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Based on medical record review, Medical Staff Rules and Regulations, policies and procedures and interviews with staff it was determined that the facility failed to conduct an appropriate transfer for one Patient (P) #1 of 20 sampled patients. P#1 arrived to the facility's Emergency Department (ED) on 2/7/24 at 7:43 p.m. after sustaining a fall. A medical screening examination was conducted, and the decision was made to transfer P#1 as soon as possible to a higher level of care. P#1 arrived at the receiving facility at 9:00 p.m. Facility staff failed to confirm that the receiving hospital had accepted P#1; failed to complete a transfer packet including physician certification; and failed to provide the receiving facility with the required medical records.

Based on medical record review, Medical Staff Rules and Regulations, policies and procedures and interviews with staff it was determined that the facility failed to provide one Patient (P) #1 of 20 sampled patients with an appropriate transfer. The Emergency Department (ED) failed to complete a transfer packet including physician certification that the medical benefits outweighed the risks of transfer. The ED failed to confirm that the receiving facility had space and qualified personnel and agreed to accept P #1 as a transfer.

Findings included:

A review of the facility's Central Log revealed that Patient (P) #1 arrived to the Emergency Department (ED) via Emergency Medical Services (EMS) and was registered as a patient on 2/7/24 at 7:43 p.m.

Review of the Emergency Department (ED) record revealed that P#1 was triaged by the Registered Nurse (RN) EE at 7:48 p.m. The Medical Screening Exam (MSE) by the Medical Doctor (MD) FF at 7:48 p.m. revealed that P#1 had head trauma due to a fall, hip pain, and hematoma of her face. There were significant signs of external trauma. MD FF instructed the nurses to call 1 (800) Bad Hurt to get auto acceptance. Review of the MSE revealed that P#1 was accepted by 1 (800) Bad Hurt and transferred in critical condition due to trauma.

Continued review P#1's ED record failed to reveal a transfer packet and physician certification of the risks and benefits of transfer. The record failed to reveal documentation that the receiving hospital had space, qualified personnel and equipment and had agreed to accept and give appropriate transfer. There were no departure/transfer times observed in the medical record.

Review of the EMS Pre-hospital Care Report on 2/7/24 at 8:30 p.m. revealed that P#1 arrived at the receiving hospital at 9:00 p.m.

Review of the Medical Staff Rules and Regulations adopted by the health system on 3/27/2018, revealed that the Emergency Room Medical Director would have the overall responsibility for emergency care, subject to the authority of the Board. Patients with conditions whose definitive care was beyond the capabilities of the hospital would be referred to the appropriate facility, when in the judgment of the attending practitioner, the patient's condition permitted such a transfer. No patient would be arbitrarily transferred, and inquiry would be made as to acceptance of the patient by the receiving hospital and physician. A copy of pertinent medical records would accompany the transfer. The hospital's procedures for patient transfers to other facilities would be followed. Patients would be evaluated by a physician prior to discharge or transfer.

Review of the "EMTALA - Transfer Policy", Version 1, Reviewed 4/20/21, revealed that transfer of an individual with an Emergency Medical Condition (EMC) must have been initiated either by a written request for transfer from the patient's legal representative or by a physician's order. When an individual who had not been stabilized was transferred, a physician would sign a certification that the medical benefits outweighed the increased risk to the individual being transferred. The receiving facility would have available space and qualified personnel for the treatment of the individual and would have agreed to accept the transfer and to provide appropriate medical treatment.

The policy further revealed that before any transfer could occur, the transferring hospital had to provide, within its capacity and capability, medical treatment to minimize the health of the individual or unborn child. The transferring hospital was required to call the receiving facility to verify the receiving hospital had available space and qualified personnel for the treatment of the individual. The receiving hospital must have agreed to accept the transfer and provide appropriate treatment. The transferring hospital must have documented its communication with the receiving hospital, including the request date and time and the name of the person accepting the transfer. The transferring hospital would send copies of all medical records related to the EMC that were available at the time of the transfer. The physician was required to sign an express written certification that, based on information available at the time of transfer, the medical benefits of transfer were reasonably expected to outweigh the increased risks to the individual or unborn child. The certification should have been specific to the condition of the patient upon transfer and contain a complete picture of the benefits to be expected from appropriate care at the receiving facility. The certification must have stated the reason for transfer.

