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Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to maintain and to include pertinent data on their Central Log (Emergency Room Register Log Book from the Women's and Children's Services Unit) [OB/GYN Unit] for each individual presenting to the Unit for 14 of 21 medical records reviewed. (MR13, MR15, MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27)

Findings include:

Review of Patient Access/Registration Department. A1 ... Director, Patient Access, dated 7/11, revealed, "TITLE ... The purpose of the Admissions Area of the Patient Access/Registration Department in keeping with the mission of the Hospital and to provide a centralized process by which patients are efficiently and courteously admitted into our healthcare facility, irregardless of ability to pay. ... ."

Review of facility policy Emergency Department, Medical Screening Examination (EMTALA), reviewed September 13, 2013. "Purpose: To meet the Medical Center's obligation under the Emergency Medical Treatment and Active Labor Act (EMTALA) by ensuring that when an individual comes to the Medical Center ... 2. Presenting for Emergency Services Has presented at the Emergency Department (ED) or at any other hospital-operated location on the hospital's campus, ... ."

A policy on the Emergency Room Register Log Book from the Women's and Children's Services Unit [OB/GYN unit] was requested. The facility was unable to produce a policy for this Log.

1. The facility Emergency Room Register Log Book from the Women's and Children's Services Unit [OB/GYN Unit] was requested and reviewed. The time frame dated March 1, 2014, to the present, failed to include documentation as to whether or not the patients presented unscheduled or scheduled as an outpatient to the OB/GYN Unit. Further review of the Log revealed gaps in completion of the required information: DOB; age; VIN number; EDC; Physician; Nature of Injury; Service rendered; Observation; Admit; Charges; Print; NST; and FFN.

2. A sample of records was reviewed. Review of 14 of 21 medical records (MR13, MR15, MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27) failed to include documentation as to whether or not the patients presented unscheduled or scheduled as an outpatient to the OB/GYN Unit for treatment of an emergency medical condition.

3. An interview was conducted with EMP6 on September 8, 2014, at 10:30 AM. "Absolutely one third of patients that present to our Unit are unscheduled. Unless they are C-sections, inductions and non-stress tests, everything else is unscheduled. We keep a scheduled book and a non-scheduled book."

4. An interview was conducted with EMP4 confirmed the above and revealed, "We could not confirm by the documentation on the Log and/or medical record review that these patients had scheduled appointments on the OB/GYN Unit."

Based on a review of facility documents, medical records, and staff interviews (EMP), it was determined the facility failed to define in their adopted By-laws and/or Rules and Regulations who is considered a qualified medical personnel with privileges to perform a medical screening examination (MSE) and/or to rule out labor, and failed to provide an appropriate MSE for five of 21 medical record reviewed. (MR13, MR16, MR22, MR26 and MR28)

Findings include:

Review of Medical Staff Bylaws, Policies, and Rules and Regulations of Mount Nittany Medical Center, reviewed December 20, 2012, revealed, "... 2.3 Medical Orders ... (c) Orders for tests and therapies shall be accepted only from: (1) members of the Medical Staff; (2) Allied Health Professionals granted clinical privileges by the Medical Center, to the extent permitted by their licenses; All orders for outpatient diagnostic tests written prior to inpatient or outpatient admission will not require the cosignature of the supervising physician. (3) other non-staff individuals who, upon verification of licensure, have been granted permission to order such tests and therapies by the Medical Center ... ."

A review of Medical Staff Bylaws, Policies, and Rules and Regulations of Mount Nittany Medical Center, reviewed December 20, 2012, revealed no documented evidence that Labor and Delivery nurses are considered qualified medical personnel that can rule out labor when patients present to the Obstetrical Unit.

Review of Medical Staff Bylaws, Policies, and Rules and Regulations of Mount Nittany Medical Center, reviewed December 20, 2012, revealed, "... Article IX. Emergency Department. Section 9.1 General Information: (a) the purpose of the Emergency Department is to provide initial evaluation and treatment to any patient with illness or injury who presents to the Department. All patients will be treated regardless of their ability to pay for these services ... Section 9.2. Delivery of Services: (a) all patients presenting to the Emergency Department must be seen by the Emergency Department practitioner or a member of the Medical Staff. Patients referred by their private physician for an Emergency Department evaluation shall be seen by the Emergency Department practitioner prior to the initiation of diagnostic studies ... ."

