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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20, and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2406: (a)(c) Appropriate Medical Screening Examination. Based on interviews and document review, the facility failed to ensure patients who presented to the facility for emergency psychiatric services received an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for the patient in 11 of 20 medical records reviewed. (Patients #1, #2, #3, #5, #7, #8, #12, #16, #17, #20, and #21). Additionally, the facility failed to ensure qualified medical personnel (QMP) performed an MSE for patients who presented to the facility to determine the presence of an EMC in 10 of 20 medical records reviewed. (Patients #4, #6, #9, #10, #11, #13, #14, #15, #17, and #19)

Tag 2409: (e) Restricting Transfer Until the Individual Is Stabilized. Based on interviews and document review, the facility failed to ensure patients were assessed and transported for medical clearance as deemed safe by a provider. The failure was identified in six of eight medical records reviewed in which patients were transferred out for medical clearance. (Patient #3, #7, #8, #14, #16, and #17)

Based on interviews and document review, the facility failed to ensure patients who presented to the facility for emergency psychiatric services received an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for the patient in 11 of 20 medical records reviewed. (Patients #1, #2, #3, #5, #7, #8, #12, #16, #17, #20, and #21). Additionally, the facility failed to ensure qualified medical personnel (QMP) performed an MSE for patients who presented to the facility to determine the presence of an EMC in 10 of 20 medical records reviewed. (Patients #4, #6, #9, #10, #11, #13, #14, #15, #17, and #19)

Findings include:

Facility policies:

The EMTALA policy defined a QMP as an individual designated to perform the MSE by the hospital's governing board (GB) through the medical staff and/or hospital bylaws. An MSE is defined as a general and focused assessment based on the patient's chief complaint with the intent to determine the presence or absence of an EMC. A psychiatric MSE will include a screening assessment by a QMP. Triage or the completion of a medical/psychiatric triage form alone does not satisfy the MSE requirement. The facility will maintain medical and other records related to individuals transferred or discharged to or from the Hospital for six (6) years. Hospitals will maintain a log of patients presenting to the hospital for treatment along with documentation indicating whether he or she refused treatment, was denied treatment, or whether the patient was treated, admitted, stabilized, and/or transferred or discharged.

The Screening Assessment and/or Level of Care/ Psychosocial Assessment policy read every patient must have a Screening Assessment. No section of the assessment should be left blank without an explanation. If the patient doesn't meet the admission criteria for inpatient, partial hospitalization program (PHP), or intensive outpatient program (IOP) then the Screening Assessment will be staffed with a provider and signed. The Screening Assessment and the Level of Care Assessments will be completed by Assessment Coordinators (intake specialists) in the Assessment Department. The Assessment Department department is staffed with Masters level therapists; registered nurses and/or licensed individuals (as required by state licensure). An Assessment Coordinator will assess the patient and complete the assessments by gathering the necessary information from the patient, the patient's family, other informants, and or the patient's referring provider/therapist. The assessments are completed for every patient who comes to the facility seeking psychiatric services.

References:

The Medical Staff Rules and Regulations read the Medical Staff Rules and Regulations are a component of the Hospital Medical Staff Bylaws. Section 21, Emergency Services of the Medical Staff Rules and Regulations read the hospital provides services to evaluate, stabilize, and transfer when necessary and appropriate, individuals who present to the hospital with conditions of an emergent or urgent nature. These services include the provision of an appropriate "medical screening examination" by a Physician or other "qualified medical personnel" for individuals who present with an "emergency medical condition" and request examination or treatment to determine if the individual is experiencing an "emergency medical condition" and shall further include appropriate treatment to stabilize the patient or transfer the patient to another facility if medically necessary. Qualified medical personnel (QMP) may include any provider acting within the scope of their licensure and medical staff/allied health professional staff privileges.

The Governing Board Bylaws, Article IV, Section 3, read the Governing Body shall have the following duties and responsibilities: Approve Medical Staff bylaws, rules, and regulations. Additionally, Article IV, Section 4, read the Governing Board shall approve, in writing, the qualified medical personnel ("QMP") who may perform the medical screening examinations ("MSE") for EMTALA purposes.

