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Based on interview and record review the facility failed to provide an appropriate transfer for five (5) of 20 sampled patients (Patient 2, 8, 9, 14, and 15).

For Patients 2, 14, and 15, there was no evidence that the facility completed the required "EMTALA Patient Transfer Form," which indicated reason for transfer, disposition, name of accepting physician and accepting facility, mode of transportation, data or records being sent to the accepting facility and physician certification of patients condition, and of explaining the specific risk and benefits of the transfer.

Patient 8 and 9's "EMTALA Patient Transfer Form," was incomplete. The physician certification did not indicate Patient 8's and Patient 9's condition (stable or unstable) and the risk and benefits of transfer were not specified on the form. In addition, Patient 9's mode of transportation was not documented.

This deficient practice had the potential to result in delay or duplicate treatment when the transferring hospital (Hospital A) did not provide all the necessary patient information to receiving hospitals upon transferring Patients 2, 8, 9, 14, and 15. (Refer to C-2409)

Findings:

During an observation and interview in the Emergency Department (ED, a hospital facility providing 24 hour, 7 days a week immediate, unscheduled care for severe injuries or illnesses) on 12/22/2025 at 10:04 a.m. with Triage Registered Nurse (TRN), TRN stated when transferring a patient to another hospital/receiving facility, the physician needed to communicate with another physician at the receiving facility. The Patient must be accepted by the accepting physician. The physician needed to state whether or not the patient was stable for transfer and needed to certify that he/she (referring physician) had explained the risk and benefits of the transfer to the patient. Both the referring physician and the patient or legally responsible party (LRP) needed to sign in acknowledgment of the condition of the patient upon transfer and that the risk and benefits had been explained to the patient. TRN presented a blank document titled, "EMTALA Patient Transfer Form." TRN stated the EMTALA Patient Transfer Form should be filled out in its entirety. The Form included, but not limited to, documentation for Reason for Transfer, Disposition (name of accepting physician, name of accepting facility, mode of transportation), data being sent to the receiving facility, vital signs, patient condition, Physician Certification, Transfer Risk and Transfer Benefits, and signature of referring physician and the patient being transferred. Patient medical records are sent to the receiving facility. TRN stated that the physician would decide the mode of transportation, whether via Emergency Medical Services (EMS, basic transport for stable patients) ambulance or paramedics (for critical or unstable patients). Vitals signs are also needed to be documented on the form. The Form should be completely filled out to ensure all the elements of an appropriate and safe transfer had been met.

During a review of Patient 2's "Emergency Department Triage," dated 8/25/2025 at 11:57 a.m., the Emergency Department Triage document indicated the following: Patient 2 arrived at the Emergency Department (ED) via ambulance for general weakness. Patient 2 also complained of cough. Patient 2 stated "I'm hungry."

During a review of Patient 2 's "Emergency Department Note," dated 8/25/2025 at 7:40 p.m., the Emergency Department Note indicated the following: Care start time: 8/25/2025 at 12:02: Patient 2 was brought by Emergency Medical Services (EMS) ambulance for feeling weakness and being hungry. Patient 2 had been lethargic and nonverbal upon arrival. Patient 2 was given Narcan (a life-saving medication that reverses an opioid overdose) "to try and wake him up ...patient (Patient 2) appears to be under the influence of drugs ...patient (Patient 2) was signed out to me (MD 2) by (MD 1). At 2:30 p.m., patient (Patient 2) was reassessed, now awake, alert, oriented and asking for food ...patient (Patient 2) was given normal saline (a sterile mixture of salt and water), azithromycin (an antibiotic) and ceftriaxone (an antibiotic) ...Disposition: patient (Patient 2) requires admission and ongoing acute care as patient (Patient 2) is at risk for decompensation ... patient (Patient 2) will be admitted for further therapy, hemodynamic monitoring and careful hydration ...Accepting Care Team: Current data and ongoing care discussed with accepting physician (AMD 1). Patient (Patient 2) accepted at 7 p.m. Patient (Patient 2) to be dispositioned to: Receiving Hospital (Hospital B). Diagnosis included: Pneumonia (lung infection), Hyponatremia (low salt level in the blood), Anemia (low red blood cells) and Meth (methamphetamine, lab-made stimulant with high addiction potential) use.

During a review of Patient 2's "Ambulatory Assessment," dated 8/25/2025 at 9:30 p.m., the Ambulatory Assessment indicated the following: Disposition: Transferred ...Patient 2 transferred to ambulance gurney for transfer to Hospital B.

