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Based on interview and record review, the facility failed to ensure two of 26 sampled patients (Patients 12 and 17) for the following:

1. The facility failed to ensure that Patients 12 and 17 and/or their Patient Representatives had transfer forms completed by ED physician, which included documentation for reason for transfer, whether patient was in stable condition, whether patient was informed of the reason for patient's transfer from the facility's emergency department (ED).

2. The facility failed to ensure that Patients 12 and 17 and/or their Patient Representatives, signed a consent acknowledging the risks and benefits of transferring to another facility.

These deficient practices resulted in Patients 12 and 17 and/or their Patient Representatives not knowing the risks and benefits of transfer to another facility which can impact the ability to make informed decisions.

Findings:

1. A review of Patient 12's face sheet (a document that summarizes a patient's medical history and other important information, including name, address and date of birth), dated 1/1/2025, indicated Patient 12 was in the emergency department (ED).

During a concurrent interview and record review on 2/4/2025 at 3:26 p.m., with the Quality Coordinator (RN) 5, Patient 12's emergency department (ED) visit records, dated 1/1/2025, were reviewed. RN 5 stated the following:

1. Chief complaint was suicidal ideation (suicidal thoughts - thinking about or planning suicide).
2. Patient (Patient 12) arrived at 11:23 a.m., as a walk-in, accompanied by her mother.
3. Patient (patient 12) was triaged (the process of assessing patients when they first arrive to determine the urgency of their condition and to prioritize which patients need immediate medical attention based on the severity of their injuries or illness) at 11:30 a.m., with a triage class of 2 (Emergency Severity Index - ESI; emergency, which could become life threatening).
4. Patient's (Patient 12) triage vital signs (the essential physiological measurements that indicates a person's basic health status, which includes temperature, pulse rate, breathing rate, and blood pressure) were obtained at 11:30 a.m.
5. Patient (Patient 12) had a medical screening examination (MSE - an initial assessment performed by a medical professional to determine if a patient has an emergency medical condition) by ED physician (MD) 1, at 1:45 p.m.
6. Another ED physician (MD) 2 took over the care of patient (Patient 12), after MD 1 planned for patient (Patient 12) to be transferred to another facility.
7. There was no transfer form filled out- all patients getting transferred from the ED should have a transfer form filled out, including the ED physician signature who ordered for the patient (Patient 12) to be transferred out to another facility, patient's/patient's representative's signature agreeing with physician's plan to transfer to another facility.
8. Patient (Patient 12) was transferred to another facility at 7:38 p.m.

A record review of Patient 12's ED physician note, dated 1/1/2025, at 1:45 p.m., indicated the following:

1. Patient (Patient 12) had a history of depression and had active thoughts of suicide.
2. Patient (Patient 12) is in critical condition that requires constant attention with immediate threat of death.
3. No history of previous psychiatric hospitalization.
4.Patient (Patient 12) was seen by psychiatry and was placed on an involuntary hold (5585 hold - mental health detention order for minors to protect minor from harming themselves and to provide necessary mental health treatment).
5. Patient (Patient 12) was medically cleared for discharge.

A record review of Patient 12's ED Timeline, dated 1/1/2025, indicated the following:
1. MD 1 discharged patient (Patient 12) to psychiatric facility at 3:15 p.m.
2. MD 2 was assigned to patient at 5:56 p.m.
3. Receiving hospital physician accepted the patient at 7:10 p.m.
4. Patient (Patient 12) was discharged from the ED at 7:37 p.m., via ambulance.

A record review of facility's Emergency Medical Screening, Examination, Treatment and Transfer (EMTALA) policy, dated 4/23/2024, indicated the following:

1. The physician may determine that the benefits reasonably expected from the provision of appropriate treatment at another facility outweigh the increased risks to the individual.
2. The transferring physician will contact a physician at the receiving facility, obtain agreement to accept the transfer, and document the receiving physician's acceptance on the facility's designated certification/patient transfer form.
3. The transferring physician will inform the patient and document the reasons for the transfer, including risks and benefits of the transfer.
4. The patient's or legal representative's informed written consent to the transfer will be obtained, using the transfer form.
5. The transferring physician will complete the transfer form certifying that patient's benefits for receiving treatment at another facility, outweigh the risks to the patient from the transfer.

