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Based on interview and record review the facility failed to:

1.Ensure 1 of 20 sampled patients (Patient 8) signed a consent acknowledging the risks and benefits of transferring to another facility after a medical emergency was identified and stabilized (state where, within reasonable clinical confidence, the emergency condition resolved or no deterioration is expected).

This deficient practice can result in Patient 8 not knowing the benefits and risks of transfer to another facility which can impact the ability to make an informed decision.

2. Ensure the receiving hospital physician agreed to accept 1 of 20 sampled patients (Patient 1) to expedite care for this patient who was not able to receive stabilizing treatment at this facility.

This deficient practice may result in a delay of care which can compromise patient safety.

Findings:

1. During an interview on 12/18/2024 at 3:22 p.m., the Quality Improvement (QI) Director acknowledged, after examining the transfer documents for Patient 8, that the consent for transfer to another hospital had not been signed by the patient or a responsible party. The QI Director subsequently stated all patients who qualify for a transfer to another facility, must sign the facility ' s consent form for further care, to be informed of the benefits and risk of transfer as stated in the facility ' s policy. The QI Director then stated the reason for Patient 8 being transferred to another facility was that this facility does not treat pediatric (less than 14 years of age) orthopedic (treatment of conditions affecting bone and muscle) patients.

During a review of the ED Note-Physician ' Final Report, ' (signed 1/15/2024), this document indicated Patient 8 , who was 12 years old, entered the emergency department with her mother for an evaluation of Patient 8 ' s left elbow pain and numbness. The mother of Patient 8 stated Patient 8 was at cheer practice when Patient 8 stumbled and dislocated her elbow. During a physical examination, Patient 8 exhibited limited range of motion (the extent or limited to which a body part can be moved around a joint) due to pain in the left elbow. This report indicated, from an x-ray of the left elbow, a dislocation (area where the ends of two bones separate at the joint where they meet) and a fracture at the point where the left elbow and left upper arm bone meet. This report indicated that the Attending Physician arranged to transfer Patient 8 to another facility because Patient 8 was a pediatric patient and may require transfer for pediatric evaluation.

During a review of the ' Patient Transfer ' form all the following were verified before transferring Patient 8: name of facility sent to; all pertinent medical records, Patient 8 ' s condition upon transfer was stable. There was no record of consent to transfer by a responsible party.

During a review of the facility ' s policy titled ' Transfers Interfacilities from the ED ' (emergency department) PolicyStat ID 15760226, this policy indicated that a charge nurse (leader of a nursing unit) in the emergency department, if the patient is stable, will initiate the inter-facility transfer form for each patient. The ' Transfers Interfacilities from the ED ' policy indicated stable as being the state where, within reasonable clinical confidence, the emergency condition resolved or no deterioration is expected.

2. During an interview on 12/19/2024 at 1:00 p.m.PM, the ED Physician stated Patient 1 entered the emergency department on 8/2/2024 with active bleeding from the left leg from injury during an automobile accident; Patient 1 had history of hemophilia (a disorder that prevents blood from clotting properly, resulting in excessive bleeding) and history of Von Willebrand disease (a disorder that prevents blood from clotting properly, but more common than hemophilia). The ED Physician stated it was her recommendation to transfer Patient 1 to another hospital having a supply of Factor VIII (an agent in the blood, when reacted with Factor IX, sets off a chain reaction to form a blood clot) and having the ability to monitor the activity level of Factor VIII (percentage of Factor VIII reacting in the blood to initiate clotting). At this time the ED Physician stated it was her understanding the mother of Patient 1 had a supply of Factor VIII with her and it was decided it (the mother ' s supply) should be given at the bedside in the emergency department. The ED Physician subsequently said that, through miscommunication, Patient 1 was sent to the other hospital before sending Patient 1and the transferringreceiving physicians had a chance to communicate with the receiving physician. Finally the ED Physician stated the process for transferring a patient by 911 (transfer by ambulance to another hospital due to the transferring facility not having ability to stabilize the patient) is as follows: if the patient meets the criteria for transfer by 911 (inability to stabilize patient), the charge nurse prepares the transfer paperwork; the unit secretary calls the receiving facility and coordinates a sending physician to receiving physician conversation; 911 is called when all the aforementioned are completed.

During an interview on 12/19/2024 at 1:23 p.m.PM, the ED Charge Nurse stated the unit secretary (name unknown) dialed 911 but did not discuss this conversation with anyone or any conversation with the receiving hospital. The ED Charge Nurse then stated the unit secretary said she (the unit secretary) asked to consult with the receiving physician and said there was an accepting physician at the other hospital. The ED Charge Nurse subsequently stated the unit secretary told the waiting ambulance staff there was an accepting physician at the other facility. The ED Charge Nurse stated this is not the normal process for 911 transfer; the order of the process is as follows: verify the patient ' s condition qualifies for 911 transfer; verify there has been a sending physician to receiving physician consultation; the transfer package is completed; the sending physician creates an order to transfer to another facility; after all above process is complete, call 911 for patient pickup. The ED Charge Nurse then stated there now is a written process for 911 transfers to follow.

