HospitalInspections.org

Based on policy review, medical record review, staff and physician interviews, the facility failed to comply with 42 CFR §489.20 and §489.24.

Findings include:

1. Based on facility policy review, medical record review, staff and physician interviews, the hospital's medical providers failed to provide an appropriate transfer by failing to document the certification of the risks and benefits at the time of transfer in 4 of 5 patients who transferred to another medical facility (Patient #1, 10, 11, and 13).

~ Cross refer to §489.24(e) Restricting Transfer Until the Individual Is Stabilized - Tag A2409

Based on facility policy review, medical record review, staff and physician interviews, the hospital's medical providers failed to provide an appropriate transfer by failing to document the certification of the risks and benefits at the time of transfer in 5 of 5 patients who transferred to another medical facility (Patient #1, 10, 11, and 13).

The findings included:

Review of the facility policy, Treatment of Patients with Emergency Medical Conditions (EMTALA), effective 06/2021, revealed, "... If the qualified medical personnel determines that an emergency medical condition exists and the patient has not been stabilized, the patient may be transferred to another medical facility when one of the following occurs: ... A physician has signed a written certification (using the EMTALA forms within (named electronic medical record system), including the risks, benefits and reasons for transfer, that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the individual, and, in the case of labor, to the unborn child from effecting the transfer... For physician-initiated transfers for medical benefits, a re-evaluation of the patient must be performed shortly prior to the actual transfer, and the findings documented in the medical record. If the patient has been stabilized or is unchanged, proceed with the transfer. If the patient's condition has declined, then the risks and benefits of the transfer should be reevaluated and newly documented..."

1. Closed medical record review of Patient #13 revealed a 47-year-old male who presented to the Dedicated Emergency Department (DED) on 06/04/2022 at 1857 with complaints of foot infection/foot injury. Review of the Physician Note dated 06/04/2022 at 1945 revealed, "... history of T2DM, IVDU (intravenous drug use), MRSA (Methicillin-resistant staphylococcus Aureus), and hepatitis who presents with 3 weeks of an infected wound on the left side of his left foot that hurts when ambulating... On exam, there is a foul-smelling necrotic wound on the left foot. Differential diagnosis includes MRSA versus osteomyelitis versus necrotizing fasciitis... He has been treated here with comycin, cefepime, and metronidazole (antibiotics/antifungals for treating infection). He will be transported to (named facility) when transport can be arranged..." Review of the Transfer form dated 06/04/2022 at 2352 by Medical Doctor (MD) #9 revealed, "... Medical Benefit for Transfer: Obtain level of care/service not available at this facility - surgery. Medical Risk for Transfer: Worsening of condition or death if not transferred..." Medical record review revealed Patient #13 was transferred from the facility at 06/05/2022 at 0920 (9 hours and 38 minutes after the certification) via BLS (basic life support) ground transportation. Medical record review failed to reveal documentation of patient specific risks and benefits of transfer at the time of transfer.

Interview on 10/26/2022 at 1505 with MD #9 revealed the transfer form was completed electronically. Interview revealed the risks and benefits had free text spaces to write patient specific information. Interview revealed the transfer form could be clarified more. Interview revealed the documented medical risks did not necessarily match what was actually discussed with each patient. Interview revealed the documented medical risks were commonly documented as the risks if the patient does not transfer instead of transferring to another facility. Interview revealed that Patient #13 had an update in the progress notes that was sufficient for the certification of stability for transfer in addition to the certification that was done the prior day.

Interview on 10/26/2022 at 1005 with Chief Medical Officer (CMO) #3 revealed the transfer form was embedded into the electronic medical record system. Interview revealed that each provider was responsible for documenting the risks and benefits on the form after discussion with the patient. Interview revealed the transfer form was completed as soon as the provider had an accepting facility and provider. Interview revealed that recently the facility had encountered delays in transport which impacted the timing between transfer form completion and the patient's facility departure. Interview revealed the expectation that the providers communicate and document patient changes in condition prior to transfer.