A review of facility policy Emergency Department Medical Screening Examination (EMTALA), reviewed September 13, 2013, was conducted. The policy revealed, "Purpose: To meet the Medical Center's obligation under the Emergency Medical Treatment and Active Labor Act (EMTALA) by ensuring that when an individual comes to the Medical Center, the Medical Center will: 1. Provide an appropriate medical screening examination (MSE); and, 2. If the individual has an emergency medical condition, either a. provide any necessary stabilizing treatment; b. transfer the individual; or c. admit the individual as an inpatient ... D. Medical Screening Examination. All patients presenting for emergency services shall receive a medical screening examination by the physician to determine the presence of an emergency medical condition as defined in the EMTALA law. Such medical screening examination shall include any necessary ancillary services that are routinely available at the Medical Center ... ."

1. An interview was conducted with EMP18 on September 9, 2014, at 11:40 AM. EMP18 confirmed that the Bylaws, Rules and Regulations do not indicate that Registered Nurses (RN) can rule out labor. EMP18 further confirmed that the Medical Executive Committee meeting minutes or any Governing Body meeting minutes do not address RNs ruling out labor.

2. A review of the Women's and Children's Services Emergency Log, of patients presenting with pregnancy related complaints, included not but limited to; rule out labor, pre-term labor, no fetal movement, kidney stones, back pain, nausea and vomiting, from March through September 7, 2014, was performed. A random sample of 21 medical records (MR13-MR33) was selected from the Log for review. It was noted that five of 21 medical records (MR13, MR16, MR22, MR26, and MR28) did not include a medical screening by a qualified member of the Medical Staff.


Review of MR13 dated August 30, 2014, revealed patient presented to Women's and Children's Services with Chief Complaint, to rule out pre-term labor. No documented evidence of a medical screening was complete before patient discharged home.

Review of MR16 dated May 5, 2014, revealed patient presented to Women's and Children's Services with Chief Complaint to check pre-term labor. No documented evidence of a medical screening was complete before patient discharged to home.
Review of MR22 dated April 4, 2014, revealed patient presented to Women's and Children's Services with Chief Complaint to rule out pre-term labor. No documented evidence of a medical screening was complete before patient discharged to home.
Review of MR26 dated March 11, 2014, revealed patient presented to Women's and Children's Services with Chief Complaint to rule out pre-term labor. No documented evidence of a medical screening was complete before patient discharged to home.
Review of MR28 dated August 15, 2014, revealed patient presented to Women's and Children's Services with Chief Complaint of abdominal pain. No documented evidence of a medical screening was complete before patient discharged to home.

3. An interview was conducted with EMP4 and EMP6 on September 9, 2014 at approximately 1:30 PM. EMP4 and EMP6 confirmed the above findings and revealed, "We cannot find documented evidence that these patients had a medical screening by a physician."

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure a safe appropriate transfer for one of six transfer records, and failed to follow their adopted policy in six of six transfer records reviewed (MR2, MR3, MR4, MR5, MR6 and MR7).
Findings include:
A review of Medical Staff Bylaws, Policies, and Rules and Regulations of Mount Nittany Medical Center, reviewed December 20, 2012, revealed, " ... Article V. Transfer. 5.1 Transfer: (a) The process for ensuring continuing care after transfer includes: (1) assessing the reason(s) for transfer; (2) establishing the conditions under which transfer can occur; (3) assessing how to shift responsibility for a patient's care from one clinician, organization, organizational program, or service to another which could include transferring complete responsibility for the patient and his or her care to others or referring the patient to others, such as one or more agencies or professionals, to provide one or more specific services); (4) evaluating mechanisms for internal and external transfer; and (5) ensuring that both the hospital initiating the transfer and the organization receiving the patient assume accountability and responsibility for the patient's safety during transfer. (b) Patients will be transferred, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.(a) Patients shall be transferred to another level of care, treatment, and/or services, different professionals, or different settings based on the patient's needs and the Medical Center's capabilities. The physician shall: (1) identify the patient's need for continuing care in order to meet the patient's physical and psychosocial needs; (2) inform patients, in a timely manner, of the need to plan for a transfer to another organization or level of care; (3) involve the patient and all appropriate licensed independent practitioners, staff, and family members involved in the patient's care, treatment, and services in the planning for transfer; (4) provide the following information to the patient whenever the patient is transferred: (i) the reason for the transfer; and (ii) available alternatives to the transfer, including the risks and benefits of those alternatives; and (5) educate the patient about how to obtain further care, treatment, and services to meet his or her identified needs, when indicated. (b) When patients are transferred, appropriate information related to the care provided shall be exchanged with other service providers, including: (1) The reason for transfer; (2) the patient's physical and psychosocial status; (3) a summary of care provided and progress toward goals; and (4) community resources or referrals provided to the patient ... ."

