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Based on interview and record review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to advise the benefits and/or risks of transfer to 3 (#9, 11, 16) of 6 patients who were transferred resulting in the potential for less than optimal outcomes for all patients seeking emergent care. Findings Include:

1. The failure to advise 3 (#9, 11, 16) of 6 patients who were transferred of the benefits and/or risks of the transfer (See tag 2409).

Based on observation and interview, the facility failed to post an EMTALA sign in the ambulance bay or just inside the emergency department from the ambulance bay resulting in the potential for all emergency department ambulance patients to not be informed of their rights to have a medical screening exam and stabilizing treatment in the emergency department. Findings include:

On 9/13/2021 at 1257, during the tour of the emergency department (ED), the ambulance bay was entered and found to have no EMTALA signage posted. Additionally, it was not posted on the outside wall of the hospital by the ambulance bay or just inside the ED from the ambulance bay. This was confirmed by Staff D at the time of discovery who stated, "No patients come in that way...well, only EMS (emergency medical services) patients. We didn't know they had to be out there."

Based on interview and record review, the facility failed to advise 3 (#9, 11, 16) of 6 patients who were transferred of the benefits and/or risks of the transfer resulting in the potential for patients making uninformed healthcare decisions which could result in physical decline and death. Findings include:

Review of the medical record of Patient #9 on 9/13/2021 at 1500 revealed the patient was an 87-year-old female who was experiencing a STEMI (ST elevation myocardial infarction) heart attack. Review of the "EMTALA Transfer Recommendation and Request Form" (#CON-RM-614) revealed the first section on page one labeled "Patient Condition" to have the patient's name present; however, the boxes indicating whether or not it was likely the patient could deteriorate as a result of the transfer were not addressed in the yes/no boxes provided. Information as to if the benefits outweighed the risks or if the on-call physician was unable to respond were left blank on the document. Further down the document in the section titled "Provider Certification" it states, "I have examined the patient and explained the following risks and benefits of being transferred/refusing transfer to the patient and his/her personal representative." Underneath the statement are two lines for documenting the benefits/risks which were left blank. On the back side of the document is a section titled "Transfer Request and Consent." This section states, "...The potential benefits of such transfer, the potential risks associated with such transfer, and the probable risks of not being transferred have been explained to me and I fully understand them..."; however, the area designating which hospital the patient was being transferred to as well as the reason for the transfer were left blank.

Review of the medical record of Patient #11 on 9/13/2021 at 1515 revealed the patient was a 52-year-old male who had experienced an open fracture of the left elbow. Review of the "EMTALA Transfer Recommendation and Request Form" (#CON-RM-614) revealed the first section on page one labeled "Patient Condition" to have the patient's name present; however, the boxes indicating whether or not it was likely the patient could deteriorate as a result of the transfer was not addressed in the yes/no boxes provided. Information as to if the benefits outweighed the risks or if the on-call physician was unable to respond were left blank on the document. Further down the document in the section titled "Provider Certification" it states, "I have examined the patient and explained the following risks and benefits of being transferred/refusing transfer to the patient and his/her personal representative." Underneath the statement are two lines for documenting the benefits/risks which were left blank. On the back side of the document is a section titled "Transfer Request and Consent." This section states, "...The potential benefits of such transfer, the potential risks associated with such transfer, and the probable risks of not being transferred have been explained to me and I fully understand them..."; however, the area designating which hospital the patient was being transferred to as well as the reason for the transfer were left blank.

Review of the medical record of Patient #16 on 9/14/2021 at 0845 revealed the patient was a 20-year-old female who had been in a motorcycle accident and experienced multiple fractures in the lower back and pelvic region. Review of the "EMTALA Transfer Recommendation and Request Form" (#CON-RM-614) revealed the first section on page one labeled "Patient Condition" to have the patient's name present; however, the boxes indicating whether or not it was likely the patient could deteriorate as a result of the transfer was not addressed in the yes/no boxes provided. Information as to if the benefits outweighed the risks or if the on-call physician was unable to respond were left blank on the document. Further down the document in the section titled "Provider Certification" it states, "I have examined the patient and explained the following risks and benefits of being transferred/refusing transfer to the patient and his/her personal representative." Underneath the statement are two lines for documenting the benefits/risks which were left blank. On the back side of the document is a section titled "Transfer Request and Consent." This section states, "...The potential benefits of such transfer, the potential risks associated with such transfer, and the probable risks of not being transferred have been explained to me and I fully understand them..."; however, the area designating which hospital the patient was being transferred to as well as the reason for the transfer were left blank.

Emergency Department (ED) Manager Staff D was queried on 9/14/2021 at 0852 as to if the "EMTALA Transfer Recommendation and Request Form" should have the risks and benefits listed to which she agreed they should be listed.

Review of facility policy titled "CC.ProvCare.8 Emergency Patient Transfer-EMTALA", #CC.ProvCare.8, version 10.0 states: "C. 1. An individual with an emergency medical condition that has not been stabilized may be transferred only in the following situations: a. The patient requests transfer after being informed of (facility name initials) obligation to provide stabilizing treatment and the risks of transfer...or b. The physician determines that the medical benefits of transfer outweigh the risks of transfer (to the individual patient or the unborn child). That is, if the physician determines the (facility name initials) staff capabilities or facilities are unable to provide the appropriate care and the patient cannot be stabilized, the patient can be transferred to another facility. Transfer of an unstable patient with an emergency medical condition to another facility for diagnostic testing must meet the same conditions as transfer for treatment... D. Procedure for Emergency Transfer...Complete Authorization for Transfer, CON-RM-614 a. For an individual to be transferred, the for Authorization for Transfer, CON-RM-614, must be completed. To complete the form, one of the three options on page one must be complete, and the entire second page must be completed..."