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Based on facility document review and staff interviews, it was determined the facility failed to conduct an appropriate transfer.

After learning of the EMTALA violation through an internal report, the facility took the following action.

The physician who refused Patient #12's transfer request was terminated on August 1, 2024. An AMA escalation protocol was implemented to ensure the risks/benefits are discussed and the documentation is complete. Also, the request is escalated to the charge nurse who involves the supervisor to discuss - Is the patient requesting transfer? Is the patient going by private vehicle to another facility?; Does this put patient at potential risk of harm? - If the answers are no, a risk report is completed. If yes, escalation continues to clinical manager, and if needed to director and administrator on call.
Leaders conducted rounds and discussion of EMTALA requirements with clinical staff.
The emergency department's (ED) lens board (an electronic touchscreen in the ED used by the facility for a communication and education) was updated with the link to the facility's EMTALA policy. All clinical staff were enrolled in Emergency Care Research Institute's (ECRI) digital training course titled, Emergency Medical Treatment and Labor Act, and required to pass with a 100%. As of September 16, 2024, all clinical staff had successfully completed the course with the exception of staff on extended leave. The ED providers, a contracted service, were instructed to complete the ECRI digital training course and required to pass with a 100%. The ED provider contract service has added the facility's EMTALA training as a mandatory requirement when onboarding new providers.

The facility was found in compliance, but previously out of compliance, with the EMTALA requirements at 42 CFR §489 (Rev. 7-19-19) regarding Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Please refer to tag A-2409 for details.

Based on document review and medical record review, it was determined the facility failed to facilitate an appropriate transfer by refusing one patient's request to transfer and by sending incomplete physician's certifications for two (2) of thirteen (13) transferred patients in the sample.

Findings:

The facility's policy titled, Transfer of Patients - EMTALA (Emergency Medical Treatment and Labor Act) last revised 04/2023, was reviewed and partly reads: "... Individuals who do have an emergency medical condition will have that condition stabilized to the point where the individual is either stable for discharge or stable for transfer. b. Transfers of unstabilized individuals are allowed only pursuant to patient request or when a Physician or qualified medical person certifies that the expected benefits to the patient from the transfer outweigh the risks for transfer... D. Reasons for Transfer 1. Patients may be transferred to other acute care facilities, under a Physician's order, for the following reasons. a. The transfer is medically indicated and the patient requires treatment that cannot be provided at the hospital. b. The patient or surrogate requests transfer... F. Completion of Physician Certification/Consent... 3. The [name of facility] Transfer Consent Form shall be completed for any patient with an emergency medical condition who is transferred to another facility...".

Patient #12 arrived by ambulance to the facility on July 27, 2024 at 5:57 PM complaining of left hip pain. After receiving an x-ray, Staff Member #14's documentation revealed that the patient had a "closed mildly displaced left femoral neck fracture deformity fracture on XR". Staff Member #14 documented the following: "I advised the patient and [patient's] family that [patient] would need surgical intervention, and that {sic} stated that they wanted to be transferred. I assured them that we have a specialist here to take care of this issue and to transfer [patient] to be {sic} against EMTALA laws. [Patient] has elected to leave AGAINST MEDICAL ADVICE and I have explained to [patient] risk for doing this. [Patient] understood all the risk and still wanted to leave." Staff Member #14 entered an AMA ED disposition at 11:49 PM on July 27, 2024. The discharge information revealed the patient departed the facility on July 28, 2024 at 12:24 AM; disposition documented as "Left Against Medical Advice" and the destination documented as "Home." Patient #12 arrived at a second facility on July 28, 2024 at 2:27 AM via private vehicle. There was no documentation in the record to support the following: The patient was informed of the risks and benefits associated with the transfer; Staff Member #14 obtained or attempted to obtain the patient's transfer request in writing; or that Staff Member #14 contacted the second facility to request and facilitate an appropriate transfer.

Patient #20's EMTALA form, dated January 1, 2024, did not contain documentation of the following: certification statement, expected benefits of transfer, potential risks of transfer, date, time or the certifying physician's electronic signature.

Patient #23's EMTALA form, dated June 30, 2024, did not contain the certifying physician's electronic signature.