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Based on record review, staff interviews and review of policy and procedure the Critical Access Hospital (CAH-A) failed to follow their policy to ensure the appropriate documentation was included on patient Transfer Forms for 7 (P1, P2, P4, P8C, P13, P17 and P18) of 20 sampled patient records. This failure has the potential to cause harm or delay in treatment for patients who are transferred. According to facility provided information the ED (Emergency Department) transfers an average of 8 patients per month.

Findings include:

Also see 2409

A. Review of facility policy "Transfer of Patient from the ER to another Facility", approved 11/22/2021 revealed, the following items that will be completed prior to transfer.
- Acceptance to the receiving facility must be made physician to physician with documentation of the receiving facility physician's name.
- Patient shall be informed of the reason for transfer:
Continued care not available at [Name of Facility]
Higher level of care needed
Specialty care needed that is not available
- Physician shall address the risks and benefits of transfer
- One of the following choices on the Patient Transfer Sheet must be addressed by the patient or authorized individual:
Transfer consent
Transfer refusal
Refusal of care and request for transfer
Transfer by private vehicle
- Additional documentation shall include but is not limited to;
Condition off the patient prior to transport
Vital signs prior to transport
The name of the receiving facility staff that report is called to
The medical information sent with the patient

B. Review of facility policy "Transfer of Patient from the ER to another Facility", approved 11/22/2021 lacked evidence of addressing the Certification of Transfer.

C. Review of medical records:
- Review of P1's medical record revealed the patient presented to the ED on 7/16/2023 with complaints of abdominal pain. P1 received a medical screening exam (MSE) and was determined to have an emergency medical condition (EMC) that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of condition of the patient and certification of transfer by medical provider prior to transfer.
- Review of P2's medical record revealed the patient presented to the ED on 7/7/2023 with complaints of intentional medication overdose. P2 received a MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of accepting physician, report to receiving nurse at receiving facility, certification of transfer by medical provider and, selected appropriate transfer consent completed prior to transfer.
- Review of P4's medical record revealed the patient presented to the ED on 6/17/2023 with complaints of meat stuck in throat. P4 received a MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of report to receiving nurse at receiving facility, certification of transfer by medical provider and, selected appropriate transfer consent completed prior to transfer.
- Review of P8C's medical record revealed the patient presented to the ED on 5/11/2023 with complaints of anxiety. P8C received a MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of report to the receiving nurse at receiving facility, patient diagnosis, patient condition, receiving physician acceptance name and, selected appropriate transfer consent completed prior to transfer.
- Review of P13's medical record revealed the patient presented to the ED on 3/3/2023 with complaints of dehydration and contractions at 34 weeks pregnant. P13 received a MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of patient condition and, certification of transfer by medical provider completed prior to transfer.
- Review of P17's medical record revealed the patient presented to the ED on 2/21/2023 with complaints of rib fractures after falling at home. P17 did not receive an appropriate MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of receiving physician acceptance name, patient diagnosis, patient condition and risk of transfer completed prior to transfer.
- Review of P18's medical record revealed the patient presented to the ED on 2/26/2023 with complaints of vomiting and lethargy. P18 received a MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of benefits of transfer and certification of transfer by medical provider completed prior to transfer.

D. During an interview on 7/26/2023 at 9:33am, Medical Doctor-A (MD-A) revealed that acceptance for P2 to Hospital-B was perceived during the phone call between MD-A and MD at Hospital-B. MD-A felt that once all recommendations were acquired then pt. 2 would be accepted by the ED physician. MD-A is unable to recall the ED physician that phone call was with. MD-A confirmed that accepting physician was not written on the transform form.

E. During an interview on 7/25/2023 at 1:48pm, Chief Nursing Officer (CNO) revealed that the facility does do closed ED chart audits and has noticed that there is missing transfer documentation on the EMTALA forms (transfer form).

F. During an interview on 7/26/2023 at 10:10am, Chief Operating Officer (COO) confirmed that the EMTALA transfer form was hard to read and cumbersome for documentation.



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Based on record review, staff interview and review of policies the CAH-A failed to ensure that 1 (P17) of 20 sampled patient records received an appropriate MSE prior to being transferred to another facility. This failure has the potential to cause harm or delay in treatment to all patients that present to CAH-A's ED. According to facility provided information the ED treats on average 107 patients per month.

Findings include:

A. Review of the facility policy Vital Signs last revised 3/28/22 revealed, that all patients will have vital sign documentation in the patient electronic health record. That documentation includes temperature, pulse, respirations, blood pressure, oxygen (O2) saturation and pain assessment. A full set of vital signs is obtained upon admission and discharge.

B. Review of facility policy "Transfer of Patient from the ER to another Facility", approved 11/22/2021 revealed, if the physician determines that the patient should be transferred to another facility for further care, EMTALA standards must be followed. The patient must: have no life-threatening condition, not be in imminent labor, not require immediate need for surgery, be medically stable and agree to the transfer.

