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Based on record review and interview, the facility staff failed to appropriately transfer a patient receiving care in the Emergency Department (ED) to another facility in 1 of 10 Patients (Patient #1) transferred in a total universe of 20 medical records reviewed.

Findings include:

The facility staff failed to appropriately transfer a patient receiving care in the Emergency Department (ED) to another facility. See Tag A-2409

Based on record review and interview, facility staff failed to appropriately transfer a patient receiving care in the Emergency Department to another facility in 1 of 10 Patients (Patient #1) who were transferred in a total universe of 20 Patient medical records reviewed.

Findings Include:

A review of facility policy #19290 "AAH EMTALA (Advocate Aurora Health Emergency Medical Treatment and Active Labor Act)," last revised 04/24/2024 revealed, " ... D. Stabilization, Transfer, or Discharge 1. Transfer or Discharge of a Patient: A physician or QMP (Qualified Medical Professional) may discharge or Transfer a Stable patient from the hospital to a Recipient Hospital for ongoing care if the following are met: a) The physician or the QMP documents that an appropriate MSE (Medical Screening Exam) has been completed and (1) The patient does not suffer from an EMC (Emergency Medical Condition); or (2) The patient has an EMC, but the physician or QMP has determined with reasonable clinical confidence that the patient has been Stabilized and has reached the point where the patient's continued care, including diagnostic work up, treatment and or other follow-up care could reasonable by performed in another setting... 3. Unstable Patient Transfers: An unstable patient may be transferred if hospital staff provide stabilizing treatment for the patient's EMC within the Capacity and Capabilities of the Hospital and sections a-d below are met: a) A physician certifies the transfer ... (1) Transfer with Certification: A physician must certify that the medical benefits expected from Transfer outweigh the risks and describe the reasons for and the potential risks and benefits of the Transfer by completing the applicable areas on the Patient Transfer Form ... (b) Recipient Hospital: A representative of the Recipient hospital must confirm prior to Transfer that: (1) The Recipient Hospital has available space and qualified personnel to treat the patient and agrees to accept the Transfer and to provide appropriate medical treatment; and (2) Hospital staff should document any communication with the Recipient Hospital, including the date and the time of the Transfer request, and the name of the person accepting the Transfer in the patient's medical record. (3) A Medicare participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department, is required to accept an appropriate transfer ..."

A review of a blank hospital form titled, "Patient Transfer Documentation" revised 08/23 revealed, "1. Section 1. Physician Certification (Physician complete section 1 ...1. Diagnosis: 2. Reason(s) for Benefits of Transfer 3. Transfer Risks 4. Accepting Facility/Hospital has agreed to accept this patient transfer and has the available space and qualified personnel for the treatment of the patient. 5. Mode/Level of Care for transfer ..."

A review of Patient #1's ED medical record, "History" written by ED PA (Physician Assistant) L on 08/29/2024 at 2:57 PM revealed, "[Patient #1] is a 55-year-old (fe/male) presenting to the emergency department in police custody on a Chapter 51 hold (involuntary detention-initiated when a person is a danger to themselves or others) after making suicidal statements. Patient was arrested overnight and had a blood alcohol of 0.09 when (s/he) left the police station this morning. They were called to (his/her) house several hours later when (his/her) counselor alerted police that (s/he) was making suicidal statements about shooting (himself/herself) with a gun. With police present (s/he) was discussing (his/her) plan for suicide by cop. Patient admits to drinking additional alcohol this morning but is unable to quantify. (S/he) reports (s/he) recently lost his son, which triggered (his/her) depression and (his/her) thoughts that (s/he) no longer wishes to be alive. (S/he) denies any attempt to kill (him/herself) today. (S/he) answers by saying "I wish I had means to do that." (S/he) denies any physical complaints ... Patient is a 55-year-old with complaint of suicidal ideation and alcohol intoxication in need of medical clearance in police custody. My differential diagnosis includes but is not limited to metabolic derangement, alcohol intoxication, electrolyte abnormality, overdose attempt among others. Medical clearance unremarkable with exception to high alcohol level. The patient was cleared for discharge into police custody for transfer to Milwaukee County [Hospital #2]."

A review of Patient #1's "ED timeline" from [Hospital #1], from 08/29/2024 at 2:46 PM through 08/29/2024 at 4:59 PM revealed, "2:46 PM: Patient arrived in ED at 2:46 ... 2:50 PM: Provider contact with patient ... 4:30 PM: Discharge Disposition Selected ... 4:42 PM: Departure Condition: Mobility at Departure: Ambulatory. Patient teaching: discharge instructions reviewed; Follow-up care reviewed; Patient verbalized understanding. Departure Mode: in police custody ... 4:59 PM: Patient discharged."

A review of Patient #1's medical record revealed, there was no "Patient Transfer Documentation" completed by ED PA L when Patient #1 was discharged from Hospital A. ED PA L discharged Patient #1 from the facility in police custody under a Chapter 51 hold. The findings were confirmed with ED Manager J, who stated, "There was no transfer form completed, the provider did not call the facility to talk to a provider who accepted [Patient #1]."

During an interview on 10/09/2024 at 3:20 PM with ED MD N who stated, "All patient transfers, including Chapter 51 patients in police custody require a phone call from doctor to doctor. Patients cannot be transferred unless a physician accepts the care."