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Based on interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for three of 21 patients, (Patients A, 1, and 2) when:

1. Hospital B contacted the hospital (Hospital A) on 2/28/23 to transfer Patient (Pt) A who was diagnosed with acute appendicitis, required surgical services and Hospital B did not have the capacity to provide the required surgical services to treat and stabilize Pt A. Hospital A did not accept transfer and had the capacity to provide surgical services to Pt A. Hospital A did not follow its policy and procedure to document and log requests for inbound transfer patients and the reason(s) to support a decision to accept or deny transfer for Pt A. Hospital A failed to have a system to log and document all requests for patient transfers and to list the reason to accept or deny the requested transfer in accordance with hospital policy and procedure. These failures resulted in Pt A being transferred on 3/1/2023 in stormy weather to a hospital 250 miles away, arriving approximately 17 hours after the request to transfer was initiated, which delayed Pt A ' s access to the surgical services her condition required, and placed her at risk for a ruptured appendix. Hospital A was less than one hour away from Hospital B. The hospital ' s current and past failure to maintain a transfer request log or follow their own policy ' s process for determining whether to accept a patient transfer request resulted in the inability of the hospital to support their compliance with Recipient Hospital Responsibilities. (Refer to A 2411)


2. Patient 1 who had diabetes (A chronic condition that affects the way the body processes blood sugar [glucose] was transferred to Hospital D with a blood glucose that had not been checked in over 4 hours while in Hospital A, and the last reading was 362 (mg/dl) (milligrams per deciliter, a unit of measure) (normal before a meal is 80-130 mg/dl) and no action to stabilize and intervene was taken. Hospital D was not informed of the high blood glucose. Pt. 2 was transferred to Hospital E with a blood pressure of 168/100 mmHg (normal blood pressure is less than 120/80) and no services or interventions were provided to stabilize prior to transfer, and Hospital E was unaware of the elevated blood pressure. These failures had the potential to cause serious medical conditions up to and including death of these 2 patients during transport and after arrival to psychiatric hospitals. (Refer to A 2409)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on interview and record review, Hospital A (transferring hospital) failed to appropriately stabilize two of 20 patients (Patients 1 and 2) prior to transferring to the receiving psychiatric hospitals when:

1. Patient (Pt.) 1 who had diabetes (A chronic condition that affects the way the body processes blood sugar [glucose] was transferred to Hospital D with a blood glucose that had not been checked in over 4 hours while in Hospital A, and the last reading was 362 (mg/dl) (milligrams per deciliter, a unit of measure) (normal before a meal is 80-130 mg/dl) and no action to stabilize and intervene was taken. Hospital D was not informed of the high blood glucose.

2. Pt. 2 was transferred to Hospital E with a blood pressure of 168/100 mmHg (normal blood pressure is less than 120/80) and no services or interventions were provided to stabilize prior to transfer, and Hospital E was unaware of the elevated blood pressure.

These failures had the potential to cause serious medical conditions up to and including death of these 2 patients during transport and after arrival to psychiatric hospitals.

Findings:

1. During a review of Pt. 1 ' s medical record, the document titled, " ED Physician Notes, " dated 3/28/23, at 12:22 a.m. by Medical Doctor (MD) 1, the document indicated Pt. 1 was a 53-year-old male who was brought in by ambulance on a 5150 hold (refers to California Welfare and Institutions Code number [5150] -an involuntary psychiatric hold of a person determined to pose a danger to themselves or others, or are gravely disabled), with a chief complaint of suicidal ideation (thoughts, feelings, or wishes to harm or kill oneself). Pt 1 had a history of schizophrenia (a mental illness characterized by a disconnection from reality, including hallucinations [having visions, hearing sounds, or smells that seem real but are not]. and delusions [an unshakable belief in something that's untrue]), diabetes, and hypertension (high blood pressure). The document indicated Pt. 1 was having auditory (refers to hearing) hallucinations telling him to hurt himself. The document indicated Pt 1 ' s blood glucose was 498 when he first arrived at the hospital, and MD 1 indicated Pt 1 ' s blood sugar, " needs to be closer to 200 for acceptance for transfer at inpatient mental health. Given large container of water to drink. Recheck blood sugar. Also ordered his [brand name of oral diabetes medication] for the morning. " At 12:22 a.m. his blood sugar was 369, and 12 units of regular insulin (medication to lower blood sugar) was given. At 3:35 a.m. his blood sugar was 331, and 10 additional units of regular insulin was given. At 4:56 a.m. is blood sugar was 289, and 6 units of regular insulin was given at 6:31 a.m. At 6:53 a.m. his blood sugar was 262, and no insulin was given.

