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Based on observation, interview and record review, the hospital failed to post signs visible to all in the Emergency Department (ED) entrance, waiting room and treatment areas, as well as the main entrance which specified the rights of individuals under the Emergency Medical Treatment and Active Labor Act (EMTALA), regarding examination and treatment for emergency medical conditions and women in labor (ready to give birth).

This failure had the potential for patients and families to be unaware of their rights under EMTALA.

Findings:

During an observation on 9/18/23 at 3:47 p.m. with the emergency room director (EDD), no signs were posted that specify the rights of individuals to examination and treatment for emergency medical conditions (EMC) and women in labor in the emergency room outside waiting area, inside waiting room, treatment rooms, or in the main lobby and admitting area.

During an interview on 9/18/23, at 4:04 p.m. with patient access manager (PAM), PAM stated, we only have an EMTALA sign in the hallway in the ED and in ED admitting area.

During an interview on 9/18/23, at 4:06 p.m. with EDD confirmed, we have an EMTALA sign in the hallway in the ED and in ED admitting area there are no other EMTALA signs posted in the hospital.

During a review of the facility's policy and procedure (P&P) titled, "The Emergency Medical Treatment and Labor Act," dated 9/29/20, the P&P indicated, Signage The hospital has signs posted conspicuously in lobbies, waiting rooms, admitting areas and treatment rooms where examination and treatment occurs in the form required by CMS that specify the rights of individuals to examination and treatment for emergency medical conditions and indicate that the hospital participated in the Medicaid program."

Based on interview and record review the Hospital A failed to maintain the accuracy of the Emergency Department (ED) central log when:

1. Patient 108 was not registered/ when the patient was brought into the ED vicinity by emergency medical services (EMS) due to being unresponsive, necessitating emergency services.

2. Patient 104's destination was not accurately documented.

These failures resulted in the ED central log to be inaccurate and out of compliance per regulation.

Findings:

1.On 9/8/23 at approximately10:16 p.m., an EMS ambulance came to the ambulance bay of Hospital A seeking emergency services for Patient 108 who had been found unresponsive, with agonal breathing (heaving ,distressed breathing) and a heart rate of 37-45 beats per minute (normal 60-100). The ED medical doctor (EDMD 1), registered nurse (RN 1), and emergency medical technician (EMT) met the EMS ambulance at the ED ambulance bay. EDM1 checked Patient 108's condition and sent the patient out to another destination (Hospital B) via the same EMS ambulance who brought the patient to the ED ambulance bay. Patient 108 did not receive any emergency medical services.

On 9/18/23 during a review of Hospital A's ED central log dated 9/8/23, indicated, Patient 108's presence on the EMS ambulance at the hospital's ED ambulance bay on 9/8/23 was not logged, so with the information of the patient being sent out to another destination (Hospital B).


During an interview with the ED registration clerk (EDRC) on 9/18/23 at 3:09 p.m., the EDRC reported not registering (logging) Patient 108 into the ED central log on 9/8/23. EDRC stated "I didn't register this patient. He (Patient 108) didn't come into the ED. I did not know if it was a male. The ED doctor, and EMT met the ambulance outside. This happened so fast, then the ambulance was on its way to (hospital's name- Hospital B).

During an interview with EDMD 1 on 9/21/23 at 10:06 a.m., EDMD acknowledged and confirmed Patient 108 was not registered (logged) in the ED central log on 9/8/23 and should have been. EDMD 1 stated "In retrospect, I should have had the patient registered in the ED."

2. A review of the ED central log, dated 3/30/23, was conducted on 9/19/23. The log indicated Patient 104 was brought into the ED of Hospital A on 3/30/23 at 5:35 a.m., with shortness of breath, and was diagnosed with acute hypoxia respiratory failure ( insufficient oxygen). Patient 104, was supposed to be transferred to another hospital on 3/30/23 at 10:39 a.m., (5 hours after). Upon review of Patient 104's medical record, the record indicated the ED physician wanted to transfer the patient to another hospital to treat his medical condition. Patient 104 refused the transfer and was admitted to the hospital's telemetry unit for further treatment.

