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 an appropriate transfer.

Findings Include:

1. See findings cited at tag A2409.

Based on document review and interview, the facility failed to follow their policy to ensure an appropriate transfer was completed for 1 of 20 patients' medical records reviewed. (Patient #1)

Findings include;

1. Facility policy titled "COBRA EMTALA - Emergency Medical Treatment and Active Labor Act", PolicyStat 14791143, last revised 12/2023 indicated the following: "I. D. Patient Transfer: 1. Transfer of a Patient with an Emergency Medical Condition. 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. b. Obtain agreement from a receiving facility that the receiving facility has the Capability and Capacity to treat the individual and that it will accept the Transfer and provide appropriate medical treatment. c. Use qualified personnel and transportation equipment as required to effect the Transfer safely. d. Send to the receiving facility copies of all available medical records related to the Emergency Medical Condition. If the patient is being transferred to a facility that does not have access to EMR (Electronic Medical Records), the Transfer Documentation/EMTALA form shall be printed from the EMR and sent with the patient. In the alternative, Form #766 may be used. As soon as practicable after the Transfer, send by facsimile copies of any records not available at time of Transfer. Records to be sent include any available history, observations of signs or symptoms, preliminary diagnosis, result of diagnostic tests or telephone reports of test results, and treatment provided."

2. Review of Patient #1's medical record from Facility #1 indicated the following:

The ED Care Timeline for Patient #1 indicated the following: Transfer Disposition Selected on 4/17/25 at 2:42 p.m. by (MD1, Doctor of Medicine/Emergency Medicine). Transfer Documentation/EMTALA Form: Completed by MD1 on 4/17/25 at 2:43 p.m., Section 1: Physician Certification: MD Certification: Patient examined, and risks explained. Patient Condition: Benefit outweighs risk. Reason for Transfer: Consult physician request. Benefits of Transfer: Capacity; Necessities available at receiving facility. Risks of Transfer: Time delay; Deterioration; Loss of IV (intravenous); Discomfort; Accidents or delays; Worsening condition. Accepting Physician: (MD5, Emergency Department Physician at Facility #2). Primary Specialty Needed for Transfer: Ophthalmology. Patient Status Update on 4/17/25 at 2:55 p.m. indicated EMS req (required), paperwork filled out and handed to N2, who is taking over care at this time, aware to call report to (Facility #2). 4/17/25 at 6:21 p.m. by (N2, Registered Nurse/Emergency Department) indicated report attempted to (Facility #2, Acute Care Facility) times 2. No answer on line provided. Patient discharged on 4/17/25 at 6:22 p.m.

An ED provider note by MD1 dated 4/17/25 at 10:38 a.m. indicated the following: Chief Complaint: (Patient #1) presents with eye problem. Sent by (Facility #3, Ophthalmology facility). (Patient #1) has no vision in right eye, sent to our emergency department for transfer to Facility #2. Needs evaluation for penetrating keratoplasty. Attempting to transfer to (Facility #2). Spoke with MD5, ED to ED transfer to (Facility #2). Disposition: Transfer to Another Facility. Final Impression: 1. Corneal ulcer of right eye.

A scanned in Certificate of Transfer for Patient #1 signed by Family Member #2 on 4/17/25 at 3:14 p.m. indicated the following: This is to certify the following information concerning the transfer of (Patient #1) from (Facility #1) on 4/17/25 at 2:55 p.m. to (MD5) (accepting physician). Patient Condition: Stabilized patient: I certify that the below named patient had an emergency medical condition but was stabilized at the time of transfer. Summary of Benefits and Risks: Principle potential benefits of transfer: Specialized care/equipment/monitoring available at the receiving hospital, capacity, necessities available at the receiving facility. Principle Potential risks of transfer: Deterioration of medical condition. Time delay, deterioration, loss of IV (intravenous), discomfort, worsening condition. Transferring Physician Certification: I certify that I have explained the risks and benefit of transfer to the patient/representative. Based upon information available to me at the time of transfer, the medical benefits reasonably expected from the provisions of appropriate medical treatment at another medical facility outweigh the increased risk to the individual. Receiving Hospital and Physician: Accepting Physician (MD5), Time: 2:42 p.m. Accepting Facility: (Facility #2). Accepting facility has capacity to treat patient. Accepting facility agrees to receive the transfer. Mode of Transportation: Ground Ambulance. Transfer Requested By: MD1. Instructions: Send Copy with patient. Keep Original with Medical Record.

3. Patient #1's medical record lacked documentation, a nurse to nurse report, medical records including the certificate of transfer, Form #766, being sent to Facility #2, and/or an appropriate transfer from Facility #1.

4. During a phone interview with A20 (Chief Risk, Regulatory and Patient Safety Officer/Facility #1) on 5/16/25 at 10:24 a.m., A20 indicated that they had received Patient #1 with no accepting physician and when they tried to get the medical records from Facility #1, but they would not provide them to us as they did not have a signed release of information from Patient #1, so to provide any continuity of care to the patient was very difficult for us. A20 indicated that (he/she) had received an email that indicated that they had received a call from an ambulance that they were 10 (minutes) out with an ophthalmology transfer that we were not expecting. They arrived with no transfer paperwork, just a printout of what they did at their facility. There was no accepting physician, no transfer paperwork, and no nurse to nurse report called.

5. During a phone interview with Patient #1 and Family Member #2 on 5/27/25 at 11:22 a.m., they indicated that they were in (Facility #1's) ED for several hours, because (Facility #2) said they did not have a room for Patient #1, but something happened and (Facility #2) ended up taking (Patient #1). (Family Member #2) indicated that they had got down to (Facility #2) and no one knew what was going on. (Family Member #2) thought that all the physicians were communicating with each other, like a big communicating circle, but no one was communicating with each other. No one knew what was going on. (Family Member #2) indicated that when they got to (Facility #2), the receptionist/nurse at the front desk of the ED asked (Facility #1's) EMS staff where the paperwork was and the EMS driver said this is all we have. They did not have anything. They took us to (Facility #2) and dropped us off.

6. During an interview with A5 on 5/29/25 at 1:45 p.m., A5 verified the medical record information for Patient #1.

7. During a phone interview with N2 (Registered Nurse/Emergency Department) on 5/29/25 at 3:15 p.m., N2 indicated that they did not know that (he/she) needed to fill out the "RN Transfer Checklist" documentation. N2 indicated that (he/she) attempted to call the phone number provided to them for (Facility #2) two times but would receive a general message to call back. N2 indicated that (he/she) then google searched the general phone number for (Facility #2's) ED. N2 indicated that (he/she) had spoken with a receptionist in the ED at (Facility #2), informed them that (he/she) needed to give report to a nurse in the ED, gave (his/her) name, call back number, and was on hold for an extended period of time. N2 indicated that (he/she) had to continue patient care and hung up the call. N2 indicated that (he/she) never received a call back from (Facility #2's) ED to give report on (Patient #1).