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Based on document review, medical record review and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, in 3 of 3 (Patient #5 - Patient #7) medical records reviewed of patients who required a transfer to another facility, each lacked documentation of "signed physician certification containing the summary of risks and benefits of transfer "

Please reference findings at Tag 2409.

Based on medical record review, document review and interview, in 3 of 3 (Patient #5 - Patient #7) medical records reviewed of patients who were transferred to another facility, each lacked documentation of the required transfer certification form.

Findings include:

-- Review of Patient #5's medical record revealed, Patient #5 presented to the emergency department (ED) on 6/9/24 at 10:46 am with a chief complaint of difficulty breathing. The patient's oxygen saturation dropped to 60% necessitating epinephrine nebulizer treatment. Patient #5 had a history of severe burns, on over 30 of their body (occurred a month ago). The patient was discharged from another Hospital (B) the previous week. The patient was being followed at Hospital B by outpatient thoracic surgery for tracheal dilatation. The provider contacted Hospital B and the patient was accepted as a transfer. The patient was transferred on 6/10/24 at 9:47am via ambulance.

"There was no documentation of a signed physician certification containing the summary of risks and benefits of transfer "

-- Review of Patient #6's medical record revealed, Patient #6 presented to the ED on 3/15/24 at 9:46 am via emergency medical services (EMS) with suspected overdose and possible opiate withdrawal. It was determined the patient intentionally overdosed on Tylenol and Advil. Acetaminophen level was 89.5 - critical (normal 10.0 - 30.0) Liver studies were elevated. The patient was transferred to a transplant center due to the overdose, elevated liver studies and fulminant liver failure. Patient was transferred on 3/16/24 at 4:00am via ambulance.

"There was no documentation of a signed physician certification containing the summary of risks and benefits of transfer ".

-- Review of Patient #7's medical record revealed, Patient #7 presented to the ED via EMS on 3/9/24 at 8:04 am with a chief complaint of chest pain. The patient was transferred from another hospital with a diagnosis of a type A Dissection of the Ascending Aortic Aneurysm. Multiple laboratory studies were done as well as an electrocardiogram and chest x-ray. The decision was made to transfer the patient to the hospital where the patient had a transcatheter aortic valve replacement (TAVR) done. The patient was transferred on 3/9/24 at 12:11 pm via ambulance.

"There was no documentation of a signed physician certification containing the summary of risks and benefits of transfer ".

-- Review of the policy and procedure titled, "Emergency Medical Treatment & Labor Act" reviewed 11/2023, in section V1-Transfer from Albany Medical Center Hospital (AMCH) indicated the transfer certification form is required and should be completed.

-- Review of the document titled "Transfer Certification," revised 5/2016 contained space to document risks and benefits, physician recommended transfer for patients who specialty care is not available at AMCH, and patient requested transfer for unstabilized patients whose medical condition can be treated at AMCH. The form required physician and patient signature.

During interview of Staff G, Director of Hospital Regulatory Affairs, on 9/13/2024 at 2:00 pm, the above findings were acknowledged.