2. Closed medical record review of Patient #10 revealed a 24-year-old female who presented to the DED (dedicated emergency department) on 07/02/2022 at 1613 with complaints of labor pain. Review of the Physician Note dated 07/02/2022 at 1712 revealed, "... PMH (previous medical history) of HTN (hypertension - condition with high blood pressure) and T2DM (type 2 diabetes mellitus - condition with high blood sugar) presenting for evaluation of labor pains... Patient is a high risk pregnancy due to pre gestational diabetes and HTN. She is on insulin (medication that lowers blood sugar) and labetalol (medication that lowers blood pressure) for her diabetes. Patient has a history of poor compliance with HTN regimen... Patient presents to the ED (emergency department) today for increased contraction frequency and intensity. Suspect likely early labor given prolonged contractions at progressively shortened frequency given... Care of patient transferred to (named) maternal child care center..."

Review of the Transfer form dated 07/02/2022 at 1718 by CMO #3 revealed, "... Medical Benefit for Transfer: Obtain level of care/service not available at this facility - Requires higher level of care with labor and delivery and obstetrics, possible NICU (neonatal intensive care unit). Medical Risk for Transfer: Worsening of condition or death if not transferred..." Medical record review revealed Patient #10 was transferred from the facility at 07/02/2022 at 1922 (2 hours and 4 minutes after the certification) via ALS (advanced life support) ground transportation. Medical record review failed to reveal documentation of patient specific risks and benefits of transfer.



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3. Medical record review, on 10/25/2022, revealed Patient #1 presented to the DED on 08/22/2022 at 0055. Review of "ED Provider Notes", date of service 08/22/2022 at 0223, revealed " ... (Patient #1) is a 78-year-old female with a history of diabetes, hypertension, hypothyroidism (low thyroid), atrial fibrillation (irregular, often rapid heart rate, where the upper chambers of the heart beat out of coordination with the lower chambers), who presents with left-sided chest pain. Onset when she was trying to fall asleep tonight, pain radiates into her left shoulder and left upper back. She feels slight tightness in her breathing, but overall no cough and not short of breath. She has chronic swelling in her lower legs ....Her left leg is more swollen than her right ....Her calf is tender ....ASSESSMENT & PLAN ....Repeat troponin (lab test) is significantly elevated from previous study ....She continues to have chest pain at 6 out of 10 ....Working to transfer .... to (Hospital Name). ..." Review of an "ED Progress Note", at 2000, by MD #12 revealed " ...presenting with chest pain, having an NSTEMI (Non-ST-Elevation Myocardial Infarction) ....Has been ruled out for PE (pulmonary embolus) and DVT (deep vein thrombosis) ....has been accepted to (Hospital Name) with bed assignment ....0151 (08/23/2022) (Transport team) at bedside to transport to (Hospital Name). She is pain free at this time, with hypertension but otherwise stable VS (vital signs). No deterioration anticipated during transit. ..." Review in Flowsheets of the "EMTALA Transfer Form", initialed by a MD #11 on 08/22/2022 at 1824, revealed " ...Medical Benefit for Transfer .... Obtain level of care/service not available at this facility .... cardiology service .... Medical Risk for Transfer .... (Specify in comment field) ...." Form review did not reveal a specified medical risk of the transfer. Review of the PHYSICIAN CERTIFICATION section of the Transfer Form revealed the Date and Time of the Certification were noted as "08/22/2022" at "1600". In smaller grayed type after both the stated date and time were two initials that matched the certifying physician's name (MD #11) then "08/25/22 1445." DED medical record review revealed Patient #1 was transferred from the facility to another acute care hospital on 08/23/2022 at 0135 (approximately 6 hours after the electronic documentation of the benefits of transfer, and two days before the initialed date and time of the certification). Medical record review failed to reveal the physician certification or documentation of patient specific risks of near the time of transfer.

Telephone interview on 10/26/2022 at 1440 with MD #11 revealed the transfer for Patient #1 was medically indicated because of needing cardiology specialists and was stable to be transferred. Interview revealed there were usually two risks on the electronic form, medical risks which would need a comment or the risk of worsening of condition if not transferred. Interview revealed he usually considered the risk of worsening of condition if not transferred. MD #11 stated he certified the patient agreed to the transfer. Once MD #11 completed the Transfer form, any further documentation, he stated, would be in the progress notes.