During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with the Clinical Analyst Registered Nurse (CARN) 1, CARN 1 stated the following: Patient 2 was transferred to Hospital B. CARN 1 verified that an EMTALA patient transfer form had not been found in Patient 2's medical record. The transfer form should have been completely filled, including the reason for transfer, physician certification of Patient 2's condition and that the risk and benefits had been explained to Patient 2, signatures of both the referring physician and Patient 2, in acknowledgement of the explanation of reason for transfer and risk and benefits have been explained. In addition, the vital signs and mode of transportation should be documented to ensure a safe transfer, along with documentation of the documents or medical records sent with Patient 2 to Hospital B. CARN 1 stated she (CARN 1) did not know why Patient 2 was being transferred, possibly for insurance reasons.

During a review of Patient 8's "Emergency Department Triage," dated 8/24/2025 at 12:17 p.m., the Emergency Department Triage record indicated the following: Patient 8 arrived at the Emergency Department (ED) from home, accompanied by parents. Patient 8 complained of flu-like symptoms, cough, sore throat, and shortness of breath.

During a review of Patient 8 's "Emergency Department Note," dated 8/24/ 2025 at 12:10 p.m., the Emergency Department Note indicated the following: "10-year-old ...brought in by mother ambulatory ...with complaint of coughing, shortness of breath, sore throat since last night ..." Medical Decision Making: Patient 8 was given Rocephin (an antibiotic used to treat bacterial infections and. Zithromax (an antibiotic to treat a wide range of bacterial infections). Patient 8 was also given Solu-Medrol (an injectable corticosteroid used to treat severe inflammation), Xopenex (a short-acting bronchodilator [rescue medication] to treat sudden airway tightening) handheld nebulizer breathing treatment, and oxygen increased to 4 Liters (L) via facemask. Diagnosis: acute Bronchopneumonia (a lung infection causing inflammation in patches in the long and nearby tissue), hypoxemia (low oxygen levels in the blood), and dyspnea (shortness of breath).

During a review of Patient 8's "Ambulatory Assessment," dated 8/24/2025 at 10:02 p.m., the Ambulatory Assessment indicated the following: At 8:25 p.m. "Gave transfer patient report to RN." Accepting facility was Hospital C. Disposition: Transferred on 8/24/2025 at 9:33 p.m., to acute care hospital.

During a review of Patient 8's "EMTALA Patient Transfer Form," dated 8/24/2025, the EMTALA Patient Transfer Form indicated Patient 8 was being transferred. The name of the receiving facility was not documented, instead, the name of facility was documented as "Long Beach," the name of a city. In addition, Patient 2's condition was blank, not documented. The Section titled, "Physician Certification - Transfer Acknowledgement & Consent," was blank. It did not indicate whether Patient 8's emergency medical condition was stabilized or not stabilized. The Form was signed by the physician and the parent for Patient 8, however, the risk (death, worsening condition, low risk, or other) and benefits (specialized treatment or my physicians are there...) of the transfer were not specified or marked on the document.

During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with CARN 1, Patient 8's EMTALA Patient Transfer Form, was reviewed. CARN 1 stated that the form was incomplete. CARN 1 stated Patient 8 was transferred to another facility because Patient 8 was a pediatric (ages birth to 18 - 21 years old) patient. Patient 8's condition upon transfer was not documented. The form was signed by the physician and the Patient 8's parent, however, the Physician Certification - Transfer Acknowledgement & Consent was blank. It did not indicate whether Patient 8's emergency medical condition was stabilized or not stabilized. In addition, it did not indicate the risk and benefits of transferring Patient 8. CARN 1 stated she did not know Patient 8's condition upon transfer. CARN 1 also acknowledged that the name of the receiving facility was not documented on the form.

During a review of Patient 9's "Emergency Department Triage," dated 8/24/2025 at 12:10 p.m., the Emergency Department Triage record indicated the following: Patient 9 arrived at the Emergency Department (ED) from home accompanied by a parent (s). Per parents, Patient 9 complained of vomiting and diarrhea since the day prior (8/23/2025).

During a review of Patient 9 's "Emergency Department Note," dated 8/24/2025 at 12:10 p.m., the Emergency Department Note indicated the following: "2-year-old ...brought by parents with complaint of nausea, vomiting, diarrhea since last night ...Medical decision making: Result the work up reviewed case, discussed with accepting physician (AMD 2), pediatrician, at Hospital C, who accepts patient (Patient 9) for transfer ...Diagnosis: Acute Gastroenteritis (inflammation of the stomach or intestines, often call "stomach flu") and dehydration (the body does not have enough water or fluid to function properly)."

