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Based on interview and record review the hospital's dedicated emergency department (ED) failed to comply with the requirements for the Emergency Medical Treatment and Labor Act (EMTALA) at 42 CFR §489.20. (Patient identifiers are #1, #2, and #8.)

Findings include:

The hospital failed to provide a medical screening examination to 1 of 20 patients reviewed who arrived to the hospital campus ED. (Patient identifier is #2). Refer to TAG 2406.

The hospital failed to complete appropriate transfers for 2 of 20 patients reviewed who were transferred from the ED to other hospitals. (Patient identifiers are #1 and #8.) Refer to TAG 2409.


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Based on record review and interview, the hospital failed to provide an appropriate medical screening examination (MSE) to 1 of 3 individuals who presented to the emergency department (ED). (Patient identifiers is #2.)

Findings include:

Patient #2

Review on 4/9/24 at approximately 11:30 a.m. of Patient #2's medical record revealed they arrived at the dedicated ED via police vehicle on 3/18/24 at approximately 4:42 p.m. with a petition to have a compulsary medical examination done evaluation at a different hospital. The patient left with the police without receiving a MSE to go to a different hopsital for evaluation.

Review on 4/9/24 of the hospital policy titled "Patient Transfer Policy" dated "5/2023" revealed the following"
"A. Transfers 1. All patients presenting to [Pronoun omitted] for treatment shall have an appropriate medical screening examination by qualified personnel."...4. The transferring physician shall explain and document the need, benefits, risks, and alternatives regarding transfer to the patient or person acting on the patient's behalf... ". No patient will be transferred to another acute care facility until the attending physician has made arrangements with the facility. Contact with and acceptance by a physician at the receiving facility will be confirmed prior to transfer...8. Patients who come or are brought to the hospital for psychiatric evaluation must be screened for an EMC. If no emergency medical condition is determined to exist, but Involuntary Emergency Admission (IEA) to a designated receiving facility is deemed necessary due to a psychiatric condition, then a physician's certification of transfer must be completed...10. Review all sections of [Pronoun omitted] transfer form["Cobra form"] to ensure that all proper areas are completed and all required signature(s) are present. "

Interview with Staff H (Quality Director) and Staff I (Chief Nursing Officer) on 4/9/24 at approximately 2:30 p.m. confirmed the above findings.

Based on interview and record review, it was determined that the hospital failed to appropriately transfer patients after determining if a patient had an emergency medical condition and the recieving hospital agreed to accept the patient for 2 of 20 patients reviewed presenting to the emergency department (ED). (Patient #1 and #8.)

Findings include:

Patient #1

Review on 4/9/24 of the facility's ED Patient Log for Patient #1 revealed that the arrival time to the ED was on 2/29/24 at 3:29 p.m. and discharged at 4:45 p.m. Further review revealed the log was coded "Transferred".

Review on 4/9/24 of Patient #1's medical record revealed that Patient #1 arrived to the emergency room on 2/29/24 with visual disturbance, right facial numbness/drooping, and the inability to focus. Further review revealed that Patient #1 was transported via 911 to another local hospital on 2/29/24 at 4:45 p.m. There was no documentation of communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer or summary of the risks and benefits of transfer. There was no documentation that the hospital sent medical records related to the emergency condition to the receiving hospital.

Review on 4/9/24 of Patient #1's Medical Screening Exam, completed by Staff A (Physician's Assistant) and co-signed by Staff B (Medical Doctor), dated 2/29/24 revealed under Emergency Department Course/Medical Decision Making, "... Following transport, I contacted the [Receiving Hospital] emergency department and advised the charge nurse of the patient's impending arrival..

Interview on 4/9/24 at approximately at approximately 1:00 p.m. with Staff J (ED Clinical Director) confirmed the above findings.

Interview on 4/9/24 at 2:18 p.m. with Staff G (Quality Staff) confirmed that the transfer paperwork was not completed and that Staff A contacted the receiving hospital after the patient had left the facility.

Patient #8

Review on 4/9/24 of the facility's ED Patient Log for Patient #8 revealed that the arrival time to the ED was 4/3/24 at 2:57 a.m. Further review revealed the log was coded "Transfer".

Review on 4/9/24 of Patient #8's ED notes revealed that the patient arrived on 4/3/24 to the ED via private car for suicidal complaints.

Review on 4/9/24 of the Transfer Certification Notice of Hospital Responsibilities revealed the physician failed to sign the certification or summarize the risks and benefit of the transfer.

Interview on 4/9/24 at approximately at approximately 1:00 p.m. with Staff J (ED Clinical Director) confirmed the above.

Review on 4/9/24 of the hospital policy titled "Patient Transfer Policy" last revised 5/23 revealed the following, "... External Acute Transfers... 1. All patients presenting to... Community Hospital for treatment shall have an appropriate medical screening examination by qualified personnel."... 3.... The physician will certify that this decision is based on information available at the time of transfer... If the physician is not readily available, the certificate may be completed by a qualified medical person in consultation with the physician. The physician, however, makes the transfer determination and countersigns the certificate within 24 hours... 4. The transferring physician shall explain and document the need, benefits, risks, and alternatives regarding transfer to the patient or person acting on the patient's behalf... 5. No patient will be transferred to another acute care facility until the attending physician has made arrangements with the facility. Contact with and acceptance by a physician at the receiving facility will be confirmed prior to transfer... 8. Patients who come or are brought to the hospital for psychiatric evaluation must be screened for an EMC. If no emergency medical condition is determined to exist, but Involuntary Emergency Admission (IEA) to a designated receiving facility is deemed necessary due to a psychiatric condition, then a physician's certification of transfer must be completed...10. Review all sections of... Hospital transfer form["Cobra form"] to ensure that all proper areas are completed and all required signature(s) are present... "