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Based on interview and record review, the facility failed to ensure the patient or patient's legal representative was informed in writing, the need for the patient to be transferred to another facility for four of 20 sampled patients (Patients 1,3,7, and 9).

This failure resulted in Patients 1, 3, 7, and 9, being transferred to another facility without consent from the patient or the patients responsible party, and the potential for the patients to not understand where they are going and why they are being transferred to another facility.

Findings:

On January 15, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility for an Emergency Medical Treatment and Labor Act (EMTALA) survey.

1 a. A review of Patient 1's medical record was conducted on January 15, 2025, at 2 p.m., with the Accreditation Regulatory Manager (ARM). The facility document titled, "ED [Emergency Department] Triage Form", dated January 1, 2025, at 6:06 p.m., indicated, Patient 1 was admitted on January 1, 2025, on a 5150 (an involuntary hold, detained for mental health assessment of patients exhibiting psychiatric/behavioral symptoms or a status post attempted suicide event), after being found in an alley and gravely disabled after being discharged from a local hospital on December 31, 2024.

Review of a facility document, titled, "ED Discharge Form," dated January 4, 2025, at 8:32 a.m., indicated, "...ED Disposition: Transfer...Discharge Comment: Pt [patient] alert and awake..."

The facility's undated document titled, "Transfer Summary," was reviewed and indicated Patient 1 was discharged to another local hospital on January 4, 2025. There was no patient signature on this form.

The facility's undated document titled, "Transfer Contact Documentation form," was reviewed and indicated, "...Transferred Date and Time: 1/4/25 [January 4, 2025] at 0843 [8:43 a.m.]..."

1 b. A review of Patient 3's medical record was conducted on January 15, 2025, at 2:30 p.m., with the ARM. The facility undated document titled, "ED Triage Form," was reviewed and indicated Patient 3 was brought in by ambulance after attempted suicide and was placed on a 5150 hold.

The facility's undated document titled, "Transfer Form," was reviewed and indicated Patient 3 was transferred to another local hospital for foreign body ingestion on January 1, 2025, at 8:25 p.m. There was no signature of the patient or the patient's responsible party noted on this form.

1 c. A review of Patient 7's medical record was conducted on January 15, 2025, at 2:50 p.m., with the ARM. The facility's undated document titled, "ED Note-Physician" was reviewed and indicated Patient 7 was admitted on January 4, 2025, on a 5150 hold for danger to self. It further indicated Patient 7 was alert and oriented.

The facility's undated document titled, "Transfer Summary," was reviewed and indicted, Patient 7 was transferred to another facility for 5150 (psychiatric services). This form did not include the patient's or a responsible party signature.

The facility's document titled, Transfer Contact Documentation form," was reviewed and indicated, "...Transferred Date and Time: 1/5/25 [January 5, 2025] at 0658 [6:58 a.m.]..."

1 d. A review of Patient 9's medical record was conducted on January 15, 2025, at 3:20 p.m., with the ARM. The facility undated document titled, "ED Note-Physician," was reviewed and indicated Patient 9 was admitted on January 4, 2025, at 9:10 p.m., on a 5150 hold for danger to self and others. It further indicated Patient 9 was alert and oriented times two [person knows who and where they are].

The facility's document titled, "Transfer Summary," was reviewed and indicted Patient 9 was being transferred to another facility for 5150 (psychiatric services). This form did not have Patient 9's or a witness signature.

The facility document titled, Transfer Contact Documentation form," was reviewed and indicted, "...Transferred Date and Time: 1/6/25 [January 6, 2025] at 2135 [9:35 p.m.]..."

On January 15, 2025, at 9:10 a.m., an interview was conducted with the Emergency Department Clinical Manager (EDCM). The EDCM stated suicidal patients are placed on a 5150 involuntary hold and transferred to another facility for inpatient treatment. The EDCM further stated consent to transfer must be obtained, either from the patient if alert and oriented, or from the patient's guardian, family member, or person with Power of Attorney, involved in the patient care, for the transfer to occur.

On January 15, 2025, at 2 p.m., an interview was conducted with the ARM. The ARM stated a Social Worker (SW) had given out information that patients on a 5150 hold, does not need to sign a consent for transfer form. The ARM stated Patients 1, 3, 7, and 9's, transfer forms did not include a signature from the patient or patient representative, and had no other documentation to support why signatures were not secured. The ARM further stated staff need to be re-educated on how to properly complete the transfer form.

On January 16, 2025, at 2:18 p.m., an interview with the ARM was conducted. The ARM stated consent and notification is important so patients understand where they are going, and why they are being transferred to another facility. The ARM further stated patient's family/next of kin should be made aware of the patient transfer so they can follow up on the patient's whereabouts.

On January 16, 2025, at 3:30 p.m., an interview was conducted with the Interim Chief Nursing Officer (ICNO). The ICNO stated it is very important to seek patient/representative consent and fill out the form during transfer. The ICNO stated it is a patient hand off tool for patient safety during transport. The ICNO stated the transfer form must be signed by the patient, or by a representative if the patient is unable to sign. The ICNO further stated, "The family or responsible party had to be notified of the patient transfer."

A review of the facility policy titled, "ASSESSMENT OF NEED OF (VOLUNTARY OR NON-VOLUNTARY) PSYCHIATRIC CARE", dated June 15, 2023, was conducted. It indicated, "Purpose: To set guidelines for a mental health assessment of patients exhibiting psychiatric/behavioral symptoms or a status post attempted suicide event and provide a service referral policy which ensures a safe discharge with an appropriate placement...NOTE: Persons detained retain their legal rights regarding consent for medical treatment..."

A review of the facility policy titled, "PATIENT RIGHTS AND RESPONSIBILITIES", dated July 18, 2024, was conducted. It indicated, "PURPOSE: To encourage awareness of patient's rights and responsibilities and provide guidelines to assist patients in making decisions regarding care and to actively participate in care planning...PATIENT RIGHTS: You and/or your representative have the right to...Receive information about your health...You have the right to effective communication and to participate in the development and implementation of your plan of care...Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment..."

A review of the facility policy titled, "EMTALA POLICY", dated June 17, 2021, was conducted. It indicated, "PURPOSE: The purpose of this policy is to set forth policies and procedures for Hospital's use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA)...Transfer of Unstable Individuals...When the Hospital transfers an individual...The Hospital must send...The written patient consent or physician certification to transfer..."