During a review of Patient 9's "EMTALA Patient Transfer Form," dated 8/24/2025 at 3:30p.m., the EMTALA Patient Transfer Form indicated Patient 9 was being transferred due to Patient 9 being a pediatric patient. The name of the receiving facility was not documented instead, the name of facility was documented as "Long Beach," the name of a city. The Section titled, "Physician Certification - Transfer Acknowledgement & Consent," was blank. It did not indicate whether Patient 9's emergency medical condition was stabilized or not stabilized. The Form was signed by the physician and Patient 9's parent, however, the risk (death, worsening condition, low risk, or other) and benefits (specialized treatment or my physicians are there ...) of the transfer were not specified or marked on the document.

During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with CARN 1, CARN 1 stated the following: Patient 9 was transferred to another hospital because Patient 9 was a pediatric patient. CARN 1 verified that Patient 9's EMTALA Patient Transfer Form was incomplete. The name of the receiving facility was not documented, only the name of the city (Long Beach) in which the hospital was located was documented. The form did not indicate the mode of transportation (ambulance or paramedics). The form was signed by the physician and Patient 9's parent, however, the Physician Certification - Transfer Acknowledgement & Consent was blank. It did not indicate whether Patient 9's emergency medical condition was stabilized or not stabilized. In addition, it did not indicate the risk and benefits of transferring Patient 9. CARN 1 stated it was very important to document the patients' condition and mode of transportation upon transfer to ensure safe and appropriate transfer.

During a review of Patient 14's "Emergency Department Triage," dated 7/25/2025 at 2:11 p.m., the Emergency Department Triage record indicated the following: Patient 14 arrived by ambulance from a skilled nursing facility to Emergency Department (ED) with a chief complaint for aggressive behavior and being assaultive towards staff. Patient 14 needed to be medically clear and then transferred to another hospital (receiving facility, Hospital D).

During a review of Patient 14's "Emergency Department Note," dated 7/25/2025 at 2:14 p.m., the Emergency Department Note indicated the following: Patient 14 was from a nursing home with complaints of bizarre behavior and aggressive behavior toward staff. Patient 14's Neurological assessment was alert and oriented to person, place, and time. Patient 14 was diagnosed with Psychotic behavior (involves a loss of contact with reality, characterized by distorted thinking, perceptions, and behaviors, primarily seen through hallucinations [seeing/hearing things not there] and delusions [false, fixed beliefs]) and was medically cleared to go to psychiatric hospital.

During a review of Patient 14's "Progress Notes Report," dated 7/25/2025 at 9:03 p.m., the Progress Notes Report indicated the following: Patient 14 was transferred by ambulance.

During an interview on 12/23/2025 at 10:26 a.m. with the Clinical Analyst Registered Nurse 2 (CARN 2), CARN 2 confirmed the following: There was no "Transfer form" documentation in the medical chart for Patient 14. No documentation signed Physician Certification of condition of patient, explaining the risk and benefits of transfer to patient. There was no documentation of accepting representatives at the accepting facility.

During a review of Patient 15's "Emergency Department Triage," dated 7/24/2025 at 11:19 p.m., the Emergency Department Triage record indicated the following: Patient 15 arrived in the Emergency Department (ED) accompanied by Deputy with a chief complaint of suicidal ideation (thoughts of considering death) and on a 5150 hold (a legal provision allowing police or mental health professionals to involuntarily detain someone for up to 72 hours for a psychiatric evaluation if they're deemed a danger to themselves or others, or are gravely disabled due to a mental health crisis, enabling stabilization and assessment before potential release or further involuntary holds).

During a review of Patient 15's "Emergency Department Note," dated 7/24/2025 at 11:19 p.m., the Emergency Department Note indicated the following: Patient 15 was a minor and got into verbal altercation at home and had thoughts of hurting self. Patient 15 was on a 5150 hold. Patient 15 needed to be transferred to Behavioral Health Unit (a specialized, secure hospital unit or facility designed to provide 24/7 care, stabilization, and treatment for individuals experiencing acute mental health crises, severe psychiatric disorders, or substance abuse issues) for evaluation.

During a review of Patient 15's "Progress Notes Report," dated 7/25/2025 at 4:09 p.m., the Progress Notes Report indicated the following: Patient 15 was transferred to another facility (receiving facility, Hospital E).

