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Based on observations, review of medical records (MR), hospital policy, Bed Census Reports, Physician On-Call List, hospital incident report, Hospital B, receiving hospital MR and interviews, it was determined that D.W. McMillan failed to ensure:
1. The receiving hospital received notification of the transfer.

2. The MR was sent to the receiving hospital.

3. There was an accepting physician's.

4. The risk of transfer was explained to the patient and/or patient representative.

This deficient practice negatively affected Patient Identifier (PI) # 2, and PI # 15, in 2 (two) of seven transfer record reviews, and had the potential to affect all patients presenting to the ED.

Findings include:

Refer to Tag A 2409.

Based on medical record (MR) review, hospital policy, Hospital Bed Census, Physician Emergency Department (ED) schedule, ED Physician Schedule, On-call list, ED Activity Log, Transfer Log, incident report documentation, Hospital B, (receiving hospital) MR and interviews, it was determined that D.W. McMillan failed to:

1. Obtain an accepting physician for transfer.

2. Explain the risks of transfer.

3. Send copies of the medical record to the receiving hospital.


These deficient practices negatively affected Patient Identifier (PI) # 2, and PI # 15, in two of seven transfer records reviewed and had the potential to negatively affect all patients who presented to the hospital.

Findings include:

Facility Policy: EMTALA Policy
Policy number: None listed.
Revised: None listed.

Purpose: To ensure compliance with the EMTALA and associated regulations.

Policy: D.W. McMillan Hospital shall comply with the emergency care obligations imposed by EMTALA. These obligations include the following...

2. Stabilizing treatment
If the medical screening examination indicates that the person has an emergency medical condition, D.W. McMillan Hospital will provide treatment with the capabilities of staff and facilities or an appropriate discharge or transfer as indicated.

3. Appropriate Discharge or Transfer
A. Stabilized person-If the person is stabilized, the person may be discharged or transferred as appropriate. A person is deemed stabilized under the following circumstances:
1. For discharge : if the person does not need continued care and /or no material deterioration is likely to result is the patient receives continued case as an outpatient or later as an inpatient and the patient is given a plan for appropriate follow-up care.
2. For transfer to another facility: If the person's emergency medical condition is resolved, although the underlying medical condition may remain, and/or no material deterioration of the person's condition is likely to result from or occur during transfer...

B. Unstabilized person- If the individual is not stabilized, D.W. McMillan will not discharge or transfer the person unless the following conditions are met:
1. Patient's consent or physician certification
2. Appropriate transfer...

7. Patient's refusal to Consent.
The person has the right to refuse examination, treatment or an appropriate transfer. In such cases, the hospital will offer the individual the examination, treatment or transfer required by EMTALA and document refusal, explain to the individual the risks and benefits of the examination, treatment, or transfer and take reasonable steps to obtain the individual's written informed refusal...

12. Signs and records.
D.W. McMillan Hospital will maintain...Transfer records and a central log on each person presenting to the hospital for emergency care.

1. PI # 2 presented to the ED on 9/21/24 at 8:03 PM with complaints of Vision problems, blurry and red.

Review of the ED Activity Log revealed, PI # 2 arrived by auto, checked in at 8:03 PM and checked out at 9:00 PM. The acuity level was semi-urgent with complaints of vision changes and Retinal detachment (an emergency when part of the eye (the retina) pulls away from its normal position) right eye. The discharge disposition was AMA.

Review of the Transfer Activity Log dated 9/21/24 revealed PI # 2 was not listed.

Review of the Physician Documentation dated 9/21/24 at 8:05 PM revealed, the diabetic patient presented with an experience of a "curtain" falling on his right eye field of vision. Offered to transfer the patient to Pensacola by ambulance but the patient elected transfer by POV and signed out Against Medical Advice (AMA).

Review of the ED Triage note dated 9/21/24 at 8:44 PM revealed an acuity level of 4, semi-urgent, vision changes, erythropsia (a visual disturbance in which all objects appear reddish) of right eye.

Review of the ED nursing note dated 9/21/24 at 8:55 PM revealed, patient to the ED in personal vehicle complains of vision changes he/she reports as a see-through red curtain over the middle of his visual field of the right eye. Patient denies pain, pupils equal in size and reactive to light. Patient reports diabetes and frequent high blood glucose with no primary care physician oversight currently.

