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Based on record review, interview and policy review, the facility failed to ensure a patient was transferred to the correct accepting facility. This affected one (Patient #1) of six patients reviewed for transfer.

See A2409

Based on record review, interview and policy review, the facility failed to ensure a patient was transferred to the correct accepting facility. This affected one (Patient #1) of six patients reviewed for transfer. This had the potential to affect all patients who arrive at the facility's emergency departments. The average daily census of the facility's emergency departments for the past year was 171.

Findings include:

Patient #1 arrived at the facility's emergency department on 06/09/24 at 4:56 PM. Patient #1 received a medical screening exam and it was determined that Patient #1 needed to be transferred to a higher level of care for vascular surgery. Patient #1 was transferred to Hospital B in West Virginia on 06/09/24 at 11:12 PM.

Resident Physician H filled out the receiving provider and facility information on the Physician Certification for Transfer form. ED Physician K signed the physician certification for the transfer of Patient #1. It was later discovered that Resident Physician H filled out the incorrect location of the hospital where Patient #1 was supposed to be transferred to. Patient #1 was supposed to be transferred to Hospital A in West Virginia. He was transported to Hospital B in West Virginia, about 150 miles past Hospital A.

An addendum by Resident Physician H on 06/10/24 at 2:01 AM stated "I was informed by EMS (Emergency Medical Services) crew that patient was apparently dropped off at the incorrect location. Originally had requested to talk to vascular surgery at [Hospital A]. After numerous attempts we were unable to contact the physician there. I have then asked to speak with [Hospital B]. I was then contacted back by a vascular surgeon via the transfer center. I was under the impression that this was a vascular surgeon at Hospital B who had accepted the patient to the emergency department when in fact this was the vascular surgeon [Physician X] we had difficulties getting ahold of at [Hospital A]. Paperwork was filled out and patient was transferred out of the emergency department and had incorrectly arrived at Hospital B with no accepting physician. It was then confirmed that patient was accepted at [Hospital A]. After some discussion with Hospital B, they had then accepted the patient for vascular services. The new accepting physician is Physician Z in the emergency department. This plan was discussed with the transfer team and the patient."

During an interview on 07/30/24 at 9:30 AM, Resident Physician H stated Patient #1 came in for vascular issues, Patient #1 had procedures done in an outside facility. "We talked to our vascular, he (the facility's vascular surgeon) doesn't do peripheral vascular things, we had difficulty getting ahold of vascular, we started looking elsewhere, we were contacting multiple facilities at the same time and getting calls back from transfer centers". Resident Physician H stated there was a breakdown in communication which resulted in the facility transferring Patient #1 to the wrong hospital. He stated the facility contacted Hospital A initially, for Physician X, a vascular surgeon. When Physician Z also a vascular surgeon, returned the call, Resident Physician B thought he was on the phone with Hospital A the entire time. Resident Physician H said Hospital B then called and said they never accepted the transfer of Patient #1. Patient #1 was accepted at Hospital A by Physician Y. Resident Physician H gave the Physician Certification for Transfer form to the health unit coordinator, who contacts the transport team based on the information on the form. Resident Physician H stated Hospital B called them around midnight regarding the arrival of Patient #1.

During an interview on 07/30/24 at 2:19 PM, Staff A verified Patient #1 was transferred to the wrong hospital.

Review of the facility policy titled "EMTALA -Transfer Policy", reviewed 12/13/23, stated, in part, the physician certification that the benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the risk of the transfer is not required for transfers of individuals who no longer have an emergency medical condition, unless otherwise required by state law. A stabilized patient may be transferred upon request or pursuant to prearranged transfers/treatment plans of state, county or other entities if the following conditions are met:
i. Documentation of patient stabilization has been prepared by a physician or a qualified medical person in consultation with a physician (physician's counter-signature is required on documentation;
ii. The transferring hospital should document its communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer;
iii. If the transfer is requested by the patient, the request must be in writing and must indicate the reason(s) for the request as well as indicate that the patient is aware of the risks and benefits of the transfer;
iv. The patient has been informed of the hospital's obligation to provide an emergency medical screening and the necessary stabilizing treatment;
v. The receiving facility: has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer of the individual and to provide appropriate medical treatment; and
vi. The individual agrees to the transfer.
h. A transfer to another facility will be appropriate only in those cases in which:
i. The facility provides medical treatment within its capabilities that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child.
ii. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate treatment.
iii. The facility sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or written certification as required in section "e" or "g" above. This documentation must also include the name and address of any on-call practitioner who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available from the transferring hospital at the time of the patient transfer) must be sent as soon as practical after such transfer. Records must accompany the patient whether or not the patient's emergency medical condition is stabilized.
iv. The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer.
i. Appropriate transfer documentation, as outlined above, must be included in the patient's medical record.
j. Each facility, through its designated personnel and/or Emergency Department physicians must obtain the consent of the receiving or recipient hospital and the receiving physician before the transfer of the patient and must make the appropriate arrangements for the patient transfer with the receiving hospital and physician.
k. The physician at the transferring facility has the responsibility to determine appropriate mode of transportation, equipment and attendants necessary to effect a transfer to a receiving or recipient facility.