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Based record review, policy review and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer (A2409).

Based on medical record review, policy review, and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer for five of five medical records of transferred patients reviewed (Patient#13, #14, #15, #16, and #17). A total of 20 medical records were reviewed. The hospital registered an average daily census in the emergency department of 162 patients in the preceding six months prior to the survey.

Findings include:

1. Review of the medical record for Patient #13 revealed an arrival date of 05/12/21 at 6:39 PM to the emergency department. The medical record contained documentation the patient was depressed, having violent outbursts, and threatening to kill family members in their sleep. The medical record contained documentation the patient was transferred to a psychiatric facility on 05/13/21 at 11:29 AM. The transfer document signed by the physician lacked documentation of a summary of the risks and benefits of the transfer.

2. Review of the medical record for Patient #14 revealed an arrival date of 07/29/21 at 6:55 PM to the emergency department. The medical record contained documentation the patient was having seizures and requested to be transferred to another facility where his/her physician had privileges. The medical record contained documentation the patient was transferred to another acute care facility on 07/30/21 at 11:18 AM. The transfer document signed by the physician lacked documentation of a summary of the risks and benefits of the transfer.

3. Review of the medical record for Patient #15 revealed an arrival date of 06/17/21 at 12:49 AM to the emergency department from another facility's emergency department. The medical record contained documentation the patient was suicidal and an order for a medical hold (involuntary admission) was dated 06/16/21 at 10:07 PM. The medical record contained documentation the patient was transferred to a psychiatric facility on 06/17/21 at 9:44 AM. The transfer document signed by the physician lacked documentation of a summary of the risks and benefits of the transfer.

4. Review of the medical record for Patient #16 revealed an arrival date of 08/14/21 at 10:36 PM to the emergency department. The medical record contained documentation the patient was suicidal and an order for a medical hold (involuntary admission) was dated 08/16/21 at 1:52 AM. The medical record contained documentation the patient was transferred to a psychiatric facility on 08/16/21 at 2:37 AM. The transfer document signed by the physician lacked documentation of a summary of the risks and benefits of the transfer.

5. Review of the medical record for Patient #17 revealed an arrival date of 09/08/21 at 1:39 PM to the emergency department. The medical record contained documentation the patient was having dizziness and chest pain. The medical record contained documentation the patient was an inmate and needed admission to a facility with an inmate unit. The medical record contained documentation the patient was transferred to another acute care facility on 09/08/21 at 11:13 PM. The transfer document signed by the physician lacked documentation of a summary of the risks and benefits of the transfer.

Review of the policy titled, "Compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA)," effective 04/30/21, revealed "A physician must sign a written certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from treatment at the receiving Hospital outweigh the increased risks of being transferred. The certification must also include a written summary of the risks and benefits upon which the decision is based and state the reason for transfer."

In an interview on 10/12/21 at 9:20 AM, Staff A and C stated the EMTALA documentation of risks and benefits of transfer were documented as a Yes or No from a drop down menu in the electronic medical record that the benefits outweighed the risk. The electronic medical record did not cue the physician to enter a list of reasons. The physician indicates the risks and benefits were discussed with the patient and/or family by signing the transfer form.