HospitalInspections.org

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Based on record review and interview, the facility failed to follow the provider's agreement to comply with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. Specifically, the facility failed to:

1) ensure the facility had an EMTALA (Emergency Medical Treatment and Labor Act) orientation and training program designed to prepare all medical staff of the hospital's responsibilities of Medicare participating hospitals in emergency cases;

2) ensure the facility had proof of official administrative monitoring and oversight of EMTALA cases, in the form of documented meeting minutes of any Leadership group; and

3) provide available stabilizing treatment prior to transfer to a higher level of care for 1 patient (#25), out of 2 transfers reviewed. Specifically, the facility failed to control active bleeding, that required multiple transfusions, prior to transferring.

These failed practices had the potential to: 1) affect emergency department (ED) patient care and treatment; 2) place patients having an emergency medical condition (EMC) at risk for inconsistent or inappropriate transfers, and/or delay in life saving care and treatment; and 3) placed Patient #25 at risk for the inability to supply blood to major organs, which could have caused organ failure and/or death, before reaching the receiving hospital for treatment.

Findings:

EMTALA Training

Review of the facility's "Bylaws of the Medical Staff of Fairbanks Memorial Hospital," dated 10/24/23, revealed: ". . . Basic Responsibilities and Requirements. As a condition of initial appointment and reappointment and as an ongoing condition of being a Member of the Medical Staff and/or holding Clinical Privileges and Scope of Practice, each member agrees to: Abide by the Bylaws, Rule and Regulations, and other policies of the Medical Staff and Hospital . . ."

Review of the facility's policies revealed they had an established policy entitled "EMTALA: Medical Screening Examination and Stabilizing Treatment," dated 8/7/24. Further review revealed: ". . . Applicability. This policy applies to Foundation Health and the applicable campus . . ."

During an interview on 1/9/25 at 1:56 PM, when asked to describe the EMTALA training medical staff receive at the facility, the Chief Medical Officer stated there was no mandatory EMTALA training and no annual EMTALA training at the facility.

Administrative Oversight of EMTALA

During an interview on 1/9/25 at 8:09 AM, when asked if there were any formal leadership meetings at the facility where EMTALA cases, or concerns about potential EMTALA violations, were discussed, the Chief Quality Officer stated EMTALA cases were verbally discussed but could not provide documented proof of any leadership meeting where meeting minutes would reflect EMTALA cases, or concerns about potential EMTALA violations.

During an interview on 1/9/25 at 1:56 PM, when asked if he was aware of any leadership meetings where EMTALA cases were discussed, the Chief Medical Officer stated he knew EMTALA cases are verbally discussed but couldn't recall a leadership meeting where the minutes would reflect discussions about EMTALA cases.

Patient #25

Incident on 12/5/24

Record review on 1/8-9/25 revealed Patient #25 was involved in a snowmobile accident. Patient #25 was transported to the facility by ambulance for treatment. Further review revealed:

- 6:07 PM: Patient #25 arrived at the facility; at which time a full trauma code was called due to the extent of his/her injuries.

- 6:08 PM: A medical screening examination was initiated to include a physical exam, blood work, x-rays of the chest and pelvis, as well as CAT scans of cervical (neck), thoracic (chest), and lumbar (low back) spines, chest, abdomen, pelvis, and head.

Further review of x-ray and CAT scans revealed Patient #25 sustained:
1) a rupture of his/her diaphragm (the primary muscle of breathing at the base of chest cavity and separates the abdomen from the chest) that caused the stomach and omentum (fatty tissue that secured and protected abdomen organs) to enter the chest cavity;
2) extensive pelvic fractures and a displaced femur fracture (where the bone ends were not aligned);
3) multiple rib fractures; and
4) flattening of the inferior vena cava (largest vein of the body which carried unoxygenated blood back to the heart and lungs) which could have been related to not enough blood in the body.