Review of the Fresh Trauma Transfer Policy poster from the receiving facility revealed that 1-800-BAD HURT would be called to initiate the transfer. Reports would include the time of injury, mechanism of injury, pre-hospital details, medication given, blood transfusions, pertinent labs and imaging, and injuries identified.

An interview took place with the ED Nurse Manager (NM) AA on 3/11/24 at 3:15 p.m. in the Conference Room. NM AA said P#1 came into the ED with Emergency Medical Services (EMS) after a traumatic fall. P#1 was evaluated by a physician who informed the nurses to call Bad Hurt and transfer her quickly. The Unit Coordinator (UC) attempted to call. Whenever Bad Hurt is called, they are given vital signs, mechanism of injury, and basic information. The UC did not have all the relevant information, so Bad Hurt could not auto accept P#1. The UC was told to call back with the information needed. The call back never happened. If the UC had called back, the patient would have been auto accepted and there would be a name of the accepting physician. Transport would have been arranged from there. There was not usually physician-to-physician discussion with auto acceptance. Nurse-to-nurse communication would occur before or at transfer when the patient was ready to leave. The ED had a transfer sheet with patient information, vital signs, accepting physician, medications, and a place where the nurse gave a report. Any patient who transferred had to have a transfer form. The transfer sheet was not completed for P#1.

A telephone interview took place with the Unit Coordinator (UC) CC on 3/11/24 at 5:18 p.m. UC CC said that she did not have P#1's vital signs when calling, so Bad Hurt said to call back with more information. UC CC asked the clinical lead if transfer paperwork was needed, and he said no. The clinical lead had a patient coding at that time, so UC CC asked the primary nurse who was in the room with P#1 if an accepting physician was needed, and he said not to worry about it. The transfer center called back when P#1 was in route, and UC CC told them the patient was on their way. UC CC conferred with the clinical lead again, and he said they did not need to do any paperwork.

A telephone interview took place with the Clinical Lead (CL) DD on 3/11/24 at 5:31 p.m. CL DD said MD FF came into the room where CL DD was working and said there was a trauma patient who needed to be gotten out as soon as possible. There was a huge baseball-sized hematoma (knot) on P#1's head. The unit coordinator called the transfer center, and CL DD asked EMS if they could help transfer P#1. The ED did not have all the paperwork together when the unit coordinator tried to call the transfer center back. CL DD told UC CC not to worry about it, because they needed to get P#1 out of the ED. EMS put P#1 on the stretcher and out the door she went on her way to the other hospital. CL DD said he called 1-800- Bad Hurt, and they had not done an auto-accept.

A telephone interview took place with the Triage Nurse (RN) EE on 3/11/24 at 6:05 p.m. RN EE said MD FF came in shortly after RN EE started triage. MD FF looked at P#1, asked a couple of questions, then said she needed to get transferred to trauma. MD FF spoke to EMS, and P#1 was going to be gotten out with the same squad that brought her to the ED. Later, RN EE got a call from the trauma nurse asking for a report. The trauma nurse said they had a patient there and they did not know what was going on. RN EE told the nurse what he remembered and gave them a report after the fact. The trauma hospital received a packet with nursing notes and MD assessments but did not get a transfer packet or doctor to whom MD FF spoke.

A telephone interview took place with the Medical Doctor (MD) FF on 3/12/24 at 4:22 p.m. MD FF said P#1 had a large hematoma (knot) on her forehead, vomiting, and a painful hip. When MD FF said to call 1 (800) bad hurt, the EMS crew asked if they should have taken her to the trauma center first. When MD FF said yes, the crew offered to take her. MD FF said that whenever bad hurt was called, if the patient was at the trauma hospital within an hour, the patient was auto accepted. There was a golden hour with trauma. MD FF said patients were always auto accepted, and he could not remember the number of times he had spoken to a person. MD FF said there was a high probability of head trauma, and if P#1 was kept at the ED with a head trauma, there were no trauma services, including orthopedics, a trauma surgeon, etc. There was multi-organ involvement with the hip and head pain. MD FF normally signed transfer paperwork and told the unit coordinator it was trauma. The physician did not call bad hurt.

A tour of the Emergency Department (ED) took place on 3/12/24 at 11:15 a.m. with the Quality Director and the Administrator. The unit coordinator provided a transfer packet to this surveyor that NM AA said would be completed at the time a patient was transferred and was not completed for P#1.