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Based on observation, record review, and interview, the facility (Hospital A) failed to comply with 489.24 and ensure all requirements of an appropriate transfer (physician certification, transmission of medical records, consent to transfer, receiving hospital acceptance) were completed and documented for two of 20 patients (Patient #1 and Patient # 10).

Refer to A2409

Based on observation, record review, and interview, the facility (Hospital A) failed to ensure all requirements of appropriate transfer were completed for two of 20 patients (Patient #1 and Patient # 10) who required inpatient psychiatric treatment. Hospital A failed to document patient consent to transfer, transmission of medical records to Hospital B, physician certification, reason for transfer, and accepting hospital information through use of a Memorandum of Transfer (MOT) form.

The findings include:

Record Review

A review of the medical records indicated:

Patient #1 presented to the Emergency Department (ED) for a suicidal attempt. The patient was provided with a psychiatric assessment and was transferred to a higher level of care due to Hospital A not having psychiatric services. The MOT form was not found in the patient record to support that a physician certification was completed, an accepting physician/hospital was obtained, patient consent was obtained, and medical records were sent to the receiving hospital. The medical record shows the patient was on an Emergency Detention Order (EDO) and was transported by police to the receiving facility.

Patient #10 presented to the ED for suicidal ideations. The patient was provided with a psychiatric assessment and was transferred to a higher level of care due to Hospital A not having psychiatric services. The MOT form was not found in the patient record to support that a physician certification was completed, an accepting physician/hospital was obtained, patient consent was obtained, and medical records were sent to the receiving hospital. The medical record shows the patient was on an Emergency Detention Order (EDO) and was transported by police to the receiving facility.


A review of facility policies indicated:

EMTALA: Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions Policy, last reviewed, revised and effective 5/2021, indicated:

An appropriate MSE should address the presenting symptoms and comply with current policies and procedures for assessment of those presenting symptoms, including but not limited to a history of the presenting problem; a documented physical examination of the involved area or system; and the use of on-call physicial examination of the involved area or system; and the use of on-call physicials and ancillary tests or services routinely available to the Hospital if needed to determine whether an EMC exists. Documentation should reflect monitoring until the patient is stabilized or transferred.

Transfer of Unstable Patient: A transfer of an unstable patient with an EMC (eg. Uncontrollable bleeding; shortness of breath; potential symptoms of a heart attack, stroke, seizure, or drug overdose; severe digestive symptoms; other major trauma or burns, etc.) to another medical facility capabe of providing the patient with the necessary stabilizing treatment may be made in the following circumstances:
" Following the MSE, a patient may be transferred to another facility if the patient or their representative requests the transfer, after being notified of the hospital's obligation and the risk of the transfer.
" The patient may be transferred to another facility if the hospital determines that it does not have the necessary medical and/or staffing resources to properly stabilize the patient, and one of the following occurs:
o A physician has signed a certification that the medical benefits of the transfer are expected to outweigh the risks of transfer. The certification will state the reason for the transfer, patient condition/ benefit/risks of transfer, receiving hospital, mode of transportation, and patient consent.
" When a patient is transferred the consent of the receiving hospital to accept the transfer must first be obtained and documented in the medical record. The hospital shall send to the receiving facility, copies of all pertinent medical records available at the time of transfer, and affect the transfer through qualified personnel and transportation equipment.

Transfer of Patient to Another Hospital Policy, last reviewed, revised and effective 8/2023, indicated:

I. Policy
" A physician's order is required for a patient transfer to another acute care facility that indicates a specific mode of transfer and any necessary hospiptal staff support.
" A "Memorandum of Transer," a "Patient Request/Refusal/Consent to Transfer," and a "Physician Certification for Transfer" will be completed and sent with all patients being transferred to any other acute hospital for Covenant Levelland.

II. Medical Record
The hospital will provide to the receiving physician and the receiving hospital, a copy of those portions of the patient's medial record which are relevant to the transfer and the continuing care of the patient. At a minimum, this includes:

1. The patient's medical history, physical exam or physical documentation
2. Reason for the transfer
3. Results of all diagnostic tests and pertinent x-ray films and reports.

III. Procedure for Transfer
1. The Charge Nurse or designee will contact the receiving hospital/transfer center administrative person to verify that arrangements are being/have been made to accept the patient and the name of the receiving physician (if not already known from the patient's attending physician).
2. The attending physician/ER physician will contact a physician at the receiving hospital or the transfer center to accept the patient.
3. A patient cannot be transferred until the receiving hospital agrees to accept the patient and a physician has agreed to care for the patient.
4. The names of the accepting physician and administrative person will be filled in on the "Memorandum of Transfer" in Section A by the Charge Nurse or designee that verified the agreements for transfer.
a. It is the responsibility of the Charge Nurse or designee to complete and sign the Memorandum of Transfer, Section A, all blanks filled in.
5. The transferring unit will contact the transport entity based on information from the attending physician as to what support/specialized care the patient will require during transport and the physician's order for transfer.
6. The nursing unit will notify the family or significant other that the patient is to be transferred to another hospital, will the approximate time to transfer, is available.
7. The original copy of the "Memorandum of Transfer," "Physician Certification for Transfer" and "Patient Request/Refusal/Consent to Transfer" will accompany the patient to the receiving hospital. A copy of these documents will placed in the patient record.

Interviews

In an interview with Staff #2, Trauma Coordinator, on 6/18/2024, Staff #2 stated Patients #1 and Patient #10 were under police custody on an emergency detention order which could explain why the transfer requirements were not completed.

In an interview with Staff #1, Chief Nursing Officer, on 6/19/2024 at 10 AM, Staff #1 acknowledged that the MOT forms were not located in the patient medical records therefore it could not be verified if the forms were completed and an appropriate transfer occurred. Staff #1 acknowledged that the policy indicates that all tranfer requiremets and an MOT form should be completed for all transfers regardless if the patients are in police custody. Staff #1 indicated that according to their ED process, the medical records would have been sent to the receiving hospital prior to transfer.