During a concurrent review of the ED central log, dated 3/30/23, Patient 104 record review, and interview with the associate director of quality (ADQ) on 9/21/23 at 11:37 a.m., The ADQ acknowledged and confirmed the ED central log was not accurate and it should be.

The hospital's policy and procedure (P&P) titled "The Emergency Medical Treatment and Labor Act (EMTALA)", dated 9/29/20, in IV(F)(G) part indicated "Central (ED) Log--is defined as a log maintained by the Hospital on each individual who comes to its Dedicated Emergency Departments or any location on the Hospital property seeking emergency assistance, and the disposition of each individual. G (4) Comes to the emergency department or comes to the hospital--is defined as an individual who: Is in a non-hospital owned ground or air ambulance that is on Hospital property for presentation for examination or Treatment for a Medical Condition at the Hospital's dedicated emergency department." Further review of the P& P, in B part indicated "The central log will record the name of each person who presents for emergency services and whether the person refused Treatment, was refused Treatment by the Hospital or whether the patient was transferred, admitted and treated, Stabilized and transferred or discharged."

Based on interview and record review Hospital (Hospital A) failed to ensure the emergency physician (EDMD 1) working in the Emergency Department (ED) on 9/8/23 perform an appropriate medical screening examination (MSE) within the capability of their ED to determine if Patient 108 had a medical emergency condition (MEC) when patient was brought to the hospital's ED by EMS (Emergency Medial Services) ambulance.

The failure of the hospital's physician of not performing an appropriate MSE, resulted in Patient 108 not having medical interventions to potentially prevent death.

Finding:

The EMS document dated 9/8/23 at 9:52 p.m., indicated Patient 108 was a 38-year-old male who was found at home unresponsive, not breathing, pupils fixed, skin warm, pale, and cyanotic (bluish or purplish discoloration (as of the skin and mucous membranes) due to deficient oxygenation of the blood). Patient's heart rate was low 37 beats/minute requiring sternal pacing (temporarily pace a heart by delivering controlled pulses of electric current). The patient was initially ventilated with a bag ventilation mask (BVM) and oral airway by EMS personnels. Narcan (reverses opioid overdose) 2 milligrams intramuscular (IM) was administered to the patient. The EMS document further indicated Patient 108 had a history of fentanyl use.

In route to the closest hospital [Hospital A] patient's ventilations became non-compliant. An intraosseous IO (placing of a sturdy needle through bone and into the medullary cavity-to emergently infuse fluids, medications, and blood products into critically ill patients) was established. An I-geal (advanced airway management device) was placed and capnography wave form was better but still poor. Patient was transported to the closest facility (Hospital A) for airway management and stabilization.

At 10:11 p.m., the EMS monitor indicated patient's Sp02 (oxygen in blood) was 49% (normal > 94%). Blood pressure 41/22 (normal 120/80). At 10:12 p.m., Sp02 was 69%. At 10:16 p.m., Sp02 was 56%. Arrived at receiving facility ER [Hospital A] with the doctor of the ER ... and staff outside. Doctor opened the back of the ambulance "asked if this most appropriate place for the patient". EMS medics (personnel) stated "Yes, due to poor compliance with airway and to stabilize the patient." Doctor stated "No". Ventura county fire department (VCFD) medic stated, "We don't have time to argue and if you do not want this patient, we will go somewhere else." Doctor said, "We don't have telemetry go to another facility" and shut the EMS ambulance doors.

During an interview with EDMD 1 on 9/12/23 at 1:32 p.m., EDMD 1 stated "A nurse told me about patient coming here. From the report I thought this was not the appropriate place for this patient. I met them (EMS ambulance) at the ambulance bay to decide from there if this was the best place for patient ... there was no CT scan, no ultrasound, no ICU, most likely patient will need to be in the ICU. There were only two registered nurses RNs in the ED. Patient would need 1:1 nursing status. This patient will take all our resources. That's why I thought the patient was better to go to (hospital's name) [Hospital B]. I talked to the medics before they unloaded patient here to see if this was the best place for him. Medics we're not receptive ... Told medics patient better to go to (hospital's name), we would have to wait three hours for another ambulance to transfer patient to (hospital's name) [Hospital B]. Medics said, "We are wasting time, just tell us now if we are going, so we can go" and they left. EDMD 1 was asked if s/he evaluated the patient. EDMD 1 stated, "Yes". EDMD was asked if patient had a medical emergency condition. EDMD 1 stated, "Yes".

