician's consent to the transfer and the receiving hospital confirmation that appropriate bed, personnel, and equipment necessary to treat the patient are available. Documentation of the above is required on the patient transfer record ... 4. A Patient Transfer Summary, signed by the physician, will accompany the patient, and will include at least the following information: b. Name of the physician at the receiving hospital consenting to the transfer, with the time and date of the consent. c. Recent for transfer. d. Declaration of the transferring physician that the patient has been stabilized for safe transport. e. A statement of the physician that the method of transport is safe for the patient. 5. It is the responsibility of the physician to determine that the required medical personnel and equipment are available throughout the transfer of the patient ... 6. An appropriate Patient Transfer Acknowledgement form will be signed by the patient or representative. This will document that the signer has been notified of the transfer and of the reasons for the transfer. Such notification is not required if the patient is unaccompanied, a reasonable effort has been made to find a representative of the patient, and notification of the patient is not possible because of the patient's physical or mental condition."

1. A record review for Patient 100 was conducted on 4/7/22 and 5/5/22. The record indicated Patient 100 was seen in the ED for bizarrely behavior and gravely disabled and placed on a 5150 (72 hour hold) waiting for CARES to place him in a psychiatric facility. The ED Provider Note, dated 2/27/22 at 2:54 p.m., indicated that at 6:59 p.m., MD 1 re-evaluated patient indicating "Plan is to medically clear, he is on a 5150, minus to reach out to facilities, likely he will not be accepted given his medical conditions and then possibly will need to transfer to a medical facility that has psychiatric consultation as an inpatient."

The Nursing Transfer Note, dated 3/2/22 at 2:29 p.m., indicated patient was transfer to the psychiatric facility [Facility B] and was transported by crisis van.

Further review of records indicated Patient 100 was obtunded, short of breath, and unstable with low room air saturation upon arrival to receiving psychiatric facility [Facility B] without capabilities of providing needed medical care and necessitating patient to be transported by EMS to another hospital ED for stabilization of his medical condition.

During a record review of the ED provider (MD 1) note, dated 2/27/22 at 2:54 p.m., and concurrent interview with MD 1 on 4/7/22 at 5:10 p.m., MD 1 confirmed this was his ED note. The Patient Transfer to Another Facility document, dated 3/2/22, was reviewed with MD 1. MD 1 confirmed his signature on this document furthermore acknowledged not indicating on the document that the patient had been stabilized for transfer to another facility. MD 1 was asked if he had approved the method of transportation to the psychiatric facility. MD 1 stated "Yes, transferring this patient by AMR (ambulance services) would have taken eight hours or plus due to AMR being very busy. So, when CARES said they would transport this patient I agreed. My concern was making sure the CARES van was safe where patient would not try to jump off the van. This was a regular enclosed van."

During another interview with MD 1 on 6/14/22 at 2:28 pm., MD 1 was asked if he spoke with a physician or psychiatrist regarding Patient 100 at the receiving facility [Facility B] on 3/2/22. MD 1 indicated not speaking with a physician or psychiatrist at the receiving facility where patient was transfer to on 3/2/22. MD 1 stated "Typically we are not involved in discussion to transfer patients to the other facility for psychiatric patients. For this patient (Patient 100), CARES did all that."

During a record review of Patient 100 and concurrent interview with the quality data analyst (QDA) on 4/7/22 at 12:30 p.m., the QDA was asked to provide all ED providers notes for the visit from 2/27/22 to 3/2/22 in search of locating documentation regarding the transport method. QDA only provided ED provider note dated 2/27/22. QDA stated "There are no more ED MDs (providers) notes. I am sure of this." The facility was not able to provide a physician statement or documentation indicating the method of transport was safe for this patient.

2. During a review of Patient 102's record and concurrent interview with the chief nursing officer (CNO) and the emergency room director (ERD), on 5/5/22 at 10:54 a.m., the Patient Transfer To Another Facility" form, dated 2/14/22 at 6:15 p.m., was reviewed. The form was left blank as to reason for transfer, accepting physician, report called to the receiving facility and method and equipment needed for safe transportation of this patient. Furthermore, there was no evidence there was a physician-to-physician communication regarding patient's transfer and acceptance to their facility for higher level of care before patient was transfer on 2/14/22. The CNO and ERD acknowledged and confirmed the findings and agreed those items are missing in the record.

