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Based on clinical record review, staff interview and facility document review, it was determined that the facility failed to comply with §489.24 by conducting an inappropriate transfer of a patient presenting to the emergency department with an emergency medical condition (A-2409).

The findings include:

See Tag A-2409
Based on clinical record review, staff interview and facility document review, it was determined the facility inappropriately transferred a patient with an emergency medical condition that had not yet been stabilized in one (1) of ten (10) records reviewed of patients who were transferred. (Medical record #11)

Based on clinical record review, staff interview and facility document review, it was determined the facility inappropriately transferred a patient with an emergency medical condition that had not yet been stabilized in one (1) of ten (10) records reviewed of patients who were transferred. (Medical record #11)

The findings include:

Twenty (20) medical records were reviewed 10/16/23-10/17/23. Ten (10) of the records reviewed were of patients who had transferred from the emergency department (ED) to other facilities.

The clinical record for patient #11 contained documentation that the patient arrived to the ED via EMS (emergency medical services) at 9:57 PM on 09/05/23 with hyperglycemia and altered mental status. At 10:13 PM, the Registered Nurse (RN) performed a sepsis screening indicating that two or more SIRS (systemic inflammatory response syndrome) criteria were present.

Point of care blood glucose testing was performed at 10:39 PM and resulted >600 mg/dL (reference range 65-117). Additional lab studies were collected at 10:40 PM and were remarkable for lactic acid 2.1 mmol/L (reference range 0.4-2.0); a critical white blood cell count value of 53.2 K/uL (reference range 4.1-11.1); and a glucose of 769 mg/dL (reference range 65-100).

The progress note for patient #11 by physician #1 reads in part: 67 year old male with a history of DM (diabetes mellitus), prostate cancer presented to the ED via EMS with chief complaint of worsening confusion for the past five to six days. Per EMS, wife stated patient was wandering around bedroom, became progressively weaker and was unable to walk today. He has had multiple recent falls in the past few days, He has been refusing to take his insulin. Patient complaints of pain "all over," denies any shortness of breath, remainder of history limited by the patient's current mentation. Per EMS patient with stable vital signs on route, mildly tachycardic. Blood sugar in the 570's. No vomiting, diarrhea, fevers, chills, shortness of breath. The history is provided by EMS personnel and the patient. Unable to perform review of symptoms: mental status change.

Physician #1 further documented the patient was ill-appearing and oriented to person only.

Medical Decision Making is documented as follows: 67-year-old male with history of DM and prostate cancer presents to the ED with confusion, generalized weakness, hyperglycemia. Dry mucous membranes on exam, no lateralizing neurodeficits. Differential includes dehydration, electrolyte abnormality, metabolic encephalopathy, intracranial bleed, intracranial mass, UTI, pneumonia. Will check basic labs, chest x-ray, head CT, lactic acid, blood cultures. Will treat with fluids, insulin, plan on admission to the hospital.

The physician also documented at 12:21 on 09/06/23, "patient with significant leukocytosis of 53, mild lactic acid elevation of 2.1. Broad spectrum antibiotics ordered. Patient has already received 30 cc/kg fluid bolus. Blood sugar in the 700's, pH normal however does have elevated anion gap. Will start on insulin drip. Discussed with [name of doctor] at [name of receiving hospital] who has graciously accepted transfer to their ED with plan for admission. Patient re-evaluated, vital signs remained stable.

The RN documented the following on 09/06/2023:

12:01 AM: Transfer Center contacted to initiate patient transfer due to HIX insurance. Patient preferred hospital is (name of hospital), 2nd choice would be (name of hospital). Transfer Center made aware.

12:08 AM: (Physician #1) talking with (name of receiving physician at this time).

12:12 AM: (Name redacted) with transfer center called. Patient is accepted by (name of doctor) ER to ER transfer. RN report (phone number).

12:58 AM: Radiology called to get imaging disc made for patient transfer.

Physician #1 documented in the EMR "EMTALA Transfer Form" at 12:20 AM:

Transfer type: Patient Requested Transfer...
Reason for Transfer: Patient Requested
Provide Reason for patient requested transfer: Insurance issue...
Receiving Service: Emergency Services
Transport Mode: ALS ambulance
Accepting Representative Name/Title: (name of accepting physician)

The scanned and signed EMTALA transfer form contained documentation of the patient's vital signs at time of transfer: Blood pressure 136/68, temperature 97.7, pulse 93, respirations 25, pulse ox 93%. The form contained a field, Patient/Responsible Adult Signature - the field appeared to have the patient's name signed by the nurse. The following was documented: Patient unable to sign for self due to medical condition. The charge nurse also signed the transfer form 09/06/23 at 3:41 AM.

The medical record to include the EMTALA transfer form failed to contain documentation of whether the patient (with altered mental status) or a member of the patient's family requested the patient's transfer. The form did not contain a signature of the patient or an authorized representative.

The last documented neurological assessment by the nurse at 11:59 PM on 09/05/23 indicated the patient opened eyes to speech, was confused, but obeyed commands and documented, "altered, unable to assess at this time. Patient does follow commands but has not given verbal response."

While in the ED, the patient was treated with IV antibiotics, a fluid bolus, and started on an insulin drip. The patient was transported via ALS ambulance as ordered on 09/06/23 at 3:41 AM. Blood glucose at time of transfer was 450.

An interview was conducted with the Quality Director (staff member #2) on 10/17/23 who stated that the nurse erroneously signed the patient's name on the EMTALA transfer form for patient #11 when the nurse should have written the name of the person who gave consent for the transfer with a second nurse. The charge nurse did sign the bottom of the transfer sheet for patient #11 but it was unclear whether or not the charge nurse was signing as a witness to a verbal consent from the patient or representative.

The facility's policy, Emergency Medical Treatment and Active Labor Act (EMTALA) was reviewed and reads in part: If the individual has an EMC (Emergency Medical Condition), the hospital will stabilize the EMC through further examination and treatment within the capabilities of the hospital's staff and facilities; if the hospital cannot stabilize the EMC, the hospital will transfer the individual to another facility in accordance with the transfer criteria set forth below in paragraph D...Stabilizing treatment: An individual with an EMC is considered stabilized when no material deterioration of the individual's condition is likely, within reasonable medical probability to result from or occur during the transfer of the individual from a facility...Transfer to another facility: If the individual's EMC has not been stabilized, the individual will not be transferred to another facility unless: 1. The individual requests the transfer (patient requested), or a physician certifies in writing that the benefits of the transfer outweigh the risks (physician initiated)...Patient Requested Transfer: If a patient (or his/her legal representative) requests a transfer, the hospital will: 1. inform the patient of the hospital's obligation to provide stabilizing treatment, and the medical risk of the requested transfer; and using the BSMH EMTALA Transfer Form in Epic, document the patient's request for transfer in writing including the reasons for the patient's request and risks and benefits associated with the transfer. The individual (or his/her legal representative) must sign the written Request to Transfer....