During an interview on 12/19/2024, the Unit Secretary Supervisor stated the unit secretary involved in the transfer of Patient 1 on 8/2/2024 was on a leave at this time but the Unit Secretary Supervisor said she is familiar with the process of 911 transfer from the emergency department but there is was no formal procedure for 911 transfers at that time. The Unit Secretary Supervisor stated she usually hears ED physician conversations and gets the authorization to call for 911 transfer of the patient from this physician; the Unit Secretary Supervisor then prepares the transfer documents. Finally, the Unit Secretary Supervisor said after preparing the documents, she requests the receiving hospital to arrange a doctor to doctor conversation regarding the 911 transfer and usually the sending doctor usually informs her that conversation did occur.

During a review of the ' Emergency/Urgent Care ' note authored by the ED Physician, the note indicated Patient 1 was evaluated by an Advanced Practice Provider (health care provider who is not a physician but performs many of the activities performed by a physician) and was evaluated for pain in the left thigh pain post motor vehicle accident. Patient 1 ' s medical history included hemophilia A (hereditary bleeding disorder caused by lack of clotting factor VIII) and Willebrand ' s disease. This document indicated Patient 1 had experienced tenderness and increased swelling over the left thigh; because of the threat of compartment syndrome (dangerous condition caused by pressure buildup from internal bleeding or swelling of tissue) and history of hemophilia the facility ' s plan was administering Factor VIII, consultation with hematology oncology (medical specialty dealing with treatment of blood cancers and disorders), transport Patient 1 to higher level of care facility. Finally, this note indicated this facility ' s staff and 911 crew were alerted that the receiving physician was not going to accept Patient 1 as Patient 1 was given Factor VIII before arriving at the receiving hospital and there was no need to transfer Patient 1. The ED Charge Nurse stated the unit secretary told the 911 crew there was an accepting physician and the 911 crew departed with Patient 1 before the receiving physician could speak with the sending physician.

During a review of the ' Emergency Medical Treatment and Labor Act of 1986 – EMTALA ' PolicyStat ID 15675670, this policy indicated this facility will provide an MSE (medical screening examination, examination by a qualified healthcare provider to determine if an emergency medical condition exists that may require stabilizing treatment). This stabilizing treatment may include admission for inpatient care, or arrangement of an appropriate transfer of the individual to another medical facility with the capability to provide the stabilizing care.

Based on interview and record review the facility failed to:

1.Ensure 1 of 20 sampled patients (Patient 8) signed a consent acknowledging the risks and benefits of transferring to another facility after a medical emergency was identified and stabilized (state where, within reasonable clinical confidence, the emergency condition resolved or no deterioration is expected).

This deficient practice can result in Patient 8 not knowing the benefits and risks of transfer to another facility which can impact the ability to make an informed decision.

2. Ensure the receiving hospital physician agreed to accept 1 of 20 sampled patients (Patient 1) to expedite care for this patient who was not able to receive stabilizing treatment at this facility.

This deficient practice may result in a delay of care which can compromise patient safety.

Findings:

1. During an interview on 12/18/2024 at 3:22 p.m., the Quality Improvement (QI) Director acknowledged, after examining the transfer documents for Patient 8, that the consent for transfer to another hospital had not been signed by the patient or a responsible party. The QI Director subsequently stated all patients who qualify for a transfer to another facility, must sign the facility ' s consent form for further care, to be informed of the benefits and risk of transfer as stated in the facility ' s policy. The QI Director then stated the reason for Patient 8 being transferred to another facility was that this facility does not treat pediatric (less than 14 years of age) orthopedic (treatment of conditions affecting bone and muscle) patients.

During a review of the ED Note-Physician ' Final Report, ' (signed 1/15/2024), this document indicated Patient 8 , who was 12 years old, entered the emergency department with her mother for an evaluation of Patient 8 ' s left elbow pain and numbness. The mother of Patient 8 stated Patient 8 was at cheer practice when Patient 8 stumbled and dislocated her elbow. During a physical examination, Patient 8 exhibited limited range of motion (the extent or limited to which a body part can be moved around a joint) due to pain in the left elbow. This report indicated, from an x-ray of the left elbow, a dislocation (area where the ends of two bones separate at the joint where they meet) and a fracture at the point where the left elbow and left upper arm bone meet. This report indicated that the Attending Physician arranged to transfer Patient 8 to another facility because Patient 8 was a pediatric patient and may require transfer for pediatric evaluation.

During a review of the ' Patient Transfer ' form all the following were verified before transferring Patient 8: name of facility sent to; all pertinent medical records, Patient 8 ' s condition upon transfer was stable. There was no record of consent to transfer by a responsible party.

