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Based on interview and record review, the hospital failed to maintain daily On-Call Physician coverage for the specialty of Ear, Nose, and Throat (ENT) physicians who could provide necessary stabilizing treatment for individuals with these types of emergency medical conditions. This failure was the direct cause of the transfer of one of the 38 sampled patients (Patient 34) to another acute care facility for treatment of his emergency medical condition..

Findings:

Record review of the hospital's On-Call Physician Lists indicated that from September, 2014, through February, 2015, there were 70 days in this six month period when there was no ENT coverage for the Emergency Department (ED).

During an interview on 2/17/15, the hospital's Director of Quality Assurance acknowledged the gaps in the ENT coverage for the ED.

During an interview on 2/17/12 at 3:20 PM, a hospital Vice President (VP) stated he was aware of the coverage gaps for ENT physicians in the ED. This VP said that there had been negotiation problems with the various groups of ENT practitioners but there was now a group who was moving their practice from another facility to this hospital. The VP felt that this group, who were currently being proctored to have privileges at the hospital, would eventually fill the gaps in the ENT On-Call Coverage for the ED. The VP said he anticipated completion of the proctoring in March, 2015, with full On-Call ENT coverage after that.

Record review of the hospital's policy and procedure "EMTALA; On-Call Responsibilities" dated 3/20/13, stated that the hospital "shall maintain on-call lists for the following specialities:...ENT."




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Record review on 02/18/15 showed Patient 34 was evaluated in the ED on 02/08/15 for left side throat swelling and difficulty swallowing. The record further showed this patient was seen in the ED previously on 02/06/15 for palpitations after injecting methamphetamines and had a normal throat exam. He was subsequently discharged home. Then, he developed left hand pain and was seen at Hospital B's ED on 02/07/15 and was treated with intravenous antibiotics for a left hand infection and discharged home with antibiotic pills. Subsequently, the patient developed throat swelling while eating and symptoms worsened which prompted him to go to the ED on 02/08/15. During the 02/08/15 ED visit, MD 2 ordered a CT scan of the neck and documented the following findings and treatment plan: " (The radiology physician) contacted me, subsequently with the CT read stating that there was a "raging infection" in the left neck extending from the left lingual and submandibular glands down the thyroid cartilage, all within the subcutaneous tissue. The airway was widely patent. There was also a large fluid collection noted below the tongue..., (The radiology physician)felt it was consistent with either an abscess or seroma..., Given that we have no ear, nose, and throat specialist on call for (Hospital A) today, I elected to discuss the case with the ear, nose, and throat specialist at (Hospital B)who agreed to accept the patient in transfer".

In an interview on 02/19/15 at 11:15 AM, MD 1 stated, " There are holes in the ENT schedule and is a chronic problem". "It had an impact on care I think once recently". "We use the service a lot for advice or follow up".

Based on interview and record review, the hospital failed to maintain complete and accurate records for all patients who presented to the Emergency Department (ED) seeking assistance, the treatment provided or refused, and the final disposition of the patient. This failure was evidenced by:

1. On 2/5/15, Patient 38 was brought to the ED for treatment of respiratory distress and was sent to another acute care facility without being entered into the ED log;

2. On 2/13/15, Patient 36 was brought to the ED for treatment of altered mental status. The log indicated Patient 36 "left after Medical Screening Exam (MSE)". The Physician's note indicated Patient 36 left before the medical screening examination was completed, refused tests, and left against medical advice;

3. On 8/07/14, Patient 16 was evaluated in the ED for nausea and vomiting for two days. The physician completed an MSE but when he returned to reevaluate the patient, she was no longer in the facility. The log indicated Patient 16 was "AMA" (Against Medical Advice) when in fact the patient eloped.

4. On 9/1/14, Patient 20 was evaluated in the ED for stress and suicidal ideations. The patient was cleared to transfer to a mental health facility. The ED log indicated the patient was admitted to Behavioral Health Unit but the facility did not have these services. The log should have indicated a transfer.

5. On 9/24/14, Patient 21 was evaluated in the ED for a choking episode. The patient was discharged home. The log indicated "left after medical screening exam". The log should have indicated a discharge.

6. On 10/15/14, Patient 24 was evaluated in the ED for a fall at home. The ED log was incomplete in the section for the "reason of the visit".

7. On 10/5/14, Patient 25 was evaluated in the ED for respiratory problems. The ED log was incomplete in the section for the "reason of the visit".