During an interview on 12/23/2025 at 10:36 a.m. with the Clinical Analyst Registered Nurse 2 (CARN 2), CARN 2 confirmed the following: There was no "Transfer form" documentation in the medical chart for Patient 15. No documentation signed Physician Certification of condition of patient, explaining the risk and benefits of transfer to the patient. No documentation regarding accepting representatives at the accepting facility.

During a review of the facility's policy and procedure (P&P) titled, "EMTALA Guidelines for Emergency Department," dated 8/2022, the P&P indicated the following: Transfer For Care Outside the Hospital:

a. Unable Patients: An individual with an emergency medical condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity [including severe pain ...] such as the absence of immediate medical attention could reasonably be expected to result in: ...Placing the health of an individual in serious jeopardy; serious impairment of bodily functions; serious dysfunction of any bodily organ or part) which has not been stabilized may only be transferred for medical reasons or if the individual makes an informed request for transfer ...2. For Medical Reasons With Physician Certification: If the physician certifies in wring on the "Transfer Summary Form," that, based on the reasonable risk and benefits to the patient, and based upon the information available at the time of the patient's transfer, the medical benefits reasonably expected for the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the patient and, if pregnant, the patient's unborn child from effecting the transfer.

b. Stable Patients: Individuals who have an EMC which has been stabilized, i.e., who is Stable for Transfer, may be transferred to another facility for definite care under one of the following: ...Recommend Transfer For Medical Reasons: If a physician recommends the transfer based on the medical benefits and the individual provides informed consent to the transfer, the transfer may then occur if the individual or legally responsible person (LRP) consents to the transfer and acknowledges the reasons for the transfer and his/her awareness of the risk and benefits of the transfer on the "Transfer Summary Form."

Patient Transfer: It is the responsibility of the physician to ensure that all transfers for immediate care of an individual to another care facility will be carried out in accordance with the following:
1. Medical Treatment: The hospital will provide, within its capacity, medical treatment that minimizes the risk of transfer/referral to the individual's health ...
2. Informed Consent: Where the transfer is medically recommended, the hospital will notify the individual or, where applicable, the individual's LRP, both orally and in writing of the recommend transfer and reasons therefore ...

3. Informed Request: Where the transfer is in response to a request for the transfer by the individual, such request must be documented on the "Transfer Summary Form" and signed by the individual or the LRP ...
a. For non-medical transfer, the "Transfer Summary Form," must include a declaration by the physician that the individual is Stable for Transfer, and an acknowledgement by the individual or LRP that he/she has been offered continuing care at the facility, as well as the risk of the transfer and the reasons for the transfer.
b. For transfers of individuals who have not been stabilized, the individual must acknowledge on the "Transfer Summary Form," the risk of the transfer, his/her right to recommended treatment at the facility and the reasons for the requested transfer.

4. Contact Receiving Facility. A representative of the receiving facility must have confirmed that:
a. The receiving facility has available space and qualified personnel to treat the individual; and
b. The receiving facility has agreed to accept transfer of the individual and to provide appropriate medical treatment.

5. Copies of Medical Records/Consents/Certification, the Hospital will send the receiving facility copies of all pertinent medical records available at transfer, including:
a. History
b. Records related to the individual's emergency medical condition.
c. Observations of signs and symptoms;
d. Preliminary diagnosis;
e. Results of diagnostic studies or telephone reports of the studies;
f. Treatment provided;
g. Results of any tests; and
h. A copy of the informed written request or certification and consent to transfer.

6. Transport By - Qualified Personnel: The transfer will be effected through qualified personnel and transportation equipment, as determined by the physician included the use of necessary and medically appropriate life support measures during the transfer ...

7. Complete Transfer Summary: The ED Physician shall ensure that a completed "Transfer Summary Form," signed by the patient or legally responsible adult ...

During a review of the facility's policy and procedure (P&P) titled, "Higher Level of Care Transfers," dated 11/2025, the P&P indicated the following: Under the direction of the Emergency Department (ED) Physician, Patients, requiring higher level of service will be appropriately transferred from the Emergency Department ...Higher level of care is defined as a level of care which cannot be provided at the Hospital.

Procedure: Emergency Department Physician advises and documents need for transfer to higher level of care ...Once a facility accepts the patient, ED physician and ED clerk are informed by the charge registered nurse. As appropriate, patient / family members are advised of transfer. Arrangements are made for transportation. All appropriate documentation is on the E.D. (Emergency Department) Summary, Nurses' Progress Notes and EMTALA Patient Transfer Form.

