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Based on Policy review, Clinical record review, Transfer Log review, Patient Care Report, and interview, it was determined the facility failed to ensure that a transfer was appropriate to another hospital with available capability and capacity was provided for 1 of 20 sampled patients with an unstable emergency medical condition; and failed to obtain a confirmed acceptance of patient #1 prior to transfering patient #1 to the receiving hospital.

Refer to findings in citation A-2409.

Based on Policy review, Clinical record review, Transfer Log review, Patient Care Report, and interview, it was determined the facility failed to ensure that a transfer was appropriate to another hospital with available capability and capacity was provided for 1 of 20 sampled patients with an unstable emergency medical condition; and failed to obtain a confirmed acceptance of patient #1 prior to transfering patient #1 to the receiving hospital.

The findings included:

Review of the facility policy, titled, EMTALA - Florida Transfer Policy, dated 10/22, documented, in part, the following:

"This policy reflects guidance under the Emergency Medical Treatment and Labor Act (EMTALA) and associated State laws only... Policy: Any transfer of an individual with an EMC [Emergency Medical Condition] must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual's behalf or by a physician order with the appropriate physician certification as required under EMTALA. EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC apply to any emergency department ("ED") or dedicated emergency department ("DED") of a hospital whether located on or off the hospital campus and all other departments of the hospital located on hospital property...1. Transfer of Individuals Who Have Not Been Stabilized: a. If an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer and meets the following conditions: The individual or a legally responsible person acting on the individual's behalf requests the transfer, after being informed of the hospital obligations under EMTALA and of the risks and benefits of such transfer. The request must be in writing and indicate: The reasons for the request as well as indicate that the individual is aware of the risk and benefits of transfer;...b. A transfer will be an appropriate transfer if: i. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health ...;
ii. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment...c. Higher Level of Care - A higher level of care should be the more likely reason to transfer an individual with an EMC that has not been stabilized. The following are examples of a higher level of care:
i. A receiving hospital with specialized capabilities or facilities that are not available at the transferring hospital ...must accept an transfer of an individual with EMC who requires specialized capabilities or facilities if the hospital has capacity to treat the individual....c. Request To Transfer Made to Receiving Facility. The transferring hospital must call the receiving hospital or the Transfer Center if the facility is part of a Transfer Center network to verify the receiving hospital has available space and qualified personnel for the treatment of the individual. The receiving hospital must agree to accept the transfer and provide appropriate treatment. The transferring hospital must obtain permission from the receiving hospital to transfer an individual. This may be facilitated by a Transfer Center. Such permission should be documented on the medical record by the transferring hospital, including the date and time of the request and the name and title of the person accepting transfer. The transferring physician shall ensure that a receiving hospital and physician that are appropriate to the medical needs of the individual have accepted responsibility for the individual's medical treatment and hospital care. If utilizing the services of a Transfer Center, the Transfer Center may facilitate this step in the process but does not take the place of the transferring physician. ...Request. The transferring hospital must document its communication with the receiving hospital, including the request date and time and the name of the person accepting the transfer..."


Clinical record review conducted on 02/13/24 revealed that Patient #1 presented to the Emergency Department (ED) at Hospital A seeking care for an emergency medical condition (EMC). The patient presented via fire rescue on 12/28/23 at 11:01 PM, with chief complaints of being unresponsive and bleeding. The patient was triaged at 11:05 PM with an emergent acuity. The nurse documented vital signs as: blood pressure 71/37, ( Blood Pressure reading under 90/60 is considered abnormally low)respirations 16, temperature 36.7 and heart rate 120 bpm [beats per minute] ( normal heart rate 60-100). The oxygen saturation was noted at 98% on 2 liters of oxygen via nasal cannula.

The physician completed a Medical Screening Exam (MSE) at 11:05 PM, documenting the patient was here for evaluation of Gl (Gastrointestinal) bleed, and the presentation included stool bright red blood and syncope (fainiting or passing out). Laboratory studies revealed critical low hemoglobin of 5.4 d/gl (normal range 12-14 d/gl).
Patient #1 was stabilized with a blood transfusion, medications and intravenous (IV) fluids.

