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Based on interview and record review, the facility failed to acquire consent from 1 of 20 sampled patients before transferring the patient (Patient 3) from this facility's emergency department to another facility for higher level of care. This deficient practice led to Patient 3 not being able to make an informed decision about the transfer.

Findings:

During an interview on 7/26/2024 at 10:15 AM, MD 1 stated that he did not specifically recall if Patient 3 was informed of her pending transfer to another facility on 7/6/2024. Subsequently MD 1 said it is the facility's usual practice to inform the patient or responsible party of the need to transfer the patient; if a responsible party is not available, nursing will sign the consent in that person's absence.

During an interview on 7/26/2024 at 11:05 AM, RN 2 stated, after reviewing Patient 3's medical record, he was one of the nurses treating Patient 3 on 7/6/2024 but did not remember the details of Patient 3's discharge. At this time, RN 2 said it is usual practice for nursing to leave 3 telephone messages to the responsible party in the event the patient is unable to verbalize his or her consent to transfer to another facility. RN 2 then confirmed if there is no verified consent by the patient or responsible party then the responsibility of acquiring consent to transfer would be escalated to the treating physician. Lastly, RN 2 said that after all attempts to attain consent for transfer have failed, two nurses can sign in place of consent by the patient or responsible party and the transfer can proceed.

During an interview on 7/26/2024 at 12:10 PM, Regulatory Compliance stated he could locate any documentation Patient 3 or an responsibility party had been informed of the risks and benefits or agreed to transfer Patient 3 to another facility.

During a review of 'Emergency Department Reports' indicated on 7/5/2024 Patient 3 presented to the emergency department with altered mentation (disruption in brain function that may lead to change in behavior), elevated heart rate, and was hot to touch. The 'Emergency Department Reports' showed that Patient 3 had a ureteral stone (crystal caught in the tubes that release urine from the kidney to the bladder) that was accompanied by sepsis (infection causing organ damage) and septic shock (the most severe form of infection causing low blood pressure). This document specified the services required to treat Patient 3 were not available at this facility; Patient 3 was stabilized and transferred to another hospital for higher level of care on 7/6/2024.

A review of the 'Patient Transfer Acknowledgement' indicated Patient 3 was unable to sign the form confirming Patient 3 understood the reasons for transfer to another hospital and agreed to the tranfer; 2 nurses signed this form dated and timed 7-6-2024 at 4:25 AM; the transferring physician confirmed Patient 3 was stable for transfer on 7/6/2024 at 4:25 AM.

A review of the document 'Standard Policy: EMTALA - Patient Transfer' (policy 20625) indicated the following procedure for those patients stable before transfer: the patient may be transferred to another facility for medical or non-medical reasons; the patient will be transferred according to the facility's hospital policies, applicable state laws, procedures and forms for the transfer of patients to another hospital or another facility.

A review of the document 'Transfer Check List AHWM Montebello' indicated if a patient is stable for transfer to another facility, the facility and patient/responsible party are required to sign the 'Patient Transfer Acknowledgement'. This part of the document stipulated there must be reason for the transfer to another facility, signature of a registered nurse witness to patient consent to transfer, and patient/caregiver signature to consent to transfer.

Based on interview and record review, the facility failed to acquire consent from 1 of 20 sampled patients before transferring the patient (Patient 3) from this facility's emergency department to another facility for higher level of care. This deficient practice led to Patient 3 not being able to make an informed decision about the transfer.

Findings:

During an interview on 7/26/2024 at 10:15 AM, MD 1 stated that he did not specifically recall if Patient 3 was informed of her pending transfer to another facility on 7/6/2024. Subsequently MD 1 said it is the facility's usual practice to inform the patient or responsible party of the need to transfer the patient; if a responsible party is not available, nursing will sign the consent in that person's absence.

During an interview on 7/26/2024 at 11:05 AM, RN 2 stated, after reviewing Patient 3's medical record, he was one of the nurses treating Patient 3 on 7/6/2024 but did not remember the details of Patient 3's discharge. At this time, RN 2 said it is usual practice for nursing to leave 3 telephone messages to the responsible party in the event the patient is unable to verbalize his or her consent to transfer to another facility. RN 2 then confirmed if there is no verified consent by the patient or responsible party then the responsibility of acquiring consent to transfer would be escalated to the treating physician. Lastly, RN 2 said that after all attempts to attain consent for transfer have failed, two nurses can sign in place of consent by the patient or responsible party and the transfer can proceed.

During an interview on 7/26/2024 at 12:10 PM, Regulatory Compliance stated he could not locate any documentation Patient 3 or an responsibilite party had been informed of the risks and benefits or agreed to transfer Patient 3 to another facility.

A review of 'Emergency Department Reports' indicated on 7/5/2024 Patient 3 presented to the emergency department with altered mentation (disruption in brain function that may lead to change in behavior), elevated heart rate, and was hot to touch. The 'Emergency Department Reports' showed that Patient 3 had a ureteral stone (crystal caught in the tubes that release urine from the kidney to the bladder) that was accompanied by sepsis (infection causing organ damage) and septic shock (the most severe form of infection causing low blood pressure). This document specified the services required to treat Patient 3 were not available at this facility; Patient 3 was stabilized and transferred to another hospital for higher level of care on 7/6/2024.

A review of the 'Patient Transfer Acknowledgement' indicated Patient 3 was unable to sign the form confirming Patient 3 understood the reasons for transfer to another hospital and agreed to the tranfer; 2 nurses signed this form dated and timed 7-6-2024 at 4:25 AM; the transferring physician confirmed Patient 3 was stable for transfer on 7/6/2024 at 4:25 AM.

A review of the document 'Standard Policy: EMTALA - Patient Transfer' (policy 20625) indicated the following procedure for those patients stable before transfer: the patient may be transferred to another facility for medical or non-medical reasons; the patient will be transferred according to the facility's hospital policies, applicable state laws, procedures and forms for the transfer of patients to another hospital or another facility.

A review of the document 'Transfer Check List AHWM Montebello' indicated if a patient is stable for transfer to another facility, the facility and patient/responsible party are required to sign the 'Patient Transfer Acknowledgement'. This part of the document stipulated there must be reason for the transfer to another facility, signature of a registered nurse witness to patient consent to transfer, and patient/caregiver signature to consent to transfer.