During a review of the facility ' s policy titled ' Transfers Interfacilities from the ED ' (emergency department) PolicyStat ID 15760226, this policy indicated that a charge nurse (leader of a nursing unit) in the emergency department, if the patient is stable, will initiate the inter-facility transfer form for each patient. The ' Transfers Interfacilities from the ED ' policy indicated stable as being the state where, within reasonable clinical confidence, the emergency condition resolved or no deterioration is expected.

2. During an interview on 12/19/2024 at 1:00 p.m.PM, the ED Physician stated Patient 1 entered the emergency department on 8/2/2024 with active bleeding from the left leg from injury during an automobile accident; Patient 1 had history of hemophilia (a disorder that prevents blood from clotting properly, resulting in excessive bleeding) and history of Von Willebrand disease (a disorder that prevents blood from clotting properly, but more common than hemophilia). The ED Physician stated it was her recommendation to transfer Patient 1 to another hospital having a supply of Factor VIII (an agent in the blood, when reacted with Factor IX, sets off a chain reaction to form a blood clot) and having the ability to monitor the activity level of Factor VIII (percentage of Factor VIII reacting in the blood to initiate clotting). At this time the ED Physician stated it was her understanding the mother of Patient 1 had a supply of Factor VIII with her and it was decided it (the mother ' s supply) should be given at the bedside in the emergency department. The ED Physician subsequently said that, through miscommunication, Patient 1 was sent to the other hospital before sending Patient 1and the transferringreceiving physicians had a chance to communicate with the receiving physician. Finally the ED Physician stated the process for transferring a patient by 911 (transfer by ambulance to another hospital due to the transferring facility not having ability to stabilize the patient) is as follows: if the patient meets the criteria for transfer by 911 (inability to stabilize patient), the charge nurse prepares the transfer paperwork; the unit secretary calls the receiving facility and coordinates a sending physician to receiving physician conversation; 911 is called when all the aforementioned are completed.

During an interview on 12/19/2024 at 1:23 p.m.PM, the ED Charge Nurse stated the unit secretary (name unknown) dialed 911 but did not discuss this conversation with anyone or any conversation with the receiving hospital. The ED Charge Nurse then stated the unit secretary said she (the unit secretary) asked to consult with the receiving physician and said there was an accepting physician at the other hospital. The ED Charge Nurse subsequently stated the unit secretary told the waiting ambulance staff there was an accepting physician at the other facility. The ED Charge Nurse stated this is not the normal process for 911 transfer; the order of the process is as follows: verify the patient ' s condition qualifies for 911 transfer; verify there has been a sending physician to receiving physician consultation; the transfer package is completed; the sending physician creates an order to transfer to another facility; after all above process is complete, call 911 for patient pickup. The ED Charge Nurse then stated there now is a written process for 911 transfers to follow.

During an interview on 12/19/2024, the Unit Secretary Supervisor stated the unit secretary involved in the transfer of Patient 1 on 8/2/2024 was on a leave at this time but the Unit Secretary Supervisor said she is familiar with the process of 911 transfer from the emergency department but there is was no formal procedure for 911 transfers at that time. The Unit Secretary Supervisor stated she usually hears ED physician conversations and gets the authorization to call for 911 transfer of the patient from this physician; the Unit Secretary Supervisor then prepares the transfer documents. Finally, the Unit Secretary Supervisor said after preparing the documents, she requests the receiving hospital to arrange a doctor to doctor conversation regarding the 911 transfer and usually the sending doctor usually informs her that conversation did occur.

During a review of the ' Emergency/Urgent Care ' note authored by the ED Physician, the note indicated Patient 1 was evaluated by an Advanced Practice Provider (health care provider who is not a physician but performs many of the activities performed by a physician) and was evaluated for pain in the left thigh pain post motor vehicle accident. Patient 1 ' s medical history included hemophilia A (hereditary bleeding disorder caused by lack of clotting factor VIII) and Willebrand ' s disease. This document indicated Patient 1 had experienced tenderness and increased swelling over the left thigh; because of the threat of compartment syndrome (dangerous condition caused by pressure buildup from internal bleeding or swelling of tissue) and history of hemophilia the facility ' s plan was administering Factor VIII, consultation with hematology oncology (medical specialty dealing with treatment of blood cancers and disorders), transport Patient 1 to higher level of care facility. Finally, this note indicated this facility ' s staff and 911 crew were alerted that the receiving physician was not going to accept Patient 1 as Patient 1 was given Factor VIII before arriving at the receiving hospital and there was no need to transfer Patient 1. The ED Charge Nurse stated the unit secretary told the 911 crew there was an accepting physician and the 911 crew departed with Patient 1 before the receiving physician could speak with the sending physician.

During a review of the ' Emergency Medical Treatment and Labor Act of 1986 – EMTALA ' PolicyStat ID 15675670, this policy indicated this facility will provide an MSE (medical screening examination, examination by a qualified healthcare provider to determine if an emergency medical condition exists that may require stabilizing treatment). This stabilizing treatment may include admission for inpatient care, or arrangement of an appropriate transfer of the individual to another medical facility with the capability to provide the stabilizing care.