During another interview with EDMD 1 on 9/21/23 at 10:06 a.m., EDMD 1 stated "In retrospect ... I should have done a thorough medical screening ... I should have brought in the patient into the ED to treat his medical emergency. EDMD 1 was asked if s/he listened to the patient's apical (chest area) heartbeat using a stethoscope to ensure there was a heartbeat. EDMD 1 stated "No, I did not". EDMD 1 was asked if s/he listened to the patient's lungs using a stethoscope to ensure patient's respiratory status was stable or oxygenating well. EDMD 1 stated "No, I did not".

During an interview with hospital's [Hospital A] emergency medical technician (EMT) on 9/18/23 at 4:35 p.m., the EMT reported the ED staff were aware an unresponsive and agonal breathing patient was coming. The ED doctor (EDMD1) and himself went outside to meet the EMS ambulance at the bay. The ED doctor asked medics if this was the appropriate facility considering patient's condition. The medics said "Are you sending us to (hospital's name)? Medics just waited for doctor to say "Yes" to go to (hospital's name). Then, medics left to go to the hospital [Hospital B]. EMT further confirmed ED doctor (EDMD 1) did not lay hands on patient to perform and evaluation (MSE).

During an interview with registered nurse (RN 1) on 9/19/23 at 11:59 a.m., RN 1 reported ED doctor (EDMD 1), EMT, and RN 1 went to the ambulance bay to meet the EMS ambulance outside the ED. The doctor was standing at the ambulance speaking to the medics for approximately 2 minutes. Then the ambulance left with the patient to go to (hospital's name) [Hospital B]. RN 1 confirmed doctor (EDMD 1) did not lay hands on patient for an evaluation (MSE).

During a review of the hospital's policy and procedure (P&P) titled "The Emergency Medical Treatment and Labor Act (EMTALA)", dated 9/29/20, in V(G) part indicated "1. An MSE must be offered to any individual who comes to the emergency department (ED) for examination or Treatment of a Medical Condition. the MSE must be provided within the capabilities of the ED, including ancillary services routinely available to the ED (including the availability of On- Call physicians). 2. An MSE is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical Condition does or does not exist. The scope of the MSE must be tailored to the presenting complaint and the medical history of the patient. The process may range from a simple examination (such as a brief history and physical) to a complex examination that may include laboratory tests, CT or diagnostic imaging, lumbar punctures, other diagnostic tests and procedures and the use of On-Call physician specialists. 4. The MSE is a continuous process reflecting undergoing monitoring in accordance with an individual's needs. Monitoring will continue while the individual is Stabilized or appropriately transferred."

Based on interview and record review Hospital A failed to ensure the emergency physician (EDMD 1) working in the Emergency Department (ED) on 9/8/23 provided stabilization services to Patient 108 within the capability and capacity of their ED when patient was brought to the hospital's ED by Emergency medical services (EMS) ambulance.

The failure of the physician to provide stabilization services to patient before being sent to another hospital [Hospital B] resulted in a delay of medical emergency services and contributing to patient's death.

