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Based on interview and record review, the facility failed to document 30 of 31 sampled EMTALA interfacility tranfer patients (Patient 1 to Patient 30) in a central log. This failure had the potential to contribute to inaccurate record keeping of EMTALA interfacility transfers and adverse health outcomes.

Findings:

During a concurrent interview and record review on 5/2/2023, at 1:49 PM, with Vice President of Quality (VPQ), a copy of a central log for EMTALA interfacility transfer was requested. VPQ stated, the facility did not have a central log for transfers, the facility should have a central log.

During an interview on 5/2/2023, at 2:00 PM, with Chief Nursing Officer (CNO), CNO stated, he had not heard of the central log.

During a review of the facility's policy and procedure (P&P) titled "EMTALA - Interfacility Transfers, MSE Emergency Care and Stabilization" undated, indicated, ". . . 2. All contacts with agencies requesting EMTALA transfer to [facility] will be kept in a Central Log to be located in the House Supervisor's Office. The log will consist of the following information:
a. Date and time of call
b. Name of transferring hospital
c. Name of the caller (position if known)
d. Telephone number of the caller
e. Name of staff member receiving the call
f. Patient name
g. Patient age
h. Name of transferring physician
i. Other basic information (no insurance information). . .3. The "Transfer Checklist and Script for Accepting Emergency Patients" form will be used for all transfer request to determine if there is an EMTALA obligation to accept a transfer. Information will be documented on the Transfer Request Central Log. If the transfer is an EMTALA request and [facility] has capacity and capability to treat the individual, the transfer must be approved."