Based on a review of 5 open and 15 closed emergency department records, it was determined that the hospital failed to inform the guardians of minor patients #6 and #12 of the risks and benefits of transfer. Patient #6 (P6) was a minor child who presented to the hospital via car. P6's parent was present. P6 was determined to require transfer to a higher level of care. Review of P6's record revealed that no certification of stabilization and risk to benefit for transfer was noted in the record. Additionally, no evidence of a parental informed consent for transfer with was found. Patient #12 (P12) was a child who presented to the hospital via emergency services. P12's parent was present. P12's parent requested transfer to a hospital where P12's orthopedist practiced. Transfer was arranged and a physician certification of stabilization was documented. However, no evidence of a parental informed consent for transfer was found.

Based on an interview and onsite review of on-call services for the emergency department, it was determined that at the time of the complaint, 1) the hospital had no consistent process or log documentation for the outcome of outside phone requests for on-call specialist services; 2) an outside phone request for transfer of patient #1 who required specialty neurosurgical services was refused for reasons other than a lack of capability and capacity. Patient #1 (P1) was a 60+ patient who presented to emergency department (ED) of hospital #A via emergency services in mid-December 2018. P1 complained of increasing back pain superimposed over chronic back pain. P1 was unable to stand due to pain, and was documented by the provider as appearing "Distressed." P1 became progressively unable to urinate and the provider suspected an emergency neurological condition that required surgical intervention. The ED provider began calling at 2130 to find specialty services for P1's transfer. The provider called hospital ED #B at 2210, spoke with and documented a call with the ED attending, " ...who states hospital policy requires I speak with a specialist before speaking to (attending) for transfer." At 2220, the attending of hospital #A spoke with, and documented a call with, "(on-call) neurosurgery who refuses to accept patient and states, "We're not your referral center. Why are you calling me? Call (hospital #C)." The provider continued to call other hospitals unsuccessfully until at 0017, one of those hospitals called back and was able to take P1 at that time. An interview with a new ED Medical Director (EDMD) on February 4, 2019 at approximately 1115 revealed that prior to a new on-call process which began January 13, 2019, hospitals calling the ED to obtain specialty on-call services would be directed to call the specialist on call. During that call, a discussion would be made with the specialist as to whether the patient was accepted for transfer. Further interview revealed that there was no specialist obligation to report back to the ED or to document the outcome of the call. If the patient was accepted by the specialist, the requesting hospital would then call the ED back again to arrange for transfer. A request for all documentation related to on-call specialty outcomes requested by phone in this manner revealed no records of any kind. Response from the ED Manager during interview with the EDMD revealed that when the new on-call process began in January, any and all prior documentation was deleted. While those patients who were accepted for specialty services would have that documentation in their records, no phone transfer request log for on-call specialties with refusals and rationales for refusal prior to 01/13/2019 was found on survey.