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Based on clinical record review and staff interview, the facility failed to comply with the requirements at CFR §489.24 regarding the completion of the Physician Certification of Transfer prior to transferring patients from the Emergency Department to a another level of care which was not provided at the facility.

The findings included:

Review of seven (7) clinical records of patients who were transferred to another level of care from the facility revealed three (3) of those patients did not have the Physicians Certification of Transfer completed informing the patient/responsible party of the risks and benefits of the transfer.

The document was either blank (not completed at all) or was incomplete.

This involved Patients #7, #14, and #21.

Based on interview and document review it was determined the emergency department staff failed to ensure the physician certification for transfer under the Emergency Medical Treatment and Labor Act (EMTALA) was completed for three (3) of seven (7) transferred patients included in the survey sample (Patients #7, #14 and #21).

The findings included:

1. Review of Patient #7's electronic medical record (EMR) revealed the patient was admitted to the facility's emergency department (ED) on 01/13/2016. Patient #7 diagnoses included Bipolar Disorder with Psychosis. A psychiatric consult was provided and it was determined the facility's behavioral health unit could not provide a bed for Patient #7. Patient #7's EMR included a "Transfer/EMTALA Form" dated 01/13/2016. The "Transfer/EMTALA Form" was incomplete; it did not specify the person accepting the transfer nor the name of the person at the receiving hospital that accepted report information related to Patient #7.

The "Physician Certification of Transfer" section of the "Transfer/EMTALA Form" was blank and did not specify if the transfer was initiated by the "Physician" or "Patient" and whether Patient #7's condition was stable, unstable, or if the transfer had been requested by the patient against medical advice. Patient #7's "Transfer/EMTALA Form" for the risk of transfer was blank and did not indicated if the physician had discussed the risks of transfer with Patient #7. The "Transfer/EMTALA Form" includes a section, ("Checklist of Documents: To Be Completed on Transfer and Sent to Receiving Facility") to indicate which documents were sent to the receiving hospital with information related to the patient's medical screening. The "Checklist of Documents: To Be Completed on Transfer and Sent to Receiving Facility" section on Patient #7's "Transfer/EMTALA Form" was blank.

An interview was conducted on 02/11/16 at approximately 2:18 p.m. with Staff #22. Staff #22 verified the above findings and provided the surveyor with a copy of Patient #7's "Transfer/EMTALA Form."


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2. A review of the clinical record for Patient #14 by the surveyor on 2/9/2016 revealed that the patient arrived in the facility's ED on 12/6/2015, had a MSE (medical screening exam), and was deemed stable for transfer. Patient #14 was admitted to the PEC (psychiatric emergency center), an extension of the ER, at 0107 AM on 12/7/2015. The PEC documentation was that Patient #14 was transferred to another facility at 1:46 PM; however, the record did not include an EMTALA (Emergency Medical Treatment and Labor Act) transfer form-physician certification of transfer.

3. A review of the clinical record for Patient #21 by the surveyor on 2/10/2016 revealed that the patient arrived in the facility's ER on 1/1/2016 at 5:55 PM, accompanied by law enforcement, with an ECO (Emergency Custody Order). The CSB (Community Service Board) was consulted, the patient had an MSE, and was deemed stable for transfer. Documentation of Patient #21's disposition was that he/she was being transferred to an outside facility via the local Sheriff's department; a receiving bed was available on 1/2/2016 at 3:02 AM, and report was called to a nurse at 6:57 AM. A nurse's note documented that a TDO (Temporary Detention Order) transfer occurred after medical screening and evaluation to another facility; time of ER departure was documented as 1/2/2016 at 10:00 AM. Patient # 21's record did not include an EMTALA (Emergency Medical Treatment and Labor Act) transfer form-physician certification of transfer.

Staff #5 and Staff #2 were made aware of the lack of EMTALA transfer forms in the above patients records on 2/10/2016 between approximately 5:30 PM and 6:00 PM.