A review of the facility's Interhospital Transfer Summary (Transfer Form), undated and blank, indicated the following elements:

Section 1, for patient information, including address, diagnosis, reason for transfer, and accepting hospital.

Section II, for patient transfer acknowledgement, indicated the patient understands their EMTALA rights, including their right to be informed of the reasons for any transfer and indicated they have received a MSE, was evaluated by a physician, who informed them of the reasons for transfer and that patient agrees with the plan for transfer, and a line for the patient's signature, relationship to the patient, date, time.

Section III for Physician Certification (to be completed by the transferring physician) indicating the physician's name, patient's name, checkboxes to indicate if patient was stable or unstable, checkboxes for the benefits of transfer, checkboxes for summary of risks, and signature space for physician signature.

Section IV for Accepting Facility and Physician Transfer Information, indicating name of receiving hospital with the capability and capacity to manage the patient's condition, name/title/contact information of supervisor from receiving patient, location where patient is going to be transferred to, name/title/time of staff transferring patient from ED, name/location/contact information of accepting physician from receiving hospital, and name/title/time of staff transferring patient from ED.

Section V for Transfer Assessment for:
a. Medical records and test results that were provided to receiving facility - indicated with checkboxes for items including transfer forms, ED records, lab, radiology.
b. Mode of transportation.
c. Physician assessment indicating transfer nursing assessment was reviewed and patient's condition remains compatible with transfer, with physician signature line, physician's printed name, and time of signature.
d. RN assessment indicating that Transfer Form and documentation packet is complete according to hospital policy/procedure, RN signature line, RN's printed name, date and time of signature.

2. A review of Patient 17's face sheet (a document that summarizes a patient's medical history and other important information, including name, address and date of birth), dated 2/3/2025, indicated patient (Patient 17) was admitted to the facility at the emergency department.

During a concurrent interview and record review on 2/5/2025 at 11:33 a.m. with Quality Coordinator (RN) 5 Patient 17's emergency department (ED) visit record, dated 2/3/2025, was reviewed. RN 5 stated the following:

1. Patient (Patient 17) arrived at 1:37 p.m. with multiple complaints, including headache, and confusion.
2. Patient (Patient 17) was triaged, at 1:37 p.m., with a triage class of 2, with vital signs taken.
3. Patient's (Patient 17) MSE was done at 3:52 p.m., by MD 3, who ordered labs and diagnostic studies, including electrocardiogram (EKG - a test to record the electric signals in the heart), computed tomography (CT - diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) of the head and brain, and x-rays of the chest.
4. MD 3's notes indicated neurosurgical physician (MD) 4, was consulted and MD 4 recommended for patient (Patient 17) to be transferred to another hospital.
5. MD 3 consulted with another facility's neurosurgical physician (MD) 5, was consulted and MD 5 accepted the patient for transfer.
6. MD 3 ordered for patient (Patient 17) to be transferred to another hospital.
7. There was no transfer form filled out- all patients getting transferred from the ED should have a transfer form filled out, including the ED physician signature who ordered for the patient (Patient 17) to be transferred out to another facility, patient's/patient's representative's signature agreeing with physician's plan to transfer to another facility.
8. Patient (Patient 17) was transferred from the ED at 9:14 p.m.

During a concurrent interview and record review on 2/3/2025 at 11:33 a.m. with RN 5, Patient 17's ED physician note, dated 2/3/2025, was reviewed. RN 5 stated the following:

1. Patient (Patient 17) presented in the ED with left facial droop, was alert and oriented, with mild confusion.
2. CT of the head indicated bleeding on both sides of the brain.
3. EKG indicated a slow heart rate.

A review of Patient 17's Case Management note, dated 2/3/2025, indicated the following:
1. Reason for ED transfer was non-member, for higher level of care.
2. Diagnosis was non-traumatic subdural hematoma (a collection of blood in the space between the brain and the outer layer of the brain that occurs without any apparent head trauma - develops spontaneously due to factors like ruptured tiny blood vessels).
3. Type of bed requested was an intensive care unit bed (a specialized unit within a hospital that provides intensive care for patient with severe neurological conditions with the brain).