Blood Transfusion Record

Review of Patient #25's Transfusion Summary report from the ED record, dated 12/5/24, revealed the ED transfused a total of eight units of PRBCs as follows

- 6:49 PM: Patient #25 received two units of packed red blood cells (prbcs) due to loss of blood from his/her injuries.

- 7:56 PM: Patient #25 received an additional two units of prbcs.

- 8:01 PM: Patient #25 received two more units of prbcs.

- 8:38 PM: Patient #25 received an additional two units of prbcs.

Further review of the physician's note, dated 12/5/24, revealed: ". . . [His/her] pelvis has multiple fractures and probable open book pelvis [a severe, life threatening, type of pelvis fracture where the pelvic bones separated at the front, resembling an open book] . . . I have discussed this with Providence Hospital in the [emergency] department staff and they have graciously agreed to accept the patient in transfer . . . We have given life med [emergency helicopter transport] 3 units of blood to go with . . ."

Decision to Transfer

Review of Patient #25's "Patient Transfer Orders" from the medical record, dated 12/5/24, revealed: "Reason for Patient Transfer . . . Unstable Patient . . . Transfer is medically indicated in the patient's best interest . . . Our hospital has provided medical treatment within its capacity to minimize the risk to the individual's health . . . The treating physician has certified that the medical benefits reasonably expected from the transfer outweigh the risks to the patient from effecting the transfer . . ."

During an interview on 1/8/25 at 5:40 PM, when asked what the main decision was to transfer Patient #25 to another hospital, Physician #2 stated that during examination and treatment, Patient #25 was actively bleeding, requiring transfusions, and needed immediate treatment from a higher level of care to surgically repair injuries sustained in the accident.

During an interview on 1/9/25 at 1:56 PM, when asked to describe the facility's emergency department (ED) and trauma capabilities, the Chief Medical Officer stated the facility was a level 4 trauma center, where the facility did not have to do definitive care of anything but must stabilize beyond what a normal ED would do, which was called "trauma stabilization."

When asked what the expectations were when a full trauma code was called in the ED, the Chief Medical Officer stated when an ED doctor called a full trauma code, all available resources would be activated to include: a general surgeon would come to the bedside, the Charge Nurse would be notified, the blood bank would be alerted for blood products, and a life flight would be placed on standby.

Review of Patient #25's "Trauma Flowsheet" from the medical records, dated 12/5/24, revealed no consults from other facility providers, like a general surgeon, was documented.

During an interview on 1/9/25 at 2:30 PM, when asked what occurred when a physician called a full trauma code, Physician #2 stated a general surgeon would come to the bedside, nurses would be alerted, blood bank would be alerted, and a life flight would be placed on standby.

When asked if a general surgeon came to the bedside on 12/5/24 when Physician #2 called the full trauma code for Patient #25, Physician #2 stated they did not. When asked why they did not come, Physician #2 stated, "I don't know."

When asked if it was possible that the facility could have performed surgery for Patient #25's injuries, Physician #2 stated it was not possible because the facility did not have Interventional Radiology (IR - medical specialty that uses minimally invasive procedures to diagnose and treat diseases. Guided surgery through medical imaging) capabilities in the operating room.

When asked if Physician #2 consulted with a specialty physician at the facility prior to transfer, Physician #2 stated he/she consulted with a facility general surgeon, Physician #7, by phone.

Record review of the facility's ED call log, dated 12/5/24, revealed Physician #7 was called at 6:34 PM. Further review revealed this call was made prior to the initiation of Patient #25's blood transfusions, which started at 6:49 PM.

The facility confirmed there were no other calls made to Physician #7 prior to Patient #25's transfer.

During an interview on 1/9/25 at 3:02 PM, Physician #7 (who was a general surgeon) stated the facility did not have IR capability in the OR setting and anyone requiring this for surgery would be transferred to another facility for treatment.

When asked about trauma stabilization capabilities at the facility for a patient who was losing blood volume that required transfusions, Physician #7 stated the overall goal would have been to stabilize prior to transport by packing off the wounds to slow bleeding.

