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Based on record review and interview, facility staff failed to ensure appropriate documentation was completed for 2 of 4 patients (Patients #5 and #6) who were transferred to another facility in a total sample of 20 emergency department medical records reviewed.

Findings include:

The facility failed to complete the appropriate documentation for 2 of 4 patients who were transferred to another facility. See Tag A-2409.

Based on record review and interview, facility staff failed to ensure appropriate documentation was completed for 2 of 4 patients (Patients #5 and #6) who were transferred to another facility in a total sample of 20 emergency department medical records reviewed.

Findings Include:

A review of the facility's policy #8304980 titled, "Emergency Medical and Treatment (EMTALA), AW (Ascension Wisconsin)," last revised 07/28/2020 revealed, "...Transfers...b. Sending Documentation. The physician or Qualified Medical Person shall complete the 'Transfer Form' prior to transfer...i. Before the patient leaves, Hospital personnel shall obtain copies of the following documentation, if available: 1. Transfer Form...ii. The indivdual completing the 'Transfer Form' shall...send the 'Transfer Form' and a copy of the other reports to the receiving facility..."

Patient #5's electronic medical record was reviewed on 11/10/2021 at 9:21 AM with Quality and Patient Safety Coordinator B and Emergency Department (ED) Registered Nurse (RN) F who confirmed the following per interview:

Patient #5 arrived at the facility's ED on 07/02/2021 at 6:00 PM via ambulance following a motorcycle collision. The "Physician Documentation" revealed on 07/02/2021 at 8:37 PM, "Observation Course...I spoke with the trauma surgeon who recommended placing chest tube in the emergency department and transferring as we do not have any ICU (Intensive Care Unit) beds available....Patient accepted for transfer to [physician name] at [facility name]."

"Disposition Summary" on 07/02/2021 at 8:41 PM revealed, "Transfer Ordered...Transfer Location: [facility name]...Reason: Physical bed unavailable...Condition: Serious..."

A review of the "Nurse's Notes" on 07/02/2021 at 9:17 PM revealed, "Transition record sent with patient, transferred by EMS (Emergency Medical Services) ground...Transfer form completed..."

Patient #5 was transferred from the Emergency Department on 07/02/2021 at 9:18 PM.

There was no Transfer Form found in Patient #5's medical record.

During an interview with Quality Coordinator B on 11/10/2021 at 11:22 AM, B stated, "We were unable to find a transfer EMTALA form for [Patient #5]."

Patient #6's electronic medical record was reviewed on 11/10/2021 at 9:28 AM with Quality and Patient Safety Coordinator B and ED RN F who confirmed the following per interview:

Patient #6 arrived at the facility's ED on 08/15/2021 at 3:14 PM via ambulance following a bicycle accident. The "Physician Documentation" revealed on 08/15/2021 at 11:05 PM, "ED course...patient has a bilateral subarachnoid hemorrhage (bleeding in the brain) with a left-sided parietal (area of the skull) fracture that is not depressed...Decision was made to transfer the patient to a facility where intervention could be possible if the patient required it, however unlikely that may be. I spoke with [Physician name] who accepted the patient to go to [city]. I also spoke with their neurosurgeon at [facility name] who accepted the patient as well. Patient was transferred in otherwise stable condition..."

A review of the "Authorization for Transfer (EMTALA)" form, completed on 08/15/2021 at 7:16 PM revealed, "Section 1 - Patient Status..." There was an "X" written in the box beside the statement, "Unstable...Individual's condition has not been stabilized. Transferred because:" There was an "X" written in the box beside the statement, "Needs higher level of care, or specialized treatment." There was no "X" written in the box beside the "Physician Request/Attestation." There were no specific risks identified.
"Section 3 - Physician Certification for Transfer..." There was an "X" written in the box beside the statment, "I certify that I have explained the risks and benefits of transfer to the patient..." The "Physician Authorizing Transfer (print)" and "Physician Signature" lines were blank. The "Patient/Reponsible Party" and "RN" signature lines include signatures, but no dates or times are filled in on the corresponding lines.

During an interview with Quality Coodinator B and ED RN F on 11/10/2021 at 9:40 AM, when asked if it was expected that dates and times accompany signatures, ED RN F stated, "Should be dated and timed." When asked if the transferring physician should have signed the transfer form, Quality Coodinator B stated s/he, "Would have to check the transfer form policy" to determine if the physician signature was required. ED RN F stated, "Yes; typically they do."