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Based on interview and record review, the facility failed to ensure that, for two of 20 sampled patients (Patients 10 and 19), the physician certifications for patient transfer on an EMTALA form (Emergency Medical Treatment and Labor Act form, refers to the documentation by the attending physician that justifies the need for transferring a patient from one healthcare facility to another) were properly filled out, in accordance with the facility's procedures and clinical guidelines. Specifically, the form did not indicate whether the patients (Patient 10 and 19) were stable (patient's emergency medical condition has been stabilized, meaning there is no significant risk of deterioration during the transfer) or unstable (patient's emergency medical condition has not been fully resolved and there is a risk of deterioration during transfer) at the time of transfer.

This deficient practice had the potential to compromise Patient 10 and 19's safety during the transfer process.

Findings:

1. During a review of Patient 10's History of Present Illness (HPI, a detailed account of the patient's current medical condition or symptoms that led them to seek medical care), dated 8/19/2024, the HPI indicated, Patient 10 presented to the facility's emergency department (ED, a medical facility or unit within a hospital designed to provide immediate care to patients who require urgent or emergency medical attention) on 8/19/2024 complaining of weakness with malaise (a general feeling of discomfort, illness or uneasiness whose exact cause is difficult to identify) and dizziness. The HPI also indicated that after ED work up, Patient 10 had abnormal electrocardiogram (EKG, a test that records the electrical activity of the heart) and showed Wellen's syndrome (EKG manifestation of critical proximal left anterior descending coronary artery stenosis), and Patient 10 had elevated troponin level (measures the amount of troponin proteins in the blood to help diagnose heart damage).

During a concurrent interview and record review on 10/02/2024 at 10:00 a.m. with the Associate Chief Nursing Officer (ACNO), Patient 10's EMTALA (Emergency Medical Treatment and Labor Act, a Federal law that requires hospitals to provide emergency care to anyone who requests it, regardless of their ability to pay or insurance status) transfer form, dated 8/19/2024, was reviewed. The EMTALA transfer form indicated, Patient 10 was consented to transfer to another facility for a higher level of care (a hospital capable of providing diagnostic, interventional, or tertiary care beyond the capacity of the hospital from which a patient originates). The EMTALA form was found incomplete, as the section where it should have indicated whether the patient's condition was stable or unstable, was not marked. The ACNO stated she (ACNO) was aware that the form for Patient 10's state of condition was not marked to indicate whether Patient 10 was stable or unstable for transfer. The ACNO also said it was important for the physician to complete this (referring to the documentation whether the patient was stable or unstable for transfer) information. The ACNO stated the form should be completed by the (transferring) physician, the form was to certify whether the patient was stable for transfer, and includes documentation of acceptance by the receiving facility, documentation about the accepting physician and a documented explanation provided to the patient regarding the risks and benefits of the transfer.

During an interview on 10/2/2024 at 2:00 p.m. with the Quality Manager (QM), QM verified that the EMTALA form had to be completed prior to transfer and had to include documentation whether the patient was stable or unstable.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Treatment and Active Labor ACT (EMTALA) and Transfer of Patient to another facility", dated 3/2019, the P&P indicated, "It is the facility's policy to comply with EMTALA obligations. The facility may not transfer any patient with an unstabilized emergency medical condition unless a patient requires a transfer, or a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving facility outweigh the risks to the patient from transfer. At the time of transfer, all medical records, including but not limited to, Physician Certification for Patient with Emergency Medical Conditions and Physician's Determination for Transfer for Stable or Stabilized Condition for patients in a stable condition, must be completed and forwarded to the accepting facility."

2. During a review of Patient 19's History of Present Illness (HPI, a detailed account of the patient's current medical condition or symptoms that led them to seek medical care), dated 10/31/2023, the HPI indicated, Patient 19 presented to the facility's emergency department (ED, a medical facility or unit within a hospital designed to provide immediate care to patients who require urgent or emergency medical attention) on 10/31/2023 complaining of abdominal pain.

During further review of Patient 19's HPI, dated 10/31/2023, the HPI indicated, Patient 19 was diagnosed with small bowel obstruction (SBO, a blockage in the small intestine that prevents the normal passage of food, fluids, and gas through the digestive tract). The HPI indicated, Patient 19 had to be transferred to another facility due to insurance reasons (the original hospital or facility is not within the patient's insurance network, or the patient's insurance plan does not cover certain treatments at the current facility).

During a concurrent interview and record review on 10/3/2024 at 11:00 a.m. with the ACNO (Associate Chief Nursing Officer), Patient 19's EMTALA (Emergency Medical Treatment and Labor Act, a Federal law that requires hospitals to provide emergency care to anyone who requests it, regardless of their ability to pay or insurance status) transfer form, dated 11/1/2023, was reviewed. The EMTALA transfer form was incomplete, as the section indicating whether the patient's emergency condition was stable or unstable, was not marked. The ACNO stated, the EMTALA form reviewed was incomplete. The ACNO said, completing the EMTALA form, and indicating whether the patient (Patient 19) was stable or unstable at the time of encounter, was important to ensure compliance with regulatory and the facility's documentation standards.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Treatment and Active Labor ACT (EMTALA) and Transfer of Patient to another facility", dated 3/2019, the P&P indicated, "It is the facility's policy to comply with EMTALA obligations. The facility may not transfer any patient with an unstabilized emergency medical condition unless a patient requires a transfer, or a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving facility outweigh the risks to the patient from transfer. At the time of transfer, all medical records, including but not limited to, Physician Certification for Patient with Emergency Medical Conditions and Physician's Determination for Transfer for Stable or Stabilized Condition for patients in a stable condition, must be completed and forwarded to the accepting facility."