During a review of document titled " ED Physician Notes " dated 3/28/23, at 6:32 a.m. by Doctor of Osteopathy (DO) 1, the document indicated, " ...We will attempt to get glucose down to 200 in order to medically clear for mental health assessment... " then, " 10:11 (a.m.) Glucose now 262. Medically cleared. " Document does not indicate any further blood glucose checks. Document also does not indicate that Pt 1 ' s high blood sugar was discussed with the accepting physician, receiving hospital, or with the patient. The document indicated DO 1 completed and signed his note at 5:11 pm on 3/28/23 and does not indicate DO 1 reassessed Pt 1 ' s condition including blood sugar value after that time prior to transfer at 8:38 p.m.

During a review of the document titled " Patient Transfer Form " dated 3/28/23 at 8:38 p.m., the document indicated Pt 1 was being transferred to a " Psych facility for treatment " with a diagnosis of " Suicidal Ideation. "

During a review of the document titled " Physician Certification Statement for Ambulance Transport " dated 3/28/23, untimed, the document indicated Pt 1 was being transferred by ambulance transport to [Name of Hospital] (Hospital D- an inpatient psychiatric hospital located 230 miles away) due to a diagnosis of " Suicidal Ideation. " The document indicated Pt 1 required mental status monitoring during transport due to altered mental status and was a flight risk due to 5150 hold.

During a concurrent interview and review of Pt. 1 ' s clinical record on 4/20/23 at 3:09 p.m. with the Manager of the Emergency Department (MED), record indicated blood sugar was not rechecked at 10:11 a.m. until 4:06 p.m. (over nine hours later) when it was 362 (dangerously high). No insulin was given during the day shift and no insulin administered after the blood sugar check at 4:06 p.m. His blood sugar was not checked again prior to his transfer to Hospital D at 8:38 p.m. Hospital D is approximately 4 hours away by ambulance. The MED stated Pt 1 was not medically stable to be transferred with a high blood sugar reading and no recheck, especially since Pt 1 ' s transfer would require a 4-hour ambulance transport.

During an interview with Director of the Emergency Department at Hospital A (DED 1), on 4/21/23 at 10:40 a.m., DED 1 stated the day shift nurse should have been aware of the high blood sugar and should have notified the physician. She stated a patient with high blood sugar could go into a diabetic coma (a life-threatening condition in which a person loses consciousness).

During an interview with the CMO on 4/21/23 at 11:50 a.m. the CMO stated, " That ' s a high blood sugar. I would not say that patient (Pt. 1) was medically stable; he may have been stable from a psychiatric perspective. The blood sugar level should have been discussed with the receiving hospital. " The CMO expressed concern that the blood sugar was monitored and treated throughout the night shift, but during the following shift the monitoring and treatment did not continue and there is no indication that it was discussed with the receiving physician.

