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Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to determine whether or not an emergency medical condition existed, appropriate to the individual's presenting signs and symptoms for the patient that presented to the ED. See deficiency at A-2406

2. The Hospital failed to to complete a physician certification regarding the medical benefits and risks of transfer, that the medical records related to the emergency condition which the patients presented were available and sent at the time of transfer, and that Patient's Transfer Form was completed to include an informed written consent from patient or family member prior to transfer. See deficiencies at A-2409, A, B and C.

Based on document review and interview it was determined that for 1 of 21 (Pt. #1) clinical records reviewed for individual who presented to the Hospital's emergency department (ED), the Hospital failed to determine whether or not an emergency medical condition existed, appropriate to the individual's presenting signs and symptoms for the patient that presented to the ED.

Findings include:

The findings were at Location A.

1. The Hospital's policy titled, "EMTALA" (revised 9/15/2021), was reviewed and required, "1. a) A MSE (medical screening examination) is tailored to each patient's presenting symptoms and complaints ... may be a simple process involving a brief history and physical examination or a complex process that involves ancillary studies... and/or other diagnostic tests and procedures ... The medical record must reflect continued monitoring ...until it is determined whether the individual has an EMC (emergency medical condition) ...he/she is stabilized or appropriately transferred."

2. On 12/15/2021, Pt.#1 clinical record was reviewed. Pt.#1 presented to the ED, on 11/7/2021 at 3:19 AM with chief complaint of hypertension and eye pain. The clinical record included the following:

- ED Triage note dated 11/7/2021 at 3:24 AM indicated, "Patient Acuity 3 (scale for priority of care 3/Urgent) ...Heart rate: 82, Respirations: 1, BP 136/94 (normal diastolic range 60-90) ... Pain Intensity-Numeric scale 0-10, 7 (eye) ..."

- ED Provider (MD#1) note dated, 11/7/2021 at 3:50 AM, indicated, "Chief Complaint: Hypertension... has associated sx (symptoms) of eye pain and eye redness, which (Pt.#1) states happens when BP [blood pressure] is high ... Physical Exam ... Eyes: Positive for pain and redness. Negative for discharge and visual disturbance ... Tono-Pen not functioning, unable to assess IOP (intraocular pressure). No slit lamp available. Considered acute closed angle glaucoma, SLE (systemic lupus erythematosus) uveitis (inflammation of the middle layer of eye). (MD#1) instructed the patient to go to (name of outside hospital) or (Hospital C- other acute care hospital) for further evaluation of his red painful eye ... Disposition ... Discharged 11/7/2021 to home/self-care."

The clinical record did not indicate that the physician (MD#1) conducted further assessment or a manual palpation to the affected eye to assess intraocular pressure and to determine if medically stable prior to discharging (Pt.#1).

- ED Care note dated 11/7/2021 at 5:20 AM, included, "Departure Condition: Ambulatory ... Discharge instructions reviewed; Follow-up at (Hospital C)... You will need further evaluation at a hospital with the ability to examine your eye more thoroughly ... Departure mode: In cab; by self.

3. On 12/15/2021 at 12:45 PM, a telephone interview was conducted with an Ophthalmology Physician (MD #2) from Location A. MD #2 stated that when a patient presents to the ED with history of HTN [hypertension], ESRD [end stage renal disease], and complaint of pain and redness to the eyes, it is vital to check the eye pressure to rule out glaucoma or retinopathy (complication of the eye). The ED (at Location A) has several Tono-Pens and a slit lamp (lamp with a microscope to view inside of the eye) and ED Physicians are trained to use them. The physician can call the on-call ophthalmologist with the measurements to discuss treatment to stabilize the eye pressure. If there are no Tono-Pens or slit lamps available the physician can do manual palpation, but it is important to start treatment right away if there are abnormal findings to prevent damage to eye-sight.

4. On 12/15/2021 at 1:35 PM and on 12/17/2021 at 1:05 PM, telephone interviews were conducted with the Hospital's Medical Director (MD#3). MD#3 stated, "There were two Tono-Pens and one slit lamp in the ED (at Location A). On this date (11/7/2021), the physician (MD#1) was having a problem operating the pen, but it was working. If (MD#1) suspected closed angle glaucoma, (Pt.#1) should have had the eye pressure checked. If there was an ophthalmologist on call, he or she should have been consulted. If the equipment was not functioning or an ophthalmologist was not on-call, the patient should have been transferred to a facility that was better equipped and not discharged. The risk for suspected close angle glaucoma is loss of vision. On 12/17/2021 MD#3 stated that during a discussion with (MD#1) regarding (Pt.#1) he felt that there was still a question about closed angle glaucoma and in his (MD#3) mind he felt that it could be a medical emergency.

5. On 12/16/2021 at 11:15 AM, an interview was conducted with the Chief Medical Officer (CMO-MD#5). MD #5 stated, "I reviewed the medical record for (Pt.#1) and based on the medical history and complaint, (Pt.#1) should have been transferred and not discharged."

A. Based on document review and interview, it was determined that for 3 of 4 patients' (Pt. #19, Pt. #20, and Pt. #21) clinical records reviewed for transfers, the Hospital failed to complete a physician certification regarding the medical benefits and risks of transfer.

Findings include:

The following was found at Location B.

1. On 12/16/2021, the Hospital's policy titled, "AAH (Emergency Medical Treatment and Labor Act) (revised by the Hospital on 9/2021) was reviewed and included, "... D. Stabilization, Transfer, or Discharge... 1) Transfer with Certification: A physician must certify that the medical benefits expected from Transfer outweighs the risks and describe the reasons for and the potential risks and benefits of the Transfer by completing the applicable areas on the Patient Transform Form..."

