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Based on interview and record review, the hospital failed to implement their policy to ensure six of 20 sampled patients (Patients 1,2,3,5,8 and 14) were explained the risks and benefits prior to transfering to another facility. This failure had the potential to result in adverse health outcomes to the patients

Findings:

1. Review of the Emergency Department (ED) Log indicated Patient 1 presented to the ED on 3/21/2022 at 12:39 PM, with suicidal ideation (SI- suicidal thoughts), chest pain, and responding to internal stimuli. Further review of the record indicated that Medical Doctor (MD) 1 determined Patient 1 was on an involuntary hold and would need to be transferred to another hospital for further psychiatric evaluation and treatment.

Review of the Interfacility Transfer form, completed by MD 2 on 3/22/2022 at 2 AM, indicated the reason for the transfer of Patient 1 was not documented on the transfer form. The risks and benefits of the transfer were not documented. The form did not include a signature by the patient or patient's representative indicating they understood the risks and benefits and agreed to the transfer. Facility staff (FS 1) verified the finding during the record review.

During an interview with MD 2 on 3/30/2022 at 2:13 PM, MD 2 stated she did not explain the risks and benefits of the transfer to Patient 1 or the patient's family.

2. Review of the ED Log indicated Patient 2, who is a minor (under the legal age of consent), presented to the ED on 3/28/22 at 2:25 PM, with SI and self-harming behaviors.

A review of Patient 2's medical record indicated the Interfacility Transfer form was signed by MD 3 on 3/29/2022 at 12 AM. There was no documentation in the patient's medical record which indicated the risks and benefits of the transfer were discussed with the patient's guardian. FS 1 verified the finding during the record review.

3. Review of the ED log indicated Patient 3 presented to the ED on 3/20/2022 at 11:42 AM, with complaints of dizziness and weakness. Further review of the medical record indicated, on 3/20/2022 at 4:35 PM, MD 4 documented the patient would be transferred to another hospital for inpatient admission. There was no documentation the risks and benefits of transfer were discussed with Patient 3 or the patient's representative. FS 1 verified the finding during the record review.

4. Review of the ED log indicated Patient 5 presented to the ED on 10/29/2021 at 11:39 PM, with paranoid (Mental disorder condition)behaviors. Further review of the medical record indicated, on 10/30/2021 at 2:18 PM, MD 1 documented Patient 5 was on an involuntary hold and would be transferred to another hospital for inpatient psychiatric admission. There was no documentation in the record which indicated the risks and benefits of the transfer were discussed with Patient 5 or the patient's representative. FS 1 verified the finding during the record review.

5. Review of the ED Log indicated Patient 8 presented to the ED on 2/8/22 at 4:17 AM, with SI. Further review of the medical record indicated, on 2/8/2022 at 11:23 AM, MD 3 documented Patient 8 was on an involuntary hold and would be transferred to another hospital for inpatient psychiatric admission. There was no documentation in the record which indicated the risks and benefits of the transfer were discussed with Patient 8 or patient's representative. FS 1 verified the finding during the record review.

6. A review of Patient 14's clinical record, the "Triage Report," (a procedure used to prioritize emergency care and identify patients who need immediate medical attention) indicated, Patient 14 presented to the ED on 1/11/2022 at 10:05 AM, with a chief complaint (the patient's reported reason for seeking medical care) of a mental breakdown.

A review of Patient 14's, "Interfacility Transfer form," dated, 1/11/2022, indicated, Patient 14 was transferred to another hospital for inpatient psychiatric admission. The risks of transferring Patient 14 were not documented.

During an interview with the Clinical Quality Coordinator/Navigator-Behavior Health (CQC), on 3/30/2022 at 9:42 AM, she confirmed Patient 14's Interfacility Transfer form was incomplete.

During an interview with the ED Medical Director, MD 5, on 3/30/2022 at 10:24 AM, MD 5 stated the ED physician is responsible for explaining the risks and benefits of the transfer to the patient and if the patient is unable to participate, it should be discussed with the family. MD 5 stated he expected the Interfacility Transfer form to be fully completed as it was a required piece of documentation and demonstrated the physician has certified the transfer.

The hospital's policy titled, EMTALA, dated 9/2001, indicated " ... Transfer of Patients with an Emergency Medical Condition. [Hospital] may not transfer any patient with an un-stabilized emergency medical condition ... unless the patient requests the transfer, or a physician certified that the medical benefits reasonably expect from the provision of treatment at the receiving facility outweigh the risk to the patient from the transfer ... [Hospital] sends the receiving facility ... the patient's informed written consent to transfer ..."