The Screening Assessment form, identified by staff as a psychiatric assessment/evaluation form used when performing an MSE, was provided by the facility. The Screening Assessment form assisted staff at the facility in acquiring information about a patient's immediate psychiatric needs and information related to the care needed by the patient. The form obtained background information, medical history, medication history, and the psychiatric concern the patient had and was completed to assist staff in determining the psychiatric services needed for the patient.

1. The facility failed to ensure patients who presented to the facility for emergency psychiatric services received a medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for the patient.

A. Patient Safety Assessment forms, Personalized Treatment Recommendations, and the facility's EMTALA logs (a list of patients who sought emergency medical treatment from the facility) were reviewed and revealed from 1/30/24 through 7/4/24 patients who presented to the facility for psychiatric emergency services were not provided an MSE.

i. Medical record review revealed Patient #20 was admitted to the facility on 3/10/24. A review of Patient #20's Screening Assessment for 3/10/24 revealed Patient #20 had a diagnosis of substance use disorder (SUD - excessive use of alcohol, medications, and or illegal drugs) and had presented to the facility three days earlier on 3/7/24.

According to the chief complaint/current symptoms section of the Screening Assessment documented on 3/10/24, while in the intake assessment area (the designated area where new patients received medical screening exams) on 3/7/24, Patient #20 overdosed on Seroquel (an anti-psychotic medication to control mood) and sleeping pills.

A review of the EMTALA log for 3/7/24 revealed at 3:30 p.m., Patient #20 presented to the facility, and three hours later at 6:30 p.m., Patient #20 had been transferred out for immediate medical interventions and treatments.

Upon request, the facility failed to show how the patient was assessed on 3/7/24 during the three hours they were at the facility to determine if an EMC existed for Patient #20. Additionally, the facility was unable to provide evidence a psychiatric MSE had been performed for Patient #20 to determine if an emergent psychiatric condition existed before the patient overdosed.

ii. According to the EMTALA log, Patient #17 presented on 5/26/24 at 5:42 p.m. one hour and 21 minutes later at 7:03 p.m. Patient #17 was transferred out for medical evaluation.

Upon request, the facility was unable to provide evidence Patient #17 received an MSE to determine if they had an emergent psychiatric condition. Additionally, the facility was unable to provide evidence the patient had been assessed by staff while at the facility.

The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #17 had received an MSE to determine if the patient had an emergent psychiatric condition.

iii. Patient #7 presented to the facility on 4/2/24 at 7:00 p.m. According to the EMTALA log, 35 minutes later at 7:35 p.m. Patient #7 was transferred out for further medical evaluation.

The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #7 had received an MSE to determine if the patient had an emergent psychiatric condition.

iv. Patient #8 presented to the facility on 4/11/24 at 1:47 p.m. According to the EMTALA log Patient #8 was transferred out for medical evaluation nine minutes later at 1:55 p.m.

The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #8 had received an MSE to determine if the patient had an emergent psychiatric condition.

v. On 7/4/24 at 1:00 p.m., Patient #3 presented to the facility for alcohol detox services. Review of the Safety Assessment completed by Patient #3 revealed they were experiencing tremors, impaired cognitive thinking (confusion, forgetfulness, and or lack of focus), and increased sweating when they presented to the facility.

According to the Personalized Treatment Recommendation Patient #3 was instructed to get a medical evaluation at the nearest emergency department (ED) and was discharged from the facility.

A review of the EMTALA log revealed on 7/4/24 at 2:00 p.m. one hour after Patient #3 had presented to the facility, Patient #3 was transferred out for further medical evaluation.

However, upon request, the facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #3 had received an MSE to determine if the patient had an emergent psychiatric condition.

vi. On 7/4/24 at 3:00 p.m. Patient #16 presented to the facility for alcohol detox services. A review of the Safety Assessment form completed by Patient #16 revealed Patient #16 was experiencing alcohol withdrawal symptoms. However, a review of the Personalized Treatment Recommendation for Patient #16 revealed Patient #16 had been instructed to undergo a medical evaluation at the closest ED and, once medically cleared, Patient #16 was to request the ED send a referral to the facility for them to be admitted.

