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Based on interview and record review, the facility failed to ensure one of 20 sampled patients (Patient 20), was appropriately transferred to a behavioral health facility when Patient 20 or their designee did not sign the "Emergency Medical Treatment and Active Labor Act (EMTALA, a federal law that requires anyone coming to an emergency department to be treated and stabilized, regardless of their insurance status or ability to pay) Transfer Form," in accordance with EMTALA regulation and the facility's policy and procedure titled, "Transfers Into and Out of the Facility."

This deficient practice had the potential for unsafe or inappropriate transfer. (Refer to C-2409)

Findings:

During a review of Patient 20's "Emergency Department (ED) Physician Notes," dated 10/31/2025, the record indicated Patient 20 was admitted to the facility for suicide (to take one's own life) attempt by taking 15 Hydroxyzine (medication used to control anxiety) pills. Patient 20 had a medical history of previous suicide attempts and anxiety. Patient 20 was later declared to be medically clear and was accepted to a behavioral health facility.

During a review of Patient 20's "Patient Insurance and Demographics," undated, the record indicated Patient 20 had an emergency contact name and phone number.

During a review of Patient 20's "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment," dated 10/31/2025, the record indicated Patient 20 was placed on a 5150 hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) on 10/31/2025 at 11:55 a.m. for danger to self.

During an interview on 12/1/2025 at 1:42 p.m. with Registered Nurse (RN) 1, RN 1 stated the process for transferring a patient to another facility included signing a transfer form. RN 1 stated the transfer form included patient information, where the patient would be transferring to, the reason for transfer, who report was given to, any interpreter, and signatures from the nurse, physician, emergency medical technicians (EMTs, individuals who transport patients by ambulance) and the patient.

During a concurrent interview and record review on 12/2/2025 at 3:59 p.m. with ED Shift Manager (SM), Patient 20's "Emergency Medical Treatment and Active Labor Act (EMTALA) Transfer Form," dated 10/31/2025, was reviewed. SM confirmed the transfer form was not signed by the patient and had a slash mark with the letters "NA" written in the area where the patient or their designee should have signed. SM stated the process to sign the form, if the patient could not sign, was for the nurse and a second witness to verify the hold was active and valid and that the patient was being transferred appropriately. SM stated if family was present, they could sign the transfer form. SM also stated the staff could call the emergency contact and do two nurse verification over the phone confirming understanding and current situation of transferring the patient to the accepting facility.

During the same interview and record review on 12/2/2025 at 3:59 p.m. with SM, Patient 20's "ED Discharge Note," dated 10/31/2025, was reviewed. The record indicated, "Pt (Patient 20) stable agree to be transported to (name of the facility) on 5150 hold." SM also confirmed Patient 20's neurological status was alert and oriented with a Glasgow Coma Scale (GCS, measures level of alertness, with 15 as the highest level and considered normal) level of 15, and Patient 20 was calm and had clear speech.

During an interview on 10/31/2025 at 4:10 p.m. with ED Shift Manager (SM), SM stated the form "should have been filled out to make sure the patient was aware of what was going on, ensuring everyone was on the same page and rights were protected for patients and doing the best we can, and ensure proper treatment."

During a review of the facility's policy and procedure (P&P) titled, "Transfers Into and Out of the Facility," dated 8/2024, the P&P indicated:

"Purpose ...To involve patients and/or their representatives in the decision-making transition process from one level of care to another. To provide patients and family with information in a timely manner of the need for discharge or transfer to another organization or level of care ...To involve all appropriate licensed independent practitioner, staff, and family members involved in the patient's care, treatment, and services.
Handling of Medical Records during the Transfer Process: ...
C. Primary Care RN will ...
2. Ensure that the transfer form is completed and signed by physician, sending Registered Nurse (RN), and patient (or patient representative)."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 12/11/2024, the P&P indicated, "Once the MSE (Medical Screening Examination) is completed and the physician or QMP (Qualified Medical Personnel) determines that the individual does not have an Emergency Medical Condition (EMC) or the EMC has been Stabilized, the individual may be (i) treated; (ii) discharged as clinically appropriate and the individual is given a reasonable plan for appropriate follow-up care or discharge instructions; or (iii) transferred for continued care in accordance with appropriate transfer procedures."

