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Based on interview and record review, the facility failed to ensure an appropriate transfer, for one of 20 sampled patients (Patients 12), when Patient 12 was transferred to another hospital (Hospital B) for further care, and staff did not complete the Emergency Medical Treatment and Active Labor Act (EMTALA- a federal law that requires hospitals participating in Medicare to provide emergency medical treatment to anyone who comes to their emergency department, regardless of their ability to pay or insurance status) transfer form for Patient 12, in accordance with the facility's "Transfer Form" policy and procedure.

This deficient practice had the potential for unsafe and inappropriate transfer. (Refer to A-2409)

Findings:

During a review of Patient 12's "ED (Emergency Department) Triage Note," dated 02/17/2025 at 5:26 a.m., the ED Triage Note indicated the following: Patient 12's Chief complaint was Suicide Ideation (thoughts of causing one's own death) and triage (the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required) assessment with a plan to overdose on pills for two weeks.

During a review of Patient 12's "ED Physician's Note," dated 2/17/2025 at 11:13 a.m., the ED Physician Note indicated the following: Patient 12 was a 57-year-old male and had thoughts of wanting to hurt himself by taking a bunch of pills. Patient 12 was diagnosed with suicide ideation and the medical decision was to find psych (psychiatric, a branch of medicine that specializes in the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) placement for Patient 12. Suicidal precaution orders were in place.

During a review of Patient 12's "ED Physician's Note," dated 2/17/2025 at 11:46 a.m., the ED Physician Note indicated the following: patient (Patient 12) with pending placement for suicidal ideation. Patient (Patient 12) agreeable with plan to be transferred to a psychiatric facility.

During a review of Patient 12's "ED Discharge Note," dated 2/17/2025 at 3:48 p.m., the ED Discharge Note indicated the following: Patient 12 was transferred to a mental health facility.

During an interview on 5/02/2025 at 10:32 a.m. with the Emergency Department Manager (EDM), the EDM stated the following: Patient 12 was transferred to a psych facility for further care and that the Emergency Medical Treatment and Active Labor Act (EMTALA) transfer form (which indicated information regarding Reasons for Transfer including Risk and Benefits of Transfer) for patient 12 was not completed. There was no signature indicating patient (Patient 12) consented for transfer nor was there a signature from the physician certifying the transfer of the patient. The EMTALA transfer form should have been completed by the staff to ensure patient was safely transferred to another facility. The EMTALA transfer form ensures patient was transferred to a different facility appropriately, and all necessary patient information was provided to both patient and to the receiving facility. The EDM also confirmed that the EMTALA Check off list was not done and should have been completed by the charge nurse prior to transferring Patient 12 to make sure all necessary requirements were completed prior to transferring patient to another facility. The EDM said that regardless of whether patients were going to a psych facility voluntarily or to any other facility, the staff still needed to complete the EMTALA transfer form. The EDM further stated, the facility will educate staff on the importance of completing the EMTALA transfer form and the EMTALA checklist.

During an interview on 5/02/2025 at 2:11 p.m. with the Emergency Department Director (EDD), the EDD stated the following: Confirmed no EMTALA Transfer form was completed for Patient 12. EDD will educate staff on completing EMTALA Transfer form to ensure appropriate patient transfer to another facility.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Treatment and Labor Act (EMTALA) Policy," dated 12/11/2024, the P&P indicated the following: Policy: It is the policy of [Name of Facility] to comply with emergency medical care and labor act (EMTALA) obligations. Procedure: 4. Treatment, Discharge or Transfer of Stabilized Individual. The medical screen exam is complete and the physician or the qualified medical person determines that the individual does not have an emergency medical condition or the emergency medical condition has been stabilized the individual may be (i) treated; (ii) discharge as clinically appropriate and the individual is given a reasonable plan for appropriate follow up care or discharge instructions; or (iii) transfer for continued care in accordance with appropriate transfer procedures.

During a review of facility's policy and procedure (P&P) titled, "Transfers Into and Out of the Facility Policy," dated 8/2024, the P&P indicated the following: Purpose: to provide optimal patient care before, during, and after transfer from [Name of the Facility]. Policy: staff members will follow EMTALA guidelines when transferring a patient to another facility for evaluation diagnostic testing or treatment. Procedure: Guidelines for adult patient transfer out of the facility. Patients may try may occasionally need to be transferred to another facility for the purposes of further evaluation or treatment. Some circumstances may include: A. necessary specialist is unavailable to provide definitive care. B. A physician's request for specialty service slash consultation is not available at CHMC. C. Diagnostic testing or medical equipment is not available. D. Patient needs skilled nursing care. E. The facility does not have the capability at the time of transfer to provide special life service for the required individual procedure. Before a patient transferred to another facility can be initiated the following must be placed. A. An order from the attending physician for the patient transfer. B. Completion of "Interfacility Transfer Consent/Physician Certification" for SNF transfers or 'Transfer Form' For all other transfers out.