A review of the EMTALA log revealed at 3:42 p.m., 42 minutes after Patient #16 had presented to the facility, Patient #16 was transferred out.

The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #16 had received an MSE to determine if the patient had an emergent psychiatric condition.

vii. Patient #5 presented to the facility on 1/30/24 at 4:55 p.m. According to the EMTALA log Patient #5 was discharged, one hour and 40 minutes later at 6:35 p.m.

Upon request, the facility failed to show how the patient was assessed during the time Patient #20 was at the facility. Additionally, the facility was unable to provide evidence Patient #5 had received an MSE to determine if the patient had an emergent psychiatric condition.

viii. Patient #1 presented to the facility on 5/2/24 at 1:55 p.m. According to the EMTALA log two hours and five minutes later at 4:00 p.m., Patient #1 was discharged.

Upon request, the facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #1 had received an MSE to determine if the patient had an emergent psychiatric condition.

ix. On 5/11/24 at 9:45 a.m. Patient #2 presented to the facility. According to the EMTALA log one hour and 48 minutes later Patient #2 was discharged.

The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #2 had received an MSE to determine if the patient had an emergent psychiatric condition.

x. On 6/26/24 at 5:25 p.m., Patient #21 presented to the facility. According to the EMTALA log for 6/26/24, Patient #21 was discharged one hour and 20 minutes later at 6:45 p.m.

The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #21 had received an MSE to determine if the patient had an emergent psychiatric condition.

xi. On 7/1/24 at 1:00 p.m., Patient #12 presented to the facility. According to the EMTALA log for 7/1/24, Patient #12 was discharged two hours and 29 minutes later at 3:29 p.m.

The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #12 had received an MSE to determine if the patient had an emergent psychiatric condition.

These medical record reviews were in contrast to the Screening Assessment and or Level of Care/ Psychosocial Assessment policy which stated every patient was required to have a completed Screening Assessment performed. Additionally, according to the EMTALA policy, a psychiatric MSE would include a screening assessment to determine the presence of an EMC.

B. Interviews with staff revealed the Screening Assessment form was the psychiatric MSE and was required for each patient who presented for emergency psychiatric services.

i. On 7/15/24 at 2:33 p.m., an interview was conducted with Specialist #6. Specialist #6 stated the Screening Assessment forms were used to evaluate the psychiatric crisis level of patients who present to the facility. Additionally, Specialist #6 stated the Screening Assessment forms reviewed the patient's risk for self-harm and harm to others.

Specialist #6 stated the Screening Assessment was required to be completed by intake specialists at the time the patients were assessed. Specialist #6 stated the Screening Assessment form was completed by intake specialists to ensure patients were not actively experiencing an emergent psychiatric condition and also to ensure the patient was not a danger to themselves or others.

This interview was in contrast to the medical records reviewed which lacked evidence a screening assessment had been performed.

ii. On 7/9/24 at 3:49 p.m., an interview was conducted with intake assessment specialist (Specialist) #7. Specialist #7 stated the screening assessment was the psychiatric assessment. Specialist #7 stated all screening assessments were performed by an intake assessment specialist or intake director (Director) #5.

Specialist #7 stated a screening assessment was performed for every patient who presented to the facility and requested emergent psychiatric services. Specialist #7 stated the intake assessment specialists were required to complete a Screening Assessment form when a psychiatric assessment was performed for patients who presented to the facility seeking emergent psychiatric services.

iii. On 7/9/24 at 9:34 a.m., an interview was conducted with Director #5. Director #5 stated the Screening Assessment form was completed for all patients who presented to the facility. Director #5 stated the Screening Assessment form was to be completed by the intake staff member who assessed the patient. Director #5 stated the Screening Assessment form ensured that patients requesting psychiatric services were not at risk of harming themselves or others and determined if they were experiencing a psychiatric or medical emergency.

iv. On 7/10/24 at 9:47 a.m. an interview was conducted with director of nursing (DON) #11. DON #11 stated the screening assessment served as the MSE for the patient. According to DON #11, the screening assessment assisted in identifying if the patient was experiencing a psychiatric emergency.

2. The facility failed to ensure patients who presented for emergency psychiatric services received an MSE by qualified medical personnel (QMP).

