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Based on interview and record review, the facility failed to provide an appropriate transfer for one of twenty-one sampled patients (Patient 1) when Patient 1 was transferred to another hospital's (Hospital B) Emergency Department (ED, hospital department that provides unscheduled outpatient services to patients whose condition requires immediate care) without providing Hospital B with the necessary patient information including, such as vital signs, diagnosis, treatment given, specific speciality care not available, medical records or Patient 1's legal representative's signed acknowledgement, to continue medical care.

This deficient practice had the potential to result in a delay or duplicate treatment when the transferring hospital (Hospital A) did not provide all the necessary Patient information to Hospital B upon transferring Patient 1.

Findings:

During a review of Patient 1's "Trauma Event - Text," dated 6/25/2024 at 8:12 p.m., the Trauma Event indicated the following: Patient 1 arrived (ambulatory) to the Emergency Department (ED) with a chief complaint of: "Tier 1 Trauma (activation of trauma team where surgeon response time is within 15 minutes of activation), reason for visit" Trauma. Triage Assessment: Tier 1 Trauma status post (S/P) blast injury to R (right) hand. Patient 1 holding mortar when it exploded. Some movement of fingers. Patient 1 endorses numbness to hand. Tracking Acuity (severity of illness or medical condition): 1 - Critical (requires high levels of medical care).

During a review of Patient 1's "ED (Emergency Department) Physician Note," dated 6/25/2024 at 8:12 p.m., the ED Physician (MD 1) Note indicated the following. Patient (1) presents with right, hand pain...14 year-old...acute severe explosion injury to the right hand...Complains of pain, missing the fourth and fifth digits (fingers), tingling of the second and third digit. Large macerated explosion injury to the palm and the thenar eminence (base of the thumb)...Musculoskeletal: Hand: Right, large gaping explosion laceration to the thenar eminence with laterally displaced MCP (knuckle)...Second and third digit are vascularly intact to the third digit with the distal fingertip missing and exposed bone. Most of fourth and fifth digits are missing...
On re-examination/Re-evaluation on 6/25/2024 9:03 p.m.. Notes:...X-ray shows obvious derangement...Decision was made after discussion with trauma surgeon (MD 2) for 911 Re-triage (process to minimize delays and expedite transfer to the designated trauma...reserved for patients with life-threatening traumatic injuries requiring emergency surgical intervention) to Hospital B for pediatric (patients up to age 14) ortho hand (bone doctor who specializes in the hand). Discussed case ED physician (MD 4) at Hospital B, who agrees with transfer.
Plan: Disposition: Transfer to other location (Hospital B), accepted by MD 4.

During a review of Patient 1's "Progress Note," dated 6/25/2024 at 8:17 p.m., by Trauma Surgeon (MD 2), the progress note indicated the following...This child is a child which we do not have a hand surgeon who would be willing to cover and had to transfer this patient (1) to Hospital B with 911 ambulance. "We have called the children ambulance and was discussed with the accepting facility and described the need to transfer this patient was 911. I (MD 2) have discussed with patient's (1) father and mother about the need to transfer this patient (1) to accepting facility (Hospital B) due to his age and extensive injury..."

During a review of Patient 1's "Case Management Note," dated 6/25/2024 at 8:28 p.m., the case management note indicated the following. ED CM (case manager) was informed that patient (1) will need HLOC (higher level of care). DX (diagnosis): right hand injury hand explosion, pinky and ring finger missing, mangled (mutilated or disfigured) extremity - palmar (palm of the hand). 14 year-old holding a mortar and blew up. ED CM called Hospital B, talked to staff - will call back once information is updated on chart.

During a review of Patient 1's "Emergency Department Interfacility Transfer Checklist for Trauma Re-Triage," dated 6/25/2024, the Transfer Checklist indicated the following. Patient (1) meets Trauma Re-Triage Criteria: Yes. Patient (1) is in the emergency department and not admitted to the hospital: Yes. If meets both criteria, follow procedure below:...
Immediately prepare Patient for transport. Copy ED records...Ensure hospital-specific transfer paperwork completed...ED RN: Calls Trauma Center and provides report to accepting RN or house supervisor.

