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Based on interview and record review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide an appropriate transfer to another facility (see A-2409) resulting in the potential for less than optimal outcomes for all patients seeking emergent care.

Based on observation and interview, the facility failed to post Emergency Medical Treatment and Labor Act (EMTALA) signs in areas likely to be noticed by all individuals that visit the emergency department (ED), resulting in the potential for all ED patients to not be informed of their rights to have a medical screening exam and stabilizing treatment in the ED. Findings include:

During the observational tour of the ED, on 10/6/20 at approximately 0930 - 1120, it was noted that there was only one small EMTALA sign (approximately 8 inches x 11 inches) posted in the corner of the "Identification" Station. The ED was a large 53 room facility. There were no signs posted in the Waiting Area, not in the Triage Rooms, and not in the Treatment Rooms/Areas. There was one other small sign (also 8 inches x 11 inches) in the ED that was covered up by a laundry shelving unit near the Ambulance Bay. The shelving unit had to be moved to visualize the EMTALA sign.

On 10/6/20 at approximately 1120, ED Nurse Director A was queried about the lack of EMTALA signs and she stated, "We thought that was all that was required." On 10/7/20 at approximately 1145, interview with Regulatory Coordinator B regarding EMTALA signs revealed that, "XYZ individual said we probably should have more..."

Based on interview and record review, the facility failed to communicate directly with the receiving facility when it transferred 1 (#8) of 12 patients to affirm acceptance of the patient for further treatment, resulting in an inappropriate Emergency Medical Treatment and Labor Act (EMTALA) transfer and potential for unsatisfactory outcomes. Findings include:

Medical record review (Facility A) revealed that patient #8 was a 44-year-old male who presented to the Emergency Department (ED) on 8/22/20 at 1253 for alcohol withdrawal symptoms of tremors, anxiety, and sweats. Other co-morbidities included diabetes mellitus and hypertension. History included recent alcohol rehabilitation, but he continued to drink a fifth of vodka a day, with the last drink that morning at around 1000. Laboratory blood levels, electrocardiogram (EKG), social work, and alcohol withdrawal assessment (CIWA) and medication protocol were performed. The patient received oral Phenobarbital per CIWA score every one-to-two hours. The Social Worker worked on placement for inpatient treatment via transfer to another hospital's Emergency Department and to their affiliated hospital C. The patient was transferred to the other Facility B on 8/23/20 at 0141 via ambulance.

Medical record review (Facility B) revealed that patient #8 arrived at the ED by ambulance on 8/23/20 at 0205. The ED notes documented that there was "No report received from the transferring facility, no EMTALA form, no accepting ED physician ..." The patient continued to have withdrawal symptoms and CIWA protocol assessments with medications of Ativan and Librium were given to reduce withdrawal symptoms. The patient was discharged on 8/23/20 at 0918 to continue on oral medications to treat withdrawal symptoms, with instructions for tapering off.

On 10/6/20 at approximately 1130, interview with Behavioral Specialist D, revealed that there was a "Patient Transfer Record" form that was to be used for patient transfers to another facility that documented physician to physician communication, risks, benefits, and physician signature. That carbonless copy form was provided. A request for patient transfer policy and procedure was requested, and the "EMTALA Guidelines, revision date 11/20/19" was provided. The ED Nursing Director stated, "There is no other policy and procedure for transfers...just the guidelines," on 10/6/20 at approximately 1600.

On 10/7/20 at 0900, interview with Social Worker L revealed that she worked and communicated with the patient and "GW Organization" (Outpatient Peer Recovery Coach) to arrange for transfer of this patient to an inpatient substance abuse treatment facility. She stated that she was a newer contingent social worker and was unaware of the paperwork required for transfer. She stated that "GW Organization" told her that the patient would have a better chance to get into the inpatient setting if he was at Facility B.

On 10/7/20 at 0920, interview with Staff Nurse M revealed that when she cared for the patient, he had tremors, occasional sweats, and increased anxiety. He had an elevated heart rate and elevated blood pressure. The Nurse gave him oral Phenobarbital for withdrawal symptoms per protocol until her end of shift at 1930 on 8/22/20.

On 10/7/20 at 1030, interview with Staff Nurse O revealed that she had taken care of the patient at transfer time on 8/23/20 at 0130. She stated that the patient was stable, but he wanted to go to an inpatient setting sooner than later. She stated that when the ambulance arrived, they insisted on a copy of the medical record before transport. Nurse O stated that she was not familiar with the EMTALA requirements for transfer. She stated that the social workers handle behavioral transfers.

On 10/7/20 at 1100, interview with ED Medical Director K stated that "the patient was stable." The Medical Director further stated that the social worker was working on substance abuse placement and that the patient should have been discharged as opposed to transferred to another ED.

On 10/7/20 at 1500, interview with ED Physician U revealed that she came on her shift at 2300 on 8/22/20. She got report that the patient was stable, and the social worker was working on placement. She stated, "I didn't know that the patient was transferred." She had not written an order or signed paperwork to discharge or transfer the patient.