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Based on record review and interview, the facility staff failed to ensure compliance with 42 CFR 49.24.

Findings include:

The facility failed to appropriately transfer 2 patients (Patient #1, #10). See tag A-2409.

Based on record review and interview, facility staff failed to appropriately transfer patients receiving care in the ED (Emergency Department) to another facility in 2 of 10 patients (Patient #1 and Patient #10) who were transferred in a total universe of 20 patient medical records reviewed.

Findings include:

A review of facility policy #KT2N6QC5SZE5-3-1918 titled, "Hospital to Hospital Transfer Process" last reviewed 7/24/2023 revealed, "To facilitate care for a patient who requires urgent or non-urgent transfer from MCHS MMC to another hospital...3.2 Physician: a. Contacts access center (MC Cares for majority of MCHS transfer coordination) to inform need of transfer and facility of choice for service. B. MD to MD communication occurs and MD at outside facility accepts patient for transfer. C. Obtain name of accepting MD and facility of choice along with discharge date. D. MMC MD decides mode of transport...e. MMC creates a discharge summary. F. MMC MD signs appropriate transfer form in form suite for transport...3.3 RN or designee completes the following ...a. Call to nursing supervisor to notify of patient transfer. B. Face sheet faxed to accepting hospital and await acceptance of patient to facility. Note: Must have acceptance by both receiving MD AND facility before patient transfers. C. Pulls Transfer Packet...d. Obtains patient or responsible persons signature on transport form...f. Works with MC Cares regarding time for transfer and assigned bed number for receiving facility...g. RN or designee calls report to receiving facility...h. Document transfer has taken place."

A review of Patient #1's medical record revealed that Patient #1 is a 29 year old female with pertinent past medical history including Autism spectrum disorder and anxiety disorder, who presented to Hospital A's ED on 5/31/2025 at 4:21 PM from her group home of which she resides. Patient #1 has a guardianship in place. Patient #1 was put on a Chapter 51 hold and was requesting to be admitted to an inpatient behavior health unit. Patient #1 was medically cleared and sent by police to Hospital B's ED to be admitted to their inpatient behavior health unit by direction of Crisis Green Bay. Patient #1 was discharged on 5/31/2025 at 10:00 PM from Hospital A and transferred to Hospital B by Police Department. Further review revealed no evidence of an accepting provider at Hospital B, no communication between Hospital A and Hospital B regarding the transfer of Patient #1 and no evidence of a completed transfer form signed by Patient #1 and ED Physician L.

A review of Patient #10's medical record revealed that Patient #10 is a 17 year old female with no pertinent past medical history who presented to Hospital A's ED on 2/15/2025 at 10:21 PM for chief complaint of suicidal ideation after ingesting 20 Midol (contains acetaminophen, which helps alleviate menstrual cramps, headaches, backaches, and muscle aches) and some liquid gelcaps of Advil. Patient #10 was evaluated by ED Physician O on 2/15/2025 at 10:45 PM. Poison control was contacted and labs order. Patient #10 "falls well below the nomogram line (the acetaminophen toxicity nomogram is a graphical tool used to assess the potential for liver toxicity after a single, acute ingestion of acetaminophen) and she is currently medically cleared at 1:45 AM. No concerning labs...We will now begin working on placement as this patient is a Chapter involuntary hold via police." Patient #10 was discharged on 2/16/2025 at 5:00 AM under police custody and transferred to an outside facility. There is no evidence of a transfer form signed, no evidence of risks and benefits of transfer discussed and no evidence of a Physician to Physician hand off occurring.

During an interview on 7/7/2025 at 12:57 PM, Quality Manager C confirmed these findings.

During an interview on 7/7/2025 at 2:15 PM, CNO B confirmed that there was no contact between any RN or Physician from Hospital A to Hospital B at any point during Patient #'1's ED admission.