During a review of Patient 1's "Patient Transfer Summary and Acknowledgement," dated 6/25/2024 at 8:32 p.m., the Transfer Summary and Acknowledgment form was incomplete / blank, as follows.

Section: Patient information:
Patient Discharge Vital signs: blank
Patient Diagnosis: blank
Treatment given: blank
Condition at time of Transfer: blank

Section: Receiving Facility / Transfer Information:
Ambulance Company Responsible for Transferring Patient: blank
MAC (Medicare Administrative Contractor) Operator Authoring Transfer: blank
Transfer by EMT, RN, etc: blank
Time of transfer: blank

Section: Transfer Checklist (documents sent to receiving facility):
X-rays: yes (indicated sent)
Medical record: blank
Nursing Notes: blank
Treatment record: blank
EKG: blank
Lab results: blank
Imaging studies: blank
IV solution, or oxygen: blank

Section: Physician Certification: "The patient noted below has had a medical screening examination, and stabilizing treatment has been completed. I have explained to the patient the benefits, risk and possible consequences of the planned transfer, and based on my examination of the patient and the clinical information available tome at this time, I approve the transfer for the following reason (s):"
"Specialized care not available at this time (specify)": blank

Section: Patient Transfer Acknowledgment was not initiated by the Patient 1's Representative), indicating acknowledgement of the following;
"I acknowledge that I have received a medical screening examination and evaluation by a physician or other appropriate personnel and, where found medically necessary, stabilizing treatment has been completed. This screening and stabilization care was given without regard to my ability to pay and was done prior to arrangements for transfer being completed."
Initials: blank
"I have been informed of the reason (s) for transfer. I have been informed of the benefits, risk and consequences associated with the planned transfer and understand that i Have the right to discuss any concerns or questions I may have regarding any aspect of the planned transfer with the treating physician or other appropriate personnel, and I have done so and received responses to my satisfaction": Initials: blank
"I understand I am being transferred to: blank, for the above reasons (s). Initials: blank
There was no signature of the patient (Patient 1) or Patient 1's Representative, no date, not time, or witness.


During a review of Patient 1's "ED Discharge Note," dated 6/25/2024 at 12:32 am, the note indicated the following. Patient (1) transferred to another Acute Care Facility...Patient (1) transported to Hospital B via 911 Re-triage...Transfer to another facility: Accepting MD name: MD 4, Accepting Facility (Hospital B), Level of Transport: ALS (Advanced Life support ambulance staffed by a paramedic or firefighter).

During an interview and record review on 7/30/2024 at 2 p.m., with the Manager of Emergency Services (MES), the MES stated the following: Patient 1 arrived to the Emergency Department (ED) on 6/25/2024 at 8:10 p.m., for a blast injury to the right hand. Patient 1 was missing the 4th digit (finger) and part of the 3rd digit, and numbness to the 2nd and 3rd digit. Patient 1 was taken to the Trauma bay immediately. Patient 1 was triaged and assessed as to be in critical condition and was seen immediately by the attending physician (MD 1) and trauma surgeon (MD 2). Patient 1 had an x-ray done to the right hand. An antibiotic and a pain medication was administered. The facility did not have a pediatric ortho hand specialist. Per physician notes, MD 1 called an outside Hospital (Hospital B) and spoke with the Emergency Department Physician (MD 4), who accepted Patient 1 for transfer. Patient 1 was transferred by ALS ambulance to Hospital B on 6/25/2024 at 8:44 p.m. The MES stated that an appropriate transfer did not take place. Hospital B did not receive necessary information, including Patient 1's last vital signs, diagnosis, treatments given, condition of Patient 1 upon transfer, and Patient 1's medical records. MD 1 did not indicate the type of specialized care that was not available in the hospital (Hospital A) In addition, Patient 1's Representative did not acknowledge the reason for transfer or that the risk and benefits had been explained. The MES stated that it was necessary to provide the information so Hospital B would be aware of the reason for transfer and the treatment already provided by the transferring Hospital (Hospital A), to avoid duplicate treatments. RN 1 should have completed all the paperwork and sent the medical records to Hospital B.