During a review of hospital policy titled, " EMTALA - Patient Transfer " dated 12/2022, the policy indicated, " ...The transferring physician and a nurse will assess and update the condition of the individual immediately prior to the transfer and document the results in the medical record... "

During a review of hospital policy titled, " Suicide Prevention " dated 9/22/20, the policy indicated, " ...If a patient is not medically stable for transfer or admission to a behavioral health facility, or discharge home from the Emergency Department, the patient may be admitted to the appropriate acute care unit based on the admission criteria... "

During a review of hospital policy titled, " EMTALA - Medical Screening Examination (MSE) and Stabilization " dated 11/19/19, the policy indicated, " ...F. Examination and Treatment after the Initial Medical Screening Examination 1. B. Further examination includes continued monitoring according to the individual ' s needs until he/she is stabilized, transferred, or discharged ... 2. If the treating physician or Qualified Medical person determines that an individual does not have an Emergency Medical Condition, or that the Emergency Medical Condition is Stabilized, the Treating Physician or Qualified Medical Person will discuss with the patient the need for any further examination and treatment to be provided in the Emergency Department or on an outpatient basis following discharge.

2. During a review of Pt. 2 ' s medical record, the document titled " ED Physician Notes " dated April 5, 2023, at 6:19 a.m. by DO 2, the document indicated Pt. 2 was a 31-year-old woman brought in by her husband for erratic behavior and talking to herself. Document indicated she did not have a history of medical or psychiatric illness or episodes. Pt 2 was in the Emergency Department from 4/5/23 at 5:42 a.m. until 4/6/23 at 9:20 a.m. During that time her blood pressure readings were as follows: On 4/5/23: 197/136 at 5:58 a.m., 147/101 at 12:00 p.m., 155/108 at 5:17 p.m., 132/91 at 8:30 p.m., and 155/92 at 12:00 a.m. (midnight). On 4/6/23: 121/82 at 3:50 a.m., 140/91 at 6:34 a.m., and 168/100 at 9:30 a.m. (time of transfer to receiving hospital). Pt. 2 had no history of hypertension (high blood pressure). No medication was given for her high blood pressure and there is no documentation indicating that Pt 2 ' s high blood pressure was discussed with the accepting physician or the receiving hospital.

During a concurrent interview and review of Pt. 2 ' s clinical record with the Manager of the Emergency Department (MED), the record indicated blood pressure was checked but there is no indication that it was discussed with the physician or with the receiving hospital. The MED stated the nurse should have notified the physician, and the physician should have noted the continued high blood pressure in the Pt. 2 ' s record and the receiving hospital should have been made aware of the continued high blood pressure.

During an interview with Director of the Emergency Department (DED1), on 4/21/23 at 10:40 a.m., DED 1 stated the day shift nurse should have been aware of Pt 2 ' s high blood pressure, especially since she had no previous known history of high blood pressure or psychiatric illness. DED 1 stated the nurse who completed the transfer form should have brought this to the physician ' s attention and the receiving hospital should have been made aware.

During an interview with the CMO on 4/21/23 at 11:50 a.m., the CMO stated high blood pressure wouldn ' t necessarily be a reason to keep the patient in the ED; it could be followed up on an outpatient basis. The CMO stated it should have been documented in the physician notes and discussed with the receiving hospital.

During a review of hospital policy titled, " EMTALA - Patient Transfer " dated 12/2022, the policy indicated, " ...The transferring physician and a nurse will assess and update the condition of the individual immediately prior to the transfer and document the results in the medical record... "

During a review of hospital policy titled, " EMTALA - Medical Screening Examination (MSE) and Stabilization " dated 11/19/2019, the policy indicated, " ...F. Examination and Treatment after the Initial Medical Screening Examination 1. B. Further examination includes continued monitoring according to the individual ' s needs until he/she is stabilized, transferred, or discharged ... 2. If the treating physician or Qualified Medical person determines that an individual does not have an Emergency Medical Condition, or that the Emergency Medical Condition is Stabilized, the Treating Physician or Qualified Medical Person will discuss with the patient the need for any further examination and treatment to be provided in the Emergency Department or on an outpatient basis following discharge.

