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Based on policy review, patient medical record reviews, and interviews, the hospital failed to comply with § 489.24(d)(5) by failing to have documentation of the description of the proposed transfer, the risks and benefits of the transfer, and the reasons for the individual's refusal for one (Patient (P) 19) of three patient records reviewed for appropriate transfer from a sample of 20 patient records. This deficient practice had the potential to affect all ED patients requiring transfer that could result in the patient experiencing a deterioration in his/her medical condition. (See findings in A2408).

Based on policy review, review of patient medical records, and interviews, the hospital failed to have documentation of the description of the proposed transfer, the risks and benefits of the transfer, and the reasons for the individual's refusal for one (Patient (P) 19) of three patient records reviewed for appropriate transfer from a sample of 20 patient records. This deficient practice had the potential to affect all ED patients requiring transfer that could result in the patient experiencing a deterioration in his/her medical condition.

Findings include:

Review of the hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy," revised 07/14/22, indicated ". . . The purpose of this policy is to define the relevant terms and provide an overview of the Emergency Medical Treatment and Labor Act (EMTALA), the regulations and rules promulgated thereunder, and the State Operations Manual interpretive guidelines. . .. If a patient accepts the transfer but refuses the facility's recommendation and offer of an appropriate means of transportation electing to travel by other means . . . then the risks associated with such a disposition must be thoroughly explained to the patient and documented. If the patient still insists on traveling by other means then the facility should take all reasonable steps to obtain the patient's or the patient representative's refusal and certification in writing using the Patient Transfer Form. The completed form must be filed in the patient's medical record and the disposition of the patient may be indicated as Transferred, but should never be indicated as "discharged. . ."

Review of the hospital's "Patient Transfer Form" indicated Section C included "Refusal of Recommended Transport Medical Risks of Refusing Medical Transport: The risks of refusing transport as recommended have been explained to me by a member of the medical staff and I understand them to be as follows: [box to check before each of the following] Deterioration/worsening of my condition(s), Lack of life-saving equipment, Additional pain or suffering, Permanent disability/disfigurement/loss of limb, organ, or function, Death (self or unborn fetus), Delays in getting to the other hospital or failure to arrive at the other hospital due to traffic, motor vehicle accident, or inability to drive, Other (specific to patient's emergency medical condition, e.g. [such as] heart attack, stroke, loss of oxygen, etc. [and so on]: Certification of Refusal and Release: This to certify that I refuse to go to the receiving hospital by the recommended transport. This is my choice and I understand this choice is against the medical advice/recommendation of the emergency physician. I accept personal responsibility for all harm or disability I may suffer from this refusal. . ."

Review of P19's medical record indicated P19 presented to the ED on 11/03/24 at 5:52 PM. Review of the P19's ED record indicated he/she was a six-year-old brought in by his/her father who stated P19 was jumping on the bed, fell off, and landed on his/her left arm and was complaining of left elbow pain.

Review of P19's x-ray report indicated P19 had a "complex distracted supracondylar fracture dislocation injury of left elbow."

Review of Phys9's documentation on 11/03/24 at 7:03 PM indicated ". . . Patient is neurovascular intact able to radially deviate the wrist extend the wrist there is no sensory deficits patient though will likely need urgent surgical intervention as such I have contacted TMC Hospital [name of physician] pediatric orthopedics who is agreeable to accept patient for transfer for surgical intervention. I have contacted the hospitalist [name of physician] is expecting patient for transfer and admission to the hospital for surgical intervention of significant supracondylar fracture patient neurovascularly intact splinted and transferred.

Review of P19's "Patient Transfer Form" indicated P19's mother signed the "Certification of Refusal and Release" on 11/03/24. Review of the form indicated no boxes were checked in Section C indicating which medical risks for refusing emergency transport had been discussed with P19's parents. There was no documentation indicating P19's parent's reasons for the refusal of transfer by ambulance, and the medical record did not contain a description of the risks and benefits of the proposed transfer that was refused on behalf of the patient.

During an interview on 12/06/24 at 1:00 PM, NA Mgr. confirmed no risks were checked on P19's "Patient Transfer Form," and there was no documentation of the risks and benefits of the proposed transfer that were refused.