8. On 10/5/14, Patient 26 was evaluated in the ED for a fall at the assisted living facility where she lived. The ED log was incomplete in the section for the "reason of the visit". Additionally, the patient's disposition was discharge "home" but the patient was transferred to the skilled nursing facility unit of her assisted living facility because the physician determined she required a higher level of care.

9. On 10/5/14, Patient 27 was evaluated in the ED for right flank pain. The ED log was incomplete in the section for the "reason of the visit".

10. On 2/6/15, Patient 32 was evaluated in the ED for abdominal pain. The physician completed an MSE but the patient did not want to wait to have additional laboratory tests or an ultrasound. The physician explained to the patient the risks and benefits for leaving before a complete evaluation was done. The log indicated the patient "left after medical screening exam". The log should have indicated an "AMA" status.


Findings:

1. On 2/5/15, Patient 38 was brought to the ED for treatment of respiratory distress and was sent to another acute care facility without being entered into the ED log.

During an interview on 2/10/15 at approximately 11:30 AM, a Registered Nurse (RN 1) stated that Patient 38 was a five week old infant having respiratory distress. His mother called a Pediatric Advice Nurse at her Pediatrician's office and it was determined that Patient 38 had a respiratory rate of 48 with audible grunting. The mother reported that Patient 38's skin color was normal and she was told by the Advice Nurse (RN 2) to take Patient 38 to the nearest Emergency Department (ED) (Hospital A) for treatment. RN 1 stated that while giving the mother these instructions RN 3 called Hospital A's Emergency Department to give them report on the mother and baby who were coming.

During an interview with RN 3 on 2/10/15 at 3:55 PM, RN 3 stated that someone at Hospital A's ED said that they did not take children and the mother should be told to take the infant to Hospital B's ED. The staff at the clinic were unable to reach the mother by phone so RN 3 called Hospital A's ED back and told them that the mother and baby were en route and could not be diverted elsewhere.. RN 3 stated that during this call the same unidentified person put the ED physician on the phone (MD 1) and MD 1 told her that Patient 38 would not be seen or receive a Medical Screening Examination for 8 hours, and the baby should go to Hospital B's ED. RN 3 explained to MD 1 that the mother and baby were en route. RN 3 stated MD 1 then said they would deal with it.

RN 3 read notes from Patient 1's Clinic record in which the mother told the pediatrician that Hospital A did not examine Patient 38 but told her to take him, by private automobile, directly to Hospital B's ED.

Record review of Hospital A's ED log did not contain any reference to Patient 38 having arrived there. Hospital A had no records for Patient 38's ED visit on 2/5/15.

During a group interview on 2/11/15 at approximately 1:30 PM at Hospital A, the Director of Quality Assurance and Risk Management (Dir), the Nurse Manager (NM) of the Emergency Department, and the Risk Manager (RM) who had spoken with the complainant (RN 3) all stated that they were aware of the incident with Patient 38. They stated that when they spoke with MD 1 he had been concerned because there were many flu patients in Hospital A's ED waiting room and he thought Patient 38 would receive faster care with less flu exposure at Hospital B. All acknowledged that Patient 38 should have been registered at Hospital A and should have received a Medical Screening Examination prior to transport.

In an interview on 02/19/15 at 10:34 AM, MD 1 stated that he was concerned that Patient 38 would be exposed to many flu patients in the waiting room while he and his mother waited for a transfer to be arranged for Patient 38. MD 1 said he observed Patient 38 and listened to his chest and felt that he would be safe for transfer by the mother to Hospital B. MD 1 said he advised Patient 38's mother that it would be faster and safer if she drove him directly to Hospital B's ED. MD 1 said he had this discussion with Patient 38's mother as soon as they arrived in the ED so Patient 38 was never triaged or logged into the ED. MD 1 said that, in hindsight, he realized that he had made a mistake when he suggested that the mother should take Patient 38 to another ED, and should have initiated full ED treatment for Patient 38 at Hospital A.

