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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined that Penn Highlands Tyrone failed to maintain an accurate Control Register for disposition of individuals presenting to the emergency department in seven of 11 medical records reviewed. (MR1, MR23, MR24, MR25, MR29, MR31, MR32)

Review of PH Tyrone Policy Stat ID 7907986 "EMTALA-Central Log" last approved May 2020 revealed "... Purpose: To maintain a system for tracking the care provided to each individual who comes to Tyrone Regional Health Network Emergency Department for an emergency medical condition. Procedure: 1. The central log will include an entry for every patient that presents to the Emergency Department. This log will also include those patients transferred from other facilities to the ED, and those patients who present to the ED, then decline to stay and have a medical screening exam (MSE) ... 3. The log must contain ... c. complaint and disposition; d. whether the individual: i. refused treatment; ii. was refused treatment; iii. left without being seen (LWBS); iv. stabilized and transferred (include facility name and time of transfer); v. transferred to another facility (include facility name and time of transfer); vi. admitted and treated; vii. discharged including date and time ... ."
1. Review of Emergency Department Log dated January 31, 2023, revealed the patient associated with MR1, indicated a disposition of discharge. Documentation in MR1 revealed the patient was transferred to another facility.

Interview with EMP4 on March 13, 2023, regarding ED Log entry for patient associated with MR1, confirmed that disposition was noted as a discharge, but should have been noted as a transfer.

2. Review of a sample of 10 medical records (MR23-MR32) associated with event reports (left without treatment/against medical advice) from January 1, 2023 - February, 28, 2023, was cross-referenced with applicable Emergency Department Log entries with EMP12 on March 13, 2022.

Review of six of the 10 medical records revealed that MR23, MR24, MR25, MR29, MR31, and MR32, revealed inaccurate disposition entries on the Emergency Department Log.

Review of the ED Log dated January 1, 2023, relative to MR23, revealed the patient was discharged, however medical record and/or event report stated patient left without being seen.

Review of the ED Log dated January 10, 2023, relative to MR24, revealed the patient was discharged, however medical record and/or event report stated patient left without being seen.

Review of the ED Log dated January 10, 2023, relative to MR25, revealed the patient was discharged, however medical record and/or event report stated patient left without being seen.

Review of the ED Log dated February 6, 2023, relative to MR29, revealed the patient was discharged, however medical record and/or event report stated patient left against medical advice.

Review of the ED Log dated February 13, 2023, relative to MR31, revealed the patient was discharged, however medical record and/or event report stated patient left against medical advice.

Review of the ED Log dated February 26, 2023, relative to MR32, revealed the patient was discharged, however medical record and/or event report stated patient left against medical advice.

Interview with EMP12, on March 13, 2022, confirmed the findings.

Based on review of facility documents, medical records (MR), credential files (CF), and staff interview (EMP), it was determined that Penn Highlands Tyrone failed to ensure an appropriate transfer, by failing to ensure physician at receiving facility accepted transfer, and by failing to ensure medical records were sent to receiving facility, for one of seven medical records reviewed for appropriate transfer, in a total sample of 31 medical records reviewed. (MR1)

Findings include:

Review of PH Tyrone Policy Stat ID 7676384 "Transfer of Emergency Patients Between Hospitals" last approved February 2020 revealed, "A patient will not be transferred arbitrarily. The following steps should be performed and documented prior to the transfer of a patient from the Emergency Department. ... f. The receiving physician should be briefed on the patient and accept the transfer of the patient. g. Copies of the Emergency Department record including laboratory and x-ray reports and Memorandum of Transfer form must be sent with the patient, or faxed within on hour ... ."

Review of PH Tyrone Policy Stat ID 7676405 "Transfer of Patient to Another Health Care Facility" last approved February 2020 revealed, "Patients must not arbitrarily be transferred to another health care facility ... If the Tyrone Hospital does not have the means for providing adequate care of the patient, the ED physician will contact the appropriate health care facility, discuss the case with the responsible physician at the facility and arrange for transportation. ... The memorandum of Transfer Form must be completed by the ED nurse/physician and patient or their representative. A copy of the ED Medical record plus any lab work, x-rays, or EKG's will be copied by the ED nurse or Patient Access and sent to the receiving facility with the patient along with the copied Memorandum of Transfer Form ... It shall also be documented as to what records were sent i.e., labs, x-ray, CT reports etc ... ."

Review of PH Tyrone Policy Stat ID 7782512 "EMTALA Transfers" last approved December 2022 revealed, "... Procedure: ... 3. The four requirements of an appropriate transfer must be met before a patient can be transferred: b. The receiving hospital must have available space and qualified personnel for the treatment of the individual, and must have agreed to accept the transfer and provide appropriate treatment. c. Copies of all available medical records pertaining to the individual's emergency condition must be sent to the hospital where the patient is being transferred. i. These documents include copies of the available history, records related to the individual's emergency medical condition, observation of signs or signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or written certification of the physician ... iii. Copies of other records not available at the time of transfer will be sent as soon as practical after the transfer via fax or electronically. iv. Copies of records must accompany the patient whether or not the patient's emergency medical condition is stabilized ... 7. An ED physician or attending physician must obtain the consent of the receiving hospital and the receiving physician before the transfer of the patient and must make the appropriate arrangements for the patient transfer with the receiving hospital and physician. ... ."

