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Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically, the failure to 1) complete required Emergency Medical Treatment and Labor Act (EMTALA) transfer documentation for 2 (P-3, 19) of 12 patients reviewed for transfer and 2) failed to provide a safe mode of transportation for 1 (P-3) of 12 patients reviewed for transfer resulting in the potential for poor patient outcomes. Findings include:

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A-2409: Failure to provide an appropriate transfer.

Based on interview and record review, the facility failed to 1) complete required Emergency Medical Treatment and Labor Act (EMTALA) transfer documentation for 2 (P-3, 19) of 12 patients reviewed for transfer and 2) failed to provide a safe mode of transportation for 1 (P-3) of 12 patients reviewed for transfer resulting in the potential for poor patient outcomes. Findings include:

P-3
Review of the medical record for P-3 revealed she was a 27-year-old female who presented to the Emergency Department (ED) 6/1/2024 at 2011 with a chief complaint of agitation, paranoid thoughts, suicidal ideation, and auditory hallucinations telling her to kill herself. The Columbia Suicide Severity Rating Scale (C-SSRS) indicated she was at moderate risk for suicide.

Further review of P-3's medical record revealed documentation in progress notes by the social worker dated 6/2/2024 at 0251 of acceptance by a named physician at a named psychiatric facility and indicated that P-3's mother would transport the patient via private vehicle.

P-3's medical record was reviewed for the presence of EMTALA transfer documentation which could not be found. There was no indication in physician documentation as to the stability of the patient, reason of transfer, the risks/benefits of transfer, or receiving facility physician acceptance of transfer.

Review of the ED timeline for discharge documentation revealed P-3 was discharged from the facility on 6/2/2024 at 0611 to an outside psychiatric facility via private vehicle. Standard discharge instructions were given. The timeline further indicated the nurse called report to the psychiatric facility on 6/2/2024 at 0612. Physician instructions dated 6/2/2024 at 0549 stated, "Go directly to (psychiatric facility name). Return for any other issues or worsening."

On 12/17/2024 at 1415, Staff K was queried as to why EMTALA documentation was not present in the medical record to which she stated it was because the patient was transferred by private vehicle.

P-19
Review of the medical record for P-19 revealed she was a 21-year-old female who presented to the ED on 9/15/2024 at 1625 with a chief complaint of suicidal ideation with a plan. Triage screening for suicide severity using C-SSRS) dated 9/15/2024 at 1903 revealed the patient was at high risk for suicide. The patient agreed to and signed for voluntary inpatient psychiatric admission requiring transfer to another hospital.

Review of P-19's medical record revealed on page 3 of the EMTALA transfer form, the "Medical records copied and sent by" line was blank. There was documentation noting that social worker staff R "sent packet" to the receiving facility on 09/16/2024 at 0806. However, it is unknown what the contents of the packet were.

Facility policy titled "Emergency Medical Condition/Treatment/Transfer Policy (Emergency Medical Treatment and Active Labor Act - EMTALA)" effective 7/16/2024 states, "Transfers from Hospitals to Other Facilities...Mode of Transportation 3.5.2.1. All transfers must be affected through qualified personnel and transportation as required, including the use of necessary and medically appropriate life support measures during the transfer. The transferring physician is responsible to determine the medically appropriate personnel, equipment, and orders for the transport....in cases in which a patient's well-being would not be jeopardized, other means of transportation besides an ambulance may be acceptable. Authorization of a patient to travel in a private car must be given by the attending physician."