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Based on interview and documentation review it was determined Hospital #1 failed to promptly report it may have received Patient #1 from Hospital #2 who had been transferred in an unstable emergency medical condition.


Findings included:

Documentation review indicated Patient #1 presented to Hospital #1 ED on 2/9/11 and was admitted to the ICU for care and treatment of a seizure disorder. Patient #1, on 2/11/11 eloped after a psychiatric evaluation determined a need of an inpatient psychiatric admission and a section 12a was completed as Patient #1 was identified at risk of self harm. The Police were called and notified of the elopement.

Review of internal Hospital #1 documentation indicated Hospital #1 had become aware on 2/12/11 at 3:46 PM of a potential EMTALA violation involving Patient #1 having been brought by police to Hospital #2 ' s ED were they were told by staff members to bring Patient #1 to Hospital #1. The police took Patient #1 to Hospital #1 as directed.

Further review of internal Hospital #1 documentation indicated on 2/17/11 at 2:11 PM Hospital #1 staff noted an EMTALA violation had occurred because no medical screening was done and the transfer elements were not met.

Review of a letter addressed to the CMS regional office indicated the letter was dated 2/22/11 and reported Hospital #2 ' s EMTALA violation that occurred 2/11/11.

Based on documentation review it was determined out of a sample of 20 ED Patient's records reviewed, 14 ED patients had been transferred from Hospital #1's ED to another facility during the time period of 8/22/10-2/22/11. Out of the 14 Patients transferred only Patient # 10 was transferred without a completed Authorization for Transfer Form that provided required information related to the appropriateness of the transfer

Findings included:

Documentation review indicated Patient #10 presented to Hospital ED and reported the reason for the visit was for necessary medical clearance prior to admission to a psychiatric facility. Patient #10 reported a history of a bipolar disorder, anxiety post traumatic stress disorder and the desire to be admitted to a dual diagnosis bed for treatment of drug use. When evaluated by the ED Physician Patient #10 indicated although there was no current active suicidal thoughts he/she had thought about it lately and when a mental health evaluation was conducted reported recent audio hallucination by a male voice telling Patient #10 to harm him/herself and others. Patient #10 was made a Section 12a (involuntary hospitalization) because of impulsivity, poor insight/judgment and recent audio hallucinations for self harm. Patient #10 was cleared medically for psychiatric referral. Patient #10's Authorization To Transfer Form did not indicate if Patient #10 Emergency Medical Condition was stabilized, the reason for transfer, a summary of the risks and benefits of transfer upon which the decision to transfer were based, that the receiving facility had available space/qualified personnel for treatment of Patient #10, the receiving facility would be provided with appropriate medical records of the examination/treatment provided and that transfer would be provided by qualified personnel utilizing appropriate transportation equipment.

The ED Policy /Procedure that addressed transfer of patients with unstable emergency medical conditions was reviewed. The Policy/Procedure stated the emergency department physician will complete and sign the Authorization for Transfer. The Transferring physician will complete and sign the Authorization for Transfer.

Based on interview and documentation review it was determined Hospital #1 failed to promptly report it may have received Patient #1 from Hospital #2 who had been transferred in an unstable emergency medical condition.


Findings included:

Documentation review indicated Patient #1 presented to Hospital #1 ED on 2/9/11 and was admitted to the ICU for care and treatment of a seizure disorder. Patient #1, on 2/11/11 eloped after a psychiatric evaluation determined a need of an inpatient psychiatric admission and a section 12a was completed as Patient #1 was identified at risk of self harm. The Police were called and notified of the elopement.

Review of internal Hospital #1 documentation indicated Hospital #1 had become aware on 2/12/11 at 3:46 PM of a potential EMTALA violation involving Patient #1 having been brought by police to Hospital #2 ' s ED were they were told by staff members to bring Patient #1 to Hospital #1. The police took Patient #1 to Hospital #1 as directed.

Further review of internal Hospital #1 documentation indicated on 2/17/11 at 2:11 PM Hospital #1 staff noted an EMTALA violation had occurred because no medical screening was done and the transfer elements were not met.

Review of a letter addressed to the CMS regional office indicated the letter was dated 2/22/11 and reported Hospital #2 ' s EMTALA violation that occurred 2/11/11.

Based on documentation review it was determined out of a sample of 20 ED Patient's records reviewed, 14 ED patients had been transferred from Hospital #1's ED to another facility during the time period of 8/22/10-2/22/11. Out of the 14 Patients transferred only Patient # 10 was transferred without a completed Authorization for Transfer Form that provided required information related to the appropriateness of the transfer

Findings included:

Documentation review indicated Patient #10 presented to Hospital ED and reported the reason for the visit was for necessary medical clearance prior to admission to a psychiatric facility. Patient #10 reported a history of a bipolar disorder, anxiety post traumatic stress disorder and the desire to be admitted to a dual diagnosis bed for treatment of drug use. When evaluated by the ED Physician Patient #10 indicated although there was no current active suicidal thoughts he/she had thought about it lately and when a mental health evaluation was conducted reported recent audio hallucination by a male voice telling Patient #10 to harm him/herself and others. Patient #10 was made a Section 12a (involuntary hospitalization) because of impulsivity, poor insight/judgment and recent audio hallucinations for self harm. Patient #10 was cleared medically for psychiatric referral. Patient #10's Authorization To Transfer Form did not indicate if Patient #10 Emergency Medical Condition was stabilized, the reason for transfer, a summary of the risks and benefits of transfer upon which the decision to transfer were based, that the receiving facility had available space/qualified personnel for treatment of Patient #10, the receiving facility would be provided with appropriate medical records of the examination/treatment provided and that transfer would be provided by qualified personnel utilizing appropriate transportation equipment.

The ED Policy /Procedure that addressed transfer of patients with unstable emergency medical conditions was reviewed. The Policy/Procedure stated the emergency department physician will complete and sign the Authorization for Transfer. The Transferring physician will complete and sign the Authorization for Transfer.