1. Review of MR1 revealed Emergency Department Physician documentation dated January 31, 2023, stated the patient presented to the Emergency Department complaining of discomfort and a tingling sensation in left leg with a tingling sensation up to mid leg. Documentation of Medical Screening Examination, Service Date and Time, January 31, 2023, 1950. Physical Examination documentation noted that patient's left foot is appreciably colder and unable to get a dorsalis pedal pulse. Physician documentation indicated concern for possible arterial occlusion of the distal left lower extremity, and unable to get a pulse by Doppler, and unable to get ultrasonographer to the Emergency Department. Physician documentation also stated that case was discussed with charge nurse at receiving facility who accepted the patient to be taken via private vehicle to their emergency department to be evaluated by OTH1.
Documentation in MR1 also revealed a Patient Transfer Form, dated January 31, 2023, which indicated the type of transferring vehicle utilized was a private car, and form also indicated physician certification that the risks and benefits of transfer were explained, and a summary of benefits of transfer were also noted to indicate improved possibility of retaining life or limb, and diagnosis of possible left, lower extremity arterial occlusion. Signature of Transferring Physician was present on the form. Also noted on the form was the patient's signature acknowledging risks and benefits of transfer and consenting to the transfer. Documentation on the Transfer Form also noted the accepting physician as OTH1, however OTH1 did not accept the patient. There was no specific documentation in the medical record to indicate why the patient went by private vehicle.

Additional documentation in MR1 revealed electronic Physician Medical Necessity Certification Entered On: 2/1/2023, at 07:44, which stated Reason for Transfer, as higher level of care, Mode of Transportation as private car, condition on transfer as stable, and that patient was able to tolerate transportation by an automobile.

Documentation in MR1 revealed the patient left Penn Highlands Tyrone on January 31, 2023, at 20:33, and review of MR2 revealed the patient arrived at receiving facility on January 31, 2023, at 21:04.

2. Interview with EMP1 on March 9, 2023, at 10:43 AM revealed [they] thought that transfer could be done on behalf of a physician, and stated [they were] unaware of the doc-to-doc rules. EMP1 stated [they] did EMTALA paperwork [they] needed to fill out and had a name of accepting physician from charge nurse. EMP1 also stated [they were] aware that there are policies and procedures that drive transfers and that [they] learned about the physician-to-physician requirement when this EMTALA concern was launched. EMP1 also stated the patient traveled via private transportation, and wanted to go somewhere else and get treatment. EMP1 stated [the patient] didn't want to wait, didn't want to hear about [their] process, and that the patient stated it was a waste of time to come to their facility.

3. Interview with EMP2 on March 13, 2023, at 10:33 AM, revealed that for the patient's transport [they] went by private vehicle and EMP1 was comfortable with that because [the patient] had family with [them] that were ready to go.

4. During review of Credential File (CF1) associated with EMP1, it was noted to contain documentation which included EMP1 signature dated September 24, 2021, indicating that [they have] read and understands the EMTALA education, entitled Penn Highlands Healthcare The Emergency Medical Treatment and Active Labor Act (Meets Criteria for Risk Management/Patient Safety) which revealed "... The Emergency Medical Treatment and Active Labor Act What is is now and how it applies to Penn Highlands Healthcare ... Appropriate Transfer to another Medical Facility ... The receiving facility's physician then must be contacted by the transferring physician and agree to accept the transfer. The agreement from the receiving facility must indicate that they have the space and qualified personnel to treat the patient and will accept the transfer and provide appropriate medical treatment. Once the transfer has been agreed upon, transfer of the patient with use of qualified personnel and transportation equipment, as required by the circumstances, including the use of necessary and medically appropriate life support measures. The patient must also be accompanied by a copy of their medical record and written certification in support of the transfer by the transferring physician ... Finally, all records that are not available at the time of transfer must be communicated to the receiving hospital when they become available ... ."

5. Interview with EMP4 on March 13, 2023, confirmed that there should have been physician to physician communication prior to transfer.

6. Review of MR1 revealed Nursing Discharge Documentation dated January 31, 2023, 8:33 PM, by EMP2 which revealed Transfer sheet sent with patient.

MR1 also revealed a Penn Highlands Tyrone Emergency Department Patient Transfer Form which was noted to contain an "attachments" section. Review of this section only noted transfer form, and did not note or indicate that the patient's medical record was sent with the patient.

7. Review of the Patient Transfer Form with EMP4 on March 13, 2023, revealed that according to documentation, no medical records were sent with the patient other than the transfer form.

8. Telephone interview with EMP2 on March 13, 2023, at 10:33 AM, confirmed that the patient was sent with only the transfer form, and stated that the medical record was not printed because there was no testing or blood work.