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Based on medical record review, staff interview, and review of facility policies and procedures, the facility failed to ensure that a patient was not transferred unless the patient requested the transfer in writing or a physician signed a certification that the medical benefits outweighed the risks for 1 of 5 patients (#15) reviewed who had an emergency medical condition and was transferred to another facility. The findings were:

Refer to A-2409 for details on the facility's failure to ensure patient #15 was not transferred to another facility without the patient's written request or a certification signed by the physician stating the benefits outweighed the risks.

Based on medical record review, staff interview, and review of facility policies and procedures, the facility failed to ensure that a patient was not transferred unless the patient requested the transfer in writing or a physician signed a certification that the medical benefits outweighed the risks for 1 of 5 patients (#15) reviewed who had an emergency medical condition and was transferred to another facility. The findings were:

1. Review of the emergency room (ER) record showed patient #15 arrived on 5/18/24 at 6:43 PM and was triaged at 7:05 PM and seen by a physician at 7:11 PM. Review of the physician's note (written by physician #1) dated 5/19/24 showed the patient presented to the ER for evaluation of suicidal ideation. The patient stated s/he was planning to shoot themselves with a friend's gun. The medical screening exam showed the patient's mood was depressed and "...active suicidal ideation." Further review showed "...I believe [s/he] is medically cleared for psychiatric treatment. [S/he] is voluntary to go to [name of inpatient psychiatric hospital] for further management of acute is acute [sic] suicidal ideation. As [s/he] is voluntary and cooperative I do not think [s/he] requires legal hold at this time. We consulted with [name of psychiatric hospital] who accepted patient for transfer. [S/he] will be transferred by ambulance to [name of psychiatric hospital] for further management of acute depression and suicidal ideation..." Review of the disposition note showed the patient was transferred to the psychiatric facility on 5/19/24 at 12:15 AM via ambulance. The following concerns were identified:
a. Further review of the ER record showed no evidence the patient requested the transfer in writing. Further, there was no certification by the physician stating the benefits outweighed the risks. In addition, there lacked documentation of the name of the person at the receiving hospital who agreed to accept the transfer.
b. On 5/30/24 at 4:12 PM the regulatory consultant stated the facility was unable to find a physician certification for the transfer.
c. During an interview on 5/31/24 at 9:40 AM physician #1 stated normally there was a form that was signed by the physician for transfers. When asked why there wasn't a form for patient #15 he stated he did not know. He stated the nurses printed off forms for the physicians to sign.
d. On 5/31/24 at 9:45 AM the ER Director confirmed there was not a transfer certification for patient #15. She stated there may have been some confusion because the patient was willing to go to the psychiatric facility voluntarily.

2. During an interview on 5/31/24 at 9:01 AM the quality assurance coordinator stated ensuring transfer certification forms were completed was not something that was currently being looked at in quality assurance because they didn't realize there was a problem.

3. Review of the facility's policy "EMTALA- Medical Screening Examination and Stabilization Treatment," revised 3/28/24, showed "...Transfer of a Patient may be considered under the following circumstances: a. The Patient is Stable for Transfer; or b. The Patient or Patient's Representative requests Transfer after being informed of the Hospital's obligation to provide stabilizing care and the risks and benefits of transfer; or c. The Patient requires a higher level of care; or d. The Hospital lacks Capacity to treat the Patient." Further, "...The Patient may be Transferred to another Hospital if: a. The physician in attendance or QMP determines that the Patient is Stable for Transfer; or b. The physician in attendance or QMP in consultation with the physician determines that the benefits of Transfer outweigh the risks; or c. The Hospital is unable to stabilize the Patient within its capacity; d. The Patient or his/her Representative requests Transfer after being advised of the Hospital's obligation to provide care and the risks and benefits of Transfer...Transfer of the Patient who is not Stable for Transfer is accomplished as follows: a. The form "Request for Transfer/Consent to Transfer/Certification for Transfer" is required and fully completed for Patients. The Patient's or Patient Representative's written consent/request is documented on this form. b. There is an accepting facility with available space and qualified personnel and documentation noting the date and time of the transfer request and the name of the individual authorized to accept the Patient on behalf of the facility. c. The Transfer is affected through appropriate means consisting of the necessary qualified personnel and transportation equipment including the use of life support measures..."