During an interview on 7/30/2024 at 2:43 p.m., with the Trauma Surgeon (MD 2), MD 2 stated he (MD 2) examined Patient 1 on 6/25/2024 and consulted with the Ortho/hand Surgeon (MD 3) regarding Patient 1 who was a 14 year old male. MD 2 stated MD 3 was not comfortable caring for the pediatric patient (Patient 1) who may need surgical intervention and admission to the pediatric intensive care unit, which was not available at this hospital (Hospital A). So, MD 1 and MD 2 decided to transfer Patient 1 to Hospital B because Hospital B was a pediatric (a branch of medicine that specializes in infants, children, and adolescents up to 18 or 21 years old) hospital with a Level 1 trauma center (capable of providing total care for every aspect of injury), and would have all the services.

During an interview on 7/30/2024 at 2:45 p.m., with the Chief Medical Officer (CMO), the CMO stated the following. A medical decision was made to activate the 9-1-1 Trauma Re-Triage (process to minimize delays and expedite transfer to the designated trauma...reserved for patients with life-threatening traumatic injuries requiring emergency surgical intervention) due to the emergent needs of life or limb saving interventions and transfer Patient 1 to Hospital B due to the extent of Patient 1's injury. Patient 1 met the criteria (provider judgement and patient in the ED) 9-1-1 Trauma Re-Triage. There should be physician-to-physician communication and the facility should follow all EMTALA requirements for an appropriate transfer.

During an interview on 7/31/2024 at 2:25 p.m., with the Director of Care Coordination (DCC), the DCC stated the following. The DCC oversees the Emergency Department (ED) case managers, who assist with transferring patients to another hospital for higher level of care. Care Coordination initiates the transfer by calling the receiving hospital, gives intake information (basic information), name of patient, urgency, demographics. There needs to be physician-to physician communication. If the patient is accepted, the CM coordinates ambulance transport, which can be bypassed if there is a 911 Re-triage. Care coordination will start the process, the physician may "Re-triage," If Re-triage occurs, the Emergency Department (ED) takes over and the primary ED registered nurse (RN) fills out the forms and coordinates the transfer.

During a review of the facility's policy and procedure (P&P) titled, "[Name of Facility A] Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy," dated 9/25/2018, the P&P indicated the following. Except where otherwise permitted by law, Emergency Medical Screening and stabilizing treatment will be provided to all individuals presenting at Dignity Health Emergency Departments (ED) requesting examination or treatment of a medical condition...either to stabilized the emergency condition or to Transfer appropriately and in conformity with the legal and regulatory requirements...E. Transfer of Individual with an Emergency Medical Condition (EMC, a medical condition manifesting itself by acute symptoms or sufficient severity [including severe pain...] such that the absence of immediate medical attention could reasonably be expected to result in:...Placing the health of the individual in serious jeopardy; Serious impairment to bodily functions: or Serious dysfunction of any bodily organ or part...)
1. If the individual has an EMC, the individual is to be treated in the Dedicated Emergency Department (DED) until the condition is stabilized or the individual is appropriately transferred...
2. Requirements for an Appropriate Transfer...the individual may be transferred in compliance with state and federal law if the hospital complies with all of the following standards:
a) The hospital provides medical treatment within its' capacity to minimize the risks the individuals health...the medical record will reflect the vital signs and condition of the individual at the time of the transfer; and...
c) The hospital send to the receiving facility all medical records (or copies thereof) available at the time of the transfer related to the emergency medical condition of the individual, including (i) records related to the individual's emergency condition: (ii) the individual's informed written consent to transfer...
d) The transfer is effecting using proper proper personnel and equipment as well as necessary and medically appropriate life-support measures as clinically indicated.