A review of Emergency Transfer to Another Facility (Anti-Dumping Policy) Emergency Department policy and procedure dated April 2014, revealed, "Policy ... C. Appropriate Transfer to Another Facility: ... 2. For any transfer to be appropriate, the following conditions must be met: a) The Emergency Department must provide the medical treatment within its capacity which minimizes the risks to the individual's health and, in the case of labor, the unborn child; b) The receiving facility must have available space and qualified personnel for the treatment of the patient, and must have agreed to accept the transfer and to provide medical treatment; c) The transfer must be made by qualified personnel with appropriate transportation equipment, including the use of necessary and appropriate life support measures during the transfer ... and; d) The Emergency Department must send copies of all medical records related to the emergency condition for which the individual has presented, available at the time of the transfer, including at a minimum: ...3) Mode of Transportation, ... 8) Condition at Time of Discharge, 9) Name of receiving Hospital and Physician, 10) Physician Certification for Transfer, 11) Signed Consent for Transfer (See attached ' Informed Consent (Refusal ) to Transfer to Another Medical Facility) ... ."


A review of Transfers/Transport-Emergent, Urgent, Routine policy and procedure dated March 18, 2014, revealed, "Definitions: The ambulance services and Mount Nittany Medical Center recognize three classifications of patients eligible for transfer: 1) Emergency 2) Urgent, and 3) Routine. Therefore the physician must designate the status of the patient. Emergent/Urgent I. Policy: A. A transfer situation exists when any of the following occur: 1. The attending physician decides that therapeutic modalities or expertise necessary for patient care are not available at Mount Nittany Medical Center. 2. The patient decides that he/she wishes to be treated at another hospital. (The physician responsible for the patient will decide if transferring the patient is safe). 3. The hospital has no available beds or facilities consistent with the patient's medical problem. ... I. Standards: ... C. Process: 1. Physician determines emergent/urgent situation exists and orders transfer. 2. Mount Nittany Medical Center physician confirms with receiving physician. ... 4. Physician informs nursing and patient/family of need for transfer and preferred route: obtains appropriate consent and authorization. ... 13. Charge Nurse/designee coordinates medical records and staff; transfer checklist, form #. Physician/designee completes Medical Necessity Certification form. ... 16. Documentation Complete the following forms: a. Physician's Medical Necessity Certification i. Emergent/Urgent Transfer Checklist, ED-004 ii. Patient Transfer Sheet, RT-047 iii. Informed Consent to Transfer to Another Facility, CF-053 ... Routine Transfer/transports I. A routine transfer is done when the physician determines patient needs assistance with transport; i.e., ambulance or van. ... V. Process A. Attending Physician 1. Determine need for transfer/transport. 2. Writes the discharge order. 3. Completes appropriate forms. 3. Informs the patient and/or family. ... B. Charge Nurse/designee 1. Verifies order. 2. Verifies completed transfer, discharge, and Physician's Medical Necessity Certification forms. ... F. Documentation 1. Complete Transfer Information Sheet, PF-024. ... ."

1. A sample of medical records of patients who were transferred were reviewed. It was determined the facility failed to ensure a safe appropriate transfer for one of six transfer records, and failed to follow their adopted policy in six of six transfer records reviewed