A record review of facility's Emergency Medical Screening, Examination, Treatment and Transfer (EMTALA) policy, dated 4/23/2024, indicated the following:

1. The physician may determine that the benefits reasonably expected from the provision of appropriate treatment at another facility outweigh the increased risks to the individual.
2. The transferring physician will contact a physician at the receiving facility, obtain agreement to accept the transfer, and document the receiving physician's acceptance on the facility's designated certification/patient transfer form.
3. The transferring physician will inform the patient and document the reasons for the transfer, including risks and benefits of the transfer.
4. The patient's or legal representative's informed written consent to the transfer will be obtained, using the transfer form.
5. The transferring physician will complete the transfer form certifying that patient's benefits for receiving treatment at another facility, outweigh the risks to the patient from the transfer.

A review of the facility's Interhospital Transfer Summary (Transfer Form), undated and blank, indicated the following elements:

Section 1, for patient information, including address, diagnosis, reason for transfer, and accepting hospital.

Section II, for patient transfer acknowledgement, indicated the patient understands their EMTALA rights, including their right to be informed of the reasons for any transfer and indicated they have received a MSE, was evaluated by a physician, who informed them of the reasons for transfer and that patient agrees with the plan for transfer, and a line for the patient's signature, relationship to the patient, date, time.

Section III for Physician Certification (to be completed by the transferring physician) indicating the physician's name, patient's name, checkboxes to indicate if patient was stable or unstable, checkboxes for the benefits of transfer, checkboxes for summary of risks, and signature space for physician signature.

Section IV for Accepting Facility and Physician Transfer Information, indicating name of receiving hospital with the capability and capacity to manage the patient's condition, name/title/contact information of supervisor from receiving patient, location where patient is going to be transferred to, name/title/time of staff transferring patient from ED, name/location/contact information of accepting physician from receiving hospital, and name/title/time of staff transferring patient from ED.

Section V for Transfer Assessment for:
a. Medical records and test results that were provided to receiving facility - indicated with checkboxes for items including transfer forms, ED records, lab, radiology.
b. Mode of transportation.
c. Physician assessment indicating transfer nursing assessment was reviewed and patient's condition remains compatible with transfer, with physician signature line, physician's printed name, and time of signature.
d. RN assessment indicating that Transfer Form and documentation packet is complete according to hospital policy/procedure, RN signature line, RN's printed name, date and time of signature.

Based on interview and record review, the facility failed to ensure two of 26 sampled patients (Patients 12 and 17) for the following:

1. The facility failed to ensure that Patients 12 and 17 and/or their Patient Representatives had transfer forms completed by ED physician, which included documentation for reason for transfer, whether patient was in stable condition, whether patient was informed of the reason for patient's transfer from the facility's emergency department (ED).

2. The facility failed to ensure that Patients 12 and 17 and/or their Patient Representatives, signed a consent acknowledging the risks and benefits of transferring to another facility.

These deficient practices resulted in Patients 12 and 17 and/or their Patient Representatives not knowing the risks and benefits of transfer to another facility which can impact the ability to make informed decisions.

Findings:

1. A review of Patient 12's face sheet (a document that summarizes a patient's medical history and other important information, including name, address and date of birth), dated 1/1/2025, indicated Patient 12 was in the emergency department (ED).

During a concurrent interview and record review on 2/4/2025 at 3:26 p.m., with the Quality Coordinator (RN) 5, Patient 12's emergency department (ED) visit records, dated 1/1/2025, were reviewed. RN 5 stated the following:

1. Chief complaint was suicidal ideation (suicidal thoughts - thinking about or planning suicide).
2. Patient (Patient 12) arrived at 11:23 a.m., as a walk-in, accompanied by her mother.
3. Patient (patient 12) was triaged (the process of assessing patients when they first arrive to determine the urgency of their condition and to prioritize which patients need immediate medical attention based on the severity of their injuries or illness) at 11:30 a.m., with a triage class of 2 (Emergency Severity Index - ESI; emergency, which could become life threatening).
4. Patient's (Patient 12) triage vital signs (the essential physiological measurements that indicates a person's basic health status, which includes temperature, pulse rate, breathing rate, and blood pressure) were obtained at 11:30 a.m.
5. Patient (Patient 12) had a medical screening examination (MSE - an initial assessment performed by a medical professional to determine if a patient has an emergency medical condition) by ED physician (MD) 1, at 1:45 p.m.
6. Another ED physician (MD) 2 took over the care of patient (Patient 12), after MD 1 planned for patient (Patient 12) to be transferred to another facility.
7. There was no transfer form filled out- all patients getting transferred from the ED should have a transfer form filled out, including the ED physician signature who ordered for the patient (Patient 12) to be transferred out to another facility, patient's/patient's representative's signature agreeing with physician's plan to transfer to another facility.
8. Patient (Patient 12) was transferred to another facility at 7:38 p.m.