C. Review of P17's medical record revealed that P17 initially presented to the physician clinic on 2/21/2023 with complaints of chest pain. P17 fell the night before and hit the bedroom dresser and has had right sided chest pain and left knee pain since the fall. Chest x-ray was completed during the clinic visit revealed posterior (back side) rib fractures of ribs 3 through 6 and lateral aspects (right outside) of ribs 5 and 6. With possible flail chest (when 2 or more ribs located next to each other are fractured in two or more places). P17 was transferred over the ED at 9:49am. After arrival in the ED a cat scan (CT- an imaging test that helps healthcare providers see images of bones and soft tissues.) of chest and x-ray of left knee was ordered and completed. CT of chest revealed right 3rd-6th rib fractures with 4th, 5th and 6th having fractures at 2 sites. These fractures place the patient at risk for flail chest. Left knee x-ray was negative for fractures. P17 does admit to pain when taking a deep breath, feeling short of breath at times and feeling like chest may be moving somewhat when taking a deep breath.
P17's medical history includes atrial fibrillation (an irregular heartbeat that can lead to blood clots, stroke and other heart related complications). Home medications were reviewed while in the ED. High risk medication included Eliquis (a medication used to prevent and treat certain types of blood clots) 5 milligrams (mg) by mouth twice daily. While in the ED awaiting transfer to hospital-C no other MSE testing was provided that was within the capabilities of CAH-A. Patient complained of chest pain upon presentation and no lab or EKG was completed. P17. never had temperature documented or pain assessed while in the ED. Pain medication was provided to the P17 twice with no reassessment or response to pain medication documented. There was no documentation of stabilizing treatment for flail chest provided prior to transfer at 11:50am.

D. During an interview on 7/26/2023 at 10:33am, CNO confirmed that Pt. 17's medical record did not have a temperature documented during ED visit.

Based on record review, staff interviews and review of policy and procedures CAH-A failed to ensure that 7 (P1, P2, P4, P8C, P13, P17 and P18) of 7 sampled transferred patient records had completed transfer forms in their medical record. The failure to ensure completeness of certification for transfer form has the potential to cause harm or delay in treatment for all transferred patients. According to the facility provided information the ED transfers an average of 8 patients per month.

Findings include:

A. Review of facility policy "Transfer of Patient from the ER to another Facility", approved 11/22/2021 revealed, CAH-A failed to follow the facility policy by medical providers not addressing the risks and benefits of transfer. Failure to address one of the following on the patient transfer sheet: transfer consent, transfer refusal, refusal of care and request for transfer, transfer by private vehicle.

B. Review of medical records:
- Review of P1's medical record revealed the patient presented to the ED on 7/16/2023 with complaints of abdominal pain. P1 received a medical screening exam (MSE) and was determined to have an emergency medical condition (EMC) that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of condition of the patient and certification of transfer by medical provider prior to transfer.
- Review of P2's medical record revealed the patient presented to the ED on 7/7/2023 with complaints of intentional medication overdose. P2 received a MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of accepting physician, report to receiving nurse at receiving facility, certification of transfer by medical provider and, selected appropriate transfer consent completed prior to transfer.
- Review of P4's medical record revealed the patient presented to the ED on 6/17/2023 with complaints of meat stuck in throat. P4 received a MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of report to receiving nurse at receiving facility, certification of transfer by medical provider and, selected appropriate transfer consent completed prior to transfer.
- Review of P8C's medical record revealed the patient presented to the ED on 5/11/2023 with complaints of anxiety. P8C received a MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of report to the receiving nurse at receiving facility, patient diagnosis, patient condition, receiving physician acceptance name and, selected appropriate transfer consent completed prior to transfer.
- Review of P13's medical record revealed the patient presented to the ED on 3/3/2023 with complaints of dehydration and contractions at 34 weeks pregnant. P13 received a MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of patient condition and, certification of transfer by medical provider completed prior to transfer.
- Review of P17's medical record revealed the patient presented to the ED on 2/21/2023 with complaints of rib fractures after falling at home. P17 did not receive an appropriate MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of receiving physician acceptance name, patient diagnosis, patient condition and risk of transfer completed prior to transfer.
- Review of P18's medical record revealed the patient presented to the ED on 2/26/2023 with complaints of vomiting and lethargy. P18 received a MSE and was determined to have an EMC that required transfer to another hospital. Review of the Patient Transfer Sheet revealed that the form lacked evidence of benefits of transfer and certification of transfer by medical provider completed prior to transfer.

C. During an interview on 7/25/2023 at 1:48pm with the CNO revealed that the facility does do closed ED chart audits and has noticed that there is missing transfer documentation on the EMTALA forms (transfer form).