HospitalInspections.org

Based on document review and interview, it was determined that in 1 (Patient #1) of 20 medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide stabilizing treatment and appropriate transfer.

Findings Include:

1. See findings cited at 42 CFR 489.24 (e) (1)-(2) Appropriate Transfer.

Based on document review and interview, the facility failed to ensure appropriate transfer was completed for 1 of 6 patients reviewed for transfers. (Patient #2)

Findings include;

1. Facility policy titled "COBRA EMTALA - Emergency Medical Treatment and Active Labor Act" last reviewed/revised 11/2017 indicated the following: "...I. A. Right to Treatment...3. If necessary, an appropriate Transfer to another facility...III. Procedure...C. Patient Transfer 1. Transfer of a Patient with an Emergency Medical Condition. 2. If an individual has an Emergency Medical Condition that has not been Stabilized, the Hospital may not transfer the individual unless: a.The individual requests in writing Transfer against medical advice after being informed of the risks of transfer and the Hospital's responsibility to provide Stabilizing treatment. b. The Transferring Physician...signs the Certificate of Transfer Form...stating that based on the information available at the time of Transfer, the medical benefits reasonably expected from the provision of medical treatment at another facility outweigh the increased risks to the individual...of the Transfer. The Certificate of Transfer must contain a summary of the risks and benefits...c. The Transfer must be an appropriate transfer...3. Appropriate Transfer ... For a Transfer to be appropriate, the Hospital must: a. Provide medical treatment within the Hospital's Capability and Capacity that minimize the risks to the individual's health..."

2. Review of Patient #2's medical record indicated the following:

The patient was delivered at 22 weeks gestation at [Facility #1] on 8/4/19 at 0655 hours and was transferred on 8/4/19 at 0715 hours to Facility #2, which does not have a Neonatal Intensive Care Unit. The medical record lacked documentation of a completed and signed Physician Certificate of Transfer for the patient.

3. During an interview on 9/4/19 at 9:58 a.m. with A1 (Quality Accreditation Specialist) and A3 (Emergency Department Manager at Facility #3), they verified the lack of a completed and signed Physician Certificate of Transfer for Patient #2.

4. During an interview on 9/4/19 at 6:11 p.m. with A3, he/she verified that the documents provided were the complete medical record for Patient 2.