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Based on record review and interview, the facility staff failed to ensure compliance with 42 CFR 49.24.

Findings include:

The facility failed to appropriately transfer one patient (Patient #1). See tag A-2409.

Based on record review and interview, the facility failed to appropriately transfer patients receiving care in the Emergency Department (ED) to another facility for 1 of 7 patients (Patient #1) who were transferred from the ED to another facility in a total sample of 20 ED medical records reviewed.

Findings Include:

A review of the facility's policy titled, "MW Region EMTALA (Emergency Medical Treatment and Labor Act)" last revised 12/09/2024 revealed, "...b) Recipient Hospital: A representative of the Recipient Hospital must confirm prior to transfer that:...agrees to accept the Transfer...Hospital staff should document any communication with the Recipient Hospital, including the date and time of the Transfer request and the name of the person accepting the Transfer in the patient's medical record..."

A review of Patient #1's medical record revealed Patient #1 was a 42 year old male who presented to Hospital A's Emergency Department (ED) on 07/27/2025 at 9:55 AM with a chief complaint of suicidal ideations.

Further review of Patient #1's "ED Nursing Notes" on 07/27/2025 at 2:00 PM written by ED RN (Registered Nurse) X revealed, "...Ride arranged per pt [patient] request to go to [Hospital B]."

A review of the "ED Provider Notes" on 07/27/2025 at 2:01 PM written by ED Physician's Assistant (PA) Y revealed, "...After being informed of discharge, patient requested assistance with transportation. He states that he wants to go to a specific facility where he has gone in the past. After further research, this facility is apparently [Hospital B]. We did not advise or suggest that this patient go to [Hospital B], he has made this decision on his own following discharge."

There was no evidence of an appropriate transfer being initiated, no evidence Hospital B was notified or accepted Patient #1 for transfer, and no evidence of physician to physician communication completed.

During an interview on 08/13/2025 at 2:59 PM, Safety Manager V confirmed the above findings and stated [ED RN X] "went against the plan of care."