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Based on document review, medical record review and interview the facility did not comply with all of the provisions for an appropriate transfer. Please reference findings under Tag A 2409.

Based on document review, medical record review and interview, the facility did not ensure a physician was consulted and countersigned the certification indicating that the transfer to a higher level of care was appropriate as documented by the mid-level provider in the emergency department (ED) for 9 of 9 transferred patients (Patients # 2-10). Not including the physician in the determination of the appropriateness of transfer could potentially have an effect on the patient.

Findings include:

Review on 02/22/2018 of the Policy titled "TLC EMTALA Policy" last revised 04/2016 revealed if a physician is not physically present at the time of transfer, then the qualified medical person (as determined by hospital bylaws and rules and regulations) must consult with a physician to determine if an individual with an emergency medical condition is to be transferred to another facility for further stabilizing treatment. A physician must certify that the medical benefits expected from transfer outweigh the risks and describe the reasons for and the potential risks and benefits of the transfer by completing the applicable areas on the Patient Transfer Physician Certification Form. For non-obstetrical patients, the Patient Transfer Physician Certification Form must be countersigned by the certifying physician in a timely manner.

Review on 02/22/2018 of the "Rules and Regulations of the Medical Staff" last revised 06/23/2015 revealed an order to transfer a patient to another institution may be given by the physician on call or the attending physician. The patient shall be transferred to another medical facility only upon the order of the attending practitioner.

Review of medical record for Patients # 2-10 revealed no evidence that the physician was consulted or that the certification indicating that the transfer to a higher level of care was appropriate was countersigned.

Interview on 02/22/2018 at 10:25 AM with Staff (D), Physician Assistant (PA) revealed before transferring a patient the physician is not routinely consulted.

Interview on 02/23/2018 at 2:30 PM with Staff (T), PA revealed consultation with a physician prior to transferring a patient does not usually occur.

Interview with Staff A, ED Administrator on 2/22/18 verified the above findings.