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Based on medical record (MR) review, document review and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, in 2 of 5 (Patient #9 and #16) medical records reviewed of patients who were transferred to a higher level of care, each lacked documentation of the benefits and risks of transfer specific to the patient's medical condition. This could lead to patients not being informed of potential risks and benefits related the transfer and untoward patient outcomes. Please reference findings at Tag 2409.

Based on medical record review, document review and interview, in 2 of 5 (Patient #9 and #16) medical records reviewed of patients who were transferred to a higher level of care, each lacked documentation of the benefits and risks of transfer specific to the patient's medical condition. This could lead to patients not being informed of potential risks and benefits related the transfer.

Findings include:

-- Per review of Patient #9's medical record, he presented to the emergency department on 10/29/2023 at 5:35 pm with a chief complaint of a fall from a roof. The provider determined Patient #9 needed to be transferred to a higher level of care for a trauma due to multiple fractures, bilateral fracture of pubic rami, left acetabular fracture, closed fracture of one rib and closed fracture of lumbar vertebra.

The transfer form titled "Consent for Transfer to Hospital," dated 9/9/2016, under the section titled "Risks" contained the following preprinted statement: "All transfers have the inherent risks of unexpected worsening of medical condition, traffic delays, accidents during transport, inclement weather, rough terrain and the limitations of equipment and personnel present in the vehicle. Other ____" (left blank). The section titled "Benefits" contained the following preprinted statement: "higher level of care at receiving facility" (initialed by provider).

There was no documentation regarding the specific risks and benefits of transfer related to the patient's condition.

-- Per review of Patient #16's medical record, she was a three week old infant who was brought to the emergency department on 1/24/2024 at 3:02 pm. The provider determined Patient #16 needed to be transferred to a higher level of care for pediatric specialty care to rule out sepsis, obtain laboratory studies and possible lumbar puncture.

The transfer form titled "Consent for Transfer to Hospital," dated 6/12/2019, under the section titled "Risks" contained the following preprinted statement: "All transfers have the inherent risks of unexpected worsening of medical condition, traffic delays, accidents during transport, inclement weather, rough terrain and the limitations of equipment and personnel present in the vehicle. Other ____ " (left blank). The section titled "Benefits" contained the following preprinted statement: "higher level of care at receiving facility" (initialed by provider).

There was no documentation regarding the specific risks of transfer related to the patient's condition.

-- Review of the hospital's policy and procedure titled "Cobra/EMTALA," revised 5/2022, indicated prior to transfer of a patient the Consent for Hospital Transfer form detailing the risks and benefits of transfer must be completed.

-- Per interview of Staff E, Education Coordinator, on 1/24/2024 at 2:00 pm, transfer documentation should include risks and benefits that are specific to each patient's condition.

-- During interview of Staff A, Emergency Department Director, on 1/24/2024 at 3:30 pm, and other times during the survey, he/she/they acknowledged the above findings.