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Based on interview and record review, the hospital failed to ensure four of four sampled patients' (Patient 11, Patient 12, Patient 13, and Patient 1) information regarding status of patient stabilization, reason for transfer, and /or risks and benefits were accurately documented prior to transfer from the hospital's Emergency Department (ED) or Labor and Delivery Unit to other hospitals. This failure had the potential for patients or their representatives to not have sufficient information to make informed decisions prior to consenting to being transferred to other hospitals.

Findings:

During a review of Patient 11's medical record, the "Emergency Room Note" (ERN) dated 9/2/23 indicated Patient 11 was a five year old male, with a history of asthma (chronic lung disease which can cause coughing, wheezing, shortness of breath and chest tightness), arrived at the hospital's ED on 9/2/23 at 12:44 p.m. with his father, with complaints of "dyspnea [difficulty breathing]" and "cough" for "4 days." The ERN indicated Patient 11 developed an "increased respiratory rate" and would be admitted and transferred to a children's hospital for a higher level of care.

During a concurrent interview and record review on 12/4/23 at 1:50 p.m. with Director of IT/Informatics (DII), Patient 11's "Physician Transfer Certification (PTC)," dated 9/2/23 at 10:31 p.m. was reviewed. The PTC indicated, Physician 1 did not check "yes" or "no" to certify if Patient 11 was "Stabilized for Transfer." Physician 1 did not complete the "Summary of Specific Medical Reason for Transfer" and did not indicate which "Risks" and "Benefits" applied to Patient 11's transfer to another hospital. DII stated the "Physician Transfer Certification" was not completed.

During a review of Patient 12's medical record, the ERN dated 9/4/23 at 1:28 a.m. indicated Patient 12 was brought to the hospital's ED via ambulance with complaints of "difficulty breathing." The "[Hospital] Imaging Report Signed" dated 9/4/23 indicated Patient 12 had a computerized tomography (CT) scan (combines series of X-ray images taken from different angles of the body to provide more-detailed information than a conventional X-ray) of the chest, abdomen, and pelvis. The CT scan results indicated Patient 12 had biliary tract obstruction (system which stores and transfer bile from the liver, pancreas, and gallbladder) and narrowing of arteries in the digestive tract. The ERN dated 9/4/23 at 2:50 p.m. indicated Patient 12 was going to be transferred to another hospital to undergo an Endoscopic retrograde cholangiopancreatography (ERCP- procedure used to identify the presence of stones, tumors, or narrowing in the biliary and pancreatic ducts).

During a concurrent interview and record review on 12/4/23 at 1:53 p.m. with DII, Patient 12's "PTC," dated 9/4/23 at 5:30 p.m. was reviewed. The PTC indicated, Physician 2 did not specify which "Risks" and "Benefits" applied to Patient 12's transfer to another hospital. DII stated no boxes were checked and the form (PTC) was not completed properly.

During a review of Patient 13's medical record, the "[Hospital] Imaging Report Signed (IRS)," dated 9/4/23 at 10:08 PM, indicated Patient 13 had a "Gunshot injury with comminuted [bone is broken into more than two pieces] fracture of the right hip at the level of the lesser trochanter [upper part of leg bone where muscle attached to the bone], suspicious for fracture extending through the right femoral neck [area connecting long shaft of leg bone to head of leg bone]." The ERN dated 9/4/23 indicated Patient 13 sustained a gunshot wound to his right hip which resulted in a fractured (broken) pelvis and would be admitted and transferred to another hospital for a higher level of care.

During a concurrent interview and record review on 12/4/23 at 2:01 p.m. with DII, Patient 13's "PTC," dated 9/4/23 at 11 p.m. was reviewed. The PTC indicated, Physician 3 did not specify which "Risks" and "Benefits" applied to Patient 12's transfer to another hospital. DII stated the form (PTC) was not completed properly.

During a review of Patient 1's medical record, the "History and Physical Report" (H&P) dated 11/5/23 indicated Patient 1 was 34 weeks pregnant (40 weeks is full term, less than 37 weeks is premature), leaking amniotic fluid (water which surrounds fetus in the womb), and the fetus had gastroschisis (birth defect where a hole in the abdominal wall allows the baby's intestines to extend outside of the baby's body). The "OB Assessment & Plan" section of the H&P indicated, "Admit to labor & delivery" and transfer to another hospital. The "Details Notes Log" dated 11/5/23 at 8:50 p.m. indicated Patient 1 was "Transfer/Discharge: To Other Facility- Per stretcher/Cart- Per Ambulance- Per Helicopter."

During a concurrent interview and record review on 12/4/23 at 4:15 p.m. with Informatics Nurse (IN), Patient 1's "PTC," dated 11/5/23 at 7:20 p.m. was reviewed. The PTC indicated Physician 4 did not complete the "Summary of Specific Medical Reason for Transfer" and did not indicate which "Risks" and "Benefits" applied to Patient 1's transfer to another hospital. IN stated the "PTC" form was incomplete.

During a review of the hospital's policy and procedure (P&P) titled "EMTALA - Interfacility transfers, MSE, Emergency Care and Stabilization" undated, the P&P indicated, "Procedure: Interfacility Transfer Procedure (EMTALA Patient) . . . B. Form # 009462 'Physician Transfer Certification" will be completed. A. Document if the individual is stabilized for transfer; b. Specify the medical reason for transfer (ex: specialty services not available at [hospital]) c. Document the risks and benefits of transfer and explain them to the individual or their representative in layman's terms."