Based on interview and record review, Hospital A failed to meet its Recipient Hospital Responsibilities for one of 21 patients, (Patient A), when Hospital B contacted Hospital A on 2/28/23 to transfer Patient (Pt) A who was diagnosed with acute appendicitis, required surgical services and Hospital B did not have the capacity to provide the required surgical services to treat and stabilize Pt A. Hospital A did not accept transfer and had the capacity to provide surgical services to Pt A. Hospital A did not follow its policy and procedure to document and log requests for inbound transfer patients and the reason(s) to support a decision to accept or deny transfer for Pt A. Hospital A failed to have a system to log and document all requests for patient transfers and to list the reason to accept or deny the requested transfer in accordance with hospital policy and procedure.

These failures resulted in Pt A being transferred on 3/1/2023 in stormy weather to a hospital 250 miles away, arriving approximately 17 hours after the request to transfer was initiated, which delayed Pt A's access to the surgical services her condition required, and placed her at risk for a ruptured appendix. Hospital A was less than one hour away from Hospital B. The hospital's current and past failure to maintain a transfer request log or follow their own policy's process for determining whether to accept a patient transfer request resulted in the inability of the hospital to support their compliance with Recipient Hospital Responsibilities.

Findings:

During the survey entrance conference on 4/18/23 at 10 a.m. with the Chief Medical Officer (CMO), the CMO stated she was aware that there had been a complaint about a potential EMTALA violation related to the hospital's (Hospital A) refusal to accept a patient transfer for a higher level of care from a hospital located 45 miles away (Hospital B). The CMO stated she received a phone call and texts from the physician from the hospital (Hospital C) that had accepted the patient. The CMO stated she was not sure of the exact date of the call, but it was in early March. The CMO stated the hospital has done their internal review.

During a concurrent interview and record review on 4/18/23 at 10:35 a.m. with the Emergency Department (ED) Manager of Hospital B (EDM-B), EDM-B stated on 2/28/23 Patient A, a 40-year-old female, presented to the ED at Hospital B and was determined to have appendicitis (inflammation of the appendix [a pouch that projects from the colon on the lower right side of the abdomen] caused by infection). EDM-B stated Hospital B (a small rural hospital) does not have surgeons on staff at the hospital to provide the treatment necessary (surgical removal of the appendix) for Pt A, so Hospital B initiated the process to transfer Pt 1 to another hospital with the capability to care for Pt A. EDM-B stated when a patient needs to be transferred from their ED to another hospital for services not available at Hospital B, ED staff call the closest hospital that can provide the level of care and services needed for the specific patient. EDM-B stated in the case of Pt A, Hospital A was called first because they are the closest hospital (45 miles) to Hospital B and Hospital A has the surgical services Pt A needed. During a review of Hospital B's document titled "Transfer Call List," dated 2/28/23-3/1/23, with EDM-B, EDM-B verified this document reflected the date and time of the call, the name of Hospital B's staff member who made the call, the name of the hospital called (Hospital A), name of the person contacted at Hospital A, and response received from Hospital A to the transfer request. The document indicated Pt A's name, date of birth, and diagnosis of acute appendicitis, and "general surgery" as the service needed for Pt A. The document indicated on 2/28/23 at 9:03 p.m., Hospital B contacted Hospital A and spoke to [House Supervisor's name] requesting to transfer Pt A. The document indicated the response from HS 1 was Hospital A would not accept the transfer of Pt A due to being "at capacity." EDM-B stated hospitals tell them if they might be able to take the patient later in that shift or the next shift as patients are discharged or staff come in and if so, Hospital B will indicate that information on the Transfer Call List and then call the hospital back after a period of time. EDM-B verified that Pt A's Transfer Call List did not indicate Hospital A had communicated they might be able to take the patient at a later time. EDM-B stated after several attempts to get Pt A accepted for transfer to other hospitals, Hospital C located 250 miles from Hospital B agreed to accept Pt A. EDM-B stated after a hospital accepts Hospital B's transfer request, Hospital B will then arrange for patient transport by ambulance to the receiving hospital. EDM-B stated in the case of Pt A, the Transfer Call List indicated on 3/1/23 from 1 a.m. to 4:45 a.m. Hospital B attempted to arrange air or ground ambulance transport to Hospital C, however due to severe weather conditions and the distance of the trip, Pt A was not able to depart from Hospital B until 3/1/23 at 8 a.m. EDM-B stated the ambulance ride to Hospital C took almost six hours.