When asked about Patient #25's condition of active bleeding that required multiple transfusions and the decision to transport, Physician #7 stated Patient #25's level of instability was not relayed to him/her during the consultation over the phone on 12/5/24 and he/she would have never recommended transport for someone who had that degree of blood loss.

Review of the facility's policy "Trauma Activation Roles and Responsibilities Guidelines," dated 6/24/24, revealed: "During the stabilization and resuscitation phase, members of the trauma team will follow the guidelines of their respective roles as listed herein. All trauma team members are required to respond to the trauma room immediately upon receipt of the activation page . . ." Review of the list of trauma team responders for a full trauma activation included the ED physician.

Further review of the policy revealed no roles and responsibilities listed for the ED physician. A general surgeon was not listed as being required to respond to the bedside upon activation of a full trauma code and there were no roles and responsibilities for the general surgeon.

Review of the facility's policy "Inter-Facility Trauma Transfer Guidelines," dated 2/2/24, revealed: ". . . Trauma transfers out of Fairbanks Memorial Hospital are managed by the patient's attending physician, including ER [Emergency Room] physician, surgeons, neurosurgeons and orthopedists, in conjunction with the AC [Administrative Coordinator] . . . physician judgement is the deciding factor in transfer. If resources are not available and it is in the best interest of the patient, then transfer to a higher-level Trauma Center should be considered . . ."

Review of the facility's on-call schedule, dated 12/5/24, revealed Physician # 7 was available during this emergency for "Surgery - 24 [hour] shift - change [at] [7:00 AM].

Review of the facility policy "EMTALA [Emergency Medical Treatment and Labor Act]: Medical Screening Examination and Stabilizing Treatment," dated 8/7/24, revealed: ". . . Transfer Requirements for the Patient. Transfer of a Patient may be considered under the following circumstances . . . The Patient may be transferred to another hospital if . . . The physician in attendance or QMP [Qualified Medical Professional] in consultation with the physician determines that the benefits of Transfer outweigh the risks; or the Hospital is unable to stabilize the Patient within its capacity . . ."
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Based on record review and interview, the facility failed to provide available stabilizing treatment prior to transfer to a higher level of care for 1 patient (#25), out of 2 transfers reviewed. Specifically, the facility failed to control active bleeding, that required multiple transfusions, prior to transferring. This failed practice placed the patient at risk for the inability to supply blood to major organs, which could have caused organ failure and/or death, before reaching the receiving hospital for treatment.

Findings:

Incident on 12/5/24

Record review on 1/8-9/25 revealed Patient #25 was involved in a snowmobile accident. Patient #25 was transported to the facility by ambulance for treatment. Further review revealed:

- 6:07 PM: Patient #25 arrived at the facility; at which time a full trauma code was called due to the extent of his/her injuries.

- 6:08 PM: A medical screening examination was initiated to include a physical exam, blood work, x-rays of the chest and pelvis, as well as CAT scans of cervical (neck), thoracic (chest), and lumbar (low back) spines, chest, abdomen, pelvis, and head.

Further review of x-ray and CAT scans revealed Patient #25 sustained:
1) a rupture of his/her diaphragm (the primary muscle of breathing at the base of chest cavity and separates the abdomen from the chest) that caused the stomach and omentum (fatty tissue that secured and protected abdomen organs) to enter the chest cavity;
2) extensive pelvic fractures and a displaced femur fracture (where the bone ends were not aligned);
3) multiple rib fractures; and
4) flattening of the inferior vena cava (largest vein of the body which carried unoxygenated blood back to the heart and lungs) which could have been related to not enough blood in the body.


Blood Transfusion Record

Review of Patient #25's Transfusion Summary report from the ED record, dated 12/5/24, revealed the ED transfused a total of eight units of PRBCs as follows:

- 6:49 PM: Patient #25 received two units of packed red blood cells (prbcs) due to loss of blood from his/her injuries.

