HospitalInspections.org

Based on interview and record review, the facility failed to ensure an appropriate transfer for one (1) of 22 sampled patients (Patient 4) when Patient 4 was transferred to another hospital (Hospital B) for further care and the Emergency Medical Treatment and Labor Act (EMTALA, a federal law that requires anyone coming to an emergency department to be treated and stabilized, regardless of their insurance status or ability to pay) form was not fully completed, in accordance with the facility's policy regarding patient transfer to another facility.


This deficient practice had the potential for unsafe and inappropriate transfer.

Findings:

During a review of Patient 4's "Patient Care Timeline," dated 1/12/2025 at 4:45 a.m., the Patient Care Timeline indicated Patient 4 presented to the emergency department (ED) with a chief complaint of chest pain.

During a review of Patient 4's "ED Provider Note," dated 1/12/2025 at 4:55 a.m., the ED Provider Note indicated that Patient 4 reported sudden onset of chest discomfort about one hour prior to arrival in the ED, along with nausea (stomach discomfort), vomiting (throwing up), and diaphoresis (sweating). An electrocardiogram (EKG, a non-invasive test that records the electrical activity of the heart) was done which showed "ST elevations in inferior leads with precordial reciprocal changes (abnormal electrical activity of the heart that signals a heart attack)," and Patient 4 was diagnosed with STEMI (ST-elevation myocardial infarction, a severe type of heart attack that requires immediate medical intervention and is diagnosed through abnormal electrical activity of the heart).

During a review of Patient 4's "Patient Care Timeline," dated 1/12/2025 at 5:35 a.m., the Patient Care Timeline indicated Patient 4 was transferred to Hospital B.

During an interview on 7/9/2025 at 9:55 a.m. with the Director of Accreditation, Regulatory, and Licensing (DARL), the DARL confirmed that the facility did not have a cath lab (cardiac catheterization lab, a specialized area of a hospital that is equipped for performing procedures on the heart using a catheter [a thin flexible tube]) so any patients requiring cardiac catheterization (a type of procedure where a catheter is used to diagnose or treat heart problems such as heart attacks) must be transferred out.

During a concurrent interview and record review on 7/9/2025 at 11:40 a.m. with Quality Coordinator (QC) 2, Patient 4's "Interhospital Transfer Summary," was reviewed. The Interhospital Transfer Summary indicated Patient 4 was transferred to Hospital B due to STEMI. "Section III" of the Interhospital Transfer Summary titled, "Physician Certification," indicated the transferring physician needed to check a box indicating whether or not Patient 4 was stable or unstable for transfer, and if he was unstable, then the physician needed to indicate why the benefits of transferring outweighed the risks. However, there was no mark indicating either "Stable for Transfer" or "Unstable for Transfer" that was checked. QC 2 confirmed that this section was not filled out and stated the physician should have filled this section out to certify (declare) if the patient was stable for transfer or to certify that the benefits of transferring an unstable patient outweighed the risks of not transferring them.

During a review of the facility's policy and procedure (P&P) titled, "ST Elevation Myocardial Infarction (STEMI) Transfer Protocol," last revised 8/2023, the P&P indicated, "Patients who present to [name of the facility] ED with STEMI findings on their EKG may be transferred to a Higher Level of Care with Cath Lab for definitive treatment if clinically stable and safe to transport. ... Complete the transfer summary sheet as per transfer protocol."

During a review of the facility's policy and procedure (P&P) titled, "Transfer of a Patient to Another Facility," last revised 8/2023, the P&P indicated, "If the Physician determines, through his/her evaluation and hospital policy, that the patient should be transferred to another facility for further care, EMTALA standards must be followed: ... Transfer Forms must be completed: A. Interhospital Transfer Summary."

During a review of the facility's policy and procedure (P&P) titled, "EMTALA/Emergency Medical Screening, Examination, Treatment, and Transfer - NTL," effective date 4/23/2024, the P&P indicated, "It is the policy of [name of the facility] to comply with the Emergency Medical Treatment and Labor Act (EMTALA) obligations applicable to hospitals with a dedicated emergency department. ... The transferring physician will complete the transfer form certifying that: ... For unstable patients, the medical benefits of receiving treatment at another facility outweigh the risks to the individual (and, if pregnant, the unborn child) from effecting the transfer, or ... For stabilized patients, within reasonable medical probability, the transfer creates no medical hazard to the individual."

