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Based on policy review, medical record review and interview, the hospital failed to appropriately document the transfer for one of 21 (Patient #15) sampled patients who presented to the Emergency Department (ED) seeking medical treatment that was transferred.

The findings included:

Medical record review for Patient #15 revealed a 26 year old female who presented to Hospital #1's ED on 8/1/2024 at 12:43 PM, with reported suicidal ideations. The Medical Screen Examination (MSE) was initiated at 1:09 PM and included an evaluation by Mobile Crisis services. The Mobile Crisis evaluator recommended psychiatric hospital placement. Patient #15 was transferred to an acute psychiatric facility on 8/1/2024 at 4:52 PM. Review of the Acute Care Transfer Form revealed ED Physician #2 did not fully complete the Patient Consent Section or the Risks and Benefits of Transfer Section.

Cross Refer to A 2409.

Based on policy review, medical record review and interview, the hospital medical staff failed to document the risks and benefits for transfer for one of 21 (Patient #15) sampled patients who presented to the Emergency Department (ED) seeking treatment that was transferred.

The findings included:

1. Review of the hospital policy "EMTALA [Emergency Medical Treatment and Labor Act], Definitions and Terminology" revised 11/2019, revealed, "...Transfer means the movement of an individual outside the Hospital's facilities at the direction of any person employed (or affiliated with) the Hospital... Transfers include transfers to a higher level of care and transfers requested by the individual..."

Review of the hospital policy "EMTALA Stabilization and Transfer" revised 11/2029, revealed, "... To ensure compliance with the Emergency Treatment and Active Labor Act [EMTALA] requirements to stabilize and in some instances transfer, individuals presenting to [named Hospital] that are found to have emergency medical conditions... Transfer Documentation... Acute Care Transfer Form: For any patient care transfer involving a potentially emergent condition, each section of the Acute Care Transfer Form must be completed to document that the Hospital followed both its policies and procedures and the requirements of EMTALA..."

2. Medical record review for Patient #15 revealed a 26 year old female who presented to Hospital #1's ED on 8/1/2024 at 12:43 PM, with reported suicidal ideations and a recent voluntary hospitalization for suicidal ideations. Triage was initiated at 12:50 PM, and MSE was initiated at 1:09 PM. Patient #15 had laboratory testing and a Mobile Crisis evaluation. The Mobile Crisis evaluator recommended psychiatric hospital placement. Patient #15 was transferred to an acute psychiatric facility on 8/1/2024 at 4:52 PM. Review of the Acute Care Transfer Form revealed ED Physician #2 did not fully complete the Patient Consent Section or the Risks and Benefits of Transfer Section.

In a telephone interview on 11/1/2024 at 11:58 AM, the Quality Director stated Physician #2 was not available for interview, as he was not on the schedule for Hospital #1 for the month of November, and she had been unable to reach him by telephone. The Quality Director verified the expectation was for the ED Physician to fully complete the Acute Care Transfer Form on all patients transferred to a higher level of care.