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Based on review of Hospital policy and procedure, document request, medical records and employee interview it was determined the Hospital failed to establish, document and implement policy requirements for providing services to patients in excess of its occupancy limits. This deficient practice poses the potential risk that patients assessed to have an emergency medical condition will not receive needed care in a safe and timely manner.

Findings include:

Hospital policy titled "Initial Medical Screen and Level of Care Assessment," Policy #PCIA 002, Revision Date: 9/2024, revealed " ...Stabilizing Treatment ...3. If the hospital is unable to stabilize an individual within its capability and/or capacity, an appropriate transfer will be implemented ...."

Hospital policy titled "Emergency Services and Patient Transfers - EMTALA," Policy #PCIA 009, Revision Date: 9/2024, revealed " ...'Patient Transfer': ...d. If a patient with an emergency medical condition refuses to consent to transfer to another medical facility after being informed of the risks and benefits of the transfer, Hospital personnel shall take reasonable steps to secure the written informed refusal of the transfer from the patient or a person acting on a patient's behalf ...i. The patient must receive an explanation of the risks and benefits of the transfer ...ii. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the patient ...iii. The documents reflecting such refusal should indicate that the patient has been informed of the risks and benefits of transfer; state the reasons for the patient's refusal; be signed, if possible, by the patient or person acting on the patient's behalf, dated, and witnessed by the attending physician or a hospital employee; placed in the patient's record ...."

Request was made for Hospital policy documenting requirements for providing services to patients in excess of its occupancy limits. None was provided.

Medical record for Patient #14 revealed the following:

Document titled "Progress Note," dated May 6, 2025 at 02:10, revealed " ...Patient was transported to facility by ...Crisis and EMT ...(Patient #14) came in stating he/she had called ahead and was told that there was a bed being held for him/her ...As facility was at capacity, patient was offered the option of being transferred to another facility, or to be held at the nearest ER and transferred back the following morning ...(Patient #14) refused both option [sic] and wanted to go home. As he/she was suicidal, he/she was then offered the option of being held in the care center on site to be admitted the following morning. He/she was agreeable ...."

Employee #8 confirmed during an interview conducted on May 29, 2025, that the Hospital has no policy documentation of requirements for providing services to patients in excess of its occupancy limits.

Based on review of Hospital policy and procedure, medical record review and employee interview, it was determined that the Hospital failed to implement and enforce Hospital policy for transferring patients assessed to have an emergency medical condition that is not stabilized. This deficient practice poses a potential risk of harm to patients by not receiving needed care in a safe and timely manner.

Findings Include:

Hospital policy titled "Emergency Services and Patient Transfers - EMTALA," Policy #PCIA 009, Revision Date: 9/2024, revealed " ...8. 'Patient Transfer': ii. If the physician on call issues orders for the transfer of a patient by telephone, those orders shall be reduced to writing in the patient's medical record, signed by the Hospital staff member receiving the order, and countersigned by the physician authorizing the transfer as soon as possible ...iii. Additional transferring physician duties include: ...a. The patient shall receive an explanation of the risks and benefits of transfer from the transferring physician or the QMHP present. This explanation shall be documented in the record ...b. The transferring physician /QMP determines and completes a certification statement, which includes a summary of risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another facility outweigh the increased risks to the patient ...The physician shall countersign the certification as soon as possible if it is completed initially by Hospital personnel ...."

Hospital policy titled "Patient Transfers to Another Facility to Another Facility [sic] From Intake," Policy #PCIA 006, Revision Date: 9/2024, revealed " ...PURPOSE: The purpose of this policy is to ensure Valley Hospital is in compliance with the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA) ...in providing ...possible transfer of persons presenting for examination or treatment who have an emergency medical condition outside the capability of Valley Hospital to treat ...Transferring a (non-patient) individual with an Emergency Medical Condition to Another Hospital ...2. Once it is determined that the individual has an Emergency Medical Condition and Valley Hospital's physician has determined that a transfer to another hospital is appropriate, a RN will meet with the individual and explain the need for the transfer and the risks and benefits of being transferred to another hospital ...6. Memorandum of Transfer (MOT) documentation will be completed and a copy provided to the receiving hospital. Included in the MOT paperwork is: a. A RN signature indicating that the physician ordered the transfer (when the physician is not on site); Note: a physician signature/authentication is required within 48 hours per Med Staff Rules and Regulations ...."

Hospital policy titled "Valley Hospital Medical Staff Rules and Regulations," Rev: 4/30/2025, revealed " ...5.4 Member Orders ...5.4.2. Verbal or telephone orders shall be authenticated by the physician within 48 hours of the order. The authentication shall include the physician's signature, and the day and time of the authentication ...."

Hospital medical records revealed the following:

Patient #4 - Document titled "Memorandum of Transfer," dated April 24, 2025, was not authenticated with a physician signature.

Patient #6 - Document titled "Memorandum of Transfer," dated April 13, 2025, was not authenticated with a physician signature.

Patient #8 - Document titled "Memorandum of Transfer," dated April 5, 2025, was not authenticated with a physician signature
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Patient #11 - Document titled "Memorandum of Transfer," dated May 11, 2025, was not authenticated with a physician signature and no documentation was present verifying "Risks and Benefits for Transfer" were assessed and explained to the patient.

Patient #12 - Document titled "Memorandum of Transfer," dated May 11, 2025, was not authenticated with a physician signature.

Patient #13 - Document titled "Progress Note," dated March 17, 2025, revealed " ...Patient presented to facility, agitated, endorsing passive SI and recent Fentanyl and methamphetamine use. As facility is at capacity, his packet was sent out to other facilities seeking placement. (Facility) called and has availability and patient was agreeable to be transferred there. (Patient #13) was picked up by Maricopa @0137 ...." No Memorandum of Transfer was present in the medical record.

Employee #8 confirmed during an interview conducted on May 29, 2025, that medical records for Patients #4, #6, #8, #11 and #12 did not contain Memoranda of Transfer that were authenticated with physician signature. Employee #8 also confirmed that medical records for Patient #11 did not contain documentation verifying "Risks and Benefits for Transfer" were assessed and explained to the patient and that the medical record for Patient #13 did not present with a Memorandum of Transfer.