Based on interview and record review, the facility failed to ensure an appropriate transfer for one (1) of 22 sampled patients (Patient 4) when Patient 4 was transferred to another hospital (Hospital B) for further care and the Emergency Medical Treatment and Labor Act (EMTALA, a federal law that requires anyone coming to an emergency department to be treated and stabilized, regardless of their insurance status or ability to pay) form was not fully completed, in accordance with the facility's policy regarding patient transfer to another facility.

This deficient practice had the potential for unsafe and inappropriate transfer.

Findings:

During a review of Patient 4's "Patient Care Timeline," dated 1/12/2025 at 4:45 a.m., the Patient Care Timeline indicated Patient 4 presented to the emergency department (ED) with a chief complaint of chest pain.

During a review of Patient 4's "ED Provider Note," dated 1/12/2025 at 4:55 a.m., the ED Provider Note indicated that Patient 4 reported sudden onset of chest discomfort about one hour prior to arrival in the ED, along with nausea (stomach discomfort), vomiting (throwing up), and diaphoresis (sweating). An electrocardiogram (EKG, a non-invasive test that records the electrical activity of the heart) was done which showed "ST elevations in inferior leads with precordial reciprocal changes (abnormal electrical activity of the heart that signals a heart attack)," and Patient 4 was diagnosed with STEMI (ST-elevation myocardial infarction, a severe type of heart attack that requires immediate medical intervention and is diagnosed through abnormal electrical activity of the heart).

During a review of Patient 4's "Patient Care Timeline," dated 1/12/2025 at 5:35 a.m., the Patient Care Timeline indicated Patient 4 was transferred to Hospital B.

During an interview on 7/9/2025 at 9:55 a.m. with the Director of Accreditation, Regulatory, and Licensing (DARL), the DARL confirmed that the facility did not have a cath lab (cardiac catheterization lab, a specialized area of a hospital that is equipped for performing procedures on the heart using a catheter [a thin flexible tube]) so any patients requiring cardiac catheterization (a type of procedure where a catheter is used to diagnose or treat heart problems such as heart attacks) must be transferred out.

During a concurrent interview and record review on 7/9/2025 at 11:40 a.m. with Quality Coordinator (QC) 2, Patient 4's "Interhospital Transfer Summary," was reviewed. The Interhospital Transfer Summary indicated Patient 4 was transferred to Hospital B due to STEMI. "Section III" of the Interhospital Transfer Summary titled, "Physician Certification," indicated the transferring physician needed to check a box indicating whether or not Patient 4 was stable or unstable for transfer, and if he was unstable, then the physician needed to indicate why the benefits of transferring outweighed the risks. However, there was no mark indicating either "Stable for Transfer" or "Unstable for Transfer" that was checked. QC 2 confirmed that this section was not filled out and stated the physician should have filled this section out to certify (declare) if the patient was stable for transfer or to certify that the benefits of transferring an unstable patient outweighed the risks of not transferring them.

During a review of the facility's policy and procedure (P&P) titled, "ST Elevation Myocardial Infarction (STEMI) Transfer Protocol," last revised 8/2023, the P&P indicated, "Patients who present to [name of the facility] ED with STEMI findings on their EKG may be transferred to a Higher Level of Care with Cath Lab for definitive treatment if clinically stable and safe to transport. ... Complete the transfer summary sheet as per transfer protocol."

During a review of the facility's policy and procedure (P&P) titled, "Transfer of a Patient to Another Facility," last revised 8/2023, the P&P indicated, "If the Physician determines, through his/her evaluation and hospital policy, that the patient should be transferred to another facility for further care, EMTALA standards must be followed: ... Transfer Forms must be completed: A. Interhospital Transfer Summary."

During a review of the facility's policy and procedure (P&P) titled, "EMTALA/Emergency Medical Screening, Examination, Treatment, and Transfer - NTL," effective date 4/23/2024, the P&P indicated, "It is the policy of [name of the facility] to comply with the Emergency Medical Treatment and Labor Act (EMTALA) obligations applicable to hospitals with a dedicated emergency department. ... The transferring physician will complete the transfer form certifying that: ... For unstable patients, the medical benefits of receiving treatment at another facility outweigh the risks to the individual (and, if pregnant, the unborn child) from effecting the transfer, or ... For stabilized patients, within reasonable medical probability, the transfer creates no medical hazard to the individual."