HospitalInspections.org

Based on record review and interview, the facility staff failed follow their Emergency Medical Treatment and Labor Act (EMTALA) policies and procedures by failing to ensure an appropriate transfer to another medical facility in 1 of 8 patients transferred to another acute care facility in a total of 20 medical records reviewed (Patient #1).

Findings include:

The facility staff failed follow their EMTALA policies and procedures by failing to ensure an appropriate transfer to another medical facility in 1 of 8 patients transferred to another acute care facility. See tag A-2409.

Based on record review and interview, the facility staff failed follow their policies and procedures by failing to ensure an appropriate transfer to another medical facility in 1 of 8 patients transferred to another acute care facility in a total of 20 medical records reviewed (Patient #1).

Findings include:

Review of policy titled Emergency Medical and Treatment (EMTALA)" #8304980, last revised 7/28/2020 under Definitions revealed ""Transfer" is the movement of a patent, including discharge, outside the Hospital's facilities at the direction of any Hospital employee." Under Transfers #3 "the transfer must be an "appropriate transfer." Under #4. "it is the policy of the Hospital to facilitate the transfer in compliance with federal EMTALA regulations. a. Contact the Receiving Facility... the physician... shall convey the following information... 5. Physician name (physician to physician contact is expected - if the receiving facility allows non-physicians to accept transfers, the non-physician's name and this fact should be noted.)... The physician or Qualified Medical Person shall complete the "Transfer Form" prior to transfer... copies of the medical record must be provided to the receiving facility... Hospital personnel shall document in the progress notes all contacts between the Hospital, the receiving facility... including date and time of the contact, name of the person(s) spoken with, and a summary of the information exchanged."

Patient #1's medical record revealed a 28-year-old with a history of anoxic brain injury, anxiety, and a known history of cutting, who presented to the emergency department (ED) with her/his group home worker on 4/10/2021 after swallowing glass with suicidal ideation. Patient #1 was placed on a Chapter 51 hold (involuntary commitment for treatment) on 4/10/2021 at 1:00 PM, assessed by the mobile crisis team 4/11/2021 at 8:45 AM who removed the hold, and was discharged back to the group home 4/11/2021 at 11:58 AM. On 4/13/2021 Patient #1 presented to the ED with the group home owner who presented paperwork from another county and stated Patient #1 was having behavioral issues, bit a group home member, and was requesting Patient #1 be put into a psychiatric hospital under emergency detention. Attempt was made, by social services, to place Patient #1 in an inpatient behavioral health bed, which was unsuccessful. Physician note dated 4/13/2021 at 5:02 PM revealed "The assessment and plan has been discussed... pending discharge ambulance transportation directly to [acute care facility]." Patient #1 was discharged and taken to [an acute care facility] in another county. There was no transfer form, physician to physician contact, or contact with the receiving facility documented in the medical record prior to transfer.

On 6/14/2021 at 1:05 PM during interview with Social Worker (SW) I, SW I stated the crisis worker from the other county arranged transportation back to their county stating s/he "assumed" they told the hospital that Patient #1 was coming.

On 6/15/2021 at 11:00 AM during interview with Emergency Director B, Director B stated it is the expectation that the social worker would notify the physician with information on the plans to transfer a patient to another facility and there would be physician to physician contact with the receiving facility prior to transfer. Director A confirmed there was no transfer form in Patient #1's medical record.

On 6/14/2021 at 3:45 PM during interview with ED Medical Doctor (MD) L, when questioned who made contact with the receiving hospital for Patient #1's transfer, MD L stated "I take the responsibility, I should have made the physician to physician contact."