During a concurrent interview and record review on 4/19/23 at 4:48 p.m. with House Supervisor (HS 1), HS 1 stated she has worked at Hospital A as a full-time HS since August of 2014. HS 1 stated she was the HS on duty at Hospital A on the night of 2/28/23. HS 1 stated the house supervisors usually receive the requests from other hospitals to transfer patients to Hospital A. HS 1 stated she does not have any specific recollection of the night of 2/28/23 but was provided her worksheet from that night to refer to for this interview. HS 1 stated at the beginning of her shift at 6 pm she received report from the dayshift HS about the overall status of the hospital at that time which included information regarding the census and staffing. HS 1 referred to her worksheet notes and stated it was a busy night and there were patients in the ED that had not yet been moved to an inpatient bed. HS 1 was informed that Hospital B's call requesting transfer of a patient with acute appendicitis who needed an appendectomy occurred at 9 p.m. HS 1 reviewed her notes and stated she does not remember the call and there is no information regarding this request on her worksheet or anywhere. HS 1 stated she makes the decision whether to accept a patient fairly quickly based on the information she has at the time from the shift report and would have declined Pt A based on being at capacity, which HS 1 stated means beds and staffing. HS 1 stated she did not check for an on-call surgeon, operating room availability, consult with the ED physician, Nurse Lead (NL) or anyone else about this transfer request. HS 1 stated after patients from ED were getting moved to their inpatient hospital beds, she did not reconsider the patient transfer request. HS 1 stated she was informed today (4/19/23) there were going to be changes in the process regarding how the hospital manages and documents patient transfer requests from other hospitals.

During an interview on 4/18/23 at 12:20 p.m. with HS 2, HS 2 stated she works as the House Supervisor on day shift. HS 2 stated she has been working at this hospital for 35 years, and in her role as HS for 23 years. HS 2 stated when she receives a call requesting transfer, she checks the computer for "specialists on-call" to see if they can provide the service, then she checks to see if they have an available room and nurse to care for the patient. If it looks like they can take the patient, she calls the physician on-call or the ED physician to discuss. HS 2 stated transfers from within their network occur daily and are almost automatic, because the physicians discuss the transfer even before the HS knows about it, but transfers from other hospitals don't happen as often.

During an interview on 4/19/23 at 10 a.m. with HS 3, she stated she is a registered nurse who has worked for the hospital for 22 years and has been an HS for 7 years. HS 3 described the process of determining if they would accept a transfer from an outside hospital: The HS receives a call asking "do you have a med/surg or ICU bed - yes or no. If no, it's due to no staff or no physical capacity. If we don't have a bed, I ask if they've checked other facilities." HS 3 stated she doesn't consult with hospitalist or ED, or anyone else if she knows they don't have staff or physical capacity. HS 3 stated, "If we might have discharges later in the shift or the next day, I let them know to call back." HS 3 stated she does not keep a log of transfer requests from other hospitals.

During an interview on 4/19/23 at 10:15 a.m. with DED 2 and ACNE 2 regarding the interview with HS 3, both stated that HS 3 should check with the hospitalist rather than making decisions independently. DED 2 stated, "We aren't consistent in how we manage incoming requests for transfer."

During an interview on 4/18/23 at 12:05 p.m. with Nurse Lead 1 (NL), NL1 stated she is a registered nurse who has worked in the ED for 22 years and has been a Nurse Lead (nurse in charge in the ED) for about 10 years. NL1 stated she receives calls from other hospitals when she is working in the ED, and she takes the information from the person calling, then she calls the HS to discuss the request. NL1 stated once the decision is made whether they can accept a patient or not based on capacity, she talks to the physician in the ED and "sometimes the physician changes our opinion" about whether we can accept the transfer or not. NL1 stated she does not document calls to request transfers, that is the responsibility of the HS.