- 7:56 PM: Patient #25 received an additional two units of prbcs.

- 8:01 PM: Patient #25 received two more units of prbcs.

- 8:38 PM: Patient #25 received an additional two units of prbcs.


Further review of the physician's note, dated 12/5/24, revealed: ". . . [His/her] pelvis has multiple fractures and probable open book pelvis [a severe, life threatening, type of pelvis fracture where the pelvic bones separated at the front, resembling an open book] . . . I have discussed this with Providence Hospital in the [emergency] department staff and they have graciously agreed to accept the patient in transfer . . . We have given life med [emergency helicopter transport] 3 units of blood to go with . . ."

Decision to Transfer

Review of Patient #25's "Patient Transfer Orders" from the medical record, dated 12/5/24, revealed: "Reason for Patient Transfer . . . Unstable Patient . . . Transfer is medically indicated in the patient's best interest . . . Our hospital has provided medical treatment within its capacity to minimize the risk to the individual's health . . . The treating physician has certified that the medical benefits reasonably expected from the transfer outweigh the risks to the patient from effecting the transfer . . ."

During an interview on 1/8/25 at 5:40 PM, when asked what the main decision was to transfer Patient #25 to another hospital, Physician #2 stated that during examination and treatment, Patient #25 was actively bleeding, requiring transfusions, and needed immediate higher level of care treatment to surgically repair injuries sustained in the accident.

During an interview on 1/9/25 at 1:56 PM, when asked to describe the facility's emergency department (ED) and trauma capabilities, the Chief Medical Officer stated the facility was a level 4 trauma center, where the facility did not have to do definitive care of anything but must stabilize beyond what a normal ED would do, which was called "trauma stabilization."

When asked what the expectations were when a full trauma code was called in the ED, the Chief Medical Officer stated when an ED doctor called a full trauma code, all available resources would be activated to include: a general surgeon would come to the bedside, the Charge Nurse would be notified, the blood bank would be alerted for blood products, and life flight would be placed on standby.

Review of Patient #25's "Trauma Flowsheet" from the medical records, dated 12/5/24, revealed no consults from other facility providers, like a general surgeon, were documented.

During an interview on 1/9/25 at 2:30 PM, when asked what occurred when a physician called a full trauma code, Physician #2 stated a general surgeon would come to the bedside, nurses would be alerted, blood bank would be alerted, and a life flight would be placed on standby.

When asked if a general surgeon came to the bedside on 12/5/24 when Physician #2 called the full trauma code for Patient #25, Physician #2 stated they did not. When asked why they did not come, Physician #2 stated, "I don't know."

When asked if it was possible that the facility could have performed surgery for Patient #25's injuries, Physician #2 stated it was not possible because the facility did not have Interventional Radiology (IR - medical specialty that uses minimally invasive procedures to diagnose and treat diseases. Guided surgery through medical imaging) capabilities in the operating room.

When asked if Physician #2 consulted with a specialty physician at the facility prior to transfer, Physician #2 stated he/she consulted with a facility general surgeon, Physician #7, by phone.

Record review of the facility's ED call log, revealed on 12/5/24 Physician #7 was called at 6:34 PM. Further review revealed this call was made prior to the initiation of Patient #25's blood transfusions, which started at 6:49 PM.

The facility confirmed there were no other calls made to Physician #7 prior to Patient #25's transfer.

During an interview on 1/9/25 at 3:02 PM, Physician #7 (who was a general surgeon) stated the facility did not have IR capability in the OR setting and anyone requiring this for surgery would be transferred to another facility for treatment.

When asked about trauma stabilization capabilities at the facility for a patient who was losing blood volume that required transfusions, Physician #7 stated the overall goal would have been to stabilize prior to transport by packing off the wounds to slow bleeding.

When asked about Patient #25's condition of active bleeding that required multiple transfusions and the decision to transport, Physician #7 stated Patient #25's level of instability was not relayed to him/her during the consultation over the phone on 12/5/24 and he/she would have never recommended transport for someone who had that degree of blood loss.