3. During a review of Patient 103's record and concurrent interview with the chief nursing officer (CNO) and the emergency room director (ERD), on 5/5/22 at 11:08 a.m., the Patient Transfer To Another Facility" form, dated 2/9/22 at 7:00 p.m., was reviewed. The form was left blank as to the time the accepting physician accepted the patient, whether the patient was stable or unstable and benefits and risks were explained to patient or family regarding the transfer to higher level of care. The CNO and ERD acknowledged and confirmed the findings and agreed those items are missing in the record.

4. During a review of Patient 104's record and concurrent interview with the chief nursing officer (CNO) and the emergency room director (ERD), on 5/5/22 at 11:25 a.m., the Patient Transfer To Another Facility" form, dated 3/29/22 at 2:58 a.m., was reviewed. The form indicated ER-ER as the accepting physician but no name, the form was left blank as to accepting time of this patient to the facility, and as to whether the benefits and risks were explained to patient or family regarding the transfer to higher level of care. The CNO and ERD acknowledged and confirmed the findings and agreed those items are missing in the record.

5. During a review of Patient 105's record and concurrent interview with the chief nursing officer (CNO) and the emergency room director (ERD), on 5/5/22 at 11:15 a.m., the Patient Transfer To Another Facility" form, dated 2/15/22, no time, was reviewed. The form indicated there was no signature of the physician completing the form. The CNO and ERD acknowledged and confirmed the finding and agreed the form must have the physician's signature.

6. During a review of Patient 106's record and concurrent interview with the chief nursing officer (CNO) and the emergency room director (ERD), on 5/5/22 at 11:30 a.m., the Patient Transfer To Another Facility" form, dated 2/11/22, at 4:53 p.m., was reviewed. The form was left blank as to patient stable or unstable upon transfer, and whether benefits and risk to transfer were explained to patient. The CNO and ERD acknowledged and confirmed the findings and agreed those items are missing on the form and should be completed.

7. During a review of Patient 107's record and concurrent interview with the chief nursing officer (CNO) and the emergency room director (ERD), on 5/5/22 at 11:35 a.m., the Patient Transfer To Another Facility" form, dated 2/16/22, at 4:20 p.m., was reviewed. The form was left blank as to patient stable or unstable upon transfer. The CNO and ERD acknowledged and confirmed the finding and agreed this is missing on the form and should have been marked.


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During an interview on 5/4/22, at 11:40 a.m., with licensed nurse (LN 1), LN 1 verbalized when a patient needs to be transferred to another facility, nurses give the report to the receiving facility. LN 1 verbalized there is a check off list of documents that need to go with the transfer packet, those documents include labs, triage notes, and physician assessment note. LN 1 verbalized the transfer forms need to be complete.

During an interview on 5/4/22, at 12:15 p.m., with licensed nurse (LN 2), LN 2 verbalized when a patient comes in on a 5150 hold need to treat the patient medically then call the CARES team (Crisis and Recovery Emergency Services-A County department for behavioral wellness) to coordinate what needs to be done to place the patient at a psychiatric facility. LN 2 verbalized when a patient is transferred to another facility the transfer form needs to be completed. LN 2 verbalized if a patient on a 5150 hold two nurses sign for the patient. When asked if two nurses signing for a patient was hospital policy, LN 2 verbalized not a policy but is our process.

8. During a review of Patient 200's "Transfer Form", dated 2/21/22, The "Transfer Form" on Section 2: Patient Condition and Risk (physician complete) was left blank. Section 2 of the form asks if the patient is stable or patient is unstable, but expected medical benefits to transfer outweighs potential risks associated with transfer, and asks if the benefits and risks of transfer were explained to the patient, family, or other (relationship), and asks for the mode of transfer, private vehicle or ambulance.

During a concurrent interview and record review on 5/5/22 at 11:45 a.m., with the chief nursing officer (CNO) and the emergency room director (ERD), Patient 200's "Transfer Form", dated 2/21/22 was reviewed. On the "Transfer Form" Section 2 Patient Condition and Risk (physician complete) was left blank. The CNO and the ERD both acknowledged there was no documentation in Section 2: Patient Condition and Risk. The CNO and ERD both acknowledged the physician should have documented on the transfer form.

