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Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to identify a patient as unstable before transfer for 1 patient (P-1) of 20 patients reviewed, resulting in the potential for unrecognized needs for all unstable patients requiring transfer. Findings include:

See tag 2409: Failure to properly transfer.

Based on record review, the facility failed to identify 1 (P-1) of 20 emergency department patients reviewed as having an unstabilized emergency medical condition (EMC) before transfer to a receiving facility, resulting in the failure to identify a patient as unstable and the potential for misunderstanding of the seriousness of the patient's EMC. Findings include:

Review of P-1's medical record dated 07-13-2023 revealed that P-1 was a 54-year-old male who presented to facility A with chest pain and left leg pain/weakness with an onset immediately after feeling a sudden pop in his back. A computed tomographic angiography (CTA) scan showed type A dissection from the aortic root through the right iliac artery. Plan was for the patient to have emergent surgical repair of the dissection at the facility of concern (facility B). However, the vascular surgeon at facility B had to attend to his current surgical case who unexpectedly became acutely ill during surgery, leaving the vascular surgeon unavailable. P-1 was transferred to another facility in critical condition.
The required stabilization for an aortic dissection is surgical repair. Since surgery was not available at facility B, the aortic dissection was not stabilized prior to the transfer of P-1 to receiving facility C. Material deterioration of type A dissection is not only reasonably medically probable without surgical repair; it is fully expected.

Record review of facility B's document titled "Emergency Transfer Record" dated 07/13/2023 for P-1 revealed under Section A, 2. "I hereby certify that the patient's emergency medical condition has been stabilized such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result or occur during transfer ...Physician signature on the form dated and timed 07/13/2023 at 1745. The transfer record from facility B erroneously reported the patient as stable.

Review of policy "Patients-Screening, Stabilization and Transfer" dated 11/21 revealed under Definitions ...5. Emergency Medial Condition: A medical condition manifesting itself by acute symptoms of sufficient severity ...such that the absence of immediate medical attention could reasonably be expected to result in placing the health of an individual ...in serious jeopardy ... 10. Stabilized: A patient with an Emergency Medical Condition is considered stabilized such that the Hospital may effectuate a transfer ...if the treating physician attending to the individual determines with reasonable clinical confidence that the Emergency Medical Condition is resolved and/or no material deterioration of the individual's condition is likely to result from or occur during transfer of the individual ...Main Campus Procedure. 2.B. (4) The receiving facility is provided with relevant records ...including; (b) applicable transfer forms, including the Emergency Transfer Record ...