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Based on review of facility policy and procedure, medical records (MR) and interviews with staff, it was determined the facility failed to:

1. Complete an appropriate transfer for one of ten transfer MRs reviewed. This had the potential to affect all patients transferred from the facility.

Findings include: Refer to Tag 2409 Restricting Transfer Until The Individual Is Stabilized CFR: 489.24(e).

Based on review of facility policy and procedure, medical records (MR) and interviews with staff, it was determined Jackson Hospital & Clinic, Inc failed to complete an appropriate transfer for one of ten transfer MRs reviewed and did affect Patient Identifier (PI) # 13 and had the potential to affect all patients transferred from the facility.

Findings include:

Facility policy: EMTALA (Emergency Medical Treatment and Labor Act) Policy
Revised Date: August 4, 2021
Effective Date: August 4, 2021

Policy:

...This policy applies to ALL persons who come to Jackson Hospital seeking emergency care...

Procedures:

B. If an EMC (Emergency Medical Condition) exists:

2. If the needed treatment cannot be provided at Jackson Hospital, with the patient's consent, the patient may be transferred to another facility, after stabilization if:

a. The type of care required by the patient is unavailable

b. The hospital is on diversion

c. Equipment vital to the care and treatment of the patient is unavailable...

4. If the patient has an EMC that has not been stabilized, Jackson Hospital will not transfer the patient unless:...

b. A physician completes an Authorization and Consent for Patient Transfer form as a certification that the benefit of the transfer exceeds the risk(s).

At a minimum, the certification will include a summary of the risks and benefits of the transfer, documentation of the EMC, the lack of service availability, and/or any other pertinent facts.

EHR (Electronic Health Record) documentation has been completed to include date and time of contact, the name of the receiving physician and receiving facility, the facts requiring transfer.

If a physician is not physically present at the time of the transfer, then the QMP (Qualified Medical Personnel) can consult with a physician to determine if the patient is to be transferred to another facility for further stabilizing treatment.

A QMP may sign the certification only after consultation with the physician authorizing the transfer and a physician's countersignature must be obtained in a timeframe according to hospital policies and procedures.

5. Prior to any transfer to another facility, Jackson Hospital will:

b. Contact, confirm, and document that the receiving physician agrees to accept transfer of the patient and report is given to the receiving facility using Authorization and Consent for Patient Transfer form.

c. Forward a complete and full copy of the medical records, radiographs, laboratory results, patient's informed written consent and physician's certification to the receiving facility.

1. PI # 13 presented to the Emergency Department (ED) on 7/5/23 at 12:18 PM with a chief complaint of Anxiety and Situational Crisis.

Review of the ED Nursing Progress note dated 7/7/23 at 9:35 AM revealed, patient transferred to the receiving facility (Geripsych) via (Ambulance).

Further review of the MR revealed no completion of the Authorization and Consent for Patient Transfer form.

An interview conducted on 8/31/23 at 10:35 AM with Employee Identifier # 1, Director of Quality and Regulatory Compliance confirmed the Authorization and Consent for Patient Transfer form was not completed per policy.