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Based on document review and interview, it was determined that in 1 (Patient #1) of 20 medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide an appropriate transfer.

Findings Include:

1. See findings cited at 42 CFR 489.24 (e) (1)-(2) Appropriate Transfer.

Based on document review and interview, the facility failed follow their policy to ensure an appropriate transfer was completed for 1 of 20 patients' medical records reviewed. (Patient #1)

Findings include:

1. Facility policy titled "COBRA EMTALA - Emergency Medical Treatment and Active Labor Act", PolicyStat 14791143, last revised 12/2023 indicated During an EMR downtime, Form #766 Certificate of Transfer should be utilized. c. The transfer must be an appropriate transfer. 3. Appropriate Transfer: For a Transfer to be appropriate, the Hospital must: a. Provide medical treatment within the Hospital's Capability and Capacity that minimize the risks to the individual's health. b. Obtain agreement from a receiving facility that the receiving facility has the Capability and Capacity to treat the individual and that it will accept the Transfer and provide appropriate medical treatment. c. Use qualified personnel and transportation equipment as required to effect the Transfer safely. d. Send to the receiving facility copies of all available medical records related to the Emergency Medical Condition. In the alternative, Form #766 may be used. As soon as practicable after the Transfer, send by facsimile copies of any records not available at time of Transfer. Records to be sent include any available history, observations of signs or symptoms, preliminary diagnosis, result of diagnostic tests or telephone reports of test results, and treatment provided."

2. Review of Patient #1's medical record lacked completed Form #766, Certificate of Transfer, during an EMR (Electronic Medical Record) downtime transfer. Patient #1 MR lacked documentation of an agreement from the receiving facility that the receiving facility has the Capability and Capacity to treat the individual and that it will accept the Transfer and provide appropriate medical treatment. Patient #1 MR lacked documentation of copies of all available medical records related to the Emergency Medical Condition being sent to the receiving facility.

3. During an interview with A6 (Emergency Department Manager) on 6/7/24 at 11:30 a.m., (he/she) verified the medical record information for Patient #1.

4. During an interview with A6 on 6/7/24 at 12:45 p.m., (he/she) verified that they did not think that it was an issue as it was a transfer and MD1 (Doctor of Medicine/Emergency Medicine) called and notified Facility #2's ED (Emergency Department) physician on call and let them know about the systems being down at the facility and notification of Patient #1 coming to their ED.

5. During a phone interview with N1 (Registered Nurse/Emergency Department) on 6/10/24 at 12:21 p.m., (he/she) verified that MD1 explained that the patient was going to leave and go to another facility and MD1 was going to call the other facility as a courtesy to tell them that Patient #1 was on her way there N1 verified that MD1 never said that Patient #1 was a transfer, but that the patient was going to another facility of their own free will. N1 verified that (he/she) did not observe and/or overhear MD1 contact the other facility. N1 verified that (he/she) did not think that Patient #1 was considered a transfer, because N1 would have filled out EMTALA paperwork as well. So N1 did not think it was a transfer.

6. During a phone interview with Patient #1 on 6/11/24 at 11:42 a.m., Patient #1 verified that the ED Physician at Facility #1 told them "I cannot tell you to go to another hospital but I recommend that you go to another hospital." Patient #1 verified that the ED physician told them they had no phone service but would use (his/her) personal phone to call (Facility #2) to let them know (he/she) was on their way to the facility and the circumstances. Patient #1 verified that (he/she) was at Facility #1's ED approximately 5-10 minutes at the most. Patient #1 verified that (he/she) went to Facility #2's ED, which is an hour from Facility #1 and was admitted and discharged two days later.

7. During a phone interview with MD3 (Doctor of Osteopathy, DO/Emergency Medicine) on 6/11/24 at 2:02 p.m., MD3 verified that an ED physician did contact (him/her) from Facility #1 on 4/10/24 and let me know that there was a patient that was going to be coming to Facility #2's ED. MD3 verified that if it was a formal transfer, I would have stated this patient transferred from another facility in Patient #1's medical record at Facility #2.