Based on interviews, medical record review and policy review, the facility failed to provide an appropriate medical screening exam prior to transfer (A2406) failed to provide stabilizing treatment prior to transfer (A2407) and failed to obtain a physician signature to certify the patient for transfer (A 2409). The cumulative effect of this systemic practice resulted in the facility's inability to ensure an appropriate transfer for all patients transferred. The hospital emergency department provided service to an average of 2,810 patients per month in 2017.

Based on medical record review and review of physician on-call logs, the facility failed to provide an appropriate medical screening exam prior to transfer of four (Patient #'s 5, 10, 14 and 17) of 20 patients reviewed who were treated in the emergency department. Findings include: Patient #5 (MDS) dated [DATE], at 9:58 AM with abdominal pain. A CT scan was performed, which demonstrated intraperitoneal free air and distended bowel loops suggestive of a perforated viscous with bowel obstruction. The patient was transferred to another facility for a "higher level of care." The hospital physician on-call log revealed a general surgeon was on-call at the time. The medical record did not document the patient received a medical screening exam by the general surgeon on-call. The transfer was to general surgery at the second facility. The record lacked documentation why the second hospital had a higher level of care. Patient #10 (MDS) dated [DATE], at 10:03 AM with a red, firm, edematous lesion in the left inguinal region that extended into the left scrotum. He also presented in diabetic ketoacidosis. A CT scan was performed, which was suggestive of Fournier's gangrene. The patient was transferred to another facility for a "higher level of care." The hospital physician on-call log revealed a general surgeon was on-call at the time. The medical record lacked documentation the patient received a medical screening exam by the general surgeon on-call. The transfer was to general surgery at the second facility. The record lacked documentation why the second hospital had a higher level of care. Patient #14 (MDS) dated [DATE] at 3:48 AM with suicidal ideations and bilateral forearm superficial cuts. The patient was transferred to another facility for a "higher level of care." The hospital physician on-call log revealed a psychiatrist was on-call at the time. The medical record lacked documentation the patient received a medical screening exam by the psychiatrist on call. The transfer was to a psychiatric unit at the second facility. The record lacked documentation why the second hospital had a higher level of care. Patient #17 (MDS) dated [DATE] at 2:37 PM with an intentional medication overdose. The patient was transferred to another facility for a "higher level of care." The hospital physician on-call log revealed a psychiatrist was on-call at the time. The medical record did not document the patient received a medical screening exam by the psychiatrist on call. The transfer was to a psychiatric unit at the second facility. The record lacked documentation why the second hospital had a higher level of care.

Based on medical record review and review of physician on-call logs the facility failed to provide stabilizing treatment for four patients (Patient #'s 5, 10, 14 and 17) prior to transferring to a second facility. Findings include: Patient #5 (MDS) dated [DATE], at 9:58 AM with abdominal pain. A CT scan was performed, which demonstrated intraperitoneal free air and distended bowel loops suggestive of a perforated viscous with bowel obstruction. The patient was transferred to another facility for a "higher level of care." The medical record did not contain documentation the general surgeon on call provided stabilizing medical treatment prior to transfer. The transfer was to general surgery at the second facility. The record lacked documentation why the second hospital had a higher level of care. Patient #10 (MDS) dated [DATE], at 10:03 AM with a red, firm, edematous lesion in the left inguinal region that extended into the left scrotum. He also presented in diabetic ketoacidosis. A CT scan was performed, which was suggestive of Fournier's gangrene. The patient was transferred to another facility for a "higher level of care." The medical record did not contain documentation the general surgeon on call provided stabilizing medical treatment prior to transfer. The transfer was to general surgery at the second facility. The record lacked documentation why the second hospital had a higher level of care. Patient #14 (MDS) dated [DATE] at 3:48 AM with suicidal ideations and bilateral forearm superficial cuts. The patient was transferred to another facility for a "higher level of care." The medical record did not contain documentation the psychiatrist on call provided stabilizing treatment prior to transfer. The transfer was to a psychiatric unit at the second facility. The record lacked documentation why the second hospital had a higher level of care. Patient #17 (MDS) dated [DATE] at 2:37 PM with an intentional medication overdose. The patient was transferred to another facility for a "higher level of care." The medical record did not contain documentation the psychiatrist on call provided stabilizing treatment prior to transfer. The transfer was to a psychiatric unit at the second facility. The record lacked documentation why the second hospital had a higher level of care.

Based on medical record review, staff interview and policy review the hospital failed to ensure a physician signed the certification for patient transfer. This affected four of thirteen patient records reviewed (Patient #5, #10, #14 and #17) who were transferred to another facility. The hospital emergency department provided service to an average of 2,810 patients per month in 2017. The total survey sample was 20 patients. Findings include: The medical record review for Patient #5 was completed on 3/29/18. Patient #5 (MDS) dated [DATE] at 9:58 AM with complaints of abdominal pain, nausea, vomiting and weakness for the past two days. The medical record did not contain physician certification for transfer. "The Authorization for Transfer" form was completed by a mid-level provider. The medical record review for Patient #10 was completed on 3/29/18. Patient #10 (MDS) dated [DATE] at 10:03 PM with complaints of abdominal pain. The medical record did not contain physician certification for transfer. "The Authorization for Transfer" form was completed by a mid-level provider. The medical record review for Patient #14 was completed on 3/29/18. Patient #14 (MDS) dated [DATE] at 3:48 AM with suicidal ideations. The medical record did not contain physician certification for transfer. The physician signature line, date and time on "The Authorization for Transfer" form were left blank. The medical record review for Patient #17 was completed on 3/29/18. Patient #17 (MDS) dated [DATE] at 2:37 PM with a drug overdose. The medical record did not contain physician certification for transfer. "The Authorization for Transfer" form was completed by a mid-level provider. The facility's Emergency Medical Treatment and Active Labor Act (EMTALA) policy (RI 23) was reviewed. The policy stated: Treatment of Patients with EMCs (Emergency Medical Conditions) A. Stabilizing Treatment Requirements I. If a patient is determined to have an EMC the hospital must provide the patient with further medical examination and treatment, within the capabilities of its staff and facilities, to resolve or stabilize the medical condition, or undertake an "appropriate'' Transfer of the patient in accordance with Section IV. As more fully described in Section IV, Transfers of unstabilized patients are allowed only at the patient's request and after the patient has been informed of the hospital's EMTALA obligations and the risks of Transfer, or when a physician or QMP, in consultation with a physician, certifies that the medical benefits reasonably expected as a result of the Transfer outweigh the risks to the patient from being transferred. B. Transfer of a Patient Who has Not been Stabilized 1. The Hospital may Transfer an unstable patient with an EMC who is receiving services required under EMTALA ONLY if one of the following criteria has been met: b. A physician or, if a physician is not physically present at the time of the Transfer, a QMP (Qualified Medical personnel) in consultation with a physician, has certified, and then documented on the Hospitals Transfer form, that the medical benefits reasonably expected from Transfer outweigh the risks associated with the Transfer (including, in the case of labor, for the unborn child). A certification that is signed by a QMP must be countersigned by a physician within 48 hours. These findings were confirmed with Staff B on 3/29/18 at 2:20 PM.