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Based on clinical record review and interview, it was determined the facility inappropriately discharged two patients without arranging an appropriate transfer (Patients #1, #4); and failed to fully disclose the risks and benefits of transfer specific to the condition of transferred patients for five (Patients #1, #7, #15, #18, #20) of nine patients. Findings follow.

Review of the clinical records revealed the following:

Patient #1:
A 44 year old male presented to the ED on 05/09/17 at 19:00 with right foot/leg pain for the past 12 hours. A physician did not examine the patient, but documented "right foot was purple, cold, without pulse and no sensation. Impression was Ischemic right leg." The physician told the patient that the hospital did not have ultrasound to obtain venous or arterial Doppler to evaluate degree or level of blockage. The family was instructed to take the patient to another hospital for evaluation in the ED and vascular surgeon management. The patient was discharged. Transfer certification was not completed as the patient was discharged home as "stable", although he was told to go to a higher level ED. A summary of risks and benefits was not provided.

Patient #4:
A 41 year old female presented to the ED on 05/27/17 at 09:20 with vaginal bleeding. A pelvic exam was done with the assistance of the nurse. Labs were obtained. The patient was told that the hospital does not have ultrasound or obstetrical care. She was discharged home and advised to go to another hospital for an ultrasound and repeat quantitative pregnancy test. The patient should have been transferred to a higher level of care.

Patient #7:
A 48 year old female presented to the ED on 05/22/17 at 06:20 with chest pain for 30 minutes which was resolved. Cardiac risk factors included hypertension and family history. The treating physician spoke to accepting physician for transfer. Transfer certification was completed, however, the summary of risks were not specific to the patient's condition.

Patient #15:
A 59 year old female presented to the ED on 04/30/17 at 10:55 with shortness of breath and urinary tract infection. She has history of COPD and is on home oxygen. She is bedbound after a femur fracture. Impression was depression, anxiety, constipation, chronic UTI, COPD, chronic back pain, and hypotension. The treating physician spoke to accepting physician for transfer. Transfer certification was completed, however, the summary of risks were not specific to the patient's condition.

Patient #18:
A 43 year old female presented to the ED on 05/08/17 at 19:05 with nausea, vomiting, and diarrhea. She had history of diabetes and blood sugar was 400 for the paramedics. The patient was diagnosed with diabetic ketoacidosis. The treating physician spoke to accepting physician for transfer. Transfer certification was completed, however, the summary of risks were not specific to the patient's condition.

Patient #20:
An 83 year old male presented to the ED on 05/13/17 at 11:54 with chest pain and epigastric pain 10/10 with nausea and diaphoresis. While in CT, the patient had an episode of bradycardia with heart rate in 30s, eyes rolled back, and fainted. An EKG and Chest/Abdomen CT were conducted. The treating physician spoke to accepting physician for transfer. Transfer certification was completed, however, the risks were not specific to the patient's condition.

During an interview on 06/08/17 at 1530, the Administrator and Quality Officer confirmed the risks and benefits of transfer were not specific to the Patient's condition.