HospitalInspections.org

Based on record review and interview, the facility staff failed to appropriately transfer patients receiving care in the Emergency Department (ED) to another facility for 1 of 8 patients (Patient #1), and failed to document risks of transfer for 4 of 8 patients (Patients #3, 4, 5, 6) who were transferred from the ED to another facility in a total sample of 20 ED medical records reviewed.

Findings include:

The facility staff failed to appropriately transfer patients receiving care in the Emergency Department. See Tag A-2409.

Based on record review and interview, the facility staff failed to appropriately transfer patients receiving care in the Emergency Department (ED) to another facility for 1 of 8 patients (Patient #1), and failed to document risks of transfer for 4 of 8 patients (Patients #3, 4, 5, 6) who were transferred from the ED to another facility in a total sample of 20 ED medical records reviewed.

Findings include:

Review of Facility Policy #19290, "[Facility] EMTALA (Emergency Medical Treatment and Labor Act)" dated 12/09/2024 revealed: ...D. Stabilization, Transfer, or Discharge 1. Transfer or Discharge of a Patient: A physician or QMP [Qualified Medical Personnel] may discharge or Transfer a Stable patient from the hospital to a Recipient Hospital for ongoing care if the following are met: a) The physician or QMP documents that an appropriate MSE [Medical Screening Exam] has been completed and : 1. The patient does not suffer from an EMC [Emergency Medical Condition]; or 2. The patient had an EMC, but the physician or QMP has determined with reasonable clinical confidence that the patient has been Stabilized and has reached the point where the patient's continued care, including diagnostic work-up, treatment, and/or other follow-up care could reasonably be performed in another setting ...Unstable Patient Transfers: ...A physician must certify that the medical benefits expected from Transfer outweigh the risks and describe the reasons for and the potential risks and benefits of the Transfer by completing the applicable areas on the Patient Transfer Form ... A representative of the Recipient Hospital must confirm prior to Transfer ..."

A review of Patient #1's medical record revealed Patient #1 was a 21 year-old who presented to Hospital A's ED on 01/15/2025 at 9:15 PM for a self-inflicted wrist laceration, in police custody, under a Chapter 51 hold (involuntary psychiatric hold). Patient #1 was discharged into police custody on 01/15/2025 at 11:20 PM to be transported to Hospital B. There was no evidence found that a transfer form was completed, no evidence Hospital B was notified and accepted the transfer, and no physician-to-physician handoff completed.

Review of Emergency Department Practitioner Note written by Physician Assistant F, dated 01/15/2025 at 11:26 PM revealed: "[Patient #1] is a 21 year old female who presents to the ED under a Chapter 51 hold for evaluation ...Patient will be discharged to [Hospital B] under a Chapter 51 hold."

During an interview on 02/26/2025 at 07:35 AM, ED RN (Registered Nurse) G stated that he never called and talked to Hospital B regarding Patient #1.

During an interview on 02/26/2025 at 09:12 AM, Physician Assistant F stated that since Patient #1 came in with the police and Patient #1 was medically cleared that a transfer form was not needed, and Patient #1's disposition could be selected as, "discharged." Physician Assistant F stated that he never called and talked to a physician at Hospital B.

Review of Patient (Pt.) #3's ED medical record revealed Pt. #3 was a 34-year-old male who arrived in the ED on 01/15/2025 at 6:28 PM with a chief complaint of Suicidal Ideation. Pt. # 3 was transferred to receiving hospital on 01/15/2025 at 11:25 PM. A review of Pt. #3's transfer form revealed no risks of transfer were documented.

Review of Pt. #4's ED medical record revealed Pt. #4 was a 44-year-old female who arrived in the ED on 01/19/2025 at 7:59 PM with a chief complaint of Suicidal Ideation and intentional overdose. Pt. #4 was transferred to a psychiatric hospital on 01/20/2025 at 12:45 AM. A review of Pt. #4's transfer form revealed no risks of transfer were documented.

Review of Pt. #5's ED medical record revealed Pt. #5 was an 89-year-old female who arrived in the ED on 01/22/2025 at 05:15 AM, with a chief complaint of falling at home with a diagnosis confirmed of a right femur fracture and a prolonged QT interval [an extended duration of the electrical depolarization and repolarization of the heart's ventricles (lower chambers). Pt. #5 was transferred to accepting facility via ambulance transfer on 01/22/2025 at 7:55 AM. A review of Pt. #5's transfer form revealed no risks of transfer were documented.

Review of Pt. #6's ED medical record revealed Pt. #6 was a 27-year-old female who arrived in the ED on 02/05/2025 at 11:42 AM, with a chief complaint of Suicidal Ideation and Bipolar. Pt. #6 was transferred to a psychiatric hospital on 02/05/2025 at 9:30 PM. A review of Pt. #6's transfer form revealed no risks of transfer were documented.

During an interview on 02/26/2025 at 3:00 PM, when asked about the expectation for documentation of risks of transfer, Quality Director B stated it was the expectation that all sections of the transfer form be completed.