Review of the facility's policy "Trauma Activation Roles and Responsibilities Guidelines," dated 6/24/24, revealed: "During the stabilization and resuscitation phase, members of the trauma team will follow the guidelines of their respective roles as listed herein. All trauma team members are required to respond to the trauma room immediately upon receipt of the activation page . . ." Review of the list of trauma team responders for a full trauma activation included the ED physician.

Further review of the policy revealed no roles and responsibilities listed for the ED physician. A general surgeon was not listed as being required to respond to the bedside upon activation of a full trauma code and there were no roles and responsibilities for the general surgeon.

Review of the facility's policy "Inter-Facility Trauma Transfer Guidelines," dated 2/2/24, revealed: ". . . Trauma transfers out of Fairbanks Memorial Hospital are managed by the patient's attending physician, including ER [Emergency Room] physician, surgeons, neurosurgeons and orthopedists, in conjunction with the AC [Administrative Coordinator] . . . physician judgement is the deciding factor in transfer. If resources are not available and it is in the best interest of the patient, then transfer to a higher-level Trauma Center should be considered . . ."

Review of the facility's on-call schedule, dated 12/5/24, revealed Physician # 7 was available during this emergency for "Surgery - 24 [hour] shift - change [at] [7:00 AM].

Review of the facility policy "EMTALA [Emergency Medical Treatment and Labor Act]: Medical Screening Examination and Stabilizing Treatment," dated 8/7/24, revealed: ". . . Transfer Requirements for the Patient. Transfer of a Patient may be considered under the following circumstances . . . The Patient may be transferred to another hospital if . . . The physician in attendance or QMP [Qualified Medical Professional] in consultation with the physician determines that the benefits of Transfer outweigh the risks; or the Hospital is unable to stabilize the Patient within its capacity . . ."
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Based on record review and interview, the facility failed to ensure:

1) all available medical records related to the emergency medical condition (EMC) were sent to the receiving hospital for 1 transferred patient (#25), out of 2 transfers reviewed; and

2) "Patient Transfer Orders" and "Physician's Certificate of Transfer and Patient Consent" paperwork of transferred patients was complete and accurate for 4 patients (#'s 4, 52, 64, and 77), out of 9 records of transferred patients reviewed.

These failed practices placed the patients at risk for incomplete medical records and delay in treatment which had the potential to affect their overall outcome and well-being.

Findings:

Medical Records for Transfers

During an interview on 1/9/25 at 8:33 AM, the Senior Manager for the Emergency Department (ED) stated when a physician order for transfer was received, the Desk Tech (technician) would be responsible to gather all related medical records and send them to the receiving hospital by two methods: 1) a transfer packet, which contained all available medical records pertaining to the EMC, would be given to the transfer team to accompany the patient, and 2) the Desk Tech would also fax the documents to the receiving hospital.

Patient #25

Incident on 12/5/24

Record review on 1/8-9/25 revealed Patient #25 was involved in a snowmobile accident. Patient #25 was transport to the facility by ambulance for treatment. Further review revealed:

- 6:07 PM: Patient #25 arrived at the facility at which time a full trauma code was called due to the extent of his/her injuries.

- 6:08 PM: A medical screening examination was started to include a physical exam, blood work, x-rays of the chest and pelvis, as well as CT scans of cervical (neck), thoracic (chest), and lumbar (low back) spines, chest, abdomen, pelvis, and head.

Further review of x-ray and CT scans revealed Patient #25 sustained:
1) a rupture of his/her diaphragm (muscle between chest cavity and stomach/intestines) causing the stomach and omentum (fatty tissue that secures and protects organs) to enter the chest cavity; 2) extensive pelvic fractures and a femur fracture that was not aligned;
3) multiple rib fractures; and
4) flattening of the inferior vena cava (largest vein which carries unoxygenated blood back to the heart and lungs) which could have been related to not enough blood in the body.