2. On 2/13/15, Patient 36 was brought to the ED by ambulance, under duress but not on a 5150 (Involuntary Hold), after neighbors noted he was not acting as usual and one of them called police and paramedics. The Physician's note indicated that he, MD 1, was able to perform a physical examination on Patient 36 and he thought Patient 36 needed further evaluation; MD 1 ordered laboratory tests including toxicology screening, an electrocardiogram (EKG), a computer assisted tomagraphy (CT scan) of Patient 36's head, and intravenous fluids. MD 1's note stated that when the nurse went to carry out these orders, Patient 36 "got up off the gurney and stated he refused all care and refused to sign out against medical advice and he walked out of the Emergency Department. Given that he is not on a hold, so we do not have any right to keep him, and he left without any instructions and without complete evaluation. Final Diagnoses: 1. Altered mental status, 2. Left before examination."

Record review of the Registered Nurse's (RN 4) note, written on 2/13/15 at 5:03 PM, indicated Patient 36 was "refusing lab draw, EKG and CT scan, patient denies complaints, ambulatory, would not stay after encouraged by this RN to have further evaluation. Gait steady, would not sign AMA form, all belongings with patient."

Record review of the ED log showed Patient 36's disposition as "Left after medical screening exam" and the chart did not contain any paperwork for left "Against Medical Advice."

During an interview on 02/19/15 at 10:45 AM, MD 1 stated he remembered Patient 36. MD 1 said that although Patient 1 had movements and behavior suggestive of exposure to toxins, Patient 36 was alert and oriented, and did not qualify for a 5150 designation since he was not a danger to himself or to others. MD 1 stated that he does not enter the final disposition into the computer, the ED nurses do. MD 1 acknowledged that Patient 36 should have been listed in the log disposition as an "AMA" discharge with paperwork for this that reflected Patient 36's refusal to sign or to wait for an explanation of the risks and benefits of leaving before testing had been completed.








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3. On 8/07/14, Patient 16 was evaluated in the ED for nausea and vomiting for two days after drinking alcohol for seven days.

Record review on 02/18/15 showed the physician performed an MSE at 7:49 PM. MD 1 documented in the medical record section titled, " Hospital Course", the following: "... I went to evaluate the patient and found that her IV (intravenous) bag was empty. She pulled her IV out, and apparently her boyfriend had left without us knowing, but she had been in the department about 2 hours before leaving, so hopefully she is much more sober".

The ED log showed the patient's discharge disposition as "left against medical advice". Further medical record review of MD 1's dictation report showed "elopement" as part of the "Final Diagnosis".

During an interview on 02/18/15 at 9:50 AM, NM stated, " It's the nurse who chooses the discharge status in the computer. The nurse did not choose correctly. They need to be re-educated". NM agreed the discharge status should have been an elopement. NM also stated the computer program they are currently using did not have a category for "elopement" in its drop down menu for disposition choices.

4. On 9/01/14, Patient 20 was evaluated in the ED for suicidal ideations. She was medically cleared by the physician to be transferred to another facility with a behavioral health unit. The ED log indicated " "Admit to Behavioral Health Unit".

In an interview on 02/18/15 at 11:08 AM, NM stated their facility did not have a behavioral health unit and agreed the log's disposition should have been a transfer.

5. On 9/24/14, Patient 21 was a six week old child evaluated in the ED for possible aspiration on liquid vitamins. Record review on 02/18/15 showed the patient had a complete work up for the visit and was discharged home in stable condition. The record showed the physician dictated the following in his report: "Medical Decision Making: It sounds like the patient had a brief laryngospasm episode from getting the liquid vitamin in or around his vocal cords. He seems to have cleared that spontaneously with the family's positioning and padding of his back, and I am comfortable. He has not required x-rays or any other workup at this point in time. Discharge Diagnosis: Brief choking episode, now cleared".

The ED log showed the patient's discharge disposition as "left after medical screening". Further medical record review showed that the patient's parent received discharge paperwork with instructions that were given on 9/24/14 at 22:37 (10:37 PM).

During an interview on 02/18/15 at 11:15 AM, NM agreed the discharge disposition should have been "discharge home".

6. On 10/15/14, Patient 24 was evaluated in the ED after a fall at home. The ED log was incomplete for indicating the reason for the visit.

During an interview on 02/18/15 at 11:43 AM, NM stated the computer system was down at the time of the patient's visit. NM stated, "The other field's in the log were filled in and the chief complaint should have been pulled in also. It was missed".

7. On 10/15/14, Patient 25 was a 3 year old patient evaluated in the ED for a "barking" cough and difficulty in breathing. The ED log was incomplete for indicating the reason for the visit.

During the same interview with NM on 02/18/15 at 11:43 AM, she stated this was another visit that was seen during the computer down time and the patient's chief complaint was not completed along with the other ED log fields when the computer system came back on line.