Based on interview and record review the facility failed to ensure an appropriate transfer, for one of 20 sampled patients (Patients 12), when Patient 12 was transferred to another hospital (Hospital B) for further care, and staff did not complete the Emergency Medical Treatment and Active Labor Act (EMTALA- a federal law that requires hospitals participating in Medicare to provide emergency medical treatment to anyone who comes to their emergency department, regardless of their ability to pay or insurance status) transfer form for Patient 12, in accordance with the facility's "Transfer Form" policy and procedure.

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

Findings:

During a review of Patient 12's "ED (Emergency Department) Triage Note," dated 02/17/2025 at 5:26 a.m., the ED Triage Note indicated the following: Patient 12's Chief complaint was Suicide Ideation (thoughts of causing one's own death) and triage (the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required) assessment with a plan to overdose on pills for two weeks.

During a review of Patient 12's "ED Physician's Note," dated 2/17/2025 at 11:13 a.m., the ED Physician Note indicated the following: Patient 12 was a 57-year-old male and had thoughts of wanting to hurt himself by taking a bunch of pills. Patient 12 was diagnosed with suicide ideation and the medical decision was to find psych (psychiatric, a branch of medicine that specializes in the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) placement for Patient 12. Suicidal precaution orders were in place.

During a review of Patient 12's "ED Physician's Note," dated 2/17/2025 at 11:46 a.m., the ED Physician Note indicated the following: patient (Patient 12) with pending placement for suicidal ideation. Patient (Patient 12) agreeable with plan to be transferred to a psychiatric facility.

During a review of Patient 12' patients "ED Discharge Note," dated 2/17/2025 at 3:48 p.m., the ED Discharge Note indicated the following: Patient 12 was transferred to a mental health facility.

During an interview on 5/02/2025 at 10:32 a.m. with the Emergency Department Manager (EDM), the EDM stated the following: Patient 12 was transferred to a psych facility for further care and that the Emergency Medical Treatment and Active Labor Act (EMTALA) transfer form (which indicated information regarding Reasons for Transfer including Risk and Benefits of Transfer) for patient 12 was not completed. There was no signature indicating patient (Patient 12) consented for transfer nor was there a signature from the physician certifying the transfer of the patient. The EMTALA transfer form should have been completed by the staff to ensure patient was safely transferred to another facility. The EMTALA transfer form ensures patient was transferred to a different facility appropriately, and all necessary patient information was provided to both patient and to the receiving facility. The EDM also confirmed that the EMTALA Check off list was not done and should have been completed by the charge nurse prior to transferring Patient 12 to make sure all necessary requirements were completed prior to transferring patient to another facility. The EDM said that regardless of whether patients were going to a psych facility voluntarily or to any other facility, the staff still needed to complete the EMTALA transfer form. The EDM further stated, the facility will educate staff on the importance of completing the EMTALA transfer form and the EMTALA checklist.

During an interview on 5/02/2025 at 2:11 p.m. with Emergency Department Director (EDD), the EDD stated the following: Confirmed no EMTALA Transfer form was completed for Patient 12. EDD will educate staff on completing EMTALA Transfer form to ensure appropriate patient transfer to another facility.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Treatment and Labor Act (EMTALA) Policy," dated 12/11/2024, the P&P indicated the following: Policy: It is the policy of [Name of Facility] to comply with emergency medical care and labor act (EMTALA) obligations. Procedure: 4. Treatment, Discharge or Transfer of Stabilized Individual. The medical screen exam is complete and the physician or the qualified medical person determines that the individual does not have an emergency medical condition or the emergency medical condition has been stabilized the individual may be (i) treated; (ii) discharge as clinically appropriate and the individual is given a reasonable plan for appropriate follow up care or discharge instructions; or (iii) transfer for continued care in accordance with appropriate transfer procedures.

During a review of facility's policy and procedure (P&P) titled, "Transfers Into and Out of the Facility Policy," dated 8/2024, the P&P indicated the following: Purpose: to provide optimal patient care before, during, and after transfer from [Name of the Facility]. Policy: staff members will follow EMTALA guidelines when transferring a patient to another facility for evaluation diagnostic testing or treatment. Procedure: Guidelines for adult patient transfer out of the facility. Patients may try may occasionally need to be transferred to another facility for the purposes of further evaluation or treatment. Some circumstances may include: A. necessary specialist is unavailable to provide definitive care. B. A physician's request for specialty service slash consultation is not available at CHMC. C. Diagnostic testing or medical equipment is not available. D. Patient needs skilled nursing care. E. The facility does not have the capability at the time of transfer to provide special life service for the required individual procedure. Before a patient transferred to another facility can be initiated the following must be placed. A. An order from the attending physician for the patient transfer. B. Completion of "Interfacility Transfer Consent/Physician Certification" for SNF transfers or 'Transfer Form' For all other transfers out.