MR2 dated July 3, 2014, revealed, "... Discharge Information; ... Transferred To: ... Psych ... Discharged With: personal belongings, dc papers ... Disposition: [facility] ... ED Visit Note The patient was accepted for voluntary psychiatric admission at ... Hospital. Patient will be transported by parents in private vehicle. ... ." There was no documented evidence in MR2 that the facility completed the required transfer documentation forms.
Further review of MR2 revealed Emergency Department Case Management - Patient seen by CAN Help mobile and assessed in the field. Patient recommended for inpatient psychiatric treatment following medical clearance. Patient refused treatment options, wants to improve on their own. Patient did agree for parents to bring to ED. Upon arrival patient wanting to leave room, patient unsure they want to stay. Per CAN Help assessment patient was making statements about being evil and feeling that patient needs to kill self as a sacrifice. A 302 petitioning statement was completed by patient's mother prior to patient's arrival, warrant not issued at that time. Contacted CAN Help, spoke with ... . Expressed concern for patient safety and decision-making. 302 warrant was issued by County and will be faxed to this Department. Amendment: ... 302 warrant received and placed on patient's chart ... Security paged to bedside due to patient attempting to leave ... Suicidal Ideation: Description: ... Plan to harm oneself ... Plan & Ability to Carry Out Plan: Has Plan/Has Ability ... Patient asking parents for nail clippers or scissors when states. I want you to have a tiny piece of my hair to remember me by ... Two Mental Health Nurses are in with the patient and parents discussing what a 302 warrant is and what a 201 admission are. States we do not want patient be a 302. We were not told what all it entailed and we feel we were inadequately informed. ... ED Visit Note: ... The 302 petition had not been completed. The patient had originally presented as a voluntary psychiatric admission, however then had some initial change of mind. Parents petitioned for a 302 and warrant was obtained. However patient then was adamant that they wanted voluntary admission and parents were withdrawing their support for a 302, stating they were misled into filing the petitioning statement in the first place. As the patient was then wanting voluntary admission, and parents who were the petitioners were no longer supportive of the 302, the 302 was denied. ... Additional Instructions: Go to ... Hospital Psychiatric Unit for admission ... Patient to go directly to ... Psychiatric Facility. Patient's father is driving them there ... ...Primary Impression: Psychosis ... Departure Disposition: Mental Health Acute Care ... Departure Condition FAIR ... ."

Additional information was received and reviewed on September 17, 2014, from the Recipient Hospital. "Initial Call Sheet, dated July 4, 2014, at 0245 hour, ... Commitment Status: 201. Reason for Hospitalization: Stating wants to cut off body parts (legs, arms, hands) and must make a sacrifice of self, wants to kill self, evil and wants to sacrifice self. ... How will patient be transported? ... Other: parents. ... Accepting physician: Dr. ... Date accepted: 07/04/2014. Time Accepted: 0322 hour. Axis I: Psychotic ... NOS MDD with psychotic symptoms. Axis II: deferred. Axis III: PCOS. Axis IV: PWPS. Axis V: 15. Notes: Call closed out on July 8, 2014. Patient jumped from parents car while driving 65 mph down Interstate 80 at mile marker 77. Police and search parties have been unable to locate patient. Patient ran into the woods."

MR3 dated September 3, 2014, revealed, "... Discharge Information: ... Transferred To: [facility] ... Discharged With: Constable ... Disposition: Transferred ... ." There was no documented evidence in MR3 that the facility completed the required transfer documentation forms.

MR4 dated July 14, 2014, revealed, "... Discharge Information: ... Transferred To: [facility] ... Discharged With: [blank] ... Disposition: Transferred ... ." Further documentation of MR4 revealed that the patient was transferred with the Constable. There was no documented evidence in MR4 that the facility completed the required transfer documentation forms.

MR5 dated March 5, 2014, revealed, "... Discharge Information: ... Transferred To: ... hospital ... Discharged With: Constable ... Disposition: Transferred ... ." There was no documented evidence in MR5 that the facility completed the required transfer documentation forms.

MR6 dated January 25, 2014, revealed, "... Discharge Information: ... Transferred To: [facility] ... Discharged With: ... EMS BLS ... Disposition: Transferred ... ." There was no documented evidence MR6 that the facility completed the required transfer documentation forms.

MR7 dated August 14, 2014, revealed, "... Discharge Information: ... Transferred To: [facility] ... Discharge With: to [facility] via ... EMS ... Disposition: Transferred ... ." There was no documented evidence in MR7 that the facility completed the required transfer documentation forms.

2. An interview was conducted with EMP5 on September 9, 2014, at 2:00 PM. EMP5 stated that EMP17 confirmed that MR2-MR7 failed to contain the required transfer documentation forms as per the facility policy.