2. On 12/16/2021 at approximately 10:30 AM, the clinical record of Pt. #19 was reviewed. Pt. #19 was brought to the Emergency Department (ED) on 12/2/2021 due to suicidal ideation. The clinical record indicated that Pt. #19 was a danger to himself and others. The clinical record indicated that Pt. #19 was transferred from the ED to another Hospital. The clinical record lacked physician certification regarding the medical benefits and risks of transfer.

3. On 12/16/2021 at approximately 10:45 AM, the clinical record of Pt. #20 was reviewed. Pt. #20 was brought to the ED on 12/4/2021 due to hypertensive emergency. The clinical record indicated that Pt. #20 had a history of heart transplant requiring cardiology and heart transplant evaluation. The clinical record indicated that Pt. #20 was transferred from the ED to another hospital for evaluation. The clinical record lacked a physician certification regarding the medical benefits and risks of transfer.

4. On 12/16/2021 at approximately 11:00 AM, the clinical record of Pt. #21 was reviewed. Pt. #21 was brought to ED on 12/10/2021 due to ear and throat pain. The clinical record indicated that Pt. #21 required ENT (ear, nose, throat) and/or oral surgery specialist service. The clinical record indicated that Pt. #21 was transferred from the ED to another hospital for evaluation and management. The clinical record lacked a physician certification regarding the medical benefits and risks of transfer.

5. On 12/16/2021, findings were reviewed with an ED attending physician (MD #6). MD #6 stated that Pt. #19, Pt. #20, and Pt. #21 psychiatric or emergency medical condition at the time of transfer was not yet stabilized. MD #6 stated that the physician certification regarding medical benefits and risks of transfer should be completed prior to transfer.

B. Based on document review and interview, it was determined that for 2 of 4 patients' (Pt. #20 and Pt. #21) clinical records reviewed for transfer, the Hospital failed to ensure that the medical records related to the emergency condition which the patients presented were available and sent at the time of transfer.

Findings include:

The following was found at Location B.

1. On 12/16/2021, the Hospital's policy titled, "AAH (Emergency Medical Treatment and Labor Act) (reviewed by the Hospital on 9/2021) was reviewed and included, "... D. Stabilization, Transfer, or Discharge...c... The Hospital staff shall send to the Recipient Hospital copies of all pertinent medical records available at the time of transfer..."

2. On 12/16/2021 at approximately 10:45 AM, the clinical record of Pt. #20 was reviewed. Pt. #20 was brought to the Emergency Department (ED) on 12/4/2021 due to hypertensive emergency. The clinical record indicated that Pt. #20 was transferred from the ED to another hospital for evaluation. The clinical record lacked documentation that copies of all pertinent medical records were sent to receiving hospital.

3. On 12/16/2021 at approximately 11:00 AM, the clinical record of Pt. #21 was reviewed. Pt. #21 was brought to the ED on 12/10/2021 due to ear and throat pain. The clinical record indicated that Pt. #21 was transferred from the ED to another hospital for evaluation and management. The clinical record lacked documentation that copies of all pertinent medical records were sent to receiving hospital.

4. On 12/16/2021 at approximately 11:00 AM, findings were discussed with E #8 (Emergency Department Stroke Coordinator). E #8 could not provide documentation that copies of medical records were sent.


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C. Based on document review and interview, it was determined that for 2 of 5 (Pt. #5 and Pt. #6), clinical records reviewed for transfer, the Hospital failed to ensure that transfer form was completed with informed written consent from patient and or family member was obtained prior to transfer to another Hospital.

Findings include:

The findings were found at Location A.

1. On 12/16/2021 at approximately 9:00 AM, the Hospital's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act" dated 09/15/2021 was reviewed and included, " ...Transfer or Discharge of a Patient: A physician ...document in medical record ...(2) ...must complete the applicable section on the Patient Transfer Form, and the patient or a legally responsible person acting on the patient's behalf must sign the Form prior to transfer ...By signing the written request for transfer, the patient acknowledge that he/she has been fully informed ..."

2. On 12/15/2021 at approximately 12:35 PM, Pt. #5's clinical record was reviewed. Pt. #5 presented to the ED on 10/28/2021, with a chief complaint of sore throat. Pt. #5's medical screening examination was done on 10/28/2021, at 2:20 PM. Pt. #5 was stabilized and transferred to another hospital for ear, nose, throat, specialty services on 10/29/2021 at 5:00 AM. Pt. #5's clinical record lacked the patient/legal representative informed consent/signature and transferring physician signature in the patient transfer form.

3. On 12/15/2021 at approximately 12:40 PM, Pt. #6's clinical record was reviewed. Pt. #6 presented to the ED on 11/23/2021, with a chief complaint of ear pain, and was triaged at 1:00PM. Pt. #6's medical screening examination was done on 11/23/2021, at 5:21 PM. Pt. #6 was stabilized and transferred to another hospital for ear, nose, throat, specialty services on 11/23/2021 at 10:18 PM. Pt. #6's clinical record lacked the patient/legal representative informed consent/signature and transferring physician signature in the patient transfer form.

4. On 12/16/2021 at approximately 9:00 AM, the ED Nurse Manager (E #5) and Director of Emergency Services (E #6) at Hospital A, were interviewed. E #5 stated that electronic transfer form should have been filled out, printed, and have patient/family member signature and consent obtained prior to transfer. E #5 stated that a copy of the transfer form should have been placed in the chart. E #6 stated that she was not aware that the signed transfer form was not scanned, and a copy is retained for the patient's chart.