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Based on facility document review, policy review, medical record review, and interview, the hospital's Emergency Department (ED) failed to appropriately transfer two of 8 (Patient #1 and #17) sampled patients requiring a higher level of care out of 21 total patients reviewed.

The findings included:

1. Medical record review revealed Patient #1 presented to Hospital #1's ED via ambulance on 4/27/25 at 7:09 AM with chief complaints of "Fever and musculoskeletal alter [alterations]." Emergency Medical Services (EMS) provider reported the Patient's parents reported possible seizure activity; however, the symptoms witnessed by EMS personnel appeared to be "shaking or tense muscles."

At 7:59 AM, a triage assessment was initiated, and Patient #1's parents reported the Patient had "seizure like activity." Patient's vital signs were obtained and revealed a temperature of 100.8 degrees and a pulse rate of 215. The Patient was assigned an ESI rating of "4."

The MSE was initiated at 8:01 AM by ED Provider #2 who documented "...Patient returns to the emergency room crying and is unconsolable. Patient has fever on arrival...mother states the child started crying this morning...Pulmonary: Scattered rhonchi...Tachycardia..." (Rhonchi are abnormal breath sounds which may be low-pitched, rattling during breathing. Tachycardia is a faster than normal heart rate.)

The Patient was treated with 83 mg of ibuprofen, a medication used to treat fever and inflammation.

ED Provider #2 documented, "X-ray of the patient's abdomen did not show any acute changes...Unconsolable child crying. Tetracaine, a numbing agent, was instilled in both the ears and also viscous lidocaine applied to the gums where patient is trying to erupt teeth. Patient fell asleep for a little bit and then woke up crying again. Patient was given ibuprofen for fever. Discussed with [Pediatric Provider] at [Hospital #2]...Patient will be transferred to that facility for further management. Assessment/Plan 1. Crying for unknown reason...2. Fever...Patient Discharge Condition Stable...Transferred to [Hospital #2]..."

Review of the Physician's Transfer Orders dated 4/27/2025 at 1:01 PM revealed "...I direct that this patient be transferred consistent with these instructions: Mode of Transfer...POV [privately owned vehicle]...Medical Orders: POV..."

Patient #1 left Hospital #1 in the care of her parents at 1:09 PM.

Hospital #1 allowed Patient #1 to be transported to a higher level of care (pediatric inpatient hospital) with her parents instead of being transported by a qualified, trained professional.

2. Medical record review revealed Patient #17 was a 16 year old female who presented to Hospital #1's ED on 2/3/2025 at 4:29 PM with chief complaints of "Suicidal Ideation." A Suicide Risk Assessment was completed which showed the Patient was "High risk" for suicide. The Patient was assigned an Emergency Severity Index (ESI) rating of "2."(ESI of 2 would designate a patient was urgent and assessment information should be brought to the attention of the physician and appropriate intervention uninitiated.)

The MSE was initiated at 7:02 PM by ED Provider#1 who documented, "...here with father...she is having hallucinations and suicidal ideation and has a history of bipolar disorder...Medically cleared for psychiatric evaluation she was accepted at [Hospital #3]...for inpatient admission...Assessment/Plan 1. Suicidal Ideation...Orders: Transfer Patient,02/03/25 21:16 [9:16 PM]..."

Review of the Discharge Information completed by RN #5 at 9:31 PM revealed, "...Discharge Disposition: Psychiatric Facility/Unit...ED Checkout Date and Time: 2/3/2025 21:27:00 [9:27 PM]...Depart Action...Patient Transferred..."

Patient #17 left Hospital #1 at 9:27 PM in the care of her father.

Hospital #1 allowed Patient #17 who was high risk for suicide to be transported to a higher level of care (inpatient psychiatric hospital) by her father instead of being transported by a qualified, trained professional.

Cross Refer to A-2409.

Based on facility document review, policy review, medical record review, and interview, the hospital's Emergency Department (ED) failed to appropriately transfer two of 8 (Patient #1 and #17) sampled patients requiring a higher level of care, out of 21 total patients reviewed.

The findings included:

1. Review of the facility's "Medical Staff Bylaws and Rules and Regulations" document updated 8/5/2024 revealed, "...Each member of the Medical Staff shall... provide his patients with care at the generally recognized professional level of quality and efficiency... abide by the Medical Staff Bylaws, the Rules and Regulations, and be all other lawful standards, policies and rules of the Hospital... The Emergency Department Staff duties are normally limited to emergency department procedures..."

