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Based on medical record (MR) review, document review, and interview, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA).



Findings:

The hospital failed to ensure that "The Physician Certification Consent To Transfer" form, documented the benefits and/or risks associated with the patient's transfer and were specific to the patient's medical condition.

See Tag A-2409

Based on medical record (MR) review, document review, and interview, in six (6) of six (6) medical records MRs reviewed, the hospital failed to ensure that The "Physician Certification Consent To Transfer" form, documented the benefits and/or risks associated with the patient's transfer and were specific to the patient's medical condition. (Patients #1, 13, 33, 37, 38, and 44)


Findings include:

Review of the hospital's policy and procedure (P&P) titled, "Emergency Treatment, Stabilization, Transfer of Patients and EMTALA (Emergency Medical Treatment and Labor Act)," reviewed 11/2022, stated: "Staff arranging transfers will follow these requirements: (d) Document all of the following in the patient's medical record in accordance with the hospital's standard descriptions of patients requiring specialized emergency care, triage protocols, and formal written transfer agreements: ... (iii) specific risks and benefits of the proposed transfer."

Review of Patient #1's MR identified: On 12/28/23, the patient was brought to the Emergency Department with a chief complaint of unresponsiveness. The patient was diagnosed with Intracerebral Hemorrhage and the physician determined that the patient needed to be transferred to another hospital.

The "Physician Certification Consent To Transfer" form, dated 12/28/23, stated the following: "I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to... Hospital, Neurology Intensive Care Unit (receiving facility): for further treatment and stabilization."
The benefits and risks associated with the transfer and specific to the patient's medical condition were not documented.

Review of Patient #13's MR identified: On 1/23/24, the patient was transferred from MSQ Hospital to MSBI Emergency Department with a chief complaint of upper respiratory infection with respiratory distress and hypoxia. The patient was diagnosed with Multifocal Pneumonia and the physician determined that the patient needed to be transferred to another hospital.

The "Physician Certification Consent To Transfer" form, dated 1/24/24, stated the following: "I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to, (receiving facility): risk of decompensation, requiring higher respiratory support." The benefits associated with the transfer and specific to the patient's medical condition were not documented.

Review of Patient #33's MR identified: On 1/22/24, the patient was brought to the Emergency Department with a chief complaint of unresponsiveness. The patient was diagnosed with Septic Shock secondary to Pneumonia and the physician determined that the patient needed to be transferred to another hospital.

The "Physician Certification Consent To Transfer" form, dated 1/22/24, stated the following: "I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to MSW Hospital, (receiving facility): informed patient representative that patient requires ICU level care and requires transfer due to space limitation and staff limitation at current hospital."
The benefits and risks associated with the transfer and specific to the patient's medical condition were not documented.

Review of Patient #37's MR identified: On 1/8/24, the patient presented to the Emergency Department with a chief complaint of cardiac workup and clearance for a procedure. The patient was diagnosed with Atrial Fibrillation and the physician determined that the patient needed to be transferred to another hospital.

The "Physician Certification Consent To Transfer" form, dated 1/8/24, stated the following: "I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to MSH, (receiving facility): benefits is specialty care; risk is atrial fibrillation with rapid ventricular rate (RVR), hypotension and death."
The benefits associated with the transfer and specific to the patient's medical condition were not documented.


Review of Patient #38's MR identified: On 1/7/24 the patient was brought to the Emergency Department with a chief complaint of slurred speech and weakness. The patient was diagnosed with Stroke and the physician determined that the patient needed to be transferred to another hospital.

The "Physician Certification Consent To Transfer" form, dated 1/7/24, stated the following: "I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to MSH, (receiving facility): decompensation, worsening of symptoms, delay care to medical facility."
The benefits associated with the transfer and specific to the patient's medical condition were not documented.

Review of Patient #44's MR identified: On 1/13/24 the patient was brought to the Emergency Department with a chief complaint of slurred speech and weakness. The patient was diagnosed with Large Vessel Obstruction (LVO)-Ischemic Stroke and the physician determined that the patient needed to be transferred to another hospital.

The "Physician Certification Consent To Transfer" form, dated 1/13/24, stated the following: "I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to MSW Hospital, (receiving facility): further treatment and stabilization."
The benefits and risks associated with the transfer and specific to the patient's medical condition were not documented.

Per interviews of Staff C, (President/Chief Operating Officer), Staff HH (Deputy Chief Operating Officer) and Staff II (Physician) on 1/31/2024 at 3:00 PM, the "Patient Transfer Summary" form for Patient #33 was reviewed and documented the following: "Risks and benefits have been reviewed with the patient and the patient/guardian accepts the transfer." They confirmed the form does not include the risks and benefits associated with the transfer and specific to the patient's medical condition. Staff HH stated the doctor reviews the risks and benefits of the transfer with the patient. They could not provide documentation that the risks and benefits were specific to the patient's medical condition.