Hospital A did not have GI coverage and initiated a transfer to a sister facility (Hospital B) located fifteen miles away. Hospital B accepted the patient.

Record review indicated Patient #1 had a change in condition and became unstable at approximately at 2:05 AM. The physician documented the patient became less responsive, noted bradycardia (Low heart rate), agonal breathing (irregular breathing, grasping breaths, indicates a sever medical emergency), and required intubation (person has breathing tube inserted through their mouth or nose into the windpipe connects to a machine that delivers air or oxygen), and a Dopamine infusion drip (medication used to treat low blood pressure).
The physician decided to transfer the patient to Hospital C, located two miles away for clinical safety.
Hospital C instructed Hospital A that they would return the call for acceptance pending approval of GI services.

Record review indicated at 3:20 AM, the transportation company left Hospital A with the patient enroute to Hospital C, while Hospital A was still waiting on acceptance from Hospital C for Patient #1.

Review of the documents, titled, EMTALA Memorandum of Transfer, did not document whether the patient was stable or unstable for transfer. The physician certified the transfer on 12/29/23 at 1:00 AM and the transfer was medically indicated for GI services not available at Hospital A. The medical risks associated with the transfers were documented. Hospital C was noted under the receiving facility, but there was no receiving physician name on the document. The form documented the nurse gave report to an 'RN' (Registered Nurse) but no name was noted, and the vital signs at 3:00 AM, prior to transfer, were noted as: pulse 48, respirations 10 (normal respiratory rate 12-20 breaths per minute), blood pressure 69/32 and oxygen level 97% on four liters of oxygen. The patient was being transported with advance life support, via a private transportation company with a paramedic and the patient was receiving a Protonix infusion (treat conditions that cause too much stomach acid, like heartburn and reflux disease)..
The memorandum did not document Patient #1's clinical presentation: the patient was intubated, receiving Dopamine drip, and had a nasogastric (NG) tube in use.

Review of the 'Transfer Center detailed call logs' documented Hospital C did not accept Patient #1.
On 12/29/23 at 3:56 AM, Hospital C informed Hospital A's transfer center that Patient #1 was not accepted, but the patient had arrived at Hospital C and was subsequently sent to Hospital B due to lack of capacity and capability.

Review of the Transportation Company document, titled, Patient Care Report, dated 12/29/23, indicated Patient #1 left Hospital A at 3:25 AM, arrived at the Emergency Room (ER) of Hospital C, was not accepted at Hospital C due to lack of capacity and capability per the nurse and ER physician, and arrived at Hospital B at approximately 4:02 AM.

The facility failed to ensure that their poliy was followed as evidenced by failing to ensure that the receiving hospital had accepted the responsibility of patient #1 on 12/28/2023 medical treated and hospital care as stated in the facility policy.

Interview with the Emergency Department (ED) Physician at Hospital A conducted on 02/13/24 at 11:45 AM revealed his recollection of Patient #1. The patient presented with GI bleed, they did not have GI On-Call, the patient was clinically stable, his vital signs were good and occult blood was positive. The diagnostic studies were completed, the patient was anemic and received blood. The physician stated a transfer to their sister facility (Hospital B) was initiated for GI services. The physician stated he followed the protocol, but later, the patient's condition changed, he became hypotensive, unresponsive, and required immediate intubation. The intubation proceeded with no issues and then he contacted Hospital B to update them on the patient's condition. The patient was unstable now, and he then decided to send the patient to Hospital C, the closest hospital with GI services and the physician from Hospital B agreed with the plan. The ED physician then spoke to the ED physician at Hospital C, who was receptive to the transfer but needed to check with the GI consultant prior to accepting the patient as the facility was over capacity.
The ED physician recalled, he went to see another patient, and when he returned Patient #1 was gone. The transport company had showed up, basically scooped up the patient and proceeded to take the patient to Hospital C without his approval. He, the physician, did not see the patient leave, but this was told to him by the Charge Nurse. The physician stated he did not think from the medical point of view that he did anything wrong, as he followed the protocol. When asked how a patient leaves the ED without the staff being aware of the transport, and what actions could be taken to prevent the incident, the physician replied, maybe the communication within transportation and the nurses could be better, maybe he could be more vigilant about the patients.