3. An interview was conducted with EMP17 on September 9, 2014, at 2:20 PM. EMP17 revealed, "It is our role to complete the forms [transfer documentation] ... . It is the nurse who is taking care of the patient who is responsible for completing the forms. If the patient is transferred by the family to the facility, then they would be a discharge and the patient would not have the forms completed. It used to be that the Clinical Supervisor would start the forms and then they were given to the Secretary to complete. Now, within the last year, the Secretary is given the forms and completes them. If the patient is transported with the Constable, then I would expect the forms to be completed. Our policy does not specify if forms are to be completed or not when the patient is transferred by car."

Based on a review of facility documentation, medical records (MR), and staff interview(EMP), it was determined that Mount Nittany Medical Center delayed the treatment of an individual who required specialized psychiatric care by failing to accept a patient in transfer from a referring hospital until the patient's insurance coverage could be verified, when the patient required specialized capabilities that the facility could provide.

Findings included:

Review of MOUNT NITTANY MEDICAL CENTER, Behavioral Health Unit, TITLE: General Admission Policy, 1007, Unit Organization, dated 3/12/14, revealed, "POLICY: The need for inpatient psychiatric hospitalization indicates a severe level of dysfunction by the patient, and is likely to be a crisis situation for his/her family. Immediate intervention is required to protect the safety and integrity of the patient and significant others, and to reduce their anxiety. The on-duty Behavioral Health Unit staff is responsible for making an initial brief physical and behavioral assessment of the patient, and for instituting an appropriate plan of care at the time of an admission. The staff participating in the admission process is responsible for informing patients of their rights at the time of admission, and obtaining written consents for voluntary admissions. PROCEDURE: A patient may only be authorized for admission by the Unit's attending psychiatrists. Referrals from other physicians or agencies, or admissions through the Emergency Department, must be reviewed by the psychiatrist On-Call for appropriateness of admission to the Unit ... A. The Voluntary Patient. 1. The patient and his/her family or significant other may go directly to Patient Registration on arrival at the Medical Center, if the person has been approved for a direct admission by the psychiatrist On-Call or the Unit Medical Director. If the patient is unable to tolerate or complete the admissions procedure, a family member may give the information. Patient Registration will notify the Unit of the patient's arrival. Patient Registration personnel will complete the usual forms as appropriate in any other admission. Patient Registration personnel will not be responsible for completing the Mental Health Forms 781 and 791 A&B. When the Patient Registration personnel has completed the usual routine, a member of the Behavioral Health Unit will go to Patient Registration to escort the patient and family or significant others to the unit. 2. A direct admission of the Voluntary patient without medical clearance must be seen by the psychiatrist within 1 - 2 hours of admission to the Unit for a complete history and physical ... 3. If coming directly from a physician's office or another hospital, the patient's physician should send or fax a copy of the office/hospital history and physical, labs, etc. performed that day prior to coming to the unit along with a statement the patient is medically stable ... 4. Check insurance. Pre-certification should be attempted before patient is sent to the Medical Center for direct admission. 5. Direct Admission of a patient transferred from another facility. Upon referral from another hospital, staff will obtain the following information and follow the following procedure ... Direct Admission of a patient transferred from another facility. Upon referral from another hospital, staff will obtain the following information and follow the following procedure: a. Clinical information indication need for inpatient treatment, including copies of a history and physical exam. b. Admission status (201 vs. 302). c. Mental Health Evaluation. d. Statement of Medical Clearance. e. Completed labs: blood work, radiology studies, EKG, Toxicology Screen. f. Copy of 302, if applicable. If 302, ensure completed appropriately with Mount Nittany Medical Center as designated treatment facility. ... k. If admission is approved, re-contact the referral source. i. Request the referral source do the insurance precertification and provide MNMC the name of person who did the precert with the insurance company, authorization/reference number, insurance contact person name, phone number, and review date ... ."

Review of Admitting Mental Health Patients A76 ... Director, Patient Access, dated 9/13, revealed, "TITLE: Admitting Mental Health Patients. RESPONSIBILITIES: A. Mental Health Patients are admitted to the Hospital by Physicians or through the Emergency Department. B. Complete information on Form AS-025 for Direct Admits ... 4. Admitting Physician. 5, Type of Admission. 7. Pre-Cert Number (3 South [Behavioral Health Unit] is responsible for obtaining pre-cert numbers) ... ."

