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Based on document review and interview, the facility failed to ensure a physician certification of the risks and benefits of patient transfer to a facility with additional treatment capabilities was completed (see tag 2409) and failed to ensure copies of all medical records related to the presenting EMC (Emergency Medical Condition) were sent with the patient to the receiving facility (see tag 2409).

Findings include:

1. See findings cited at 489.24(e)(1)(ii)(B) and 489.24(e)(2)(iii) A2409.

Based on document review and interview, the facility failed to ensure a physician certified the benefits and risks of patient transfer and obtained the written patient consent to transfer for Emergency Department (ED) patients transferring to an accepting facility for 4 of 20 medical records (MR) reviewed (Patients #1, 5, 6 & 8) and failed to ensure copies of all medical records related to the presenting EMC (Emergency Medical Condition) were sent with the patient to the receiving facility for 1 of 20 MR reviewed (Patient #5).

Findings include:

1. Review of the policy/procedure Emergency Medical Treatment and Patient Transfer - EMTALA (revised 9-13) indicated the following: "Appropriate transfer occurs when 1) the transferring hospital provides medical treatment within its capacity and capability that minimizes risks to the individual's health...[and]...3) the transferring hospital sends to the receiving hospital all medical records (or copies thereof) related to the Emergency Medical Condition, including...treatment provided and the informed written consent of certification required..."

2. Review of the policy/procedure Transition of Care (TOC), Continuity of Care Document (CCD) - Transfer to Another Facility and Patient Discharge (revised 6-19) indicated the following: "V. Transferring Patient to Another Facility or Hospital...G...If patient is being transported by stretcher/ambulance, have physician complete "Patient Transfer Form" (Emprint ER-3401-2) (aka Physician Certification Statement)..."

3. Review of the document titled Patient Transfer Form ER-3401-2 (revised 10-19) indicated the following: "To Be Utilized for All Patient Transfers - Emergency and Non-Emergency Complete Sections A and B for All Patient Transfers. Complete Section C Only for Emergency Transfers...Section A...1. Appropriate medical records of the examination and treatment of the patient provided to the receiving facility at the time of transfer...Section B...Risks related to transfer acknowledgement...I acknowledge I have been informed of the above and agree to transfer by the mode determined by the physician...[and]...I have been informed by the physician that the medical benefits of transfer outweigh the risks...[followed by a blank space for a signature of the patient or patient's representative and date & time when signed]...Section C Additional Physician Documentation To Be Completed For Transfers From the Emergency Department and Labor & Delivery...Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated...Check only one...The patient is being transferred because of failure, refusal, or inability of an on-call physician to respond...I certify that the medical benefits expected from the provision of appropriate medical care at another facility outweigh the increased risks to the individual...[followed by a blank space for the signature of the Transferring Physician]..."

4. Review of the MR for Patient #5 indicated a copy of the [facility name] Critical Care Transport Patient Signature Form (authorizing the financial responsibility for services provided) was signed on 11-22-19 by Family Member FM21 for Patient #5 and the patient was transferred to facility F075 on 11/22/19, and the MR lacked documentation of a Patient Transfer Form ER-3401-2 including documentation of the physician certification of the benefits and risks of patient transfer and/or the signed informed patient consent for transfer to facility F075 and/or an indication of the MR copies sent from facility F016 to the receiving facility F075.

5. On 2-19-2020 at 1205 hours, the Interim ED Director A4 confirmed the MR for Pt#5 lacked documentation of a Patient Transfer Form ER-3401-2 including a Physician Certification of Transfer Need, a signed Patient Consent for Transfer, or the MR copies sent with the patient to the accepting facility.

6. Review of the 8-9-19 MR for Patient #1, the 1-23-2020 MR for Patient #6, and the 12-9-19 MR for Patient #8 lacked documentation indicating a Patient Transfer Form ER-3401-2 was completed for each patient including documentation of the physician certification of the benefits and risks of patient transfer and/or a signed patient consent for transfer to the receiving facility F479.

7. On 2-19-2020 at 1205 hours, 1312 hours and 1346 hours, staff A4 confirmed the MRs for Patients #1, 6 & 8 lacked the indicated transfer documentation.