A record review of Patient 12's ED physician note, dated 1/1/2025, at 1:45 p.m., indicated the following:

1. Patient (Patient 12) had a history of depression and had active thoughts of suicide.
2. Patient (Patient 12) is in critical condition that requires constant attention with immediate threat of death.
3. No history of previous psychiatric hospitalization.
4.Patient (Patient 12) was seen by psychiatry and was placed on an involuntary hold (5585 hold - mental health detention order for minors to protect minor from harming themselves and to provide necessary mental health treatment).
5. Patient (Patient 12) was medically cleared for discharge.

A record review of Patient 12's ED Timeline, dated 1/1/2025, indicated the following:
1. MD 1 discharged patient (Patient 12) to psychiatric facility at 3:15 p.m.
2. MD 2 was assigned to patient at 5:56 p.m.
3. Receiving hospital physician accepted the patient at 7:10 p.m.
4. Patient (Patient 12) was discharged from the ED at 7:37 p.m., via ambulance.

A record review of facility's Emergency Medical Screening, Examination, Treatment and Transfer (EMTALA) policy, dated 4/23/2024, indicated the following:

1. The physician may determine that the benefits reasonably expected from the provision of appropriate treatment at another facility outweigh the increased risks to the individual.
2. The transferring physician will contact a physician at the receiving facility, obtain agreement to accept the transfer, and document the receiving physician's acceptance on the facility's designated certification/patient transfer form.
3. The transferring physician will inform the patient and document the reasons for the transfer, including risks and benefits of the transfer.
4. The patient's or legal representative's informed written consent to the transfer will be obtained, using the transfer form.
5. The transferring physician will complete the transfer form certifying that patient's benefits for receiving treatment at another facility, outweigh the risks to the patient from the transfer.

A review of the facility's Interhospital Transfer Summary (Transfer Form), undated and blank, indicated the following elements:

Section 1, for patient information, including address, diagnosis, reason for transfer, and accepting hospital.

Section II, for patient transfer acknowledgement, indicated the patient understands their EMTALA rights, including their right to be informed of the reasons for any transfer and indicated they have received a MSE, was evaluated by a physician, who informed them of the reasons for transfer and that patient agrees with the plan for transfer, and a line for the patient's signature, relationship to the patient, date, time.

Section III for Physician Certification (to be completed by the transferring physician) indicating the physician's name, patient's name, checkboxes to indicate if patient was stable or unstable, checkboxes for the benefits of transfer, checkboxes for summary of risks, and signature space for physician signature.

Section IV for Accepting Facility and Physician Transfer Information, indicating name of receiving hospital with the capability and capacity to manage the patient's condition, name/title/contact information of supervisor from receiving patient, location where patient is going to be transferred to, name/title/time of staff transferring patient from ED, name/location/contact information of accepting physician from receiving hospital, and name/title/time of staff transferring patient from ED.

Section V for Transfer Assessment for:
a. Medical records and test results that were provided to receiving facility - indicated with checkboxes for items including transfer forms, ED records, lab, radiology.
b. Mode of transportation.
c. Physician assessment indicating transfer nursing assessment was reviewed and patient's condition remains compatible with transfer, with physician signature line, physician's printed name, and time of signature.
d. RN assessment indicating that Transfer Form and documentation packet is complete according to hospital policy/procedure, RN signature line, RN's printed name, date and time of signature.

2. A review of Patient 17's face sheet (a document that summarizes a patient's medical history and other important information, including name, address and date of birth), dated 2/3/2025, indicated patient (Patient 17) was admitted to the facility at the emergency department.