Review of Pre-Certification A16, Director, Patient Access, dated 7/12 revealed, "TITLE: Pre-Certification. RESPONSIBILITIES: A. Elective Admissions: 1. Pre-Certification for patients being scheduled for elective admissions to the Hospital is the responsibility of the patient's physician. a. SDA's insurance verification is done through Case Management. b. SDS' insurance verification is done by Patient Access Associate ... ."

1.Review of MR1 dated August 18, 2014, Notes: ... seems very paranoid, worried about people watching ... can't trust anybody and that might be being drugged. ... Severity: Currently symptoms are moderate ... Orders: ... Crisis Consult ... Disposition: Admit for Crisis ... When Crisis spoke with [patient] reports ... people are watching them and that [patient] was being surrounded ... family is requesting an inpatient admission for [patient] due to the onset of this and patient's inability to care for self when in this state of mind ... Crisis spoke with [patient] about staying inpatient and was in agreement and willing to sign 201; 302 GROUNDS DO EXIST AT THIS TIME (paranoia, delusions, inability to care for self, no psychotropic medications or outpatient). Crisis reviewed case with Dr. ... felt admission was needed and approved transfer. Mount Nittany declined to accept due to insurance concerns. Pt has Dean Health Plan based out of Wisconsin and they were unable to be contacted at night due to office being closed; no precert could be completed. Mount Nittany EMP7 explained to Crisis that they are unable to verify insurance, if they are in Network, and guarantee payment and would be unable to accept because of this ... PLAN: 201 to 3G. Pt will remain in ED throughout the night until tomorrow morning when bed search will continue or admission to 3G if there are discharges ... ."

Review of documentation dated August 18, 2014, revealed, "... received a Consult for patient, [MR1] ... due to odd behaviors and possible psychosis on August 18, 2014, at 1700. Patient met criteria for inpatient admission ... was willing to sign voluntary 201 commitment but met criteria for involuntary 302. This facility was unable to accept due to having no available beds on inpatient psych, 3G. Crisis performed bed search to Mount Nittany Hospital and spoke with EMP7 and gave needed information. EMP7 called Crisis back with questions pertaining to MR1's insurance ... Crisis attempted to completed precertification but was unable due to office being closed. EMP7 called Crisis back and reported that they were unable to accept [patient] because they can not verify [patient] insurance, determine if Mount Nittany is in Network,or guarantee payment. EMP7 told Crisis, "It is in the best interest of the patient due to possible financial difficulties in the future if their insurance is unable to pay." Crisis asked EMP7, "are you guys denying acceptance due to insurance reasons? EMP7 replied, "If the patient would decide to leave tomorrow if their insurance does not pay then the hospital would not receive payment." Crisis thanked Mount Nittany for taking information for bed search ... signed by ... Crisis Counselor."

2. An interview was conducted with EMP2 on September 9, 2014, at 10:30 AM. "It was just miscommunication between the psych nurse and the Crisis worker at the sending hospital. The patient was stable and was a voluntary commitment. We said, we'll take the patient, but the insurance is from Wisconsin and the patient may have a big bill. The Crisis worker got upset and hung up. We didn't even know until the next day that the patient had a 302 commitment as a backup."

3. An interview was conducted with EMP3 on September 9, 2014, at approximately 12:30 PM. "... When we have psychiatric patients in the Emergency Department (ED), we send a Psychiatric Liaison to ED to do a mental health evaluation. The Liaison notifies the physician and gets orders to admit the patient. The insurance information is obtained. Before the patient goes to in-patient status (admission) the insurance company is contacted for authorization. If this is not authorized, the insurance company can deny payment, if the patient is out of Network provider. If the facility is out of Network the patient is responsible for the cost of the admission. The other option is to transfer the patient to an in-Network provider. This authorization process is done to prevent the patient from being admitted and then transferred. With this case from ... Facility we were trying to get approval for admission. However, we did not have enough clinical information about this patient ... EMP7 did not follow the process, [EMP7] took a verbal referral and spoke with the physician without all the clinical information. EMP7 skipped the part where they get all the clinical information faxed and forwards it to the doctor. [EMP7] called the physician prior to having all the clinical information ... The sequence of events was out of order. We have had instances where we transferred patients out because of insurance and being out of Network. The insurance companies sometimes with negotiate a single case agreement for patients that are out of Network."