Review of the facility's "Medical Staff Rules and Regulations" document revealed, "...Every individual who presents to this Hospital requesting examination or treatment will receive an appropriate medical screening examination. A Physician (or a Physician's assistant under consultation with the Physician) will perform the medical screening exam within the capability of the Hospital's emergency department and ancillary services to determine whether or not an emergency medical condition exist...When the patient's condition warrants specialty care beyond the area of professional competence of the attending Physician, the attending Physician should request a consultation for the patient from a Physician well qualified to give an opinion in the case. Such cases may include psychiatric consult for a patient seen in the ED for a suspected suicide attempt...This may require transfer if the specialty Physician is not available at [Hospital #1]..."

2. Review of the facility's "EMTALA Guidelines" policy approved 9/2023 revealed, "...If a patient is to be transferred for medical necessity, the following guidelines must be followed...The individual risks and benefits must be documented, and the patient's medical record must support these..."

Review of the facility's "EMTALA 20 Commandments" policy approved 9/2023 revealed, "...THOU SHALT: Provide medical appropriate vehicles, personnel, and life-support equipment for all transfers...THOU SHALT: Provide a physician certification with clearly stated risks and benefits of transfer for all transfers..."

Review of the facility's "Disposition/Admits/Home/Transfers" policy revised 2/2025 revealed, "...Procedure...Transfer to Another Facility...Appropriate level of transport will be obtained through private vehicle, private ambulance, or air ambulance... A bedside hand-off report will be provided to medical transporter...along with all paperwork, including en-route transport orders..."

3. Review of the Emergency Medical Services (EMS) Patient Care Report dated 4/27/2025 revealed EMS Provider #1 was dispatched to Patient #1's home on 4/27/2025 at 7:30 AM, 7 hours and 22 minutes after the Patient was discharged from the hospital's ED, for possible seizure activity. The crew was on-scene with Patient #1 at 7:39 AM. The report revealed, Patient #1 had been seen at Hospital #1 the day before and was diagnosed with "bronchitis and fever." The Patient had 101 fever this morning and possible febrile seizure activity. "...upon arrival to find Pt [patient] family holding Pt outside the residence. Pt family assisted to EMS unit and placed on stretcher...Pt appears in no obvious distress and appears Un obtunded [obtunded describes a state of impaired consciousness where someone is mentally dull or has a reduced level of alertness] at this time...transported non-emergency...Family shows EMS what they think is SZ [seizure] activity and Pt is crying during episode and has no noted loss of consciousness no respiratory compromise, and no post ictal state noted. EMS notes what appears to be a fussy baby and has no obvious distress noted...report given to [Registered Nurse (RN) #3]..." EMS documented a hospital arrival time of 7:55 AM.

Review of the hospital's ED log revealed Patient #1 presented to the ED on 4/27/2025 at 7:59 AM with complaints of "Fever, Musculoskeletal Altera [alterations]."

A triage assessment was completed on 4/27/2025 at 7:59 AM by RN #3 who documented Patient #1's mother reported the Patient had fever and "seizure-like activity. ems states it is more like shaking or tense muscles..." The Patient's vital signs were T 100.8, P 215, R 30, and O2 sat 100%. The Patient was assigned an Emergency Severity Index (ESI) rating of "4."(ESI of 4 would designate a patient was non-emergent, and there was no threat to the patient's life.)

ED Provider #2 documented, "...Unconsolable child crying. Tetracaine [a numbing agent], was instilled in both the ears and also viscous lidocaine applied to the gums where patient is trying to erupt teeth. Patient fell asleep for a little bit and then woke up crying again. Patient was given ibuprofen for fever. Discussed with [Pediatric Provider] at [Hospital #2]...Patient will be transferred to that facility for further management. Assessment/Plan 1. Crying for unknown reason...2. Fever...Patient Discharge Condition Stable...Transferred to [Hospital #2]..."

Review of the Physician's Certification Statement for Ground Ambulance Transport completed on 4/27/2025 at 11:35 AM revealed "...Part 2: Medical Necessity...Was ground ambulance transportation medically necessary for this patient?" There was neither a "Yes" or "No" selected under Part 2 to indicate whether ground ambulance transportation was necessary for Patient #1. The area listed under "Select the patient's medical condition that warranted the need for specialized equipment associated with ground ambulance transport:" had the letters "POV" [private owned vehicle] handwritten over the possible responses. The area signed by ED Provider #2 and RN #3 revealed, "I certify that the patient's medical condition, as described above, warrants the use of ground ambulance transportation. If "NO" was answered to the first question of Part 2 above, my signature certifies the ground ambulance transportation was not medically necessary..."