8. On 10/15/14, Patient 26 was evaluated in the ED after a fall at home and fractured her left wrist. The ED log was incomplete for indicating the reason for the visit.

During the same interview with NM on 02/18/15 at 11:43 AM, she stated this was another visit that was seen during the computer down time and the patient's chief complaint was not completed along with the other ED log fields when the computer system came back on line.

The patient's disposition was discharge to "home" but the ED physician documented that the patient required a higher level of care by dictating the following notes: " Following successful sedation reduction and splinting of the patient's left wrist, decision was made to discharge the patient home, however, the patient is coming to us for assisted living. She seemed perhaps confused to go there, so she was allowed to sleep in the ER, has the medications, she was given wore off in the morning. The patient was awakened apparently at her baseline mental status. However, we tried to ambulate her. She is too unsteady in her feet to an assisted living facility. Therefore, social worker has been involved and we tried to place her in a higher level of care. The patient's facility does have skilled nursing sections, so it may be possible simply to transfer her there".

In an interview with on 02/18/15 at 1:36 PM, Dir stated when a patient is transferred to a skilled nursing facility from the acute hospital, an interfacility transfer form is completed and this translate to be the same process for the ED.

9. On 10/15/14, Patient 27 was evaluated in the ED for right flank pain. The ED log was incomplete for indicating the reason for the visit.

During the same interview with NM on 02/18/15 at 11:43 AM, she stated this was another visit that was seen during the computer down time and the patient's chief complaint was not completed along with the other ED log fields when the computer system came back on line.

10. On 02/06/15, Patient 32 was 3 weeks pregnant and was evaluated in the ED for abdominal pain. Review of the medical record showed MD 1 performed an MSE at 12:22 PM. The physician's dictated report stated that he wanted to obtain additional information from another facility to confirm the patient's pregnancy and this process took an additional hour. The physician wrote: "... I reobtained records from (the other facility) which took up approximately an hour, and her figures were accurate, but in order to comment, they had asked her to follow up with her private physician, but in any case, I at that point, ordered a repeat quantitative beta-hCG (pregnancy test) and urinalysis and wanted to see the results of the beta-hCG before ordering an ultrasound, but apparently, the patient did not wish to wait and she left without any instructions given". The physician's "Final Diagnosis" documented the patient as "Left before complete evaluation".

In an interview on 02/19/15 at 10:55 AM, MD 1 stated he stopped the patient on her way out the front door of the ED and explained the risks and benefits of her leaving before completing his evaluation and MD 1 said she understood. MD 1 agreed the case should have been an "AMA" but he did not complete the documents for an AMA patient. The ED log indicated, "Left after medical screening evaluation" and should have been an "AMA" as MD 1 indicated during the interview.

Based on interview and record review, the facility failed to provide a medical screening examination for one of the thirty eight sampled patients when Patient 38's mother was advised to take the baby to another Hospital's Emergency Department (ED) for evaluation and treatment.

Findings:

On 2/5/15, Patient 38 was brought to the ED (Hospital A) for treatment of respiratory distress and his mother was advised to take him to to another ED (Hospital B) for examination, treatment, and possible inpatient admission.

During the entrance conference on 2/17/15 at approximately 9:00 AM, the Director of Quality Assurance (Dir) was asked to provide any records the hospital had of Patient 38's ED visit on 2/5/15. The Dir acknowledged that the hospital had no documentation of registration, examination, treatment, or transfer records for Patient 38 on 2/5/15.

In an interview on 02/19/15 at 10:34 AM, MD 1 stated that he was concerned that Patient 38 would be exposed to many flu patients in the waiting room while he and his mother waited for a transfer to be arranged for Patient 38. MD 1 said he observed Patient 38 and listened to his chest and felt that he would be safe for transfer by the mother to Hospital B.

MD 1 said he advised Patient 38's mother that it would be faster and safer if she drove him directly to Hospital B's ED. MD 1 said he had this discussion with Patient 38's mother as soon as they arrived in the ED so Patient 38 was never triaged or logged into the ED. MD 1 said that, in hindsight, he realized that he had made a mistake by sending Patient 38 away without doing the medical screening examination, and he should have initiated full ED treatment for Patient 38.
Record review indicated that Patient 38 was seen in Hospital B's ED at 10:50 AM on 2/5/15. There Patient 38 was listed as a level 2-emergent case in triage and he received a medical screening examination and was diagnosed with acute bronchiolitis ("Bronchiolitis is a common lung infection in young children and infants. It causes congestion in the small airways (bronchioles) of the lung. Bronchiolitis is almost always caused by a virus" - mayoclinic.org). After stabilizing treatment Patient 38 was transferred by ambulance to Hospital C for inpatient admission to the Pediatric unit.