Findings:

During a review of the EMS document, dated 9/8/23 at 9:52 p.m., created by EMS medics and an interview with EDMD 1 on 9/21/23 at 10:25 a.m., it was communicated to EDMD 1 that on 9/8/23, Patient 108 required stabilization services based on the patient's EMS document which indicated patient had a medical emergency condition (MEC). According to the patient's EMS document patient was found unresponsive with agonal breathing. Patient's initial heart rate was 37 (normal 60-100) for which external pacing was required. Patient was transported to the closest facility for airway management and stabilization. Initial Sp02 was 64% (normal > 94%) on high concentration of oxygen delivery, Sp02 remained low ranging from 49% to 51 %, and it was 56% when patient arrived at the [Hospital A] ED at approximately 10:16 p.m. Patient's blood pressure was not captured until 10:11 p.m., which was 41/22 (normal 120/80), significantly low, therefore patient necessitating stabilization services for the emergency condition (MEC). Patient was sent to another ED [Hospital B] by EDMD 1 without providing any services at this hospital. EDMD 1 stated "In retrospect, I should have brought in the patient to the ED to treat his medical emergency, to stabilize him with our limited resources here ... This patient was not stabilized or stable. I should have place an endotracheal tube ETT, it would have taken me seconds ..."

A review of Hospital B, Patient 108 medical record was conducted on 9/12/23. The Emergency Record dated 9/8/23 at 10:49 p.m., in the initial Nursing Assessment conducted at 10:48 p.m., indicated "Patient unresponsive, skin pale in color, mottled, heart rate asystole (heart stopped), apneic (breathing stopped), chess expansion unequal and movement asymmetrical, and deviated trachea. Patient bag with BVM on arrival.

During a review of the Doctor Notes, dated 9/8/23 at 11:45 p.m., indicated "When EMS pacer pads were removed, patient was in asystole and no pulse. Cardio-Pulmonary Resusciatation ( CPR) was started. Despite several rounds of epinephrine ( medication to start heart rate) and CPR, patient did not regain spontaneous circulation. Time of death was at 10:57 p.m."

During a review of the hospital's policy and procedure (P&P) titled "The Emergency Medical Treatment and Labor Act (EMTALA)", dated 9/29/20, in part V(J) indicated "When it is determined that individual has an Emergency Medical Condition, the Hospital will within the Capability of the Hospital, provide further medical examination and Stabilization Treatment for the individual."

Based on interview of hospital staff, patient closed clinical records and hospital policies and procedures review, the facility failed to ensure there was documentation that 18 of 32 sampled patients had been informed of the risks and benefits of transfer to another facility and that a physician had certified that the medical benefits of transfer, outweighed the risks.

This failure did not ensure patients have knowledge and understanding of what is to come for their health needs and plans which has the potential to violate the patient's right to know.


Findings:

During a review the hospital's policy and procedure (P&P) titled "The Emergency Medical Treatment and Labor Act (EMTALA)", dated 9/29/20, in part V(K) indicated "The hospital may not transfer any patient with an unstabilized emergency medical condition ... unless the patient requests the transfer or a physician signs a Physician Certification that the medical benefits reasonably expected from the provision of Treatment at the receiving facility outweighs the risks to the patient from the transfer." Further review of the P&P indicated "A patient with an unstabilized emergency medical condition may be transfer only if the Hospital complies with all of the following standards: a. The hospital provides medical treatment within its capacity to minimize the risk to the individual's health ...b. The receiving hospital has available space and qualified personnel for treatment of the patient and the receiving physician has agreed to accept the patient ...c. The hospital sends to the receiving facility all medical records at the time of transfer related to the emergency medical condition... d. The transfer is effected using proper personnel and equipment ..."

1.On 9/8/23 at approximately10:16 p.m., an Emergency Medical Services (EMS) ambulance came to the ambulance bay of Hospital A seeking emergency services for Patient 108, a 38 -year- old who had been found down unresponsive, with agonal breathing ( heavy distressed breathing), and heart rate 37-45 beats per minute (normal 60-100). Patient was externally paced (delivering of controlled pulses of electric current) and a temporarily airway (tube into thrachea to breath) was placed. In route to Hospital A Emergency Department (ED), patient's condition remained unstable. Upon arrival to at the ED, the ED staff including a physician (EDMD1) met the EMS ambulance outside the ED. EDMD 1 directed the EMS ambulance medics, to transfer the patient to Hospital B without providing an MSE ( Medical Screening Evaluation), stabilizing patient's MEC ( Medical Emergency Condition), without explaining the risk and benefits to the next of kin, of transferring patient to Hospital B. The Physician Certification document was not completed or signed by EDMD1.

