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Based on interview and document review, it was determined that facility staff failed to ensure that an Emergency Medical Treatment and Labor Act (EMTALA) transfer authorization form was complete for six (6) of six (6) patients who were transferred from the ED to another facility (Patients #4, 5, 8, 15,19, and 27), and that EMTALA transfer forms had a countersignature of a physician when the forms were completed by a Qualified Medical Person (QMP) for four (4) of six (6) patients (Patients #5, 15, 19, and 27).

Findings included:

During a review of twenty-seven (27) medical records while onsite from January 6, 2020 through January 9, 2020, the surveyor discovered the following.

Patient #4 was transferred to another facility. The EMTALA transfer authorization form lacked the following required information: equipment or services unavailable at Norton Community Hospital (NCH), the mode of transport and what support and or treatment was necessary for the transfer, date and time that the transferring physician spoke with the accepting physician, and although the patient's signature was present on the form, the form was not marked to indicate whether Patient #4 consented to the transfer, refused transfer, or requested transfer. The form also lacked the manner in which the patient's accompanying documentation was sent to the accepting facility.

Patient #5 was transferred to another facility. The EMTALA transfer authorization form lacked the following required information: date and time that the transferring clinician spoke with the accepting physician, physician countersignature in addition to the signature of a Family Nurse Practitioner (FNP), relationship of the responsible person to Patient #5, and what accompanying documentation was sent with the patient, as well as how the documentation was sent to the accepting facility.

Patient #8 was transferred to another facility. The EMTALA transfer authorization form lacked the following required information: the name and title of the hospital personnel accepting transfer of Patient #8, and how the information was sent to the accepting hospital.

Patient #15 was transferred to another facility. The EMTALA transfer authorization form lacked the following required information: physician countersignature in addition to the signature of a FNP, name and title of hospital personnel accepting the transfer of Patient #15, how accompanying documentation was sent to the accepting facility, date/time of transfer, and the signature of facility clinical staff.

Patient #19 was transferred to another facility. The EMTALA transfer authorization form lacked the following required information: the condition determined by a medical screening evaluation (MSE) which precipitated the need for transfer, the risks and benefits of transfer, countersignature in addition to the signature of a Physician Assistant (PA-C), what accompanying documentation was sent with the patient and how that information was sent, the title of the person to whom report was given at the receiving facility, and the time of Patient #19's transfer.

Patient #27 was transferred to another facility. The EMTALA transfer authorization form lacked the following required information: countersignature by a physician in addition to the signature of a FNP, name and title of hospital personnel accepting Patient #27's transfer, time/date of transfer, and signature of clinical staff. Staff Member #5 told the surveyor on 1/9/2020 at 10:45 a.m., that the Community Services Board (CSB) mental health professional makes transfer arrangements to psychiatric facilities and that the hospital does not have access to that information and that is why the name and title of the hospital personnel accepting the transfer of Patient #27 was not completed on the transfer form.

A telephone interview was conducted with Staff Member #13, Medical Director of the Emergency Department (ED) on 1/9/2020 at 8:00 a.m. The surveyor inquired as to how ED clinicians receive EMTALA training and facility policy and procedure updates. Staff Member #13 responded that EMTALA training is done through the Shuemaker EMTALA portal as a part of yearly compliance, and as a part of the hospital re-credentialing process. Staff Member #13 also advised the surveyor that most of the training is through the Ballad system, and is generalized information, rather than facility specific. Staff Member #13 said that as ED Medical Director, new information related to policies and procedures or other changes, usually go through them. The ED Medical Director is on the Medical Executive Committee (MEC), and when changes occur, they share with ED staff through email. Staff Member #13 told the surveyor that staff are required to send a response certifying that they have read the training.

Concerns related to incomplete documentation on six (6) of six (6) EMTALA transfer authorization forms, and four (4) of six (6) EMTALA transfer forms signed by mid-level QMP's without physician countersignature, were discussed with Staff Members #1,2, 3, 4, and 11 on 1/9/2020 at 11:00 a.m. The surveyor also discussed the fact that the Governing Body Rules and Regulations state that transfers should always be physician to physician, not mid-level to physician. Staff Member #1 was in agreement that the Governing Body Rules and Regulations did not allow for mid-level signatures on the EMTALA transfer authorization forms.

The facility's policy titled "Emergency Medical Treatment and Patient Transfer", effective 9/8/17, last reviewed 9/8/17 was reviewed, and revealed the following information, in part: "...VII. Procedure: ...1. Any person who comes to a DED [dedicated emergency department] seeking examination or treatment for ANY medical condition must be provided an MSE [medical screening exam] by the hospital's QMP to determine if an emergency medical condition exists or if a woman is in true labor...C. Transfer of an Unstabilized Patient or a Stabilized Patient Without Expected Return: ...i. If the physician is not physically present in the emergency department at the time of transfer, a QMP must determine and certify in signed writing that the physician, after consultation with the QMP, has made the determination described above and the physician must subsequently countersign the certification...4. Prior to transfer, the physician must confirm positive acceptance by a physician at the receiving facility and confirm the receiving physician's name. a. The physician must also complete, or confirm the information contained in, the other physician-required sections of the Transfer Authorization Form...5. Prior to transfer, the RN [Registered Nurse], Case Manager, or Social Worker must confirm positive acceptance by the receiving facility, including bed availability and qualified staff awaiting patient's arrival...".

The facility's Medical Staff Bylaws, policies, and Rules and Regulations for Norton Community Hospital, revised and approved 3/2018, were reviewed, and revealed the following, in part: "...12.3 EMTALA Transfers: The transfer of a patient with an emergency medical condition from the Emergency Department to another hospital will be made in accordance with the Hospital's applicable EMTALA policy. Transfers to or from the Hospital should always be physician to physician, not mid-level to physician".