A. Document review revealed Governing Board Bylaws and Medical Staff Rules and Regulations had not designated intake assessment specialists as QMPs to perform MSEs.

According to the Governing Board Bylaws, a QPM was any provider who worked within their license and the privileges granted by the medical staff.

The bylaws did not state the intake director and intake assessment specialists were considered medical staff or privileged staff at the facility.

B. Medical record review revealed intake specialists performed the MSE for patients who presented for emergency psychiatric services, even though intake specialists were not designated as QMPs by the governing board.

i. On 1/25/24 at 11:05 a.m. Patient #14 presented to the facility after the patient had attempted suicide. A review of the Screening Assessment form for Patient #14 revealed Patient #14 had endorsed having thoughts of self-harm and also endorsed a plan to commit suicide by "jumping into traffic or strangling" themselves. Additionally, Patient #14 had walked into traffic before presenting to the facility. According to the Screening Assessment form the MSE for Patient #14 had been conducted by intake specialist (Specialist) #2.

ii. On 2/2/24 at 5:25 p.m. Patient #13 presented to the facility. According to the Chief Complaint/Current Symptoms section of the Screening Assessment, Patient #13 did not meet the inpatient criteria for medical detox.

Additionally, the MSE for Patient #13 was performed by Specialist #3 on 2/2/24 and subsequently signed by Specialist #4 on 2/3/24.

iii. On 1/8/24 at 1:28 p.m. Patient #11 presented to the facility. A review of Patient #11's Screening Assessment form revealed Patient #11 had requested inpatient detox services. The MSE was conducted by Specialist #2.

iv. On 2/20/24 at 4:20 p.m. Patient #15 presented to the facility. According to Patient #15's Screening Assessment form, Patient #15, requested inpatient detox services for alcohol after the patient relapsed earlier in the day. The MSE for Patient #15 was performed by intake director (Director) #5.

v. On 3/30/24 at 10:15 p.m. Patient #6 presented to the facility. According to Patient #6's Screening Assessment form, Patient #6 had requested inpatient detox services. The MSE was conducted by Specialist #12.

vi. On 4/28/24 at 8:00 p.m., Patient #9 presented to the facility. According to the Screening Assessment form for Patient #9, the patient presented for inpatient detox services. Patient #9 endorsed continuous alcohol consumption daily and a history of shakes, tremors, seizures, nausea, and vomiting when detoxing from alcohol. The MSE for Patient #9 was performed by Specialist #10.

vii. On 4/29/24 at 2:04 p.m. Patient #4 presented to the facility and requested inpatient detox services for alcohol. According to the Screening Assessment form for Patient #4, the patient reported continuous alcohol consumption daily and a history of shakes, tremors, sweats, chills, nausea, and vomiting when detoxing from alcohol. At 3:30 p.m. Patient #4 was discharged from the facility. The MSE for Patient #4 was performed by Specialist #3 and Specialist #6.

viii. A review of the June 2024 EMTALA log revealed Patient #19 presented to the facility on 6/23/24 and 6/24/24.
On 6/24/24 at 12:03 p.m., Patient #19 presented to the facility for inpatient detox services. A review of the Screening Assessment for Patient #19 revealed the Screening Assessment form and MSE were completed by Specialist #7.

ix. On 5/26/24, Patient #17 presented to the facility at 9:00 p.m. for inpatient detox services for alcohol. A review of the Screening Assessment form for Patient #17 revealed the MSE was completed by Specialist #6.

x. On 6/3/24 at 9:13 a.m. Patient #10 presented to the facility for inpatient detox services for alcohol. A review of the Screening Assessment form for the patient revealed the MSE was completed by Specialist #6.