During an interview with EDMD 1 on 9/21/23 at 10:25 a.m., EDMD 1 acknowledged and confirmed Patient 108 transfer was not an appropriate transfer. EDMD 1 stated " I am the doctor who should have made the decision to bring patient into the ED, register the patient in the ED, perform a medical screening, treat his medical emergency and once stabilization is completed then transfer patient with all the paperwork required. I had forgotten about the transfer Physician Certification form."

2. A review of Patient 102 medical record was conducted on 9/19/23. Record indicated on 5/11/23, a 69-year-old male became unresponsive, pulseless, and apneic (stopped breathing) and CPR (chest compressions) was initiated at the nursing home where he resided. Patient gain Return of spontaneous circulation (ROSC). Patient was brought into the hospital's ED for airway management. Patient was orally endotracheal intubated (insertion of tube from mouth to windpipe into lungs to provide air or oxygen) then was transferred to another hospital. The record was reviewed for the risks and benefits of transferring patient to another hospital however no risks and benefits were in the record.

During a concurrent review of the hospital's Physician Certification form and interview with the ED medical director (EDMD 2) on 9/21/23 at 9:30 a.m., EMDM 2 explained the Physician Certification form must be completed. The physician marks the box A or B to determine or indicate whether patient's condition has been stabilized or not. Then physician documents s/he has explained the risks and benefits of transferring the patient, in the ED note. The risks and benefits have to be individualized according to the patient's individual situation. Those risks and benefits can also be written here on this form, but they have to be individualized for each patient. The language and this form is general when checking box, A or B.

3. A review of Patient 104 medical record was conducted on 9/19/23. Record indicated on 3/30/23, an 83- year -old male presented to the ED with shortness of breath, hypoxic, and notably tachypneic (high respiration rate). Hospital does not have cardiology services required to treat patient's medical condition therefore requiring transfer to another hospital that can provide required treatment. Patient was accepted at another hospital to treat his medical condition. Patient refused to be transferred to another hospital. However, the patient's refusal of transfer documentation was not completed in Section 4 of the Physician Authorization for Transfer form and in the Consent form in the part titled "Patient Refusal of Transfer."

During a concurrent review of the hospital's Physician Authorization for Transfer, Physician Certification, and Consent to Transfer for Medical Treatment forms and interview with the ED medical director (EDMD 2) on 9/21/23 at 9:30 a.m., EMDM 2 explained that in the Physician Authorization for Transfer form, Section 4 and in the Consent to Transfer for Medical Treatment form, the section labeled Patient Refusal of Transfer must be completed, if the patient refuses to be transferred.

4. A review of Patient 105 medical record was conducted on 9/19/23. Record indicated on 5/1/23, an 80-year-old male presented to the ED with complaint of dizziness and slow heart rate. Diagnosis included Sick Sinus Syndrome (a group of heart rhythm problems due to problems with the sinus node), Bradycardia (heart rate < 60), and near Syncope (fainting) necessitating cardiology services which were not available at this hospital. Patient was accepted to another hospital where cardiology services will be provided to treat his medical condition. While patient waiting for transport to arrive, Atropine (increases heart rate) 0.5 milligrams IV intravenous was administered for an episode of bradycardia (low heart rate) with visible episodes of PR disassociation. The record was reviewed for the risks and benefits of transferring patient to another hospital however no risks and benefits were in the record. Further review of the record indicated there was no documentation regarding patient's condition being stabilized for transfer. The Physician Certification form was left blank, on the check box section, to indicate if the patient's condition was stabilized or not before transfer.

During a concurrent review of the hospital's Physician Certification form and interview with the ED medical director (EDMD 2) on 9/21/23 at 9:30 a.m., EMDM 2 explained the Physician Certification form must be completed. The physician marks the box A or B to determine or indicate whether patient's condition has been stabilized or not. Then physician documents s/he has explained the risks and benefits of transferring the patient, in the ED note. The risks and benefits have to be individualized according to the patient's individual situation. Those risks and benefits can also be written here on this form, but they have to be individualized for each patient. The language and this form is general when checking box, A or B.

