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Based on clinical record review, staff interview and facility document review, it was determined that the facility failed to comply with §489.24 by conducting an inappropriate transfer of a patient presenting to the emergency department with an emergency medical condition (A-2409).

The findings include:

See Tag A-2409
Based on clinical record review, staff interview and facility document review, it was determined the facility failed to conduct an appropriate EMTALA transfer for one (1) of twenty (20) patients sampled.

Based on clinical record review, staff interview and facility document review, it was determined the facility failed to conduct an appropriate EMTALA transfer for one (1) of twenty (20) patients sampled.

Findings:

A surveyor review of the medical record for Patient (P)4, along with other facility provided documentation, failed to contain evidence of the following as per the facility's policy for EMTALA transfers:

There was no documented evidence that the RN: contacted the Nurse Manager/Director/House Supervisor/Designee of pending EMTALA transfer as appropriate; collaborated with emergency department social worker and/or Behavioral Health Access Team Members to initiate contact with potential receiving facility ensuring requirements are met for transfer; contacted the Charge Nurse/Nurse Manager/Director/House supervisor to facilitate transfers to acute care facilities as appropriate; or contacted Charge Nurse/Nurse Manager/Director/House Supervisor/designee to review documentation prior to the transfer.

There was no documentation that the Nurse Manager/Director/House Supervisor/Designee and Birthing Care/BH Director/Manager Designee: facilitated the outbound EMTALA transfer by reviewing outbound EMTALA documentation... confirm compliance with policy requirements including confirmation with transporting of personnel of correct patient and correct destination; and if there was a concern about the outbound EMTALA transfer, enact the chain of command and, as soon as practicable, contact the Corporate Compliance Department.

During an interview on 3/7/2023 at 10:39 a.m., Staff Member (SM) 4 confirmed there was no documentation related to nursing supervisor ' s communication with the receiving facility or of the nursing supervisor facilitating the patient ' s transfer. SM 4 showed the surveyors a paper ED transfer log that contained the documentation that Patient #4 was transferred to medical/surgical bed nineteen (19) at the receiving hospital. The patient was a direct admission to inpatient and did not go to the receiving facility's emergency department. SM4 verbalized that the nursing supervisor at the receiving facility was notified by "a provider" that a patient was coming, but there was no documented evidence of this notification. SM4 showed documentation that the report was called to a nurse on the receiving hospital's medical/surgical unit.

A review of the facility's policy titled "EMTALA - Emergency Medical Treatment & Active Labor Act" last revised/reviewed Effective Date: June 2020 states in part:
... b) RN Responsibilities:
1) Contacts the Nurse Manager/Director/House Supervisor/Designee of pending EMTALA transfer as appropriate.
2) Collaborates with emergency department social worker and/or Behavioral Health Access Team Members to initiate contact with potential receiving facility ensuring requirements are met for transfer.
6) Contacts the Charge Nurse/Nurse Manager/Director/House supervisor to facilitate transfers to acute care facilities as appropriate ...
7) Contacts Charge Nurse/Nurse Manager/Director/House Supervisor/designee to review documentation prior to the transfer.
c) Nurse Manager/Director/House Supervisor/Designee and Birthing Care/BH Director/Manager Designee Responsibilities:
1) Facilitates all outbound EMTALA transfers by reviewing outbound EMTALA documentation.
... confirm compliance with policy requirements including confirmation with transporting of personnel of
(a) Correct patient; and
(b) Correct destination.
3) if there is a concern about an outbound EMTALA transfer, enacts the chain of command and, as soon as practicable, contacts the Corporate Compliance Department ....