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Based on document review and interview the facility failed to ensure an appropriate transfer for 1 of 20 ED/ER (Emergency Department/Emergency Room) MRs (Medical Record) reviewed. (Patient # 17).

Findings Include:

1. See findings cited at 42 CFR 489.24 (e) (1)-(2) Appropriate Transfer.

Based on document review and interview the facility failed to ensure an appropriate transfer for 1 of 20 ED/ER (Emergency Department/Emergency Room) MRs (Medical Record) reviewed. (Patient # 17).

Findings include:

1. Facility policy titled: EMTALA Treatment and Transfer of Individuals Who Request Emergency Services, policy number: none listed, indicated on page 3, K. Transfer means movement of an individual outside the hospital; on page 6, under D. Individuals who do not have an Emergency Medical Condition, 1. If a qualified medical person determines, as a result of a medical screening examination, that the individual does not have an emergency medical condition, the individual may be transferred to another healthcare facility (if in need of further care); shall be in accordance with the hospital's transfer procedure; 2. Appropriate transfer forms will be completed if the patient is transferred to another facility; on page 11, under 5. The transferring hospital must send to the receiving hospital appropriate medical records, treatment provided, written informed consent for transfer, and on page 13, under Explanation of Forms, 4. Transfer Information form documents information necessary for implementing an appropriate transfer. Last reviewed 7/2024.

2. Review of MR # 17 for AH # 40, indicated the following:
(a). Nurse note on 3/13/2025 at 9:06 pm, by N # 20 (RN/Registered Nurse - SANE (Sexual Assault Nurse Examiner) reflected N # 20 introduced self and explained her/his role as a SANE nurse. Patient told this RN (Registered Nurse) that she took a bus and walked here to be evaluated for sexual assault. Patient states that she/he was raped by FM # 1's (Family Member) friend last night while she/he was sleeping. Patient states that she/he was in and out of it during sleep and does not recall any details of the event. Patient denies any vaginal pain or discharge. Patient states that she/he did change clothes; but has not had a shower in a few weeks.
(b). ER provider note on 3/13/2025 at 9:47 pm, by MD # 30 (Doctor of Medicine/MD-ER/ED Staff) reflected chief complaint SA (sexual assault). Patient came to ER stating that she/he was raped last night in a tent. Patient does have some vaginal soreness. Denies any other complaints such as bruising or chest pain or injury. Patient decided to come to ER at 8:30 pm. Chose AH # 40 (Acute Care Hospital) since she/he could walk here. Physical exam completed. Patient alert & oriented, no distress. Medical decision making: includes possible sexual assault. At this time patient is requesting to go to AH # 41 (Acute Care Hospital) where there is a SANE (Sexual Assault Nurse Examiner) program. Patient was offered treatment here however she/he wants to go to AH # 41. At this time she/he is medically cleared and will be released. MD # 30 was told that the police will take patient to AH # 41 from AH # 40. Once again she/he was offered treatment here; she/he would like to go to AH # 41. Disposition: Patient released with the police to go to AH # 41. Discharge diagnosis will be reported sexual assault.
(c). Nurse note on 3/13/2025 at 10:25 pm, by N # 20 reflected patient given discharge instructions. Patient informed that local police has been dispatched and should be coming to take statement and transport patient to AH # 41 at patient's request; as she/he wants to be seen by AH # 41's forensic department.
(d). The MR lacked required documentation for an appropriate transfer to AH # 41. Lacked completed transfer form; no communication with AH # 41's ED/ER staff by ED/ER staff at AH # 40 for patient's request & patient transfer.

3. Review of MR # 17 for AH # 41, indicated the following:
(a). ER/ED MD - provider note on 3/14/2025 at 12:00 am, reflected patient presents to ED for safe evaluation. Was a victim of a sexual assault, this occurred down near theater in the city. She/he was assaulted by a homeless individual; she/he - herself/himself is homeless. Was brought in by local police. Had been previously evaluated at AH # 40. ROS (review of systems) and physical exam completed. Patient was seen and evaluated by SANE nurse. Patient was sexually assaulted in the city. Patient stable for discharge. It has been determined that the patient is safe. The SANE nurse determined that the patient was safe for discharge. Results and plan of care discussed with patient.

4. In interview on 4/8/2025 at approximately 10:22 am, with A # 3 (Director ED), confirmed the following:
a. AH # 41 has a full program - wrap around program with community services and follow-up visits for patients/victims of sexual assault/alleged sexual assault.
b. Did not consider as a transfer; patient # 17 was stable, discharged. Patient wanted to go to AH # 41.

5. In interview on 4/8/2025 at approximately 10:25 am, at approximately 12:30 pm, and at approximately 5:30 pm, with A # 4 (ED Manager - SANE Nurse), confirmed the following:
a. Sounds familiar; recent patient to different hospital with SANE program.
b. There was no courtesy call to AH # 41; nurse to nurse; for patient (Patient # 17) going over to AH # 41.

6. In interview on 4/8/2025 at approximately 6:15 pm, with N # 20 (RN/Registered Nurse - SANE (Sexual Assault Nurse Examiner), confirmed the following:
a. Patient # 17 stated sexually assaulted, when presented to ER. Patient was triaged, received MSE by MD # 30.
b. N # 20 informed patient # 17 that was a SANE trained nurse; could do kit, screening for STIs (sexually transmitted infection), speak with social worker, could call law enforcement and could provide prophylaxis medications. Patient asked is that all. Informed patient more resources in community available through SANE program - Forensic department at AH # 41. Patient stated would like to go to AH # 41. N # 20 let MD # 30 know about patient wanting to go to AH # 41.
d. Local police called; as patient # 17 wanted to give statement. Patient asked if they could provide transportation, as she/he walked here. Police agreed to give patient ride to AH # 41.