Further review of the ED nursing note dated 9/21/24 at 9:00 PM revealed the patient left the ED AMA. The physician recommended transport via Emergency Medical Services (EMS) to Hospital B in Pensacola Fl for higher level of care due to visual changes. Patient refused transport and chose to transport via privately owned vehicle (POV).

Review of the Release from Responsibility for Discharge form revealed, risks of leaving, blindness. Benefits of staying, advises pt to go straight to Pensacola via EMS. Patient elected POV transfer.

An interview was conducted with PI # 2 on 11/6/24 at 10:42 AM, PI # 2 stated " I came (to the ED) because my eye was filling up with blood, the doctor thought I had a detached retina." The patient confirmed he was asked which hospital he wanted to go to and was transferred to " Hospital B". He/She also confirmed that paperwork was signed that released him/her to go without the EMS and the risks were explained, but was told to go on and go. When he/she arrived at Sacred Heart, there was not a specialist there. He/she stated an ultrasound was received and was sent to a specialist the next morning.

An interview was conducted with EI # 4, Emergency Room (ER) Registered Nurse (RN) on 11/7/24 at 8:05 AM. who confirmed the physician saw PI #2 but there was no ophthalmologist (a physician that is an eye care specialist) available and the physician recommended a higher level of care due to the vision problems. The patient did not want to pay for EMS.

An interview was conducted with EI #1, Emergency Room Physician, on 11/7/24 at 8:42 AM. The physician stated PI # 1 was seen in the ER and there was no ophthalmologist available, the patient was told they needed a higher level of care. PI # 2 was told they needed to go to Hospital B by EMS, and the patient refused EMS transport. PI # 2 elected to travel by POV and signed out AMA. EI # 1 did not coordinate care with Hospital B.

An interview was conducted on 11/7/24 at 10:32 AM with EI # 2, Medical Director of the Emergency Department. EI #2 stated that if an AMA was used only for the mode of transport then all other elements of the transfer would still apply.

A review of the Provision of Care Event form (incident report) dated 9/22/2024 revealed, Patient left against medical advice. The brief factual description documented: Patient presented to ED with visual changes, The physician assessed the patient and suggest transport to Hospital B ER for higher level of care related to them having an ophthalmologist on staff. Patient refused transport by EMS and insisted on transport by private vehicle despite the physician's warning patient of possibility of further complications including potential blindness. Patient left against medical advice and signed appropriate paperwork.

A review of the MR, from Hospital B, revealed, PI # 2 presented to the ED on 9/21/24 at 11:44 PM with an eye problem.

A review of Hospital B's ED Physician note dated 9/21/24 at 11:57 PM revealed, Chief complaint, Patient presents to ER from D.W. McMillian with a diagnosis of detached retina.
History of Present Illness, Patient presents with decreased right vision. States at work earlier today he developed a " dark curtain that flowed down the right eye." He/she states that he was seen at D.W.McMillan and underwent no imaging, no ultrasound. He/she was told that he was being "transferred" to our facility for definitive management. Denies being signed out Against Medical Advice. Has no paperwork with them.

Further review of the physicians note dated 9/21/24 revealed, the physician called the physician at D.W. McMillan to get a better understanding of how the patient ended up in our emergency department with absolutely no record of transfer. He/she states that " If we call ahead we have to send them by ambulance." I explained to the physician that we do not have a retinal specialist on tonight and that I would have to transfer the patient elsewhere.


A review of the transfer certification revealed no receiving physician was documented.



2. PI # 15 presented to the ED on 9/21/24 at 7:45 PM with complaints of Vomiting, unspecified.

Review of the physician's ED documentation dated 9/21/24 at 7:54 PM revealed PI # 15, a kidney transplant patient, had projectile vomiting since early afternoon.

Review of the Transfer Certification dated 9/19/24 at 9:00 PM (correct date is 9/21/24) revealed the risks of transfer for nephrology care, via air medical transport, was not explained and not documented on the transfer document.

Further review of the Transfer Certification revealed no copies of the medical record were sent to the receiving hospital.

An interview was conducted on 11/6/24 at 2:15 PM with EI # 6, who confirmed there was no documentation the physician explained the risk of transfer to the minor patient's guardian, and no documentation medical record copies were sent to the receiving hospital.




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