Based on interview and record review, the facility failed to provide an appropriate transfer for one of twenty-one sampled patients (Patient 1) when Patient 1 was transferred to another hospital's (Hospital B) Emergency Department (ED, hospital department that provides unscheduled outpatient services to patients whose condition requires immediate care) without providing Hospital B with the necessary patient information including, such as vital signs, diagnosis, treatment given, specific speciality care not available, medical records or Patient 1's legal representative's signed acknowledgement, to continue medical care.

This deficient practice had the potential to result in a delay or duplicate treatment when the transferring hospital (Hospital A) did not provide all the necessary Patient information to Hospital B upon transferring Patient 1.

Findings:

During a review of Patient 1's "Trauma Event - Text," dated 6/25/2024 at 8:12 p.m., the Trauma Event indicated the following: Patient 1 arrived (ambulatory) to the Emergency Department (ED) with a chief complaint of: "Tier 1 Trauma (activation of trauma team where surgeon response time is within 15 minutes of activation), reason for visit" Trauma. Triage Assessment: Tier 1 Trauma status post (S/P) blast injury to R (right) hand. Patient 1 holding mortar when it exploded. Some movement of fingers. Patient 1 endorses numbness to hand. Tracking Acuity (severity of illness or medical condition): 1 - Critical (requires high levels of medical care).

During a review of Patient 1's "ED (Emergency Department) Physician Note," dated 6/25/2024 at 8:12 p.m., the ED Physician (MD 1) Note indicated the following. Patient (1) presents with right, hand pain...14 year-old...acute severe explosion injury to the right hand...Complains of pain, missing the fourth and fifth digits (fingers), tingling of the second and third digit. Large macerated explosion injury to the palm and the thenar eminence (base of the thumb)...Musculoskeletal: Hand: Right, large gaping explosion laceration to the thenar eminence with laterally displaced MCP (knuckle)...Second and third digit are vascularly intact to the third digit with the distal fingertip missing and exposed bone. Most of fourth and fifth digits are missing...
On re-examination/Re-evaluation on 6/25/2024 9:03 p.m.. Notes:...X-ray shows obvious derangement...Decision was made after discussion with trauma surgeon (MD 2) for 911 Re-triage (process to minimize delays and expedite transfer to the designated trauma...reserved for patients with life-threatening traumatic injuries requiring emergency surgical intervention) to Hospital B for pediatric (patients up to age 14) ortho hand (bone doctor who specializes in the hand). Discussed case ED physician (MD 4) at Hospital B, who agrees with transfer.
Plan: Disposition: Transfer to other location (Hospital B), accepted by MD 4.

During a review of Patient 1's "Progress Note," dated 6/25/2024 at 8:17 p.m., by Trauma Surgeon (MD 2), the progress note indicated the following...This child is a child which we do not have a hand surgeon who would be willing to cover and had to transfer this patient (1) to Hospital B with 911 ambulance. "We have called the children ambulance and was discussed with the accepting facility and described the need to transfer this patient was 911. I (MD 2) have discussed with patient's (1) father and mother about the need to transfer this patient (1) to accepting facility (Hospital B) due to his age and extensive injury..."

During a review of Patient 1's "Case Management Note," dated 6/25/2024 at 8:28 p.m., the case management note indicated the following. ED CM (case manager) was informed that patient (1) will need HLOC (higher level of care). DX (diagnosis): right hand injury hand explosion, pinky and ring finger missing, mangled (mutilated or disfigured) extremity - palmar (palm of the hand). 14 year-old holding a mortar and blew up. ED CM called Hospital B, talked to staff - will call back once information is updated on chart.

During a review of Patient 1's "Emergency Department Interfacility Transfer Checklist for Trauma Re-Triage," dated 6/25/2024, the Transfer Checklist indicated the following. Patient (1) meets Trauma Re-Triage Criteria: Yes. Patient (1) is in the emergency department and not admitted to the hospital: Yes. If meets both criteria, follow procedure below:...
Immediately prepare Patient for transport. Copy ED records...Ensure hospital-specific transfer paperwork completed...ED RN: Calls Trauma Center and provides report to accepting RN or house supervisor.

