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Based on document review and interview, the facility failed to complete an appropriate transfer of a patient to another facility, for 1 of 20 medical records reviewed.

Findings Include:

1. See findings cited at 42 CFR 489.24 (1), A2409.

Based on document review and interview, the facility failed to complete an "appropriate transfer" to another facility for 1 of 20 medical records reviewed.

1. P1's MR indicates the patient presented to F1 on 12/30/2021 with chest pain and nausea. An emergency medical screening was completed with abnormal elevated blood pressure, and abnormal elevated Troponin lab results being noted. Based on these findings MD2, Medical Doctor, Emergency Department, notes that P1 needed to be admitted. P1 requested to be sent to facility F2 for admission. F2 was called, and they were not able to accept P1 due to being on full diversion. P1's spouse indicated that P1 would be taken by the spouse to F2 by private vehicle in order to have P1 admitted to F2. P1 was treated with morphine for pain, and Zofran for nausea while at F1. P1 was discharged in stable condition, and was taken by the family member to F2. MD2 MR documentation with P1 on 12/30/2021 did not indicate any coordinated transfer plan or communication between F1 and F2. The MR did not include any "Facility to Facility Transfer" form for review.

2. An incident report was filed by RN1, Registered Nurse, Emergency Department, regarding P1's care. RN1 noted that MD2 felt P1 should be admitted. When P1 expressed a desire to be transferred to F2, RN1 called F2 to request transfer, but F2 was under complete diversion at that time. RN1 voiced concerns regarding a non-ST elevated myocardial infarction (NSTEMI) but MD2 felt P1 suffered from an acute cardiac syndrome diagnosis. RN1 relayed the diversion information, and the urgency of further evaluation to P1 and the spouse. P1's spouse opted to take the patient via private auto to F2, and MD2 "was agreeable." The incident report also noted that MD2 did not feel Against Medical Advice (AMA) was warranted for this situation.

3. Facility policy titled "Emergency Medical Treatment and Transfer," HPP.112, effective 01/06/2021, indicates that either an "Appropriate Transfer" or for an "Appropriate Transfer Refusal" procedure must be completed by the emergency provider on duty per facility policy. This procedure requires signature or declination noted on the F1 "Facility to Facility Transfer" form be completed, and communication with the receiving facility be initiated.

4. On 1/10/2022 at 1200 hours, S1, Director, Organizational Improvement, confirmed that no "Facility to Facility Transfer" form was available for review in P1's medical record for 12/30/2021. This transfer form is required for either an "Appropriate Transfer" or for an "Appropriate Transfer Refusal" by facility policy. S1 confirms that MD2 did not facilitate an "Appropriate Transfer" or "Appropriate Transfer Refusal," based on facility written policies during the patient interaction on 12/30/2021.