Based on interview and record review the facility failed to provide an appropriate transfer for five (5) of 20 sampled patients (Patient 2, 8, 9, 14, and 15).

For Patients 2, 14, and 15, there was no evidence that the facility completed the required "EMTALA Patient Transfer Form," which indicated reason for transfer, disposition, name of accepting physician and accepting facility, mode of transportation, data or records being sent to the accepting facility and physician certification of patients condition, and of explaining the specific risk and benefits of the transfer.

Patient 8 and 9's "EMTALA Patient Transfer Form," was incomplete. The physician certification did not indicate Patient 8's and Patient 9's condition (stable or unstable) and the risk and benefits of transfer were not specified on the form. In addition, Patient 9's mode of transportation was not documented.

This deficient practice had the potential to result in delay or duplicate treatment when the transferring hospital (Hospital A) did not provide all the necessary patient information to receiving hospitals upon transferring Patients 2, 8, 9, 14, and 15.

Findings:

During an observation and interview in the Emergency Department (ED, a hospital facility providing 24 hour, 7 days a week immediate, unscheduled care for severe injuries or illnesses) on 12/22/2025 at 10:04 a.m. with Triage Registered Nurse (TRN), TRN stated when transferring a patient to another hospital/receiving facility, the physician needed to communicate with another physician at the receiving facility. The Patient must be accepted by the accepting physician. The physician needed to state whether or not the patient was stable for transfer and needed to certify that he/she (referring physician) had explained the risk and benefits of the transfer to the patient. Both the referring physician and the patient or legally responsible party (LRP) needed to sign in acknowledgment of the condition of the patient upon transfer and that the risk and benefits had been explained to the patient. TRN presented a blank document titled, "EMTALA Patient Transfer Form." TRN stated the EMTALA Patient Transfer Form should be filled out in its entirety. The Form included, but not limited to, documentation for Reason for Transfer, Disposition (name of accepting physician, name of accepting facility, mode of transportation), data being sent to the receiving facility, vital signs, patient condition, Physician Certification, Transfer Risk and Transfer Benefits, and signature of referring physician and the patient being transferred. Patient medical records are sent to the receiving facility. TRN stated that the physician would decide the mode of transportation, whether via Emergency Medical Services (EMS, basic transport for stable patients) ambulance or paramedics (for critical or unstable patients). Vitals signs are also needed to be documented on the form. The Form should be completely filled out to ensure all the elements of an appropriate and safe transfer had been met.

During a review of Patient 2's "Emergency Department Triage," dated 8/25/2025 at 11:57 a.m., the Emergency Department Triage document indicated the following: Patient 2 arrived at the Emergency Department (ED) via ambulance for general weakness. Patient 2 also complained of cough. Patient 2 stated "I'm hungry."

During a review of Patient 2 's "Emergency Department Note," dated 8/25/2025 at 7:40 p.m., the Emergency Department Note indicated the following: Care start time: 8/25/2025 at 12:02: Patient 2 was brought by Emergency Medical Services (EMS) ambulance for feeling weakness and being hungry. Patient 2 had been lethargic and nonverbal upon arrival. Patient 2 was given Narcan (a life-saving medication that reverses an opioid overdose) "to try and wake him up ...patient (Patient 2) appears to be under the influence of drugs ...patient (Patient 2) was signed out to me (MD 2) by (MD 1). At 2:30 p.m., patient (Patient 2) was reassessed, now awake, alert, oriented and asking for food ...patient (Patient 2) was given normal saline (a sterile mixture of salt and water), azithromycin (an antibiotic) and ceftriaxone (an antibiotic) ...Disposition: patient (Patient 2) requires admission and ongoing acute care as patient (Patient 2) is at risk for decompensation ... patient (Patient 2) will be admitted for further therapy, hemodynamic monitoring and careful hydration ...Accepting Care Team: Current data and ongoing care discussed with accepting physician (AMD 1). Patient (Patient 2) accepted at 7 p.m. Patient (Patient 2) to be dispositioned to: Receiving Hospital (Hospital B). Diagnosis included: Pneumonia (lung infection), Hyponatremia (low salt level in the blood), Anemia (low red blood cells) and Meth (methamphetamine, lab-made stimulant with high addiction potential) use.

During a review of Patient 2's "Ambulatory Assessment," dated 8/25/2025 at 9:30 p.m., the Ambulatory Assessment indicated the following: Disposition: Transferred ...Patient 2 transferred to ambulance gurney for transfer to Hospital B.

