HospitalInspections.org

Based on record review and interview, the facility staff failed to ensure compliance with 42 CFR 49.24.

Findings include:

The facility failed to appropriately transfer 2 patients (Patient #19, #20). See tag A-2409.

The facility failed to accept a patient (Patient #1) for transfer. See tag A-2411.

Based on record review and interview, the facility staff failed to explain the risks and benefits of transfer to 2 of 4 patients (Patient #19 & Patient #20) transferred in a total universe of 20 medical records reviewed.

Findings include:

Review of facility's policy 3-208 "EMTALA (Emergency Medical Treatment and Labor Act) Policy" dated 07/24/2023 revealed: " ...Determining the appropriate receiving facility must be based on the physician's sound clinical judgment. This requires an assessment of the expected risks and benefits of the transfer but may also include an evaluation of the continuity of care available to the individual, such as system affiliation or other aspects of clinical integration, specialist availability, or other relevant factors. While the proximity of the destination may be considered part of the clinical decision-making process and overall risk assessment, it need not be the determining factor in all cases..."

Review of ED provider meeting minutes dated 07/24/2024 08:00 AM-09:00 AM revealed: " ...EMTALA transfer-if voluntary psych admission to a hospital-put in for discharge, then don't need the EMTALA transfer paperwork. If not voluntary-it's transfer, and need the paperwork ..."

Review of ED (Emergency Department ) staff meeting minutes dated 10/09/2024 revealed: " ...We need to fill out forms (e-form or paper forms/packets) for all patient transfers. This includes involuntary behavioral health transfers, voluntary behavioral health transfers that are medically indicated (i.e. we don't discharge them to go themselves the next day, we are arranging transfer), and medical transfers (i.e. to facility with higher level of care or to different facility per patient desire) ..."

Patient #19 was a 13 year-old who presented to the ED on 04/14/2025 at 4:14 PM following a suicide attempt. Patient #19 was transferred to an inpatient psychiatric facility on 04/14/2025 at 11:30 PM via private vehicle. A review of Patient #19's ED medical record revealed no documented evidence of a physician certification for transfer or that risks and benefits of transfer were discussed.

During an interview on 05/06/2025 at 12:05 PM, the above findings were discussed with and confirmed by ED Manager B.

Patient #20 was a 40 year-old who presented to the Emergency Department (ED) on 05/02/2025 at 12:23 AM for anxiety and suicidal ideation. Patient #20 was transferred to an inpatient psychiatric facility on 05/02/2025 at 6:20 AM via cab. A review of Patient #20's ED medical record revealed no documented evidence of a physician certification for transfer or that risks and benefits of transfer were discussed.

During an interview on 05/06/2025 at 12:05 PM, the above findings were discussed with and confirmed by ED Manager B.

Based on record review and interview, the facility staff failed to accept a patient (Patient #1) for transfer who required a higher level of care even though the hospital had the staff, beds, and specialty care needed in 1 patient reviewed for transfer out of 30 transfer request logs reviewed.

Findings include:

Review of facility's policy 3-1199 "Patient Divert Process" dated 08/07/2023 revealed: " ... [Facility service goal is to be open and accessible for all patients. In unusual cases, the hospital or a service may be at maximum capacity which results in a divert status being activated ...All efforts should be made to continue to accept patients from referral facilities ..."

Review of facility's policy 3-208 "EMTALA (Emergency Medical Treatment and Labor Act) Policy" dated 07/24/2023 revealed: "...A hospital with specialized capabilities or facilities ...or identified regional referral centers, may not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the recipient hospital has the capacity to treat the individual ..."

Patient #1 was a 62 year-old with a history of recent (date unknown) spinal cord stimulator placement at an outside hospital (Hospital #2). Patient #1 presented to another hospital's Emergency Department (ED) (Hospital #1) on 03/28/2025 at 5:53 PM with symptoms of sepsis (severe infection).

Review of Patient #1's ED medical record from Hospital #1 revealed Hospital #2 was initially contacted for a request for transfer. Hospital #2 did not have the capability to accept the patient (no Neurosurgery available) and requested Hospital #1 contact Hospital #3 for transfer. Hospital #3 declined the transfer, and Patient #1 was ultimately transferred to another hospital (Hospital #4) for a higher level of care.

A review of Hospital #3's census for 03/28/2025 revealed 20 available Med-Surg beds and 4 available ICU Intensive Care Unit) beds.

A review of Hospital #3's Neurosurgeon call schedule for 03/01/2025 through 03/31/2025 revealed Neurosurgeon availability all shifts for the entire month.

Review of "MC Cares" (Hospital #3's transfer center) log dated 03/28/2025 at 10:33 PM revealed the following:
9:13 PM: Call made from Hospital #1 to Hospital #3. Bed availability confirmed.
9:40 PM: Neurosurgeon M was paged. 9:44 PM: Neurosurgeon M called MC Cares back. " ...Pt (patient) info given, he is not the original surgeon as well, [Neurosurgeon M] asked for [Patient #1] to be discussed with [different outside hospital] neurosurgeon and hospitalist first."
9:46 PM: Telephone call to Hospital #1 updating them on what Neurosurgeon M stated.
10:04 PM: "TC (telephone call) to [hospital #3] NS (nursing supervisor), updated on declination..."

During an interview on 05/07/2025 at 09:20 AM with Service Line Administrator E, when asked about accepting patients in transfer, Administrator E stated they try and take patients if there is bed capacity, staffing and physician availability and if the patient needs a higher level of care. When asked if those criteria were present with Patient #1, Administrator E stated yes. When asked if there was a reason why Patient #1 was not accepted, Administrator E stated they were not sure, but that Neurosurgeon M had stated he did not feel Patient #1's condition was related to a neurosurgery issue.

During an interview with Neurosurgeon M on 05/07/2025 at 12:20 PM, Neurosurgeon M stated he would have accepted Patient #1 if Hospital #1 had called back and stated that Patient #1 needed a Neurosurgeon.