5. A review of Patient 106 medical record was conducted on 9/19/23. Record indicated on 3/26/23, an 11-year-old female sustained an injury to the left knee, requiring orthopedic services. The left knee X-ray report dated 3/26/23 indicated an acute non-displace transverse fracture of the superior Patella. Diagnosis included open patellar fracture (broken bone within the knee). Patient was anxious and received Versed (medication used to relax prior to a procedure) 5 milligrams by mouth on 3/26/23 at 8:05 p.m. Orthopedic On-Call requested for patient to be transferred to [hospital's name] for orthopedic evaluation and treatment. Patient was transferred to [hospital's name] on 3/26/23 at 8:52 p.m., by private car.

During a concurrent review of the Patient 106 medical record and interview with the ED medical director (EDMD 2) on 9/21/23 at 9:35 a.m., EMDM 2 stated "I agree with your concern regarding this patient being transferred by a private car after receiving Versed 5 milligrams orally at 8:05 p.m. Then, transferring patient to [hospital's name] at 8:52 p.m., 47 minutes after medication administration, by a private car. This would not be an appropriate transfer." EDMD 2 further reviewed the record in search for explanation of the risks and benefits of transferring this patient by private car. EDMD 2 acknowledged and agreed there were no risks and benefits documented in the record.

6. A review of Patient 107 medical record was conducted on 9/19/23. Record indicated on 4/11/23, a 55-year-old male presented with concerned of toothache. However, while in the ED patient also reported being suicidal and states he plans to cut his wrist. Patient is medically clear for voluntarily placement to psychiatric facility. Patient was transferred to a psychiatric facility on 4/11/23 at 10:41 p.m. The record was reviewed for the risks and benefits of transferring patient to another hospital however no risks and benefits were in the record.

During a concurrent review of the hospital's Physician Certification form and interview with the ED medical director (EDMD 2) on 9/21/23 at 9:30 a.m., EMDM 2 explained the Physician Certification form must be completed. The physician marks the box A or B to determine or indicate whether patient's condition has been stabilized or not. Then physician documents s/he has explained the risks and benefits of transferring the patient, in the ED note. The risks and benefits have to be individualized according to the patient's individual situation. Those risks and benefits can also be written here on this form, but they have to be individualized for each patient. The language and this form is general when checking box, A or B.

7. A review of Patient 109 medical record was conducted on 9/19/23. Record indicated on 3/19/23, a 41-year-old female brought in by EMS ambulance due to respiratory arrest, seizures, altered mental status and allergic reaction. On- Call neurologist was contacted and requested for patient to be transferred to [hospitals name] for neurology evaluation. Patient was transferred to [hospital's name] on 3/20/23 at 1:20 a.m. The record was reviewed for the risks and benefits of transferring patient to another hospital; however, no risks and benefits were in the record.

During a concurrent review of Patient 109 medical record an interview with EDMD 2 on 9/21/23 at 9:45 a.m., EDMD 2 review the record searching for documentation of explanation of the risks and benefits of transferring this patient to another hospital. However, no risk and benefits were in the record. EDMD 2 confirmed the record was missing the risks and benefits explanation and documentation.

8. A review of Patient 110 medical record was conducted on 9/19/23. Record indicated on 4/17/23, an 80-year-old female presents with acute onset of right upper extremity weakness and associated aphasia. Diagnosis included cerebral vascular accident (CVA) vs transient ischemic attack (TIA) necessitating neurology consultation. Arrangements were performed to transfer this patient to a higher level of care hospital where she could receive the treatment for her medical condition. Patient was transferred to another hospital on 4/18 23 at midnight. The record was reviewed for the risks and benefits of transferring patient to another hospital; however, no risks and benefits were in the record.

