HospitalInspections.org

Based on policy review, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20(l) and §489.24.

Findings included:

The hospital failed to provide documentation of appropriate transfers to 2 of 28 patients transferred to other acute care hospitals (Pts # 12, 13) when there was no documented physician certification that the benefits of transfer exceeded the risks and no actual risks of transfer noted in the medical record.

~cross refer to §489.24(e), Appropriate Transfer - Tag A2409

Based on policy and procedure reviews, DED (Dedicated Emergency Department) medical record reviews and staff and physician interviews the hospital failed to provide documentation for appropriate transfers to 2 of 28 patients transferred to other acute care hospitals (Pts # 12, 13) when there was no signed physician certification that the benefits of transfer exceeded the risks and no actual risks of transfer noted in the medical record.

The findings included:

Review of the EMTALA policy, dated 05/21/2021, revealed "...Transfer of an Un-stabilized individual for Medically Indicated Reasons ....If transfer to a facility with higher capacity and capability is deemed necessary, the the individual may be transferred, subject to the following requirements: a. The transfer is an appropriate transfer....and b. .... The physician certifies in writing that the expected benefits of the transfer outweigh the increased risks of transfer....The physician will sign a certification. (a) The emergency physician....shall complete and sign the transfer form, stating that, based on the information available at the time of transfer, the medical benefits reasonable expected from the care anticipated at the receiving hospital outweigh the risks of transfer....(b) a summary of the risks and benefits upon which this conclusion is based will be documented. ..."

1. DED record review on 08/17/2022 revealed Patient #12, a 12-year-old, arrived to the DED with an arrival complaint of "Heart rate issues." Review of the "ED Provider Note", date of service 07/24/2022 at 1838, revealed "...Patient has been discussed with Dr. (Name) at (Hospital Name) PICU (Pediatric ICU) who is excepted (sic) the patient. Patient will be transported by helicopter. EMTALA is completed. ..."

Review of the electronic EMTALA Transfer form revealed, at 1936, " ...Emergency Medical Condition ....Identified, Patient UNstable for transfer .... Clinical Impression/Diagnosis: DKA .... Reason for Transfer: Medically indicated ....Medical Benefit for Transfer: Obtain level of care/service not available at this facility .... Medical Risks .... Worsening of condition or death if not transferred. ..."

Review of the Transfer form did not reveal documentation that the physician certified the benefits of transfer outweighed the transfer risks. Review failed to reveal any actual risks of transfer documented. Review revealed the only risks documented in the risk of transfer portion of the form were noted as risks of not transferring.

Requests for interview with MD #8, the transferring physician, revealed the MD was not available for interview.

2. DED medical record review revealed Patient #13 arrived to Campus B on 08/09/2022 at 2221 with a chief complaint of chest pain. Review of the ED Provider Note, date of service 08/09/2022 at 2246, revealed "...He was made a code STEMI (ST Elevation Myocardial Infarction- severe heart attack) and arrangements were made to transport to (Hospital Name) where he was accepted by (name of Physician) ....ED Course ....2250 ECG 12 Lead ....positive acute STEMI ....Diagnosis: 1. Acute anterior wall MI ....2. Primary hypertension (elevated BP) ...,.3. History of type 2 diabetes mellitus ....4. Mixed hyperlipidemia ...Disposition: ....Transfer. ..."

ED Care Timeline review revealed at 2230 the EMTALA Transfer Form was started. Review revealed "PHYSICIAN COMPLETES" Medical Condition; EMC Identified, Stable: ....Patient stable for transfer Clinical Impression/Diagnosis: Acute Anterior MI .... Medical Benefit for Transfer: Obtain level of care/service not available at this facility ....Medical Risk for Transfer: Worsening of condition or death if not transferred. ..."

Review revealed Patient #13 was transferred out at 2304. Review of the record failed to reveal physician certification that the benefits of transfer exceeded the risks and failed to reveal any actual documented risks of transfer.

Interview with MD #6, on 08/18/2022 at 0920, revealed the facility had recently gone to a new computer system. Interview revealed MD #6 just learned at a meeting "this morning" that there were two physician sections that had to be completed on the transfer form in the new system. Interview revealed it was very possible MD #6 missed the second section and the certification of benefits exceeding risks for Patient #13. Interview revealed in planning for the new computer system there were individual physician meetings to "personalize" the documentation but MD #6 did not recall if there were discussions about the EMTALA transfer form. Regarding the statement "worsening of condition or death if not transferred" being listed as a risk of transfer, MD #6 stated providers might not be able to see the full sentence on the screen when selecting risks of transfer. MD #6 said "worsening of condition" was a fall back choice and could have been selected because they considered worsening of condition to be a risk of transfer and did not realize the documentation they saw ended with "if not transferred." Interview revealed the document needed to be changed.

Interview with the ED Medical Director (MD #9), on 08/18/2022 at 1510, revealed a new computer documentation system had been implemented in July. Interview revealed the new electronic transfer form had two sections physicians needed to complete. Interview revealed the new transfer form included a physician section, followed by a patient section, and then another physician section which included the certification of the benefits exceeding the risks of transfer. Interview revealed some physicians had not realized there was another physician section and thought they were finished documenting when they came to the patient section. Interview revealed there was an ED provider staff meeting just this morning (08/18/2022) and MD #9 discussed the issue and explained the need for physicians to complete both sections of the form. MD #9 stated the issue should be resolved now. In regards to physicians documenting the risks as worsening condition if not transferred, interview revealed physicians probably did not realize what the full statement said. Interview revealed the entire sentence was not visible to physicians on the computer screen. Interview revealed physicians could not immediately see the words "if not transferred" on the screen so they may have thought they were choosing an actual risk of worsening condition or death during transfer. Interview revealed the wording on the form definitely needed to be addressed because it was not a risk of transfer as it was currently written but it would have to be fixed within the computer system.