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Based on interview and record review, the facility failed to facilitate an appropriate transfer for one of four sampled transferred patients (Patient 10) when a Physician Certification & Authorization (physician signed certification of the risks and benefits of transfer) and a Patient Transfer Acknowledgement (consent) for Patient 10 were not available. This failure had the potential for Patient 10's responsible party to be unable to make informed decisions before consenting to the transfer.

Findings:

During a concurrent interview and record review on 3/31/21, at 2:10 PM, with Clinical Informationist 2 (person skilled in the facility's electronic medical records), Patient 10's Emergency Department (ED) records, dated 1/18/21, at 8:30 AM, were reviewed. Patient 10's "Emergency Documentation" indicated the following:
Patient 10 was 4 years old, born prematurely at 31 weeks (A preterm or premature baby is delivered before 37 weeks of the pregnancy), had cerebral palsy (a condition marked by impaired muscle coordination, typically caused by damage to the brain before or at birth), Infantile Spasm Seizures (burst of uncontrolled electrical activity between brain cells causing muscles in the arms and legs to stiffen and bend the baby's head forward), and asthma (swelling and narrowing of the airways [tubes] in the lungs).
Patient 10 arrived by ambulance with mother for seizure-like activity and vomiting. Patient 10 received Versed (medication used to treat seizures) 0.37 milligrams (mg, unit of measurement) prior to arrival at the ED. In the ED, Patient 10 had full body tonic-clonic (type of seizure characterized by stiffening and rhythmic jerking) seizure activity. Patient 10 received an additional two doses of Versed 1.5 mg and Keppra (medication used to treat seizures). The facility pediatrician recommended Patient 10 transfer to a children's specialty hospital.
Clinical Informationist 2 was unable to provide neither a Physician Certification & Authorization nor a signed Patient Transfer Acknowledgement for Patient 10.

During an interview on 3/31/21, at 10:50 AM, with Clinical Informationist 1 (CI) 1, CI 1 stated, transfer records should be located in the scanned documents; there was no other place the patient transfer documentation would be.

During an interview on 3/31/21, at 2:37 PM, with ED Clinical Educator (EDCE), EDCE stated, the medical provider should provide a risk and benefit statement to the patient and document the discussion in the medical record.

During an interview on 3/31/21, at 4:30 PM, with Risk Management staff (RM), RM staff stated, she would contact medical records for the transfer records related to Patient 10's transfer.

During a review of a handwritten note, (undated) from RM staff, on 4/1/21, at 1:21 PM, the handwritten note indicated, "Unable to locate [transfer] Forms."

During a review of the facility's Medical Staff Rules and Regulations, approved 12/21/20, the Rules and Regulations indicated, EMTALA Transfers: (a) The transfer of a patient with an emergency medical condition from the Emergency Department to another hospital will be made in accordance with the District's applicable policy and in compliance with all applicable state and federal laws, such as EMTALA. (b) Before any such transfer occurs, a physician must see the patient and enter a certification in the patient's medical record indicating that the medical benefits to be received at another medical facility outweigh the risk to the patient of being transferred. . .(4) provide the following information to the patient whenever the patient is transferred: (i) the reason for the transfer (ii) the risks and benefits of the transfer; and (iii) available alternatives to the transfer."

During a review of the facility's policy and procedure (P&P) titled "Compliance with EMTALA," approved 1/29/2020, the P&P indicated, [facility name] sends to the receiving facility all medical records (or copies thereof) available at the time of transfer related to the emergency condition of the patient, including; ...b. the patient's informed written consent to transfer or the physician's certification (or copy thereof). The P&P indicated, the "Physician Certification - The written certification by the treating physician ordering a transfer and setting forth, based on the information available at the time of transfer, that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual ..."

During a review of the facility's P&P titled "Compliance with EMTALA, Attachment B," approved 1/29/2020, Attachment B indicated, "Patient Transfer Acknowledgement I understand that I have a right to receive...and that I have a right to be informed of the reasons for any transfer...and have been informed of the reasons for my transfer."

During a review of the facility's P&P titled "Compliance with EMTALA, Attachment B," approved 1/29/2020, Attachment B indicated, "Physicians Certification & Authorization...Based on this examination, the information available to me at this time, and the reasonable risks and benefits to the patient, I have concluded for the reasons which follow that, as of the time of transfer, the medical benefits reasonably expected from the provision of treatment at another facility outweigh any increased risks to the patient."

During a review of the facility P&P titled "Interfacility: Transfer, Access & Stabilization," approved 1/28/2020, the P&P indicated, "Physician Certification of Medical Benefit...physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of emergency medical treatment at another facility outweigh the increased risks to the individual. . .the 'Physician Certification' (Form B), will be completed and signed by the physician. . .Accompanying Records and Documentation All of the following must be transferred with the individual: Copies of the individual's medical records. . .and the written informed consent or certification. . .Notice to Patient 1. The patient, or the patient's legal representative if present, must be notified of the transfer and of the reasons for transfer. The individual's acknowledgement of this notification shall be reflected in "Patient Transfer Acknowledgement (Form F)."