Based on interview and record review, the hospital failed to (1) provide necessary stabilizing treatment for one of the thirty eight sampled patients, when the ED physician (MD 1) advised Patient 38's mother to take Patient 38, by private automobile, to Hospital B's Emergency Department without providing any medical care at Hospital A; (2.a) complete the required paperwork for Patient 36 when he refused care, refused to sign the AMA form (leaving Against Medical Advice), and left the the hospital; (2.b) complete the AMA form for Patient 32 when she refused tests, had a discussion of the risks and benefits of the proposed care, and left the hospital; and (2.c) complete the required AMA form when Patient 16 was listed in the ED log with a disposition of AMA.

Findings:

(1) On 2/5/15, Patient 38 was brought to the ED for treatment of respiratory distress and his mother was advised to take him to to another acute care facility emergency department for a medical screening examination, stabilizing treatment, and possible inpatient admission.

During the entrance conference on 2/17/15 at approximately 9:00 AM, the Director of Quality Assurance (Dir) was asked to provide any records the hospital had of Patient 38's ED visit on 2/5/15. The Dir acknowledged that the hospital had no documentation of registration, examination, treatment, or transfer records for Patient 38 on 2/5/15.

In an interview on 02/19/15 at 10:34 AM, MD 1 stated that he was concerned that Patient 38 would be exposed to many flu patients in the waiting room while he and his mother waited for a transfer to be arranged for Patient 38. MD 1 said he observed Patient 38 and listened to his chest and felt that he would be safe for transfer by the mother to Hospital B. MD 1 said he advised Patient 38's mother that it would be faster and safer if she drove him directly to Hospital B's ED. MD 1 said that, in hindsight, he realized that he had made a mistake sending Patient 38 to another hospital and he should have initiated full ED treatment for Patient 38.

Record review indicated that Patient 38 was seen in Hospital B's ED at 10:50 AM on 2/5/15. There Patient 38 was listed as a level 2-emergent case in triage and he received a medical screening examination and was diagnosed with acute bronchiolitis ("Bronchiolitis is a common lung infection in young children and infants. It causes congestion in the small airways (bronchioles) of the lung. Bronchiolitis is almost always caused by a virus" - mayoclinic.org). While in the ED of Hospital B, Patient 38 received intravenous fluids and airway suctioning to stabilize his respiratory efforts, before his transfer, by ambulance, to Hospital C.

(2.a) On 2/13/15, Patient 36 was brought to the ED by ambulance, under duress but not on a 5150 (Involuntary Hold), after neighbors noted he was not acting as usual and one of them called police and paramedics. The Physician's note indicated that he, MD 1, was able to perform a physical examination on Patient 36 and he thought Patient 36 needed further evaluation; MD 1 ordered laboratory tests including toxicology screening, an electrocardiogram (EKG), a computer assisted tomography (CT scan) of Patient 36's head, and intravenous fluids. MD 1's note stated that when the nurse went carry out these orders, Patient 36 "got up off the gurney and stated he refused all care and refused to sign out against medical advice and he walked out of the Emergency Department. Given that he is not on a hold, so we do not have any right to keep him, and he left without any instructions and without complete evaluation. Final Diagnoses: 1. Altered mental status, 2. Left before examination."

Record review of the Registered Nurse's (RN 4) note, written on 2/13/15 at 5:03 PM, indicated Patient 36 was "refusing lab draw, EKG and CT scan, patient denies complaints, ambulatory, would not stay after encouraged by this RN to have further evaluation. Gait steady, would not sign AMA form, all belongings with patient."

Record review of the ED log showed Patient 36's disposition as "Left after medical screening exam" and the chart did not contain any paperwork for left "Against Medical Advice."

The hospital's Computer System Navigator (RN 5)acknowledged the absence of the AMA form.







