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§489.24(e) Transfer not in accordance with Emergency Medical Treatment and Active Labor Act [EMTALA] requires hospital with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and request such examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition [EMC] within 72 hours

Based on interview and record review, the hospital failed to report an inappropriate transfer within 72 hours for one of 31 sampled patients (Patient 1). This failure had the potential to result in the recurrence of not reporting inappropriate transfer of patients and adversely affect the safety and health condition of patients.

Findings:

During a review of Hospital 2's "Risk Management Report (RMR)," undated, the RMR indicated, "Date of Notification to RM (Risk Management): 11/10/2021. . .Date Reported to CDPH (California Department of Public Health): 11/15/2021[5 days]. . .on 11/10/21, EMS was dispatched for a patient with possible gastrointestinal (digestive system that leads from the mouth to the anus) bleed. . .EMS (Emergency Medical Services) was on site at Hospital 1. Hospital 1's ED Charge Nurse refused to have the patient examined. The patient was diverted to Hospital 2."

During a concurrent interview and record review on 2/15/22, at 1:10 PM, with Clinical Information Specialist (CIS), Patient 1's "Emergency Documentation," dated 11/10/21 was reviewed. The Emergency Documentation indicated, Patient 1, was a 43 year old male was brought in by ambulance to Emergency Department (ED) on 11/10/21, at 2:23 PM with chief complaints of dark coffee ground emesis (throwing up/vomiting) for 3 days and dark blood in stools.

During an interview on 2/15/22, at 4 PM, with Risk Management Clinical Specialist (RMCS), RMCS stated, she was made aware on 11/10/21 by the Emergency Department Director (EDD) of a possible EMTALA violation, when Patient 1 was diverted from Hospital inappropriately. RMCS stated, a courtesy call was made to Hospital 1 to verify information, but several calls went unanswered or Hospital 1 responded they were busy. RM reported the violation to CDPH on 11/15/21. RMCS stated, the EMTALA violation was reported late and should have been reported within 72 hours.

During a review of the facility's policy and procedure (P & P) titled "Compliance with EMTALA" dated 1/29/20, the P & P indicated, ". . . III. Policies. . . F. Reporting EMTALA Violations: If (Hospital 2) has a reason to believe it has received a patient whose transfer was not in accordance with EMTALA requirements (Physician to Physician acceptance, appropriate documentation of condition prior to transfer, consent, etc.), Hospital 2 must report the concern to CMS, or the California Department of Public Health, within 72 hours."