Interview conducted on 02/13/24 at 12 noon with the ED Medical Director (ED-MD) of Hospital A revealed he was made aware of the event. The ED-MD revealed the facility does not always have GI coverage. The patient was transported to Hospital C without proper approval. The ED-MD was asked what they could do better and stated maybe they should not give the transfer paperwork to the transport company until the transfer has been approved. The ED-MD stated the facility has implemented the following corrective actions: EMTALA education to providers regarding the transfer policy and documentation of stable versus unstable.

Interview with Staff A, the Charge Nurse, conducted on 02/13/24 at 3 PM, revealed she was the charge nurse on 12/28/23, her shift is 7 PM - 7AM, she had never done charge duties before, she is a new nurse, and that night she did not have a unit secretary.
Staff A recalled the patient needed to be transferred out. She called the Transfer Center (TC) and informed them. The TC personnel asked for patient information and then the physician spoke to them. The patient was initially going to Hospital B, the patient was accepted, but later during the shift, the patient started to decline, and the physician asked her to call the TC to send the patient to a closer hospital. They spoke to the doctor at Hospital C and the patient was accepted pending GI approval. Staff A confirmed she prepared the paperwork for transfer to Hospital C, walked away from the desk, and when she returned the patient was gone.
Staff A elaborated that the paramedic wanted to take the patient to Hospital C from the beginning and she told him that Patient #1 had not been accepted yet.

Interview with Staff B, the Primary Nurse, was conducted on 02/14/24 at 10:05 AM. Staff B recalled Patient #1 came in via fire rescue, he was in and out of consciousness, and he was a GI bleed with melena. They followed the GI bleed protocol: did an EKG, he received intravenous fluid and a blood transfusion. Staff B stated at first, the patient was going to be transferred to Hospital B, then the paramedic came, and he was not comfortable taking the patient there. Staff B stated she was not sure why, as there have been many patients more unstable and other paramedics transported them to Hospital B with no issues.
The Charge Nurse stated she did not know she could challenge the paramedic, and he (paramedic) made the call. She recalls the paramedic talking to the ED physician but is not sure of what was said.
Staff B stated the patient deteriorated and was intubated. Prior to that, he was alert and responding. She was aware the paramedic was taking the patient to Hospital C, and again stated she did not know what else to do. She stated she knows Hospital C is the trauma center and they always have surgeons available, so she did not push back on the paramedic. The nurse confirmed she did not give report to Hospital C, as she was not able to do so after the patient's change in condition.

Interview with the Director of the Transfer Center and the Transfer Center Registered Nurse (TCRN), who assisted with Patient #1's request for transfer, was conducted on 02/15/24 at 7:20 AM. The TCRN revealed she received the intake call from Hospital A, the facility was requesting a transfer to Hospital B for GI services not available at Hospital A. The patient was accepted, and transportation was arranged. As far as she knew, the case was closed and completed. The TCRN stated, later, she was not clear on what was happening, and called Hospital A to inquire about the case, as she saw that Hospital C had been contacted. When she called, the charge nurse told her that the transportation company had taken the patient to Hospital C, without their acceptance, and she then contacted Hospital C's Transfer Center for notification. The TCRN verified the TC is responsible for contacting the transferring facility with acceptance or denial of all transfers. The decisions are not communicated by the nurse or physician on duty, as they (TCs) are the ones making all the necessary arrangements including transportation.

Interview conducted with the paramedic of the Transport Company on 02/20/24 at 1:47 PM revealed he responded to the call to transport Patient #1. When he arrived, the patient was hypotensive and barely breathing, and told the nurse he needed to be intubated. The physician intubated and started the pressors. The nurse told him the patient was going to Hospital B. He told them the patient was unstable and should go to Hospital C, as they were closer. He proceeded to transfer the patient to the stretcher and waited. He kept telling them the patient was going to code and he needed to transport the patient. They did say Hospital C was 'on hold'; but he proceeded to take the patient to Hospital C based on the patient's condition. He called Hospital C to advise them of the patient, and they responded, ok, we will see you when you get here. When he arrived, the nurse and doctor told him they did not have GI on-call. He was at Hospital C less than five minutes and was told to take the patient to Hospital B and he did so.

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