During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with the Clinical Analyst Registered Nurse (CARN) 1, CARN 1 stated the following: Patient 2 was transferred to Hospital B. CARN 1 verified that an EMTALA patient transfer form had not been found in Patient 2's medical record. The transfer form should have been completely filled, including the reason for transfer, physician certification of Patient 2's condition and that the risk and benefits had been explained to Patient 2, signatures of both the referring physician and Patient 2, in acknowledgement of the explanation of reason for transfer and risk and benefits have been explained. In addition, the vital signs and mode of transportation should be documented to ensure a safe transfer, along with documentation of the documents or medical records sent with Patient 2 to Hospital B. CARN 1 stated she (CARN 1) did not know why Patient 2 was being transferred, possibly for insurance reasons.

During a review of Patient 8's "Emergency Department Triage," dated 8/24/2025 at 12:17 p.m., the Emergency Department Triage record indicated the following: Patient 8 arrived at the Emergency Department (ED) from home, accompanied by parents. Patient 8 complained of flu-like symptoms, cough, sore throat, and shortness of breath.

During a review of Patient 8 's "Emergency Department Note," dated 8/24/ 2025 at 12:10 p.m., the Emergency Department Note indicated the following: "10-year-old ...brought in by mother ambulatory ...with complaint of coughing, shortness of breath, sore throat since last night ..." Medical Decision Making: Patient 8 was given Rocephin (an antibiotic used to treat bacterial infections and. Zithromax (an antibiotic to treat a wide range of bacterial infections). Patient 8 was also given Solu-Medrol (an injectable corticosteroid used to treat severe inflammation), Xopenex (a short-acting bronchodilator [rescue medication] to treat sudden airway tightening) handheld nebulizer breathing treatment, and oxygen increased to 4 Liters (L) via facemask. Diagnosis: acute Bronchopneumonia (a lung infection causing inflammation in patches in the long and nearby tissue), hypoxemia (low oxygen levels in the blood), and dyspnea (shortness of breath).

During a review of Patient 8's "Ambulatory Assessment," dated 8/24/2025 at 10:02 p.m., the Ambulatory Assessment indicated the following: At 8:25 p.m. "Gave transfer patient report to RN." Accepting facility was Hospital C. Disposition: Transferred on 8/24/2025 at 9:33 p.m., to acute care hospital.

During a review of Patient 8's "EMTALA Patient Transfer Form," dated 8/24/2025, the EMTALA Patient Transfer Form indicated Patient 8 was being transferred. The name of the receiving facility was not documented, instead, the name of facility was documented as "Long Beach," the name of a city. In addition, Patient 2's condition was blank, not documented. The Section titled, "Physician Certification - Transfer Acknowledgement & Consent," was blank. It did not indicate whether Patient 8's emergency medical condition was stabilized or not stabilized. The Form was signed by the physician and the parent for Patient 8, however, the risk (death, worsening condition, low risk, or other) and benefits (specialized treatment or my physicians are there...) of the transfer were not specified or marked on the document.

During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with CARN 1, Patient 8's EMTALA Patient Transfer Form, was reviewed. CARN 1 stated that the form was incomplete. CARN 1 stated Patient 8 was transferred to another facility because Patient 8 was a pediatric (ages birth to 18 - 21 years old) patient. Patient 8's condition upon transfer was not documented. The form was signed by the physician and the Patient 8's parent, however, the Physician Certification - Transfer Acknowledgement & Consent was blank. It did not indicate whether Patient 8's emergency medical condition was stabilized or not stabilized. In addition, it did not indicate the risk and benefits of transferring Patient 8. CARN 1 stated she did not know Patient 8's condition upon transfer. CARN 1 also acknowledged that the name of the receiving facility was not documented on the form.

During a review of Patient 9's "Emergency Department Triage," dated 8/24/2025 at 12:10 p.m., the Emergency Department Triage record indicated the following: Patient 9 arrived at the Emergency Department (ED) from home accompanied by a parent (s). Per parents, Patient 9 complained of vomiting and diarrhea since the day prior (8/23/2025).

During a review of Patient 9 's "Emergency Department Note," dated 8/24/2025 at 12:10 p.m., the Emergency Department Note indicated the following: "2-year-old ...brought by parents with complaint of nausea, vomiting, diarrhea since last night ...Medical decision making: Result the work up reviewed case, discussed with accepting physician (AMD 2), pediatrician, at Hospital C, who accepts patient (Patient 9) for transfer ...Diagnosis: Acute Gastroenteritis (inflammation of the stomach or intestines, often call "stomach flu") and dehydration (the body does not have enough water or fluid to function properly)."