Based on interview and record review, the facility failed to ensure one of 20 sampled patients (Patient 20), was appropriately transferred to a behavioral health facility when Patient 20 or their designee did not sign the "Emergency Medical Treatment and Active Labor Act (EMTALA, a federal law that requires anyone coming to an emergency department to be treated and stabilized, regardless of their insurance status or ability to pay) Transfer Form," in accordance with EMTALA regulation and the facility's policy and procedure titled, "Transfers Into and Out of the Facility."

This deficient practice had the potential for unsafe or inappropriate transfer.

Findings:

During a review of Patient 20's "Emergency Department (ED) Physician Notes," dated 10/31/2025, the record indicated Patient 20 was admitted to the facility for suicide (to take one's own life) attempt by taking 15 Hydroxyzine (medication used to control anxiety) pills. Patient 20 had a medical history of previous suicide attempts and anxiety. Patient 20 was later declared to be medically clear and was accepted to a behavioral health facility.

During a review of Patient 20's "Patient Insurance and Demographics," undated, the record indicated Patient 20 had an emergency contact name and phone number.

During a review of Patient 20's "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment," dated 10/31/2025, the record indicated Patient 20 was placed on a 5150 hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) on 10/31/2025 at 11:55 a.m. for danger to self.

During an interview on 12/1/2025 at 1:42 p.m. with Registered Nurse (RN) 1, RN 1 stated the process for transferring a patient to another facility included signing a transfer form. RN 1 stated the transfer form included patient information, where the patient would be transferring to, the reason for transfer, who report was given to, any interpreter, and signatures from the nurse, physician, emergency medical technicians (EMTs, individuals who transport patients by ambulance) and the patient.

During a concurrent interview and record review on 12/2/2025 at 3:59 p.m. with ED Shift Manager (SM), Patient 20's "Emergency Medical Treatment and Active Labor Act (EMTALA) Transfer Form," dated 10/31/2025, was reviewed. SM confirmed the transfer form was not signed by the patient and had a slash mark with the letters "NA" written in the area where the patient or their designee should have signed. SM stated the process to sign the form, if the patient could not sign, was for the nurse and a second witness to verify the hold was active and valid and that the patient was being transferred appropriately. SM stated if family was present, they could sign the transfer form. SM also stated the staff could call the emergency contact and do two nurse verification over the phone confirming understanding and current situation of transferring the patient to the accepting facility.

During the same interview and record review on 12/2/2025 at 3:59 p.m. with SM, Patient 20's "ED Discharge Note," dated 10/31/2025, was reviewed. The record indicated, "Pt (Patient 20) stable agree to be transported to (name of the facility) on 5150 hold." SM also confirmed Patient 20's neurological status was alert and oriented with a Glasgow Coma Scale (GCS, measures level of alertness, with 15 as the highest level and considered normal) level of 15, and Patient 20 was calm and had clear speech.

During an interview on 10/31/2025 at 4:10 p.m. with ED Shift Manager (SM), SM stated the form "should have been filled out to make sure the patient was aware of what was going on, ensuring everyone was on the same page and rights were protected for patients and doing the best we can, and ensure proper treatment."

During a review of the facility's policy and procedure (P&P) titled, "Transfers Into and Out of the Facility," dated 8/2024, the P&P indicated:

"Purpose ...To involve patients and/or their representatives in the decision-making transition process from one level of care to another. To provide patients and family with information in a timely manner of the need for discharge or transfer to another organization or level of care ...To involve all appropriate licensed independent practitioner, staff, and family members involved in the patient's care, treatment, and services.
Handling of Medical Records during the Transfer Process: ...
C. Primary Care RN will ...
2. Ensure that the transfer form is completed and signed by physician, sending Registered Nurse (RN), and patient (or patient representative)."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 12/11/2024, the P&P indicated, "Once the MSE (Medical Screening Examination) is completed and the physician or QMP (Qualified Medical Personnel) determines that the individual does not have an Emergency Medical Condition (EMC) or the EMC has been Stabilized, the individual may be (i) treated; (ii) discharged as clinically appropriate and the individual is given a reasonable plan for appropriate follow-up care or discharge instructions; or (iii) transferred for continued care in accordance with appropriate transfer procedures."