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Based on record review and interview, facility staff failed to appropriately transfer a patient receiving care in the ED (Emergency Department) to another facility in 1 of 9 patients (Patient #1) who were transferred in a total universe of 20 patient medical records reviewed.

The facility failed to appropriately transfer a patient receiving care in the ED to another facility. See Tag A-2409.

Based on record review and interview, facility staff failed to follow their hospital policy to appropriately transfer a patient receiving care in the ED (Emergency Department) to another facility in 1 of 9 patients (Patient #1) who were transferred in a total universe of 20 patient medical records reviewed.

Findings Include:

A review of the facility's policy titled, "MW Region EMTALA (Emergency Medical Treatment and Labor Act)" last revised 12/09/2024 revealed, " ... b) Recipient Hospital: A representative of the Recipient Hospital must confirm prior to transfer that: ... agrees to accept the Transfer ... Hospital staff should document any communication with the Recipient Hospital, including the date and time of the Transfer request and the name of the person accepting the Transfer in the patient's medical record ..."

A review of Patient #1's medical record revealed that Patient #1 was a 58-year-old male with a history of diabetes, depression and suicidal ideation who presented to Hospital A on 03/19/2025 at 1:38 PM for shoulder pain and depression. Patient #1 was discharged from Hospital A in stable condition on 03/19/2025 at 9:08 PM via cab arranged by Hospital A staff to Hospital C. Patient #1 presented to Hospital C on 03/19/2025 at 9:46 PM for depression.

During an interview on 04/29/2025 at 12:41 PM with ED Manager E, when asked about Patient #1, ED Manager E stated, "It was the patient's request to go to [Hospital C]. He told [ED RN I] this information. [Patient #1's] disposition should have been to transfer instead of discharge based on his request to go to [Hospital C]."