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Based on clinical record review and interview, it was determined the facility failed to inform the patient of the risks and benefits of being transferred to another facility for two (#3 and #5) of four (#1, #2, #3 and #5) patients reviewed. The failed practice did not ensure the patients were aware of or accepted the risks or benefits of the transfer. The failed practice had the potential to affect all patients being transferred to another facility from the Emergency Department. The findings follow:

A. Review of Patient #3's clinical record on 03/07/13 revealed the patient was transferred to another acute care hospital on 11/22/12. There was no evidence the patient or guardian was informed of the risks or benefits of the transfer.

B. Review of Patient #5's clinical record on 03/07/13 revealed the patient was transferred to another acute care hospital on 10/12/12. There was no evidence the patient was informed of the risks or benefits of the transfer.

C. Review of the policy "EMTALA - Stabilization and Transfer" on 03/06/13 revealed, 1) "Transfer Requirements: Stable Persons. At a minimum, transfer of the stable person requires: an explanation of the risks and benefits of the transfer." 2) "Transfer Requirements: Unstable Persons. If the MSE (Medical Screening Exam) reveals that the person has an EMC (Emergency Medical Condition) and Hospital does not have the capability to stabilize the person, or if the person requests a transfer, then Hospital will transfer the person to another hospital or facility that has the capability to provide stabilizing treatment. To be a valid transfer request, the request must be in writing, signed by the person or the person's representative, such as the holder of the healthcare power of attorney, and certify the following: that the person has received an explanation of the risks and benefits of the transfer. If the transfer is due to Hospital's lack of capability to stabilize a person, the Emergency Department Physician/Attending Physician must certify in writing that, based on the information available at the time of transfer, the medical benefits expected from the medical treatment available at another facility outweigh the increased risks to the person (or unborn child) from the transfer. The certification will contain a summary of the risks and benefits upon which this decision if based. If the physician is not physically present at Hospital at the time the person is transferred, then another physician may sign the certification in consultation with the physician making the determination and such physician will later countersign the certification."

D. The findings were confirmed in an interview with the Director of Patient Care Services on 03/06/13 at 1300.