Further review of the physician's note, dated 12/5/24, revealed: ". . . [His/her] pelvis has multiple fractures and probable open book pelvis [a severe, life threatening, type of pelvis fracture where the pelvic bones separated at the front, resembling an open book] . . . I have discussed this with Providence Hospital in the [emergency] department staff and they have graciously agreed to accept the patient in transfer . . ."

Review of Patient #25's "Patient Transfer Orders," dated 12/5/24, revealed: "Reason for Patient Transfer . . . Unstable Patient . . . Transfer is medically indicated in the patient's best interest . . . Our hospital has provided medical treatment within its capacity to minimize the risk to the individual's health . . . The treating physician has certified that the medical benefits reasonably expected from the transfer outweigh the risks to the patient from effecting the transfer . . ."

Further review revealed order instruction #2 ". . . copies of available medical records, tests, orders, consents, certification, and radiographs will accompany the patient" was left blank.

Review of the receiving hospital report of Patient #25 on 12/5/24 revealed the patient arrived without a provider history and physical report or labs.

Review of Patient #25's medical record, dated 12/5/24, revealed the physician documented he/she shared the results of the CT scans with the receiving hospital. Further review revealed no documentation to reflect what other items of the medical record were sent to the receiving hospital.

During an interview on 1/9/25 at 8:33 AM, when asked how the facility could prove what medical records were sent and/or faxed, and when, to a receiving hospital, the Senior Manager for the ED stated the facility identified a gap in their processes concerning this about two weeks ago. The Senior Manager of the ED stated the facility could show when a fax was sent, but not what was faxed. Because of this gap, a new fax coversheet was created to document which items from the medical record were sent.

Record review of the facility's fax log, dated 12/5/24, revealed no fax was logged to show medical records were sent to the receiving hospital for Patient #25.

Record review of the facility's print log (what items were printed) revealed items from Patient #25's medical record were printed on 12/5/24 at 7:23 PM, however could not identify what items from the medical records were printed or why they were printed.

Review of the facility's policy "EMTALA: Medical Screening Examination and Stabilizing Treatment," dated 8/7/24, revealed: ". . . Transfer of the Patient who is not Stable for Transfer is accomplished as follows . . . Copies of all medical records related to the EMC [emergency medical condition] are sent with the Patient to the accepting facility. Other records, including test results, not available at the time of Transfer must be sent as soon as practicable after Transfer . . ."

Complete and Accurate Medical Records

Patient #4

Record review on 1/8-9/24 revealed Patient #4 was seen in the ED on 11/3/24: ". . . [Patient #4] presents via EMS [emergency medical services - ambulance] for worsening generalized fatigue, severe skin ulcers/rash, worsening generalized edema and deconditioning. . ."

Further review revealed Patient #4 was diagnosed with acute renal failure, hyperkalemia (high potassium levels), acute CHF (congestive heart failure) exacerbation, pulmonary edema, pericardial effusion (the buildup of too much fluid around the heart), soft tissue infection, and sepsis (a serious condition which the body responds improperly to infection).

The decision was made to transfer Patient #4 to a higher level of care where dialysis could be provided. An order for transfer was made.

Review of Patient #4's "Patient Transfer Orders," dated 11/3/24, revealed the following order instructions were left blank: "Reason for Patient Transfer" and #2, "copies of available medical records, tests, orders, consents, certification, and radiographs will accompany the patient".

Review of Patient #4's "Physician's Certificate of Transfer and Patient Consent," dated 11/3/24, revealed section C, "Transport," was left blank.

Patient #52

Record review on 1/8-9/24 revealed Patient #52 was seen in the ED on 10/12/24: ". . . [Patient #52] presenting [to] emergency department for evaluation of straddle injury [genital trauma]. Patient's presentation is concerning for pelvic fracture, urethral injury, testicular injury . . ."

Further review revealed Patient #52 was diagnosed with an inferior pubic rami fracture (a pelvic bone near the bottom of the pelvis) and perineal trauma (genital region injury).