C. Interviews with facility staff revealed the facility was unaware intake specialists needed designation as QMPs by the Governing Board to perform the MSE.

i. On 7/15/24 at 2:33 p.m. an interview was conducted with intake specialist (Specialist) #6. Specialist #6 stated they performed psychiatric MSEs. Specialist #6 stated screening assessment forms were completed by intake specialists to determine if an emergent psychiatric condition existed for the patient.

ii. On 7/10/24 at 3:40 p.m., Director #5 was interviewed. Director #5 stated they were not aware intake specialists had to be designated as QMPs to perform the MSE. Director #5 also stated the facility determined the intake staff would perform the psychiatric MSE for patients who presented and requested emergent psychiatric services.

iii. On 7/15/24 at 3:54 p.m., chief executive officer (CEO) #9 was interviewed. CEO #9 stated they were unaware intake specialists and the intake director were not designated as QMPs to perform MSEs. CEO #9 further stated at the 3/27/24 Governing Board meeting, the board reviewed and approved QMP designations. However, the facility was unable to provide evidence upon request that the board had designated intake specialists and the intake director as QMPs.

The medical record reviews and interviews contrasted with the Governing Board bylaws, Medical Staff Rules and Regulations, and EMTALA policy. The Governing Board bylaws and EMTALA policy required the Governing Board to approve QMPs in writing, defining a QMP as someone designated by the board through the medical staff rules and regulations. According to the Medical Staff Rules and Regulations, intake specialists were not designated as medical staff or allied health professionals, who alone could serve as QMPs within the scope of their licensure and privileges.

Based on interviews and document review, the facility failed to ensure patients were assessed and transported for medical clearance as deemed safe by a provider. The failure was identified in six of eight medical records reviewed in which patients were transferred out for medical clearance. (Patient #3, #7, #8, #14, #16, and #17)

Findings include:

Facility policies:

The Emergency Medical Treatment and Active Labor Act (EMTALA) policy read, transfer means the movement (including discharge) of an individual outside the hospital's facilities at the direction of any qualified medical personnel employed by the hospital. When a patient is being transferred from the facility to another facility, staff shall discuss transfer and risks with the patient. If the patient consents for transfer, call EMS for transfer. The facility will call EMS or the local sheriff's department for the patient's transfer to the receiving hospital. If the patient refuses to be transferred and is not at imminent medical risk, complete a copy of the Consent to Transfer EMTALA Form noting the patient's refusal, and complete the assessment process.

The Transfer to Another Facility policy read, if there is a medical emergency or medical clearance is required for a patient in assessment who has not been admitted, an appropriate hospital transfer will take place. The RN assesses and determines if the patient has an unstable medical condition. The RN will contact the physician and they will provide orders to transfer the patient. The physician will contact the emergency department physician and provide clinical information about the patient. The assessment staff will arrange for the transfer. The assessment staff will complete the EMTALA transfer form and send the original with the patient. When transportation arrives, i.e. ambulance, give the sealed envelope to the attendant.

1. The facility failed to ensure patients who needed medical clearance were transported by ambulance to ensure patient safety.

A. Medical Record Review

i. On 7/4/24 at 1:00 p.m., Patient #3 presented to the facility for alcohol detox treatment. The personalized treatment recommendation form read the patient needed to seek medical clearance via the nearest emergency department (ED). After seeking clearance, the facility would review the ER records for admission consideration at the facility. The patient was transported in a private vehicle by a sobriety sponsor.

Upon request the facility was unable to provide evidence of a medical screening exam (MSE) completed by a qualified medical professional (QMP) and an RN assessment was performed to determine if the patient had an unstable medical condition. Additionally, there was no evidence the appropriate level of transfer and the risks of transportation by private vehicle were discussed with the patient by a QMP. Also, there was no evidence of the emergency department being contacted by the physician to provide clinical information about the patient.

ii. On 7/4/24 at 3:00 p.m., Patient #16 arrived for alcohol detox treatment. The personalized treatment recommendation form read the patient needed to seek medical clearance at the local ER and that once the patient was medically cleared, the hospital could send a referral to the facility for review. The EMTALA log revealed Patient #16's disposition was marked as private transport.

Upon request the facility was unable to provide evidence of a medical screening exam (MSE) completed by a qualified medical professional (QMP) and an RN assessment was performed to determine if the patient had an unstable medical condition. Additionally, there was no evidence the appropriate level of transfer and the risks of transportation by private vehicle were discussed with the patient by a QMP.

iii. On 4/2/24 at 7:00 p.m., Patient #7 arrived for alcohol detox treatment. Patient #7 reported they had been experiencing hallucinations and felt shaky. The EMTALA log showed Patient #3 was a medical send-out.