During an interview on 4/18/23 at 12:15 p.m. with the ED Unit Clerk (UC), the UC stated she occasionally takes calls from outside hospitals requesting transfers. UC stated the calling hospital usually tells her what services are needed, and she talks to the NL about it, and the NL talks with the HS and the physician. UC stated she documents if they accept the patients but does not document if they decline the transfer.

During an interview on 4/18/23 at 4 p.m. with NL 2, NL 2 stated he has been working for Hospital A for 13 years and has been a Nurse Lead for 2 years on night shift. NL 2 stated, "If they call and request a transfer, it goes physician to physician. I get the call, and contact the MD." NL 2 stated, "They give me the information first - a quick preliminary so I know what to tell the physician, otherwise, I leave it for the MD to decide. They do both direct admits and ED to ED." NL 2 stated after the doctors talk to each other, the physician asks him or the HS to see if they have beds or make sure the surgeon is on board with the case. NL 2 stated "We may have to call the facility back. Sometimes they call the ED directly, sometimes they call the HS. The HS occasionally ask if it's okay to send if we are full, but we always say yes as long as there's an accepting physician and a bed upstairs. I think the HS documents if we accept or do not accept. I think the doctors document their own stuff, but I'm not sure."

During a concurrent interview and record review on 4/19/23 at 2:25 pm with the Director of Quality Management (DQM), the document titled, "Root Cause Analysis" (RCA) for Pt 1 was reviewed on a facility computer. The RCA was done on 3/10/23 regarding the potential EMTALA after the CMO was notified by a surgeon at Hospital C on 3/7/23. The CMO, PCE, DQM, and DED 1 comprised the group who attended and participated in the RCA. The group identified that Hospital A was not following their policy (AD-60-020-S: Acceptance of Emergency Transfers) and that the hospital does not maintain a log of incoming transfers and declined transfers. The DQM stated the group identified they do not have a process in place to notify hospital Administration when they decline a transfer. The group determined that the policy is appropriate, but staff were not following the policy. The DQM stated HS1 was not asked to attend the RCA.

During a concurrent interview and record review on 4/19/23 at 2:45 p.m. with DED 1, DED 1 stated, "we don't have a log to show that we didn't accept the patient. We are going to start that." DED 1 stated that even though the RCA identified staff did not follow the Emergency Transfer policy and there is a need to document information about hospital requests for transfer, no system process has been developed or implemented five weeks after the RCA.

During a concurrent interview on 4/19/23 at 3:30 p.m. with the Patient Care Executive (PCE) and CMO, the CMO stated that on 3/7/23 she received a call from a physician at Hospital C stating there was an EMTALA related to this facility (Hospital A) refusing to accept a transfer from Hospital B. The CMO stated, "Right away, we started talking about what needed to be done." The CMO stated the RCA was done on 3/10/23, and "we determined the need to follow the policy for declinations [refusing a transfer]." The CMO stated they determined that not logging declinations was a gap that needed to be corrected. The PCE stated, "We didn't roll out that change, obviously." The PCE stated hospital leadership did not hold staff members accountable for the changes that needed to be made.

During a concurrent interview and record review on 4/21/23 at 10:40 a.m. with DED 1, the staffing log for the ED dated 2/28/23 was reviewed. DED 1 stated it appeared that the ED was busy at the beginning of the shift, but later in the shift the census had dropped to 16 patients, and they sent one staff home due to low census. DED 1 stated, "When I look at that, I don't see the "disaster" that would have kept our facility from receiving an urgent transfer in." DED 1 stated there was a "break in the process." DED 1 stated HS 1 did not use the correct process when she made the decision to decline to accept Patient 1 who had acute appendicitis and was in need of the surgical services that Hospital A is able to provide.


