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Based on record review and interview the hospital failed to restrict transfer until the physician certification was completed that included but was not limited reason for transfer, condition at time of transfer, risks and benefits of transfer, contact with accepting facility, date/time of transfer and/or consent from patient/family for a sample of 13 (Patient #26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, and 38) of 38 emergency department (ED) patients transferred to a higher level of care from 12/15/18 to 03/07/19.

This failed practice had the likelihood to result in adverse patient outcomes and increased risk to patient safety for a sample 13 (Patient #26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, and 38) of 38 ED patients who were transferred to a higher level of care from 12/15/18 to 03/07/19 due to no documentation of risk/benefits of transfer, reason for transfer, date/time of transfer, condition at time of transfer, contact with accepting facility, and/or consent from patient/family.

Findings:

Review of hospital policy titled "EMTALA - Medical Screening, revised 03/17" showed an appropriate transfer included but was not limited the provision of medical treatment that decreased the risks to the patient's health ...provided informed written consent or required certification, necessary stabilizing treatment ...physician certification was a "written certification by the treating physician ordering the transfer" ...included but not limited to reasonable benefits that would outweigh the increased risks to the patient expected from the transfer, reason(s) for the transfer, and signature of the physician or qualified medical person.

Review of hospital policy titled "Stabilization, revised 03/17" showed for patients who had been provided medical screening examination (MSE), determination of an emergency medical condition (EMC), and provision necessary stabilizing treatment, a transfer may be facilitated if ... "physician signed a certificate ...the medical benefits of the transfer to another medical facility are reasonably expected to outweigh the risks to the individual ...from being transferred ...Qualified medical person has signed certification after consultation with physician and subsequently countersigns the certification."

Review of hospital policy titled "Transferring Patients to Other Hospitals, revised 03/18" showed a patient with an EMC that had not been stabilized should not be transferred without a physician certification that included a description of the medical benefits that outweighed the increased risks to the patient ...reason(s) for transfer ..."rational may be documented on the certification form or elsewhere in the medical record" ...documentation should include date and time of transfer request and "name of person accepting transfer of the patient".

A review of medical records showed that thirteen (Patient #26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, and 38) of thirty eight contained incomplete physician certification documentation for EMTALA transfers.

* Patient # 38 was admitted on 12/27/18 with suicidal ideations with plan and acute psychotic event. There was no evidence of a physician certification for transfer that included but was not limited to: reason for transfer, benefits that outweighed the increased risks of transfer to the patient, informed written consent, condition at the time of transfer, or contact with the receiving hospital.

* Patient #26, 27, 28, 29, 30, 32, 34, 36, and 37, did not show evidence of benefits that outweighed the increased risks of transfer to the patient and the reason for transfer,

* Patient #31, 33, 35, did not show evidence of benefits that outweighed the increased risks of transfer to the patient, reason for transfer, date and time of transfer, or contact with the receiving hospital.

* Patient #31, and 36 did not show evidence that a physician had signed the certification.

On 03/14/19 at 8:38 am, Staff B stated he/she did not see a transfer form (physician certification) for Patient #38 and there was no documentation in the patient's medical record. Staff B stated review of a patient's transfer record on 12/29/18 showed no documentation of an accepting facility or physician. Staff B stated review of a patient's transfer record on 12/03/18 showed no indication for transfer or documentation of benefits that outweighed the increased risks of transfer to the patient.

On 03/14/19 at 9:04 am, Staff D he/she would pull a report from the database each morning for all patients transferred. Staff D stated he/she would then pick up a copy of all the EMTALA forms in the ED and prepare a report that had the patient's name, account number, date of transfer, name of transferring physician, if the patient was EOD, name of receiving facility, whether the form were completed and if it was not completed, what items were not. Staff D stated normally he/she would review all the forms from the previous day and complete the chart audit. She stated she had been assigned other tasks and had not performed chart audits since December 2018.