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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2409 - Appropriate Transfer - The facility failed to provide an appropriate transfer through qualified personnel and transportation. The facility failed to ensure patients transferred to a higher or specialized level of care were transferred with appropriate documentation of EMTALA specific requirements for 3 of 9 patients who were transferred (Patients #6, #8 and #15). This failure created the potential for patients to transfer without full disclosure of their rights and risks of transfer.

Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.24 related to the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Specifically, the facility failed to ensure patients requiring a higher or specialized level of care were transferred with appropriate documentation of EMTALA specific requirements for 3 of 9 patients who were transferred (Patients #6, #8 and #15).

This failure created the potential for patients to transfer without full disclosure of their rights and risks of transfer.

FINDINGS:

POLICY

According to the policy, EMTALA - Emergency Patient Transfers, a physician must sign an express written certification that based on the information available at the time of transfer the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred.

1. The facility failed to ensure the EMTALA transfer certification form was signed by the physician. Additionally, the facility failed to ensure the transfer form was signed by the patient, when possible, stating s/he consented to or refused the transfer.

a) During an interview, on 02/02/16 at 11:49 a.m., Nurse Manager #1, stated the EMTALA transfer information was entered into the facility's electronic medical record (EMR). The transfer form was to be printed out and signed by the physician and patient. The physician signature represented s/he examined the patient, the benefits of transfer outweighed the risks and the risks and benefits had been explained to the patient. The patient was to sign indicating s/he understood the risks and benefits.

Additionally, the form contained a section for the patient to consent to the transfer or refuse the transfer. According to Nurse Manager #1 all sections of the form were to be signed by the physician and patient.

b) Review of Patient #6's medical record showed s/he was an 8 month old child brought in to the Emergency Department (ED) on 10/03/16 at 10:36 p.m. by his/her parent with difficulty breathing. According to the ED provider notes, dated 10/04/16, at 1:00 a.m., the patient was demonstrating improvement but still had mild respiratory distress with stridor and required an admission on observation status to make sure s/he stayed stable and continued to improve. Patient #6's parent requested s/he be transferred to a different hospital.

Review of the Physician Certification showed the pediatric patient was transferred with a diagnosis of croup with ongoing respiratory distress. The MD Certification noted the patient was examined and risks were explained. However, the physician certification was not signed by the physician or the patient's guardian. Additionally, the consent to transfer was not signed by the patient's guardian.

On 02/01/17 at 10:30 a.m., Nurse Manager #1 stated the facility was unable to locate a signed physician certification and consent for transfer on Patient #6.

There was no documentation to show the pediatric patient's guardian was aware of the risks and benefits of transfer, his/her request or acceptance of transfer, and acknowledgement of the facility's obligations for treatment and transfer.

c) Review of Patient #8's record revealed s/he presented to the ED on 01/17/17 at 6:34 p.m. The patient was evaluated by a crisis assessment coordinator, put on a mental health hold (M-1 hold) and was to be transferred to a psychiatric hospital for further treatment.

Review of the Physician Certification showed the patient was transferred for a higher, specialized level of care on 01/18/17 at 7:56 p.m. The certification noted the patient was examined and the risks and benefits of transfer were explained to the patient. However, the certification for transfer was not signed by the physician.

On 02/02/17 at 8:30 a.m. the facility was asked for Patient #8's signed Physician Certification for transfer. Nurse Manager #1 stated the facility was unable to locate the signed form.

d) Review of pediatric Patient #15's medical record showed s/he presented to the ED on 12/25/16 at 5:11 p.m. for difficulty breathing. According to the ED Provider Notes, dated 12/25/16 at 11:57 p.m., Patient #15 was a 6 year old who was transferred emergently to a higher level of care with possible new onset diabetic ketoacidosis (DKA).

Review of the Physician Certification showed the pediatric patient was transferred with a diagnosis of diabetic ketoacidosis. According to the MD Certification the patient was examined and the risks of transfer were explained. However, the physician certification was not signed by the physician or the patient's guardian. Additionally, the consent to transfer was not signed by the patient's guardian.

There was no documentation to show the pediatric patient's guardian was aware of the risks and benefits of transfer, his/her request or acceptance of transfer, and acknowledgement of the facility's obligations for treatment and transfer.