9. During a review of Patient 202's "Transfer Form", dated 3/11/22, On the "Transfer Form" Section 2: Patient Condition and Risk (physician complete) where the form asks if the benefits and risks of transfer were explained to the patient, family, or other (relationship), was left blank. Section 3: Patient Consent to Transfer is to be signed by the patient or legally responsible individual and a witness. Section 3: for Patient 202 had 5150 (an adult who is experiencing a mental health crisis to involuntarily be detained for 72-hour psychiatric hospitalization when evaluated to be a danger to self or others, or gravely disabled) documented as the patient signature and two nurses signatures as the witnesses.

During a concurrent interview and record review on 5/5/22 at 11:22 a.m., with the chief nursing officer (CNO) and the emergency room director (ERD), Patient 202's "Transfer Form", dated 3/11/22 was reviewed. The CNO and the ERD both acknowledged there was no documentation in Section 2 that the risks and benefits were explained to Patient 202 and there should be. The CNO and the ERD both acknowledged Patient 202 did not sign consent to transfer in Section 3.

10. During a review of Patient 203's "Transfer Form", dated 3/14/22, On the "Transfer Form" Section 2: Patient Condition and Risk (physician complete) where the form asks if the benefits and risks of transfer were explained to the patient, family, or other (relationship), was left blank. Section 3: Patient Consent to Transfer is to be signed by the patient or legally responsible individual and a witness. Section 3: for Patient 203 had 5150 documented as the patient signature and two nurses signatures as the witnesses.

During a concurrent interview and record review on 5/5/22 at 12:00 a.m., with the chief nursing officer (CNO) and the emergency room director (ERD), Patient 203's "Transfer Form", dated 3/14/22 was reviewed. The CNO and the ERD both acknowledged there was no documentation in Section 2 that the risks and benefits were explained to Patient 203 and there should be. The CNO and the ERD both acknowledged Patient 203 did not sign consent to transfer in Section 3.

11. During a concurrent interview and record review on 5/6/22 at 11:51 p.m., with the chief nursing officer (CNO) and the emergency room director (ERD), Patient 209's "Transfer Form", dated 4/13/22 was reviewed. On the "Transfer Form" Section 3: Patient Consent to Transfer is to be signed by the patient or legally responsible individual and a witness. Section 3 for Patient 209 had 5150 documented as patient signature and no other signatures were documented. The CNO and the ERD acknowledged Patient 209 did not sign consent to transfer.

During a review of Patient 205's "Transfer Form", dated 3/29/22, The "Transfer Form" on Section 2: Patient Condition and Risk (physician complete) was left blank. Section 2 of the form asks if the patient is stable or patient is unstable, but expected medical benefits to transfer outweighs potential risks associated with transfer, and asks if the benefits and risks of transfer were explained to the patient, family, or other (relationship), and asks for the mode of transfer, private vehicle or ambulance.

12. During a concurrent interview and record review on 5/6/22 at 12:10 p.m., with the chief nursing officer (CNO) and the emergency room director (ERD), Patient 205's "Transfer Form", dated 3/29/22 was reviewed. On the "Transfer Form" Section 2: Patient Condition and Risk (physician complete) was left blank. The CNO and the ERD both acknowledged there was no documentation in Section 2 if Patient 205 was stable, and no documentation the risks and benefits were explained to Patient 205 and there should be.

13. During a review of Patient 206's "Transfer Form", dated 4/1/22, The "Transfer Form" on Section 2: Patient Condition and Risk (physician complete) was left blank. Section 2 of the form asks if the patient is stable or patient is unstable, but expected medical benefits to transfer outweighs potential risks associated with transfer, and asks if the benefits and risks of transfer were explained to the patient, family, or other (relationship), and asks for the mode of transfer, private vehicle or ambulance. Section 3: Patient Consent to Transfer is to be signed by the patient or legally responsible individual and a witness. Section 3: for Patient 206 had 5150 documented as the patient signature and no other signatures were documented.

During a concurrent interview and record review on 5/6/22 at 12:15 p.m., with the chief nursing officer (CNO) and the emergency room director (ERD), Patient 206's "Transfer Form", dated 4/1/22 was reviewed. The CNO and the ERD both acknowledged there was no documentation in Section 2 if Patient 206 was stable, and no documentation the risks and benefits were explained to Patient 206 and there should be. The CNO and the ERD acknowledged Patient 206 did not sign consent to transfer in Section 3.