During a concurrent review of the hospital's Physician Certification form and interview with the ED medical director (EDMD 2) on 9/21/23 at 9:30 a.m., EMDM 2 explained the Physician Certification form must be completed. The physician marks the box A or B to determine or indicate whether patient's condition has been stabilized or not. Then physician documents s/he has explained the risks and benefits of transferring the patient, in the ED note. The risks and benefits have to be individualized according to the patient's individual situation. Those risks and benefits can also be written here on this form, but they have to be individualized for each patient. The language and this form is general when checking box, A or B.




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2. Review of hospital policy and procedure titled, "The Emergency Medical Treatment and Labor Act," dated, "9/29/2020" pg 3. "Physician Certification- is defined as the written certification by the treating physician ordering a transfer and setting forth, based on the information available at the time of the transfer, that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual and in the case of a woman in labor, to the unborn child, from effecting the transfer."

9. Review of Patient 200's medical record indicated Patient 200 was seen by emergency room physician (EDMD2), on 7/26/23, diagnosis of cardiac arrest, with a "high probability of imminent or life threatening deterioration due to cardiac arrest." EDMD arranged transfer to Hospital A, who had accepted Patient 200 and had the capacity, capability and closest to emergency room transferring facility. Family refused and requested a transfer to Hospital B. Patient 200 was transferred to Hospital B with ALS (advanced life support) and a critical care nurse accompanied Patient 200 during transport. Further review of medical record did not reveal hospital's obligations of risks to transfer to further distanced Hospital B. There was no documentation of family requested reasons for refusal to transfer to Hospital A.

During a concurrent interview and Patient 200's medical record review on 9/19/23, starting at 2 p.m., with emergency room director (EDD), EDD acknowledged there was no documentation or other evidence to indicate that the risks, benefits, alternatives or failure to transfer the Patient 200's had been placed into the medical record for Patient 200. EDD also acknowledged there was no documentation of reasons for family refusal to transfer to Hospital A. EDD stated, "I would have expected the doctor would have documented the risks and benefits."

10. Review of Patient 203's medical record indicated Patient 203 was seen by emergency room physician (EDMD2), on 7/22/23, at 2:23 p.m., for a psychiatric emergency of suicidal ideation. Patient 203 was transferred to another hospital on 7/23/23, at 10 a.m. Further review of medical record for Patient 203, did not reveal any documentation of risks and benefits to transfer Patient 203.

During a concurrent interview and Patient 203's medical record review on 9/21/23, starting at 9:20 a.m., with EDD, EDD acknowledged there was no documentation or other evidence to indicate that the risks, benefits, to transfer Patient 203's had been placed into the medical record for Patient 203. EDD stated, "No I don't see anything (documentation)."

11. Review of Patient 205's medical record indicated Patient 205 is a five year old who was seen by emergency room doctor (MDED3), on 7/31/23, at 5:33 p.m., with diagnosis of right forearm fracture, right elbow fracture and right elbow dislocation. Patient 205 was transferred to another hospital via private transportation on 7/31/23, at 8:40 p.m. Further review of medical record for Patient 205, did not reveal any documentation of risks and benefits to transfer Patient 205.

During a concurrent interview and Patient 205's medical record review on 9/21/23, starting at 9:10 a.m., with EDD, EDD acknowledged there was no documentation or other evidence to indicate the risks, to transfer Patient 205's had been placed into the medical record for Patient 205.

12. Review of Patient 208's medical record indicated Patient 208 was seen by emergency room doctor (EDMD2) on 8/7/23, at 9:21 a.m., with diagnosis of food impaction of esophagus ( a hollow, muscular tube that passes food and liquid from the throat to the stomach). Patient 208 was transferred to another hospital via private transportation on 8/7/23, at 11:20 a.m. Further review of medical record for Patient 208, did not reveal any documentation of risks and benefits to transfer Patient 208.

During a concurrent interview and Patient 208's medical record review on 9/21/23, starting at 9:00 a.m., with EDD, EDD acknowledged there was no documentation or other evidence to indicate that the risks, benefits, to transfer Patient 208's had been placed into the medical record for Patient 208. EDD stated, "No, it's completely blank (certification form) and there is nothing I can see in the clinical notes."




