Telephone interview with MD #12 on 10/26/2022 revealed that the certification was to show the physician intended to transfer the patient, that it was "like a physician order to transfer." Interview revealed the physician signed the Transfer form once the patient was assigned a bed. Interview revealed they had been coached to document a set of vital signs/ condition before transfer. MD #12 stated she made a note at 0151 and stated if she was not physically at the bedside she was looking at the monitor and giving report on the patient. Interview revealed that was to update and say the patient was still stable.

Interview on 10/26/2022 at 1505 with MD #9, ED Medical Director, revealed the transfer form was completed electronically. Interview revealed the risks and benefits had free text spaces to write patient specific information. Interview revealed the transfer form could be clarified more. Interview revealed the documented medical risks did not necessarily match what was actually discussed with each patient. Interview revealed the documented medical risks were commonly documented as the risks if the patient does not transfer instead of transferring to another facility.

4. Medical record review, on 10/26/2022, revealed Patient #11 presented to the DED on 09/19/2022 at 1330. Review of "ED Provider Notes" by MD #12, date of service 09/19/2022 at 1412, revealed "... ASSESSMENT & PLAN 44-year-old with history of severe depression, borderline personality disorder, PTSD (post traumatic stress disorder), currently using cocaine, presents with law enforcement requesting help with suicidal ideation. She has persistent thoughts of wanting to step into traffic, says she has barely stopped herself from doing this. Also wants to jump off a bridge. She called for help, says she does not want to put her family through more pain. Last cocaine use this morning. She is committed to working toward sobriety from cocaine. She reports that she has been taking her medications, and is willing to continue to do so. Appreciate telepsych consultation form (hospital initials). They recommend inpatient care with involuntary commitment at this time. Working towards medical clearance as the cocaine wears off of her system. No evidence of acute illness at this time. Labs notable for anemia, which is chronic, at her baseline. K (Potassium) is mildly low, replaced orally ....6:23 PM Medically clear at this time, can proceed with bed finding for acute inpatient pasych stabilization. At change of shift I will sign her care over to (MD #13). ..." Review of the ED Progress Note by MD #13 at 1941 revealed " ...7:42 PM I assumed care of patient from (MD #12) ....she is IVC'd (involuntarily committed) and medically cleared. Patient has been accepted to (Name of Psych facility) and law enforcement will transport her at 8AM." Review in Flowsheets of the "EMTALA Transfer Form", initialed by MD #13 on 09/19/2022 at 2024, revealed "...Medical Benefit for Transfer .... Obtain level of care/service not available at this facility .... Inpatient psych." Review of the "Medical Risk for Transfer", initialed by MD #13 on 09/19/2022 at 2024 revealed "Worsening of condition or death if not transferred." Form review did not reveal a specified medical risk of transfer; instead it revealed a risk of not being transferred. Review of the "PHYSICIAN CERTIFICATION" section of the Transfer Form revealed the Date and Time of Certification were documented and initialed by MD #13 on 09/19/2022 at 2024 (12 hours prior to transfer). On 09/20/2022 at 0759 DED record review revealed vital signs of temperature 98.5, heart rate 98, respirations 18, blood pressure 147/85 and pulse oximetry of 100% and Patient #11 was transferred out by law enforcement at 0840. While review revealed vital signs taken close to the time of transfer, record review did not reveal certification that benefits exceeded risks at the time of transfer, did not reveal any updated provider notes after 2024 and did not reveal any documented risks of transfer.

Telephone interview with MD #12 on 10/26/2022 revealed the certification was to show the physician intended to transfer the patient, that it was "like a physician order to transfer." Interview revealed the physician signed the Transfer form once the patient was assigned a bed and generally made progress notes after that. Interview revealed the purpose of the progress note was to update that the patient was still stable.

Interview on 10/26/2022 at 1535 with MD #13 revealed that in relation to risk, she usually checked the box on the form about worsening condition or death. Further interview revealed if there was no change in the patient or accepting condition or hospital, they would usually document in a progress note.