The decision was made to transfer Patient #52 to a higher level of care where urology (specialty focused on diagnosing and treating conditions the urinary tract and male reproductive organs) was available. An order for transfer was made.

Review of Patient #52's "Patient Transfer Orders," dated 10/12/24, revealed the following order instructions were left blank: #2 "copies of available medical records, tests, orders, consents, certification, and radiographs will accompany the patient;" #3 "Mode of transfer;" #4 "Escort requirements/equipment or life support services required to accompany patient;" and #5 "Special transport orders." Further review revealed the physician's signature was not dated or timed.

Review of Patient #52's "Physician's Certificate of Transfer and Patient Consent," dated 10/12/24, revealed section C, "Transport (Do Both)," was left blank. Under section D "Analysis of Risks and Benefits of Transfer," neither "Worsening the condition or death if the patient stays here" and/or "Obtain level of care not available at this facility" were marked.

Patient #64

Record review on 1/8-9/24 revealed Patient #64 was seen in the ED on 10/9/24: "This is [Patient #64] with likely recurrent right hip dislocation . . ." Further review revealed the patient had a history of a hip replacement and through the examination on 10/9/24 discovered the patient's hip prosthesis was disarticulated from itself (separated at the prosthesis's joint).

The decision was made to transfer Patient #64 to a higher level of care for prosthesis repair. An order for transfer was made.

Review of Patient #64's "Patient Transfer Orders," dated 10/9/24, revealed the following order instructions were left blank: #2 "copies of available medical records, tests, orders, consents, certification, and radiographs will accompany the patient;" #3 "Mode of transfer;" #4 "Escort requirements/equipment or life support services required to accompany patient;" and #5 "Special transport orders."

Review of Patient #64's "Physician's Certificate of Transfer and Patient Consent," dated 10/9/24, revealed section C, "Transport (Do Both)," was left blank.

Patient #77
Record review on 1/8-9/24 revealed Patient #77 was seen in the ED on 9/20/24 due to preterm labor at 29 weeks gestation.

The decision was made to transfer Patient #77 to a higher level of care were NICU (Neonatal Intensive Care Unit) capabilities were available if labor could not be stopped. An order for transfer was made.

Review of Patient #77's "Patient Transfer Orders," dated 9/20/24, revealed order instruction #2, "copies of available medical records, tests, orders, consents, certification, and radiographs will accompany the patient" was left blank.

Review of the facility policy "Inter-Facility Trauma Transfer Guidelines," dated 2/2/24, revealed: ". . . Procedural Documentation. Patient Transfer Orders form is completed by the transferring physician and RN [registered nurse]. Physician's certificate of transfer and patient consent form is completed by the transferring physician . . ."

Review of the facility's policy "EMTALA: Medical Screening Examination and Stabilizing Treatment," dated 8/7/24, revealed: ". . . Transfer of the Patient who is not Stable for Transfer is accomplished as follows. The form "Request for Transfer/Consent to Transfer/Certification for Transfer" is required and fully completed for Patients . . ."
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Based on record review and interview, the facility failed to provide proof of compliance with recipient hospital responsibilities. This failed practice placed all patients in need of emergency transport at risk for potential refusal to accept care and/or delay in care.

Findings:

During an interview on 1/8/25 at 1:14 PM, the Senior Manager for the ED stated calls from other facilities to request transfers were received by calling the emergency department (ED) number. These calls were handled two ways: 1) A charge nurse would take the call and take the report from the provider calling. The charge nurse could prepare for the arrival or get a facility provider to talk to the provider calling; and 2) the nursing supervisor would take the call, and they would get a facility provider who was on-call to talk to the provider calling.

When asked to see the facility's call log for calls received requesting transfer to their facility, the Senior Manager of the ED stated there was no call log. The Senior Manager of the ED further stated if a facility provider took a call and decided the patient needed to go elsewhere, there was no log or documentation to show who called, which facility provider took the call, or what was decided.
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