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13. Review of Patient 303's medical record indicated, Patient 303 was seen by emergency room doctor (EDMD 4), on 5/29/23, at 8:09 p.m., with diagnosis of appendicitis. Patient 303 was transferred to another hospital via EMT transportation on 5/30/23, at 12:42 a.m. Further review of medical record for Patient 303, did not reveal any documentation of risks and benefits to transfer Patient 203.

During a concurrent interview and Patient 303's medical record review on 9/21/23, at 9:27 a.m., with EDD, EDD acknowledged there was no documentation or other evidence to indicate the risks and benefits, to transfer Patient 303's had been placed into the medical record for Patient 303.

14. Review of Patient 304's medical record indicated Patient 304 was seen by emergency room doctor (EDMD 5), on 5/31/23, at 4:25 p.m., with diagnosis of alcohol abuse with withdrawal. Patient 304 was transferred to another hospital via Paramedic unit EMT transportation on 5/31/23, at 10:49 p.m. Further review of medical record for Patient 304, did not reveal any documentation of risks and benefits to transfer Patient 304.

During a concurrent interview and Patient 304's medical record review on 9/21/23, at 9:29 a.m., with EDD, EDD acknowledged there was no documentation or other evidence to indicate the risks and benefits, to transfer Patient 304's had been placed into the medical record for Patient 304.

15. Review of Patient 305's medical record indicated Patient 305 was seen by emergency room doctor (EDMD 4), on 5/30/23, at 3:05 a.m., with diagnosis of ST elevation myocardial infarction (heart attack) (STEMI). Patient 305 was transferred to another hospital via Paramedic transportation on 5/30/23, at 3:51 a.m. Further review of medical record for Patient 305, did not reveal any documentation of risks and benefits to transfer Patient 305.

During a concurrent interview and Patient 305's medical record review on 9/21/23, at 9:32 a.m., with EDD, EDD acknowledged there was no documentation or other evidence to indicate the risks and benefits, to transfer Patient 305's had been placed into the medical record for Patient 305.

16. Review of Patient 306's medical record indicated Patient 306 was seen by emergency room doctor (EDMD 6), on 7/1/23, at 11:14 p.m., with diagnosis of GI bleed (digestive tract). Patient 306 was transferred to another hospital via Paramedic transportation on 7/1/23, at 3:18 a.m. Further review of medical record for Patient 306, did not reveal any documentation of risks and benefits to transfer Patient 306.

During a concurrent interview and Patient 306's medical record review on 9/21/23, at 9:34 a.m., with EDD, EDD acknowledged there was no documentation or other evidence to indicate the risks and benefits, to transfer Patient 306's had been placed into the medical record for Patient 306.

17. Review of Patient 307's medical record indicated Patient 307 was seen by emergency room doctor (EDMD 7), on 7/8/23, at 3:31 p.m., with diagnosis of acute respiratory failure with hypoxia. Patient 307 was transferred to another hospital on 7/823, at 8:43 p.m. Further review of medical record for Patient 307, did not reveal any documentation of risks and benefits to transfer Patient 307.

During a concurrent interview and Patient 307's medical record review on 9/21/23, at 9:36 a.m., with EDD, EDD acknowledged there was no documentation or other evidence to indicate the risks and benefits, to transfer Patient 307's had been placed into the medical record for Patient 307.

18. Review of Patient 308's medical record indicated Patient 308 was seen by emergency room doctor (EDMD 8), on 3/27/23, at 7:49 p.m., with diagnosis of overdose by ingestion. Patient 308 was transferred to another hospital via Paramedic transportation on 3/28/23, at 11:42 a.m. Further review of medical record for Patient 308, did not reveal any documentation of risks and benefits to transfer Patient 308.

During a concurrent interview and Patient 308's medical record review on 9/21/23, at 9:36 a.m., with EDD, EDD acknowledged there was no documentation or other evidence to indicate the risks and benefits, to transfer Patient 308's had been placed into the medical record for Patient 308.


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