During a review of Patient 9's "EMTALA Patient Transfer Form," dated 8/24/2025 at 3:30p.m., the EMTALA Patient Transfer Form indicated Patient 9 was being transferred due to Patient 9 being a pediatric patient. The name of the receiving facility was not documented instead, the name of facility was documented as "Long Beach," the name of a city. The Section titled, "Physician Certification - Transfer Acknowledgement & Consent," was blank. It did not indicate whether Patient 9's emergency medical condition was stabilized or not stabilized. The Form was signed by the physician and Patient 9's parent, however, the risk (death, worsening condition, low risk, or other) and benefits (specialized treatment or my physicians are there ...) of the transfer were not specified or marked on the document.

During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with CARN 1, CARN 1 stated the following: Patient 9 was transferred to another hospital because Patient 9 was a pediatric patient. CARN 1 verified that Patient 9's EMTALA Patient Transfer Form was incomplete. The name of the receiving facility was not documented, only the name of the city (Long Beach) in which the hospital was located was documented. The form did not indicate the mode of transportation (ambulance or paramedics). The form was signed by the physician and Patient 9's parent, however, the Physician Certification - Transfer Acknowledgement & Consent was blank. It did not indicate whether Patient 9's emergency medical condition was stabilized or not stabilized. In addition, it did not indicate the risk and benefits of transferring Patient 9. CARN 1 stated it was very important to document the patients' condition and mode of transportation upon transfer to ensure safe and appropriate transfer.

During a review of Patient 14's "Emergency Department Triage," dated 7/25/2025 at 2:11 p.m., the Emergency Department Triage record indicated the following: Patient 14 arrived by ambulance from a skilled nursing facility to Emergency Department (ED) with a chief complaint for aggressive behavior and being assaultive towards staff. Patient 14 needed to be medically clear and then transferred to another hospital (receiving facility, Hospital D).

During a review of Patient 14's "Emergency Department Note," dated 7/25/2025 at 2:14 p.m., the Emergency Department Note indicated the following: Patient 14 was from a nursing home with complaints of bizarre behavior and aggressive behavior toward staff. Patient 14's Neurological assessment was alert and oriented to person, place, and time. Patient 14 was diagnosed with Psychotic behavior (involves a loss of contact with reality, characterized by distorted thinking, perceptions, and behaviors, primarily seen through hallucinations [seeing/hearing things not there] and delusions [false, fixed beliefs]) and was medically cleared to go to psychiatric hospital.

During a review of Patient 14's "Progress Notes Report," dated 7/25/2025 at 9:03 p.m., the Progress Notes Report indicated the following: Patient 14 was transferred by ambulance.

During an interview on 12/23/2025 at 10:26 a.m. with the Clinical Analyst Registered Nurse 2 (CARN 2), CARN 2 confirmed the following: There was no "Transfer form" documentation in the medical chart for Patient 14. No documentation signed Physician Certification of condition of patient, explaining the risk and benefits of transfer to patient. There was no documentation of accepting representatives at the accepting facility.

During a review of Patient 15's "Emergency Department Triage," dated 7/24/2025 at 11:19 p.m., the Emergency Department Triage record indicated the following: Patient 15 arrived in the Emergency Department (ED) accompanied by Deputy with a chief complaint of suicidal ideation (thoughts of considering death) and on a 5150 hold (a legal provision allowing police or mental health professionals to involuntarily detain someone for up to 72 hours for a psychiatric evaluation if they're deemed a danger to themselves or others, or are gravely disabled due to a mental health crisis, enabling stabilization and assessment before potential release or further involuntary holds).

During a review of Patient 15's "Emergency Department Note," dated 7/24/2025 at 11:19 p.m., the Emergency Department Note indicated the following: Patient 15 was a minor and got into verbal altercation at home and had thoughts of hurting self. Patient 15 was on a 5150 hold. Patient 15 needed to be transferred to Behavioral Health Unit (a specialized, secure hospital unit or facility designed to provide 24/7 care, stabilization, and treatment for individuals experiencing acute mental health crises, severe psychiatric disorders, or substance abuse issues) for evaluation.

During a review of Patient 15's "Progress Notes Report," dated 7/25/2025 at 4:09 p.m., the Progress Notes Report indicated the following: Patient 15 was transferred to another facility (receiving facility, Hospital E).

