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Based on record review and interview, the facility failed to gain the receiving facility's agreement to accept the transfer for 7 of 8 transferred in-patients (Patient #1, #2, #3, #4, #5, #6, and #7) utilizing 911 services.

Findings

Patient #1's, #2's, #3's, #4's, #5's, #6's, and #7's record (in-patients) did not reflect completed MOT (Memorandum of Transfer) to include the agreement to accept the patient prior to the transfer.

During an interview and record review on 6/08/2020 ending at 1:46 PM, Personnel #3 was asked for the MOT for Patient #1. Personnel #3 stated, "I don't see one." Personnel #3 was asked about emergent transfers via 911 and the use of the MOT to document the receiving facility's acceptance, physician to physician, and nurse to nurse reports. Personnel #3 stated, "We get an order, call 911, and send them out. We don't delay the emergent care of the patient for the MOT completion. When we call, they refuse to do an MOT with us. They (acute hospital) say are they (patient) already on the way and they (acute hospital) don't need it (MOT)."

The facility was asked for copies of the 8 patients' MOTs. Three patients had MOTs. One patient had the MOT process completed with receiving facility acceptance, physician to physician, and nurse to nurse reports.

During an interview on 6/08/2020 ending at 3:25 PM, Personnel #4 was asked about Patient #1. Personnel #4 stated, "She had a seizure. We took care of her, called the doc, and he ordered 911 transport. Once she was taken, I called for the fax number to send the MOT, accepting administrator, and nurse report. They (acute hospital) said if she was on the way. I said yes. They (Acute Hospital) said they didn't want the MOT. Would not give an accepting ACO or Doctor. They didn't refuse the patient. Just wouldn't do an MOT with me." Personnel #4 discussed the records that were copied and sent with the ambulance.

During a telephone interview on 6/09/2020 ending at 10:58 AM, (Personnel #3 was present) Personnel #5 he was asked if he was called before 911. Personnel #5 stated, "Yes. In this case, I was not in the facility. They called me first, described the situation. I asked if there was previous history of seizures. I was told no, then I gave order for 911 due to grand mal seizure - new episode, and to immediately send for further eval and treat. Possibly IV (intravenous) anticonvulsants, and CT scan." Personnel #5 was asked if they do IVs at facility. Personnel #5 stated, "No."

Personnel #3 interrupted the interview with the physician to add, "The patient was postictal, but not quite recovered when the paramedics arrived. She was still having seizure like activity. She was not clear and able to speak correctly." Personnel #3 was asked if the patient was speaking during the seizure. Personnel #3 stated, "No."

During a telephone interview (Personnel #3 was present) on 6/09/2020 at 11:01 AM, Personnel #6 stated she responded to the code blue and took care of the patient. Personnel #6 was asked if she dealt with the patient and then later wrote her note. Personnel #6 stated, "Yes." Personnel #6 was asked what the 17:02 time referred to. Personnel #6 stated, "When I went to the cafeteria. Multiple nurses and staff responded. When I got there the patient was on the pillow and stabilized." Personnel #6 was asked what she meant by stabilized. Personnel #6 stated, "She was on her side and everything was cleared away, so she wouldn't hurt herself during the seizure."

Personnel #6 was asked that the vitals documented were stable. Ms. Moore stated, "Yes, ma'am. But non-coherent speech at the time." Personnel #6 was asked if she called the doctor and what was her report to him. Personnel #6 stated, "She was having a seizure - had no history of seizures - post-partum - broken, garbled speech - I think she needs to go out."

Personnel #6 was asked if 911 was called before the doctor was called. Personnel #6 stated, "No. Ma'am."

Personnel #6 was asked how long the seizure was. Personnel #6 stated, "about 16 minutes." Personnel #6 was asked if EMS was opposed to transporting the patient. Personnel #6 stated, "No."

Personnel #6 was asked the condition of the patient (blue, low sats, unstable vital signs, foaming at the mouth, hit her head) during and after the seizure. Personnel #6 stated, "I would not say foaming, saliva but not foaming. She did not hit her head that I was aware of. The PCA (Patient Care Assistant/Tech) noticed her having issues and assisted her down to the ground."

Personnel #6 was asked if the patient recovered before the EMS arrived. Personnel #6 stated, "The jerking had stopped, but she was rigid and groggy. She wasn't completely recovered."

Personnel #6 was asked about using the MOT process. Personnel #6 stated, "Not for 911. We take care of the patient, send them out, then the house supervisor contacts the facility for faxing the MOT, the nurse to nurse, physician to physician, etc." Personnel #6 was asked about records. Personnel #6 stated, "They make copies of the MAR (Medication Administration Record), H&P (History & Physical), Allergies, CPE (comprehensive psychiatric eval) and send with 911."

Personnel #6 added, "In Psychiatry, we send a staff member if the hospital allows it. The reason to ensure safety of the patient until it is decided if the patient will admit. We keep eyes on them."

Personnel #3 added, "We try to send a staff member because they are still our patient. We are still responsible with them unless they admit. We now ask for permission to send staff. During COVID they refused. They would not let our staff in and if they weren't with the patient, they could not give information to them." Personnel #3 was asked for additional polices to support. Ms. Sandra stated, "I have not found others."

The facility's February 2020 "Medical Staff Rules and Regulations" required, "The Hospital's transfer policy and procedures, which conform to regulatory and legal requirements, shall be adhered to and only medically necessary, appropriate transfers shall be made..."

The facility's January 2020 "Transfer to Another Facility" policy required, "Physician duties...determine the medical needs and to ensure that the proper transfer procedures are used...Prior to transfer, the transferring physician shall ensure the receiving hospital and a receiving Physician that are appropriate to the medical needs of the patient have accepted responsibility for the patient's medical treatment and hospital care...Transfer of patients who have Emergency Medical Conditions...If a patient at a Hospital has an emergency medical condition which has not been stabilized or when stabilization of the patient's vital signs is not possible because of the hospital or emergency department does not have the appropriate equipment or personnel to correct the underlying process, evaluation and treatment shall be performed and transfer shall be carried out as quickly as possible...A physician has signed a certification which includes a summary of the risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient...from effecting the transfer...a qualified medical person may sign a certification...after consult with the physician. The physician shall countersign the physician certification within a reasonable period of time..."