During a review of Patient 1's "Patient Transfer Summary and Acknowledgement," dated 6/25/2024 at 8:32 p.m., the Transfer Summary and Acknowledgment form was incomplete / blank, as follows.

Section: Patient information:
Patient Discharge Vital signs: blank
Patient Diagnosis: blank
Treatment given: blank
Condition at time of Transfer: blank

Section: Receiving Facility / Transfer Information:
Ambulance Company Responsible for Transferring Patient: blank
MAC (Medicare Administrative Contractor) Operator Authoring Transfer: blank
Transfer by EMT, RN, etc: blank
Time of transfer: blank

Section: Transfer Checklist (documents sent to receiving facility):
X-rays: yes (indicated sent)
Medical record: blank
Nursing Notes: blank
Treatment record: blank
EKG: blank
Lab results: blank
Imaging studies: blank
IV solution, or oxygen: blank

Section: Physician Certification: "The patient noted below has had a medical screening examination, and stabilizing treatment has been completed. I have explained to the patient the benefits, risk and possible consequences of the planned transfer, and based on my examination of the patient and the clinical information available tome at this time, I approve the transfer for the following reason (s):"
"Specialized care not available at this time (specify)": blank

Section: Patient Transfer Acknowledgment was not initiated by the Patient 1's Representative), indicating acknowledgement of the following;
"I acknowledge that I have received a medical screening examination and evaluation by a physician or other appropriate personnel and, where found medically necessary, stabilizing treatment has been completed. This screening and stabilization care was given without regard to my ability to pay and was done prior to arrangements for transfer being completed."
Initials: blank
"I have been informed of the reason (s) for transfer. I have been informed of the benefits, risk and consequences associated with the planned transfer and understand that i Have the right to discuss any concerns or questions I may have regarding any aspect of the planned transfer with the treating physician or other appropriate personnel, and I have done so and received responses to my satisfaction": Initials: blank
"I understand I am being transferred to: blank, for the above reasons (s). Initials: blank
There was no signature of the patient (Patient 1) or Patient 1's Representative, no date, not time, or witness.


During a review of Patient 1's "ED Discharge Note," dated 6/25/2024 at 12:32 am, the note indicated the following. Patient (1) transferred to another Acute Care Facility...Patient (1) transported to Hospital B via 911 Re-triage...Transfer to another facility: Accepting MD name: MD 4, Accepting Facility (Hospital B), Level of Transport: ALS (Advanced Life support ambulance staffed by a paramedic or firefighter).

During an interview and record review on 7/30/2024 at 2 p.m., with the Manager of Emergency Services (MES), the MES stated the following: Patient 1 arrived to the Emergency Department (ED) on 6/25/2024 at 8:10 p.m., for a blast injury to the right hand. Patient 1 was missing the 4th digit (finger) and part of the 3rd digit, and numbness to the 2nd and 3rd digit. Patient 1 was taken to the Trauma bay immediately. Patient 1 was triaged and assessed as to be in critical condition and was seen immediately by the attending physician (MD 1) and trauma surgeon (MD 2). Patient 1 had an x-ray done to the right hand. An antibiotic and a pain medication was administered. The facility did not have a pediatric ortho hand specialist. Per physician notes, MD 1 called an outside Hospital (Hospital B) and spoke with the Emergency Department Physician (MD 4), who accepted Patient 1 for transfer. Patient 1 was transferred by ALS ambulance to Hospital B on 6/25/2024 at 8:44 p.m. The MES stated that an appropriate transfer did not take place. Hospital B did not receive necessary information, including Patient 1's last vital signs, diagnosis, treatments given, condition of Patient 1 upon transfer, and Patient 1's medical records. MD 1 did not indicate the type of specialized care that was not available in the hospital (Hospital A) In addition, Patient 1's Representative did not acknowledge the reason for transfer or that the risk and benefits had been explained. The MES stated that it was necessary to provide the information so Hospital B would be aware of the reason for transfer and the treatment already provided by the transferring Hospital (Hospital A), to avoid duplicate treatments. RN 1 should have completed all the paperwork and sent the medical records to Hospital B.