During an interview on 12/23/2025 at 10:36 a.m. with the Clinical Analyst Registered Nurse 2 (CARN 2), CARN 2 confirmed the following: There was no "Transfer form" documentation in the medical chart for Patient 15. No documentation signed Physician Certification of condition of patient, explaining the risk and benefits of transfer to the patient. No documentation regarding accepting representatives at the accepting facility.

During a review of the facility's policy and procedure (P&P) titled, "EMTALA Guidelines for Emergency Department," dated 8/2022, the P&P indicated the following: Transfer For Care Outside the Hospital:

a. Unable Patients: An individual with an emergency medical condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity [including severe pain ...] such as the absence of immediate medical attention could reasonably be expected to result in: ...Placing the health of an individual in serious jeopardy; serious impairment of bodily functions; serious dysfunction of any bodily organ or part) which has not been stabilized may only be transferred for medical reasons or if the individual makes an informed request for transfer ...2. For Medical Reasons With Physician Certification: If the physician certifies in wring on the "Transfer Summary Form," that, based on the reasonable risk and benefits to the patient, and based upon the information available at the time of the patient's transfer, the medical benefits reasonably expected for the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the patient and, if pregnant, the patient's unborn child from effecting the transfer.

b. Stable Patients: Individuals who have an EMC which has been stabilized, i.e., who is Stable for Transfer, may be transferred to another facility for definite care under one of the following: ...Recommend Transfer For Medical Reasons: If a physician recommends the transfer based on the medical benefits and the individual provides informed consent to the transfer, the transfer may then occur if the individual or legally responsible person (LRP) consents to the transfer and acknowledges the reasons for the transfer and his/her awareness of the risk and benefits of the transfer on the "Transfer Summary Form."

Patient Transfer: It is the responsibility of the physician to ensure that all transfers for immediate care of an individual to another care facility will be carried out in accordance with the following:
1. Medical Treatment: The hospital will provide, within its capacity, medical treatment that minimizes the risk of transfer/referral to the individual's health ...
2. Informed Consent: Where the transfer is medically recommended, the hospital will notify the individual or, where applicable, the individual's LRP, both orally and in writing of the recommend transfer and reasons therefore ...

3. Informed Request: Where the transfer is in response to a request for the transfer by the individual, such request must be documented on the "Transfer Summary Form" and signed by the individual or the LRP ...
a. For non-medical transfer, the "Transfer Summary Form," must include a declaration by the physician that the individual is Stable for Transfer, and an acknowledgement by the individual or LRP that he/she has been offered continuing care at the facility, as well as the risk of the transfer and the reasons for the transfer.
b. For transfers of individuals who have not been stabilized, the individual must acknowledge on the "Transfer Summary Form," the risk of the transfer, his/her right to recommended treatment at the facility and the reasons for the requested transfer.

4. Contact Receiving Facility. A representative of the receiving facility must have confirmed that:
a. The receiving facility has available space and qualified personnel to treat the individual; and
b. The receiving facility has agreed to accept transfer of the individual and to provide appropriate medical treatment.

5. Copies of Medical Records/Consents/Certification, the Hospital will send the receiving facility copies of all pertinent medical records available at transfer, including:
a. History
b. Records related to the individual's emergency medical condition.
c. Observations of signs and symptoms;
d. Preliminary diagnosis;
e. Results of diagnostic studies or telephone reports of the studies;
f. Treatment provided;
g. Results of any tests; and
h. A copy of the informed written request or certification and consent to transfer.

6. Transport By - Qualified Personnel: The transfer will be effected through qualified personnel and transportation equipment, as determined by the physician included the use of necessary and medically appropriate life support measures during the transfer ...

7. Complete Transfer Summary: The ED Physician shall ensure that a completed "Transfer Summary Form," signed by the patient or legally responsible adult ...

During a review of the facility's policy and procedure (P&P) titled, "Higher Level of Care Transfers," dated 11/2025, the P&P indicated the following: Under the direction of the Emergency Department (ED) Physician, Patients, requiring higher level of service will be appropriately transferred from the Emergency Department ...Higher level of care is defined as a level of care which cannot be provided at the Hospital.

Procedure: Emergency Department Physician advises and documents need for transfer to higher level of care ...Once a facility accepts the patient, ED physician and ED clerk are informed by the charge registered nurse. As appropriate, patient / family members are advised of transfer. Arrangements are made for transportation. All appropriate documentation is on the E.D. (Emergency Department) Summary, Nurses' Progress Notes and EMTALA Patient Transfer Form.