During a review of the Mayo Clinic reference article "Appendicitis," dated 8/7/21, the article indicated, "...Appendicitis is an inflammation of the appendix, a pouch that projects from the colon on the lower right side of the abdomen...Appendicitis causes pain in the lower right abdomen...As inflammation worsens, appendicitis pain increases and eventually becomes severe...A blockage in the lining of the appendix that results in infection is the likely cause of appendicitis. The bacteria multiply rapidly, causing the appendix to become inflamed, swollen and filled with pus. Severe abdominal pain requires immediate medical attention. If not treated promptly, the appendix can rupture. A rupture spreads infection throughout the abdomen. Possibly life-threatening, this condition requires immediate surgery to remove the appendix and clean the abdominal cavity..."

During a review of Hospital A's document titled, "General Surgery On-Call" for the month of February 2023, the document indicated on 2/28/23 there was a surgeon on-call to provide 24-hour surgery coverage. During a review of Hospital A's "General Surgery On-Call" for the month of March 2023, the document indicated on 3/1/23 there was a surgeon on-call to provide 24-hour surgery coverage.


During a review of Hospital A's document "Surgery Schedule," dated 2/28/23, the document indicated the start time of the last scheduled surgery on 2/28/23 was 5:30 p.m.


During a review of hospital policy titled, "MODEL POLICY: EMTALA - ACCEPTANCE OF EMERGENCY TRANSFERS" dated 10/20/16 and reviewed 3/29/23, the policy indicated, "I. Transfer Request Log: The Nursing Supervisor will maintain a log of incoming requests to accept patient Transfers. The log will include I. The time of the call; II. The name of the requesting facility; III. The name of the transferring physician or requesting facility staff member; IV. The name of the individual; V. Whether the Hospital accepted or refused the Transfer, the reasons for refusing a transfer (as applicable) ... The Transfer Request Log and documentation will be retained in accordance with hospital policies, but not less than five (5) years...Reporting of Denial of Transfer Requests: If a physician and/or house nursing supervisor refuses a transfer he/she will submit a written report to [Risk Management] within 24 hours. The written report will include the name of the patient's condition and need for care, the reason given for the Transfer [request], and the reason that the physician or house nursing supervisor declined the transfer...Transfer Agreements. Each hospital may enter into Transfer agreements with other facilities from whom requests for Transfers may be received that facilitate the consideration and acceptance of Transfers, and which may establish additional conditions for a Transfer that do not violate the requirements of EMTALA ...The Hospital will accept an appropriate transfer of a patient with an unstabilized emergency medical condition who requires specialized capabilities or facilities if the Hospital has the capacity to treat the individual. Requests to accept Transfers will be handled in accordance with Hospital policies and procedures. Specialized Services are any services (including surgery) provided by the receiving hospital that are necessary to stabilize the patient's emergency medical condition that are a higher level of care at the time of the transfer than the level of care available at the sending hospital at the time of the transfer..."


During a review of hospital document titled "RECIPROCAL HOSPITAL TRANSFER AGREEMENT" signed by the Chief Financial Officer of Hospital A on 11/4/19, the document indicated, "This Agreement is made and entered into as of the 15th day of October 2019, by and between [Hospital A] and [Hospital B.] RECITALS: ...B. Hospital B operates a licensed acute care facility, located at (address) which at times has some patients who: 1. May need more specialized care that Hospital B can provide ... C. The parties wish to enter into an agreement for the transfer of patients, such as those described above, from one hospital to the other and to specify the rights and obligations of each of the parties in this Agreement ... 2. Responsibilities of the Receiving Hospital. Receiving Hospital shall have the following duties and obligations under this Agreement: a. The Receiving Hospital agrees to accept a patient transferred in accordance with this Agreement and to provide or arrange for the Provision of medical services to the patient, provided (i) a physician on the Receiving Hospital's medical staff has accepted the patient; (ii) the Receiving Hospital has appropriate beds, equipment, and personnel available to serve the patient..."

During a review of the Weather Underground website data for the historical weather conditions in the area of Hospital B, the data indicated for the period of 2/28/23 at 10 p.m. until 3/1/23 at 7 a.m. the weather was rainy off and on, with temperatures between 37 to 46 degrees Fahrenheit, winds up to 28 miles per hour (mph) with wind gusts up to 41 mph.