During an interview on 7/30/2024 at 2:43 p.m., with the Trauma Surgeon (MD 2), MD 2 stated he (MD 2) examined Patient 1 on 6/25/2024 and consulted with the Ortho/hand Surgeon (MD 3) regarding Patient 1 who was a 14 year old male. MD 2 stated MD 3 was not comfortable caring for the pediatric patient (Patient 1) who may need surgical intervention and admission to the pediatric intensive care unit, which was not available at this hospital (Hospital A). So, MD 1 and MD 2 decided to transfer Patient 1 to Hospital B because Hospital B was a pediatric (a branch of medicine that specializes in infants, children, and adolescents up to 18 or 21 years old) hospital with a Level 1 trauma center (capable of providing total care for every aspect of injury), and would have all the services.

During an interview on 7/30/2024 at 2:45 p.m., with the Chief Medical Officer (CMO), the CMO stated the following. A medical decision was made to activate the 9-1-1 Trauma Re-Triage (process to minimize delays and expedite transfer to the designated trauma...reserved for patients with life-threatening traumatic injuries requiring emergency surgical intervention) due to the emergent needs of life or limb saving interventions and transfer Patient 1 to Hospital B due to the extent of Patient 1's injury. Patient 1 met the criteria (provider judgement and patient in the ED) 9-1-1 Trauma Re-Triage. There should be physician-to-physician communication and the facility should follow all EMTALA requirements for an appropriate transfer.

During an interview on 7/31/2024 at 2:25 p.m., with the Director of Care Coordination (DCC), the DCC stated the following. The DCC oversees the Emergency Department (ED) case managers, who assist with transferring patients to another hospital for higher level of care. Care Coordination initiates the transfer by calling the receiving hospital, gives intake information (basic information), name of patient, urgency, demographics. There needs to be physician-to physician communication. If the patient is accepted, the CM coordinates ambulance transport, which can be bypassed if there is a 911 Re-triage. Care coordination will start the process, the physician may "Re-triage," If Re-triage occurs, the Emergency Department (ED) takes over and the primary ED registered nurse (RN) fills out the forms and coordinates the transfer.

During a review of the facility's policy and procedure (P&P) titled, "[Name of Facility A] Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy," dated 9/25/2018, the P&P indicated the following. Except where otherwise permitted by law, Emergency Medical Screening and stabilizing treatment will be provided to all individuals presenting at Dignity Health Emergency Departments (ED) requesting examination or treatment of a medical condition...either to stabilized the emergency condition or to Transfer appropriately and in conformity with the legal and regulatory requirements...E. Transfer of Individual with an Emergency Medical Condition (EMC, a medical condition manifesting itself by acute symptoms or sufficient severity [including severe pain...] such that the absence of immediate medical attention could reasonably be expected to result in:...Placing the health of the individual in serious jeopardy; Serious impairment to bodily functions: or Serious dysfunction of any bodily organ or part...)
1. If the individual has an EMC, the individual is to be treated in the Dedicated Emergency Department (DED) until the condition is stabilized or the individual is appropriately transferred...
2. Requirements for an Appropriate Transfer...the individual may be transferred in compliance with state and federal law if the hospital complies with all of the following standards:
a) The hospital provides medical treatment within its' capacity to minimize the risks the individuals health...the medical record will reflect the vital signs and condition of the individual at the time of the transfer; and...
c) The hospital send to the receiving facility all medical records (or copies thereof) available at the time of the transfer related to the emergency medical condition of the individual, including (i) records related to the individual's emergency condition: (ii) the individual's informed written consent to transfer...
d) The transfer is effecting using proper proper personnel and equipment as well as necessary and medically appropriate life-support measures as clinically indicated.