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Based on policy review, medical record review, and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer (A2409).

Based on policy review, medical record review, and staff interview; the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer for three of seven medical records of transferred patients reviewed (Patient #2, #3 and #12). A total of 20 medical records were reviewed. The hospital registered an average of 3,986 patients per month in the preceding six months prior to the survey.

Findings include:

Review of the "EMTALA - Definitions" policy, effective 11/16/16, last approved/reviewed 12/12/19, revealed a Physician Certification "must include a summary of the risks and benefits upon which the certification is based and the reason(s) for the Transfer."

Review of the "EMTALA - Transfer Policy," effective 11/16/16, last approved/reviewed 12/12/19, revealed an Appropriate Transfer includes a written certification of the treating physician.

1. Review of the medical record for Patient #2 revealed an emergency room visit on 04/09/21. The patient had a history of frequent falls, was agitated and had hallucinations. After medical clearance, the patient was transferred to another acute care facility for a geropsych admission. The "Patient Transfer Form" was signed by the physician but lacked documentation of the risks and benefits of the transfer. This was verified in an interview on 06/23/21 at 11:04 AM by Staff A.

2. Review of the medical record for Patient #3 revealed an emergency room visit on 04/13/21. The pediatric patient had a nearly constant cough with intermittent upper body shaking. The patient was transferred to a pediatric acute care facility for further management and subspecialty consultation. The "Patient Transfer Form" was signed by the physician but lacked documentation of the risks and benefits of the transfer. This was verified in an interview on 06/23/21 at 11:04 AM by Staff A.

3. Review of the medical record for Patient #12 revealed an emergency room visit on 05/24/21. The patient had nausea, vomiting, diarrhea, an abnormal urinalysis, and hypokalemia. Due to capacity issues, the patient was transferred to another acute care facility for admission. The "Patient Transfer Form" was signed by the physician but lacked documentation of the risks and benefits of the transfer. This was verified in an interview on 06/23/21 at 4:26 PM by Staff A.

On 06/23/21 at 10:45 AM, Staff C stated in an interview that the expectation would be for the risks and benefits to be listed on the transfer form.