HospitalInspections.org

Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failure to ensure the Emergency Department Physicians informed the patient, or a legally responsible person acting on the patient's behalf, in writing of the risks and benefits of the transfer as evidenced by failure to have documented evidence that 1 (#5) of 20 ED patients (#1-#20) (or their responsible party) transferred were informed of the risks and benefits of transfer (see findings in A-2409).

Based on record review and interview, the hospital failed to ensure the Emergency Department Physicians informed the patient, or a legally responsible person acting on the patient's behalf, in writing of the risks and benefits of the transfer as evidenced by failure to have documented evidence that 1 (#5) of 20 ED patients (#1-#20) (or their responsible party) transferred were informed of the risks and benefits of transfer.
Findings:

A review of hospital policy titled "EMTALA Guidelines for Emergency Department Services and Transfer Policy," last revised 07/2023, revealed in part: "The Hospital may not transfer patients with an emergency medical condition that has not been stabilized when the Hospital has the capability to treat the patient unless the following apply: A physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected form the provision of appropriate medical treatment at the other medical facility outweigh the increased risks to the patient ... The certification must contain a summary of the risks and benefits upon which it is based. A physician certification for transfer must meet these additional requirements: (1) there must be an express written certification (it cannot be implied from the findings in the patient medical record and the fact that the patient was transferred); (2) the certification must state the reasons for the transfer; and (3) the certification must contain a complete picture of the benefits to be expected from care at the receiving facility and risks associated with the transfer, including the time away from an acute care setting necessary to effect the transfer. Appropriate documentation related to a transfer under this section will be included in the patient's medical record, including any patient request or physician certification related to a transfer."

A review of hospital policy titled "Standards of Care - Emergency Department" effective date 09/07/2023, revealed in part: "X. Transfers to Other Facilities: A. EMTALA transfers: EMTALA transfer guidelines must be followed when transferring patients with emergency medical conditions to another facility. An appropriate EMTALA transfer must include: a. The patient or person acting on behalf of the patient is informed of the risks and benefits of the transfer; c. A physician signed certification that the benefits of the transfer outweigh the risks; d. Consent of physician and facility acceptance from the receiving hospital. C. The following will be completed on all transfers: d. Transfer form."

A review of Patient #5's medical record revealed that Patient #5 presented to the Emergency Department for stroke symptoms. Patient #5 received treatment in the ED and was transferred to another facility for higher level of care.

Review of Patient #5's medical record failed to reveal that the Emergency Department Physician informed Patient #5, or a legally responsible person acting on the patient's behalf, in writing of the risks and benefits of the transfer and request for the transfer. Further review failed to reveal a transfer form in Patient #5's medical record.

In an interview on 11/25/2024 at 3:42 p.m., S4EDD confirmed that there was no documentation by a physician that Patient #5, or a legally responsible person acting on the patient's behalf, was informed of the risks and benefits of the transfer. S4EDD also confirmed that there was no signed transfer form in Patient #5's medical record.