There was no documentation to indicate how the patient was transferred. Additionally, the facility was unable to provide evidence an RN had performed an assessment to determine if the patient had an unstable medical condition prior to the patient being transferred out. Also, there was no evidence in the medical record an MSE had been completed by a QMP to determine the appropriate level of transfer.

iv. On 4/11/24 at 1:47 p.m., Patient #8 arrived for detox treatment. At 1:55 p.m. the EMTALA log read Patient #8 was a medical send-out.

There was no documentation to indicate how the patient was transferred. Additionally, the facility was unable to provide evidence an RN had performed an assessment to determine if the patient had an unstable medical condition prior to the patient being transferred out. Also, there was no evidence in the medical record an MSE had been completed by a QMP to determine the appropriate level of transfer.

v. On 1/25/24 at 11:05 a.m., Patient #14 arrived for treatment after a suicide attempt. Five hours later at 4:05 p.m., Patient #14 was transferred out for further medical evaluation.

There was no documentation to indicate how the patient was transferred. Additionally, the facility was unable to provide evidence an RN had performed an assessment to determine if the patient had an unstable medical condition prior to the patient being transferred out. Also, there was no evidence in the medical record an MSE had been completed by a QMP to determine the appropriate level of transfer.

vi. On 5/26/24 at 5:41 p.m., Patient #17 presented to the facility. According to the disposition noted on the EMTALA log, one hour and 22 minutes later Patient #17 was transferred out for further medical evaluation.

There was no documentation to indicate how the patient was transferred. Additionally, the facility was unable to provide evidence an RN had performed an assessment to determine if the patient had an unstable medical condition prior to the patient being transferred out. Also, there was no evidence in the medical record an MSE had been completed by a QMP to determine the appropriate level of transfer.

B. Interviews

i. On 7/15/24 at 2:33 p.m., an interview was conducted with intake specialist (Specialist) #6. Specialist #6 stated when the EMTALA log stated medical send out by 911 it meant intake staff called 911 and the patient was transferred out by ambulance to an ED for further medical evaluation. Specialist #6 stated when private transport was listed on the EMTALA log, it meant the patient needed additional medical evaluation but 911 was not called, and a friend or family member transported the patient to an ED for further medical evaluation. Specialist #6 stated an EMTALA form should have been completed for patients who were transferred by ambulance and by private transport.

This was in contrast to the review of the EMTALA log which was lacked evidence of whether the patient was sent out by ambulance or by private transport for Patients # 7, #8, #14, #17. This was also in contrast with the review of Patients #3, #7, #8, #14, #16, and #17, which showed no evidence of an EMTALA form to verify that the patient was transferred appropriately and in accordance to the facility's policies.

ii. On 7/11/24 an interview was conducted with director of nursing (DON) #11. DON #11 stated they were unable to locate an EMTALA form for Patient's #7, #8, #14, and #17.

DON #11 stated an EMTALA transfer from would not have been completed for Patient #3 and Patient #16 since the disposition for both patients was medical send out, private transport. DON #11 stated "medical send" out meant the patient required further medical evaluation for acute medical symptoms the facility could not treat. Additionally, DON #11 stated "private transport" meant the patient transported themselves or had another person transport them.

iii. On 7/9/24 at 9:34 a.m. an interview was conducted with intake director (Director) #5. Director #5 stated patients in intake who needed additional medical evaluation were transferred out by ambulance. Director #5 stated intake staff would call 911, and EMS will transport the patient. Director #5 stated how the patient was transported out would be listed on the EMTALA log under the disposition. Director #5 stated an EMTALA transfer form was completed for patients transferred out by ambulance.

The medical record reviews and interviews contrasted with the EMTALA policy and the Transfer to Another Facility policy which stated for patients who have not been admitted to the facility and required medical clearance a transfer to an external facility should be conducted under the guidance and approval of a QMP. The facility should complete an EMTALA transfer form for the patient. Additionally staff should discuss the transfer and associated risks with the patient before the patient has been transferred. Lastly, EMS or local law enforcement should be called to transfer the patient.