Review of the Consent for Transfer dated 4/27/2025 at 11:42 AM revealed, "...Provisional Diagnosis: Fever...The patient has been stabilized such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from transfer...Based on the reasonable risks and benefits to the patient, and upon the information available at the time of examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from affecting the transfer...The patient will be transferred by available qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures..." The area noted for "Signature of Patient of Responsible Party" had the letters "POV."
There was no documentation indicating why the Patient was transported in a private vehicle instead of an ambulance.

Review of the Physician's Transfer Orders dated 4/27/2025 at 1:01 PM revealed "...I direct that this patient be transferred consistent with these instructions: Mode of Transfer...POV...Medical Orders: POV..."

Review of the "EMTALA Form" completed by RN #3 on 4/27/2025 at 1:01 PM revealed, "...Emergency Medical Condition: Stable at Discharge Mode of Transport for Transfer: Private Car Reason for Transfer: Medically indicated Support/Treatment During Transfer: None Medical Benefit: Obtain level of care/services not available at this facility Required Personnel for Transfer: Other: mother and father...Medical Risk: Worsening of condition, or death, if patient stays here..."

During an interview on 5/13/2025 at 8:27 AM, ED Provider #2 stated Patient #1 "needed to see a pediatric specialist...We don't admit pediatrics and don't have a pediatric specialist." The Provider stated Patient #1's family "chose to take private vehicle. We recommended EMS, but they didn't want to wait...Family chose not to wait for EMS transport; their decision, not mine."

Patient #1 was discharged from Hospital #1 on 4/27/2025 at 1:09 PM. Patient #1 had diagnoses of Crying for Unknown Reason and Fever and needed a higher level of care not available to Hospital #1. Hospital #1 allowed Patient #1 whose underlying medical condition had not been determined to be transported to a higher level of care [Hospital #2] with family members instead of being transported by a qualified, trained professional.

4. Review of the hospital's ED log revealed Patient #17, a 16 year old female, presented to the ED on 2/3/2025 at 4:29 PM with complaints of "Suicidal Ideation."

A triage assessment was completed by RN #4 at 5:00 PM and revealed, Patient #17 reported suicidal ideations. Patient #17's Suicide Risk Assessment was "High risk." The Patient was assigned an Emergency Severity Index (ESI) rating of "2."(ESI of 2 would designate a patient was and urgent and assessment information should be brought to the attention of the physician and appropriate intervention initiated.)

At 7:00 PM, RN #4 documented, "call placed to [center to help troubled children]..."

The MSE was initiated by ED Provider#1 at 7:02 PM. The ED Provider documented, Patient #17 "is here with father he states that she is having hallucinations and suicidal ideation and has a history of bipolar disorder...Awake alert no acute distress heart and lung exam normal neurologic exam normal she is expressing suicidal ideation...Medically cleared for psychiatric evaluation she was accepted at [Hospital #3]...for inpatient admission...Assessment/Plan 1. Suicidal Ideation...Orders: Transfer Patient,02/03/25 21:16 [9:16 PM]..."

At 7:50 PM, RN #6 documented, "[named personnel from the center to help troubled children] states looking for placement. States [center to help troubled children] is ok with father transporting once placement is made..." There was no documentation from [center for troubled children] that they approved the transfer of Patient #17 by her Father.

Review of the EMTALA form completed by RN #5 at 9:20 PM revealed, "Stable at Discharge Reason for Transfer: Medically Indicated Support/Treatment During Transfer: None Medical Benefit: Obtain level of care/service not available at this facility Required Personnel for Transfer: Other: POV...Medical Risk: Worsening of condition, or death, if patient stays here..."

Review of the Consent for Transfer dated 2/3/2025 at 9:17 PM revealed, "...Provisional Diagnosis: Suicidal Ideation...The patient has been stabilized such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from transfer...Based on the reasonable risks and benefits to the patient, and upon the information available at the time of examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from affecting the transfer..." Section III D. which showed, "The patient will be transferred by available qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures..." was not checked. The area that stated, "List special instructions:" revealed, the handwritten letters, "POV."

Review of the Discharge Information completed by RN #5 at 9:31 PM revealed, "...Discharge Disposition: Psychiatric Facility/Unit...ED Checkout Date and Time: 2/3/2025 21:27:00 [9:27 PM]...Depart Action...Patient Transferred..."

In an email correspondence on 5/15/2025 at 9:57 AM, the Chief Quality Officer (CQO) verified there was no EMS documentation because the Patient was "transported by private vehicle.

Patient #17 was discharged from Hospital #1 on 2/3/2025 at 9:27 PM. Patient #17 had diagnosis of Suicidal Ideation and needed a higher level of care not available at Hospital #1. Hospital #1 allowed Patient #17 who was at High Risk for suicidal ideations to be transported to a higher level of care (Hospital #3) with her father instead of being transported by a qualified, trained professional.