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Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 482.24.

Findings include:

1. The Hospital failed to ensure the receiving hospital agreed to accept the transfer of the patient. A-2409 A.

2. The Hospital failed to ensure the transferring hospital sent to the receiving facility all medical records related to the emergency condition which the individual presented that were available at the time of transfer. A-2409 B.

A. Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) patients requiring transfer for alcohol treatment, the Hospital failed to ensure the receiving hospital agreed to accept the transfer of the patient.

Findings include:

1. The Hospital's policy titled, "EMTALA Guidelines for Emergency Department, Labor and Delivery, and Behavioral Health Services (3/18/2020)" was reviewed on 11/9/2021 and included, "Transfer of Stabilized Transfer to Another Facility: When transfer of a stabilized patient to another facility is medically necessary (see policy ... "Transfer to Other Facilities.")"

2. The Hospital's policy titled, "Transfer to Other Facility's", (dated 10/26/2020), was reviewed on 11/9/2021, and required, "Upon knowledge of or planning for the transfer of a patient to another facility, acute or long term ... The following requirements will be met prior to transfer: If the transfer is to another acute care/tertiary care hospital, the [Hospital] physician requesting transfer must arrange for an accepting physician at the receiving hospital prior to the completion of any other transfer arrangements. The receiving facility has available space and qualified personnel for treatment of the patient. The receiving facility has agreed to accept the patient and agrees to provide appropriate medical treatment.

3. The clinical record of Pt. #1 was reviewed on 11/9/2021. Pt #1 presented to Hospital A's (transferring Hospital) ED (emergency department) on 4/11/2021 at 8:21 PM, with a chief complaint of ETOH (excessive ingestion of drinking alcohol).

- Pt #1's HPI (History of Present Illness), documented by the ED Physician (MD #1), dated 4/11/21 at 10:18 PM, included, "Patient ...presents requesting admission for detox from alcohol ...Patient reports multiple attempts with both inpatient and outpatient treatment, but continues to abuse alcohol. Most recently patient reports 5 days of heavy drinking, staying in motel, as currently homeless. The patient is intoxicated now, reports drinking throughout the day, and would like to be admitted for detox at this facility. Patient reports he is beginning to withdrawal ..."

- The blood alcohol level of Pt. #1, ordered 4/11/2021 at 10:18 PM by MD#1, was resulted as 405.7 (normal is negative-0).

- ED note, documented by the ED Registered Nurse (E #2), dated 4/12/2021 at 12:30 AM), included, "Transportation arranged for patient per notification from [Sobriety Program], [E #3], that patient has been accepted to [Hospital B - receiving Hospital] to the ED department for treatment."

- The ED physician's (MD#1) MDM (medical decision making) note, dated 4/12/2021 at 1:17 AM, included, "[Sobriety Counselor] interviewed the patient [Pt. #1], and was able to find placement at [Hospital B]. Nursing report was provided to the accepting facility, they do not request additional labs at this time... [Pt. #1] remained calm and cooperative and thermodynamically stable until transfer."

- Pt #1's ED Disposition (4/12/2021 at 1:00 AM) was documented as, "Transfer to other facility outside [Hospital B]." Pt #1 was transported out by EMS (emergency medical service/ambulance) via stretcher.

4. The clinical record of Pt. #1, from Hospital B, was reviewed on 11/9/2021. The emergency department attending physician's note, dated 4/12/2021 at 3:19 AM included, "HPI [history of present illness] - male who endorses history of alcohol abuse and alcohol withdrawal seizures presents for evaluation from [Hospital A] in Rockford. Apparently, [Pt. #1] had been in their emergency department and they called here and spoke with our central access team about if we had any Detox beds to which they were told we do have a Detox program, but then their Facility [Hospital A] never contacted us for transfer and instead put the patient [Pt. #1] in an ambulance and sent [Pt. #1] for an alcohol Detox admission.

5. On 11/10/2021 at 9:15 AM, an interview was conducted with the ED Medical Director (MD #2). MD #2 stated that a Patient with an alcohol level over 400 depends on each patient's clinical situation. One patient could be walking and talking, and another patient may be comatose. MD #2 stated that a medical transfer requires a Doctor to Doctor acceptance of the patient. If there is a Detox transfer, "typically, the Counselor sees the patient," locates the Facility, arranges the cab ride, and the patient is discharged. If the Doctor thought the patient might go into delirium tremens (DTs), the patient would be admitted. The Patient must be medically stable before discharge.

B. Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) patients requiring transfer for alcohol treatment, the Hospital failed to ensure the transferring hospital sent to the receiving facility all medical records related to the emergency condition which the individual presented that were available at the time of transfer.

Findings included:

1. The Hospital's policy titled, "Transfer to Other Facility's", (dated 10/26/2020), was reviewed on 11/9/2021, and required, " Upon knowledge of or planning for the transfer of a patient to another facility, acute or long term ... The following requirements will be met prior to transfer: ... A transfer form will be completed on all patients transferred from any patient care area as [Hospital] to another facility."

2. The clinical record of Pt. #1 was reviewed on 11/9/2021. Pt #1 presented to the Hospital A's (transferring Hospital) ED (emergency department) on 4/11/2021 at 8:21 PM, with a chief complaint of ETOH (excessive ingestion of drinking alcohol).

- The ED physician (MD#1) MDM (medical decision making) note, dated 4/12/2021 at 1:17 AM, included, "[Sobriety Counselor] interviewed the patient [Pt. #1], and was able to find placement at [Hospital B]. Nursing report was provided to the accepting facility, they do not request additional labs at this time. ... [Pt. #1] remained calm and cooperative and hemodynamically stable until transfer."

- Pt #1's ED Disposition (4/12/2021 at 1:00 AM) was documented as, "Transfer to other facility outside [Hospital A]." Pt #1 was transported out by EMS (emergency medical service/ambulance) via stretcher.

- Pt #1's clinical record did not include a discharge or transfer order from the ED Physician. The clinical record also lacked any documentation from the ED Physician indicating that the Physician at the receiving Hospital was notified; documentation that medical records, including examination, treatment and a transfer form were sent with Pt #1.

3. The clinical record of Pt. #1, from Hospital B, was reviewed on 11/9/2021. The emergency department attending physician note, dated 4/12/2021 at 3:19 AM included, "HPI [history of present illness] ... There are no discharge medications for this patient [from Hospital A]."

4. On 11/10/2021 at 9:15 AM, an interview was conducted with the ED Medical Director (MD #2). MD #2 stated that paperwork sent to the receiving Hospital for a medical transfer includes a transfer form documenting the acceptance of the patient. Whereas, with a Detox patient, it is a discharge not a transfer, and only discharge papers for the Patient are required.