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(2 b). On 02/06/15, Patient 32 was 3 weeks pregnant and was evaluated in the ED for abdominal pain. Review of the medical record on 02/18/15 showed MD 1 performed an MSE at 12:22 PM. The physician's dictated report stated that he wanted to obtain additional information from another facility to confirm the patient's pregnancy and this process took an additional hour. The physician wrote: "... I reobtained records from (the other facility) which took up approximately an hour, and her figures were accurate, but in order to comment, they had asked her to follow up with her private physician, but in any case, I at that point, ordered a repeat quantitative beta-hCG (pregnancy test) and urinalysis and wanted to see the results of the beta-hCG before ordering an ultrasound, but apparently, the patient did not wish to wait and she left without any instructions given". The physician's "Final Diagnosis" documented the patient as "Left before complete evaluation".

In an interview on 02/19/15 at 10:55 AM, MD 1 stated he stopped the patient on her way out the front door of the ED and explained the risks and benefits of her leaving before completing his evaluation and MD 1 said she understood. MD 1 agreed the case should have been an "AMA" but he did not complete the documents for an AMA patient. The ED log indicated, "Left after medical screening evaluation" and should have been an "AMA" as MD 1 indicated during the interview.

(2 c). On 8/07/14, Patient 16 was evaluated in the ED for nausea and vomiting for two days after drinking alcohol for seven days.

Record review on 02/18/15 showed the physician performed an MSE at 7:49 PM. MD 1 documented in the medical record section titled, " Hospital Course", the following: "... I went to evaluate the patient and found that her IV (intravenous) bag was empty. She pulled her IV out, and apparently her boyfriend had left without us knowing, but she had been in the department about 2 hours before leaving, so hopefully she is much more sober".

The ED log showed the patient's discharge disposition as "left against medical advice". Further medical record review of MD 1's dictation report showed "elopement" as part of the "Final Diagnosis". Paperwork for AMA was not completed to show the patient eloped,

During an interview on 02/18/15 at 9:50 AM, NM stated, " It's the nurse who chooses the discharge status in the computer. The nurse did not choose correctly. They need to be re-educated". NM agreed the discharge status should have been an elopement. NM also stated the computer program they are currently using did not have a category for "elopement" in its drop down menu for disposition choices.

Based on interview and record review, the hospital failed to perform an appropriate transfer for one of the thirty eight sampled patients when Patient 15 was allowed to travel to another hospital's Emergency Department (ED), in a private automobile, without completion of any transfer forms.

Findings:

On 12/25/14 at 7:07 PM, Patient 15 presented to the ED at Hospital A with a chief complaint of abdominal pain.

Record review of Patient 15's ED chart indicated Patient 15 was seen and evaluated by a Physician's Assistant (PA 1) and the ED Physician (MD 2). From the tests they performed on Patient 15 they could not determine the cause of his abdominal pain and they wanted to a computer assisted tomography (CT scan) of his abdomen to help them complete their evaluation.

PA 1 and MD 2 wrote in their notes that Hospital A's CT scanner was broken and would not be fixed until noon the following day.

Record review of this Emergency Documentation - MD indicated that since Patient 15 was a Marine and usually got his care at a VA Hospital in San Diego, MD 2 decided to contact the ED physician (MD 3) at Hospital D. MD 2 wrote "I spoke to MD 3 who stated he would be happy to see the patient and arrange for the CT of the abdomen and pelvis, and asked that the patient be discharged and could come by private vehicle."

Record review of the note written by PA 1 indicated that PA 1 wrote "He (MD 3) was advising us (PA 1 and MD 2) to have the patient discharged and sent directly over to the emergency room in (town name)." PA 1 wrote an order to "Discharge" at 9:40 PM on 12/25/14.

Record review of the ED Discharge Note written by the ED Registered Nurse (RN 6) indicated the Discharge Disposition was "Transferred to another Acute Care Facility" by Private Vehicle. There was nothing in the notes by RN 6 to indicate that any of the medical records, test results, or other required transfer documents were sent with Patient 15 when he went to Hospital D's ED.

Record review did not demonstrate a completed certification by the physician that the benefits of the transfer to Hospital D outweighed the risks of the transfer. There was nothing signed by Patient 15 in this record to indicate he understood the risks and benefits of the transfer and that he, Patient 15, wanted to proceed with the transfer. There were no documents in Patient 15's record where he signed a form declining transportation to Hospital D's ED with qualified personnel in a vehicle with appropriate life support equipment.

The hospital's Computer System Navigator (RN 5) acknowledged the absence of the transfer forms.