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Based on interview and document review, the hospital failed to ensure compliance with the requirements of 42 CFR 489.24 as evidenced by the deficient practice cited at 489.24(e)(1)-(2).

Based on interview and document review, the hospital failed to obtain the patient's signed consent to transfer to the recipient hospital and failed to send the patient's emergency room record to the recipient hospital, in 1 of 7 patients reviewed (P9), who required transfer to another hospital to resolve an emergency medical condition (EMC). Findings include:

The ED record, dated 12/05/13, indicated that P9 arrived to the ED by ambulance at 10:31 a.m. P9 was immediately triaged and roomed with a suspected gastrointestinal (GI) bleed. At 10:41 a.m., Nurse (G)/RN assessed P9. P9 was alert and oriented. P9 reported that he had a history of GI bleeds and had been throwing up blood all morning. P9's blood pressure was 93/61. At 10:44 a.m., Physician (H)/MD examined P9 and ordered numerous stat lab tests, including blood chemistry, cardiac enzymes, and hepatic profile. The ED record indicated that at 11:30 a.m. on 12/05/13, P9 had a large 400 cc emesis that was dark-colored. P9's blood pressure fell to 69/40. A stat EKG was obtained. Stat x-rays of the chest and abdomen were conducted. Lab studies were repeated. P9 was typed and crossed for two units of packed red blood cells. Physician/ (H) consulted Physician (I)/MD, who was the Gastroenterologist on-call. Physician/(I) recommended intubation to protect P9's airway, which was performed by Physician/(H).The ED record indicated that at 12:30 p.m. on 12/05/13, P9 was examined by Physician/(I). Physician/(I) reviewed all of P9's lab results that had been conducted in the ED. Physician/(I) concluded that P9 was having an obvious active upper GI bleed and urgent endoscopy was warranted. The Upper GI Endoscopy report, dated 12/05/13, indicated that P9 tolerated the procedure well. Procedural findings included evidence of gastric varices. P9 needed an emergent TIPS procedure (a shunt to decrease portal pressure) and required transfer to another hospital where a TIPS procedure could be performed.

The Emergency Room Report, dated 12/05/13, indicated that arrangements were made to transfer P9 to the recipient hospital. At the time of departure, P9's hemoglobin was 7.5 and his blood pressure was 130/86. P9 was transferred to the recipient hospital at 3:00 p.m., by ambulance, in critical condition.

The Transfer Assessment and Certification Hospital to Hospital form, dated 12/05/13, indicated that Physician (M)/MD at the recipient hospital had accepted transfer of P9 and agreed to provide the medical care required by P9. Physician/(H) had signed the transfer form. The written consent to transfer to the recipient hospital was not signed by P9 or P9's family member.
Physician (I)/MD was interviewed on 01/06/14 at 11:10 a.m. Physician/(I) stated that she performed P9's endoscopy in the ED, which revealed P9 had life-threatening gastric varices. P9 needed an emergent TIPS procedure, which was the only intervention that would save P9's life. P9 required transfer to another hospital for the TIPS procedure. Physician/(L) at the recipient hospital agreed to accept P9 in transfer and perform the TIPS procedure. Physician/(I) spoke to P9's family member about the risks and benefits of P9's transfer to the recipient hospital. At the time of P9's transfer to the recipient hospital, P9's vital signs were stable.

PA/(J) was interviewed on 01/06/14 at 2:05 p.m. PA/(J) stated that she contacted the interventional radiologist at the recipient hospital/Physician/(L) and reviewed the information that the transferring ED had collected about P9's present illness, including labs that were done in the ED. PA/(J) then contacted Physician/(M), an intensivist at the recipient hospital, who agreed to accept P9's care for inpatient management following the pending TIPS procedure. PA/(J) printed copies of the GI consultation, endoscopic procedural findings, liver flow sheets, and final lab results; PA/(J) placed these documents in an envelope, which was given to emergency personnel at the time of P9's transfer. Physician (H)/MD was interviewed on 01/06/14 at 11:40 a.m. Physician/(H) signed P9's transfer form to the recipient hospital, which indicated the name of the accepting physician at the recipient hospital. Physician/(H) acknowledged that he overlooked obtaining the signature of P9's family member on the transfer form.

Nurse (G)/RN was interviewed on 01/06/14 at 10:35 a.m. Nurse/(G) stated she was the care giver assigned to P9's care after P9 was roomed. Nurse/(G) stated she was not able to document contemporaneously, as things occurred, and as a result, Nurse/(G)'s documentation was not timely. When it was decided that P9 was being transferred to the recipient hospital, Nurse/(G)'s documentation of P9's care interventions was incomplete. Nurse/(G) stated she was aware PA/(J) had some paperwork in an envelope that was being sent with P9 to the recipient hospital, but Nurse/(G) did not know what documented information was contained in the envelope. Nurse/(G) did not prepare any paperwork to accompany P9 to the recipient hospital, other than the transfer form signed by Physician/(H). Nurse/(G) acknowledged that she completed most her documentation after P9 was transferred. Nurse/(G) acknowledged that she did not send P9's ED record to the recipient hospital after she finished her documentation. An ambulance report, dated 12/05/13, indicated that P9 was transported from the transferring hospital at 2:59 p.m. and arrived to the recipient hospital at 3:02 p.m.
The recipient hospital's ED progress notes contained a late entry, dated 12/06/13, regarding the transfer of P9 on 12/05/13. At 3:05 p.m., when ED nurse/(O) first observed P9, P9 was unresponsive, on a portable vent, grey, cool, and diaphoretic. P9's blood pressure was 48/33. Medical record documentation from the transferring hospital was absent, including what medications and doses had been given to P9, the time P9 had been intubated and what medications had been administered in connection with the intubation, ongoing lab results, ongoing vital signs, whether any blood had been administered, or information regarding P9's state of illness. P9 was prepped for the emergent TIPS procedure with the only documented information available, which was the minimal information that PA/(J) had sent with emergency personnel at the time of P9's transfer. This included the GI consultation, endoscopic procedural findings, liver flow sheets, and final lab results.

The transferring hospital's EMTALA policy, dated July/2012, indicated "If an SMDC-owned hospital transfers a patient with an unstabilized medical emergency condition upon patient request or physician certification benefit, it will...obtain the written consent of the patient or surrogate, send to the receiving facility all medical records relating to the emergency medical condition including consent to transfer."