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Based on document reviews, record reviews, policy reviews and interviews, the hospital failed to ensure Physician Certification for EMTALA was documented for one of 12 patient records reviewed for transfer from the Emergency Department (ED) to another hospital for Patient 2.

Findings included:

Cross refer to 2409.

Based on document reviews, record reviews, policy reviews and interviews, the hospital failed to ensure Physician Certification for EMTALA was documented for one of 12 patient records reviewed for transfer from the Emergency Department (ED) to another hospital for Patient 2.

Findings included:

Review of Patient 2's record on 03/26/25 at 10:22 AM revealed Patient 2 presented to the ED on 01/02/25 at 8:35 AM with complaints of shortness of breath. The final diagnoses were chronic obstructive pulmonary disease and acute respiratory failure. Patient 2 was transferred to a local sister hospital at 7:05 PM on the same day. Review of the ED Provider Note...ED Course revealed, "...Medical ICU consulted. Patient will be transferred to (name of local sister hospital) ICU. Patient stable at time of transport." There was no documented evidence of a signed Physician Certification for EMTALA that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweighed the increased risks and no documented evidence of a summary of the risks and benefits upon which that would be based. There was no documented evidence of the receiving facility having the available space and qualified personnel for treatment or that the receiving facility agreed to accept the transfer of Patient 2.

Patient 2's record was reviewed with the ED Nurse Manager (EDNM) 2, Chief Nursing Officer (CNO) and ED Assistant Nurse Manager (EDANM) 1 on 03/27/25 at 10:35 AM. EDNM 1 confirmed the findings stating, "I don't see one (Physician Certification for EMTALA.)

On 03/27/25, review of the hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)..." dated 10/22/24 revealed, "...6. Patient Transfers...6.2.2. An individual with an EMC that has not been stabilized may be transferred if the transfer is appropriate as defined by EMTALA, and...If a physician certifies in writing that based on the information available at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual...A summary of the risks and benefits upon which the decision is based must be included...6.3...A transfer to another medical facility will be appropriate in those cases in which...the receiving hospital has agreed to accept the transfer..."