During a concurrent interview and record review on 2/5/2025 at 11:33 a.m. with Quality Coordinator (RN) 5 Patient 17's emergency department (ED) visit record, dated 2/3/2025, was reviewed. RN 5 stated the following:

1. Patient (Patient 17) arrived at 1:37 p.m. with multiple complaints, including headache, and confusion.
2. Patient (Patient 17) was triaged, at 1:37 p.m., with a triage class of 2, with vital signs taken.
3. Patient's (Patient 17) MSE was done at 3:52 p.m., by MD 3, who ordered labs and diagnostic studies, including electrocardiogram (EKG - a test to record the electric signals in the heart), computed tomography (CT - diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) of the head and brain, and x-rays of the chest.
4. MD 3's notes indicated neurosurgical physician (MD) 4, was consulted and MD 4 recommended for patient (Patient 17) to be transferred to another hospital.
5. MD 3 consulted with another facility's neurosurgical physician (MD) 5, was consulted and MD 5 accepted the patient for transfer.
6. MD 3 ordered for patient (Patient 17) to be transferred to another hospital.
7. There was no transfer form filled out- all patients getting transferred from the ED should have a transfer form filled out, including the ED physician signature who ordered for the patient (Patient 17) to be transferred out to another facility, patient's/patient's representative's signature agreeing with physician's plan to transfer to another facility.
8. Patient (Patient 17) was transferred from the ED at 9:14 p.m.

During a concurrent interview and record review on 2/3/2025 at 11:33 a.m. with RN 5, Patient 17's ED physician note, dated 2/3/2025, was reviewed. RN 5 stated the following:

1. Patient (Patient 17) presented in the ED with left facial droop, was alert and oriented, with mild confusion.
2. CT of the head indicated bleeding on both sides of the brain.
3. EKG indicated a slow heart rate.

A review of Patient 17's Case Management note, dated 2/3/2025, indicated the following:
1. Reason for ED transfer was non-member, for higher level of care.
2. Diagnosis was non-traumatic subdural hematoma (a collection of blood in the space between the brain and the outer layer of the brain that occurs without any apparent head trauma - develops spontaneously due to factors like ruptured tiny blood vessels).
3. Type of bed requested was an intensive care unit bed (a specialized unit within a hospital that provides intensive care for patient with severe neurological conditions with the brain).

A record review of facility's Emergency Medical Screening, Examination, Treatment and Transfer (EMTALA) policy, dated 4/23/2024, indicated the following:

1. The physician may determine that the benefits reasonably expected from the provision of appropriate treatment at another facility outweigh the increased risks to the individual.
2. The transferring physician will contact a physician at the receiving facility, obtain agreement to accept the transfer, and document the receiving physician's acceptance on the facility's designated certification/patient transfer form.
3. The transferring physician will inform the patient and document the reasons for the transfer, including risks and benefits of the transfer.
4. The patient's or legal representative's informed written consent to the transfer will be obtained, using the transfer form.
5. The transferring physician will complete the transfer form certifying that patient's benefits for receiving treatment at another facility, outweigh the risks to the patient from the transfer.

A review of the facility's Interhospital Transfer Summary (Transfer Form), undated and blank, indicated the following elements:

Section 1, for patient information, including address, diagnosis, reason for transfer, and accepting hospital.

Section II, for patient transfer acknowledgement, indicated the patient understands their EMTALA rights, including their right to be informed of the reasons for any transfer and indicated they have received a MSE, was evaluated by a physician, who informed them of the reasons for transfer and that patient agrees with the plan for transfer, and a line for the patient's signature, relationship to the patient, date, time.

Section III for Physician Certification (to be completed by the transferring physician) indicating the physician's name, patient's name, checkboxes to indicate if patient was stable or unstable, checkboxes for the benefits of transfer, checkboxes for summary of risks, and signature space for physician signature.

Section IV for Accepting Facility and Physician Transfer Information, indicating name of receiving hospital with the capability and capacity to manage the patient's condition, name/title/contact information of supervisor from receiving patient, location where patient is going to be transferred to, name/title/time of staff transferring patient from ED, name/location/contact information of accepting physician from receiving hospital, and name/title/time of staff transferring patient from ED.

Section V for Transfer Assessment for:
a. Medical records and test results that were provided to receiving facility - indicated with checkboxes for items including transfer forms, ED records, lab, radiology.
b. Mode of transportation.
c. Physician assessment indicating transfer nursing assessment was reviewed and patient's condition remains compatible with transfer, with physician signature line, physician's printed name, and time of signature.
d. RN assessment indicating that Transfer Form and documentation packet is complete according to hospital policy/procedure, RN signature line, RN's printed name, date and time of signature.