Based on interview and record review, the facility failed to ensure that, for two of 20 sampled patients (Patients 10 and 19), the physician certifications for patient transfer on an EMTALA form (Emergency Medical Treatment and Labor Act form, refers to the documentation by the attending physician that justifies the need for transferring a patient from one healthcare facility to another) were properly filled out, in accordance with the facility's procedures and clinical guidelines. Specifically, the form did not indicate whether the patients (Patient 10 and 19) were stable (patient's emergency medical condition has been stabilized, meaning there is no significant risk of deterioration during the transfer) or unstable (patient's emergency medical condition has not been fully resolved and there is a risk of deterioration during transfer) at the time of transfer.

This deficient practice had the potential to compromise Patient 10 and 19's safety during the transfer process.

Findings:

1. During a review of Patient 10's History of Present Illness (HPI, a detailed account of the patient's current medical condition or symptoms that led them to seek medical care), dated 8/19/2024, the HPI indicated, Patient 10 presented to the facility's emergency department (ED, a medical facility or unit within a hospital designed to provide immediate care to patients who require urgent or emergency medical attention) on 8/19/2024 complaining of weakness with malaise (a general feeling of discomfort, illness or uneasiness whose exact cause is difficult to identify) and dizziness. The HPI also indicated that after ED work up, Patient 10 had abnormal electrocardiogram (EKG, a test that records the electrical activity of the heart) and showed Wellen's syndrome (EKG manifestation of critical proximal left anterior descending coronary artery stenosis), and Patient 10 had elevated troponin level (measures the amount of troponin proteins in the blood to help diagnose heart damage).

During a concurrent interview and record review on 10/02/2024 at 10:00 a.m. with the Associate Chief Nursing Officer (ACNO), Patient 10's EMTALA (Emergency Medical Treatment and Labor Act, a Federal law that requires hospitals to provide emergency care to anyone who requests it, regardless of their ability to pay or insurance status) transfer form, dated 8/19/2024, was reviewed. The EMTALA transfer form indicated, Patient 10 was consented to transfer to another facility for a higher level of care (a hospital capable of providing diagnostic, interventional, or tertiary care beyond the capacity of the hospital from which a patient originates). The EMTALA form was found incomplete, as the section where it should have indicated whether the patient's condition was stable or unstable, was not marked. The ACNO stated she was aware that the form for Patient 10's state of condition was not marked to indicate whether Patient 10 was stable or unstable for transfer. The ACNO also said it was important for the physician to complete this (referring to the documentation whether the patient was stable or unstable for transfer) information. The ACNO stated the form should be completed by the (transferring) physician, the form was to certify whether the patient was stable for transfer, and includes documentation of acceptance by the receiving facility, documentation about the accepting physician and a documented explanation provided to the patient regarding the risks and benefits of the transfer.

During an interview on 10/2/2024 at 2:00 p.m. with the Quality Manager (QM), QM verified that the EMTALA form had to be completed prior to transfer and had to include documentation whether the patient was stable or unstable.
During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Treatment and Active Labor ACT (EMTALA) and Transfer of Patient to another facility", dated 3/2019, the P&P indicated, "It is the facility's policy to comply with EMTALA obligations. The facility may not transfer any patient with an unstabilized emergency medical condition unless a patient requires a transfer, or a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving facility outweigh the risks to the patient from transfer. At the time of transfer, all medical records, including but not limited to, Physician Certification for Patient with Emergency Medical Conditions and Physician's Determination for Transfer for Stable or Stabilized Condition for patients in a stable condition, must be completed and forwarded to the accepting facility."

2. During a review of Patient 19's History of Present Illness (HPI, a detailed account of the patient's current medical condition or symptoms that led them to seek medical care), dated 10/31/2023, the HPI indicated, Patient 19 presented to the facility's emergency department (ED, a medical facility or unit within a hospital designed to provide immediate care to patients who require urgent or emergency medical attention) on 10/31/2023 complaining of abdominal pain.

During further review of Patient 19's HPI, dated 10/31/2023, the HPI indicated, Patient 19 was diagnosed with small bowel obstruction (SBO, a blockage in the small intestine that prevents the normal passage of food, fluids, and gas through the digestive tract). The HPI indicated, Patient 19 had to be transferred to another facility due to insurance reasons (the original hospital or facility is not within the patient's insurance network, or the patient's insurance plan does not cover certain treatments at the current facility).

During a concurrent interview and record review on 10/3/2024, at 11:00 a.m. with the ACNO (Associate Chief Nursing Officer), Patient 19's EMTALA (Emergency Medical Treatment and Labor Act, a Federal law that requires hospitals to provide emergency care to anyone who requests it, regardless of their ability to pay or insurance status) transfer form, dated 11/1/2023, was reviewed. The EMTALA transfer form was incomplete, as the section indicating whether the patient's emergency condition was stable or unstable, was not marked. The ACNO stated, the EMTALA form reviewed was incomplete. The ACNO said, completing the EMTALA form, and indicating whether the patient (Patient 19) was stable or unstable at the time of encounter, was important to ensure compliance with regulatory and the facility's documentation standards.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Treatment and Active Labor ACT (EMTALA) and Transfer of Patient to another facility", dated 3/2019, the P&P indicated, "It is the facility's policy to comply with EMTALA obligations. The facility may not transfer any patient with an unstabilized emergency medical condition unless a patient requires a transfer, or a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving facility outweigh the risks to the patient from transfer. At the time of transfer, all medical records, including but not limited to, Physician Certification for Patient with Emergency Medical Conditions and Physician's Determination for Transfer for Stable or Stabilized Condition for patients in a stable condition, must be completed and forwarded to the accepting facility."