Based on policy review, medical record review. and staff interview; it was determined the facility failed to ensure that all patient transfers had documentation of the risk and benefits of the transfer and that these risks and benefits were discussed with the patients (A2409). The cumulative effect of this systemic practice resulted in the facility's inability to ensure that all emrgency department patient transfers had documentation of the risk and benefits of the transfers and that these risks and benefits were discussed with the patients. The emergency department averaged 8,617 cases per month for the last six months.

Based on policy review, medical record review and staff interview the facility failed to ensure that all patient transfers had documentation of the risk and benefits of the transfers and that these risks and benefits were discussed with the patients. This deficient practice affected four patients of 20 emergency department medical records reviewed (Patients #1, #3, #6, and #8). The emergency department averaged 8,617 cases per month for the last six months. Findings include: 1. Review of the "Medical Screening Examination and Treatment for Emergency Medical Conditions and Women in Labor" policy revealed a patient who has not been stabilized may be transferred to another facility if the patient, after being informed of the risks and the hospital's obligations, requests a transfer or the physician has signed a certification that the benefits of the transfer outweigh the risks to the patient. A stabilized patient may be transferred upon request if the documentation of patient stabilization has been completed by the physician, the communication with the receiving facility has been documented, the receiving facility has agreed to accept the patient, and the patient agrees to the transfer. If a patient requests a transfer, the request must be in writing and indicate the reason for the transfer as well as the patient was aware of the risks and benefits of the transfer. In addition the policy defines physician certification as written certification by the treating physician ordering the transfer that the medical benefits reasonably expected from the transfer outweigh the increased risks to the patient. The certification would contain the summary of the risks and benefits upon which the certification was based and the reason for the transfer. 2. Review of the medical record for Patient #1 revealed the patient (MDS) dated [DATE] for facial swelling and shortness of breath. The patient reported not going to dialysis for the last two weeks because he/she had a "closed artery in chest" and that the dialysis physician would not listen to the patient. A chest x-ray and an EKG, which showed normal sinus rhythm, were completed. An attempt to start an IV (intravenous access) and to draw blood was made without success and the patient refused further attempts. The medical record contained documentation by the physician that the patient requested to go to another hospital where his/her vascular surgeon was. The physician documented communication with the physician at the other facility who accepted the patient for transfer. The patient was transferred by ambulance to the other facility on 06/04/15 at 10:11 PM. The medical record lacked documentation of the risks and benefits of the transfer or evidence the patient was advised of the risks and benefits of the transfer. The medical record did not contain documentation the patient's condition was stabilized or that the emergency medical condition had resolved. 3. Review of the medical record for Patient #3 revealed the patient (MDS) dated [DATE] at 9:48 PM by ambulance for chest pain. The patient reported chest pain off and on for three days with increased chest pain for an hour and a half prior to arrival even with three nitroglycerin tablets taken. The patient was placed on a cardiac monitor with vital signs monitoring and placed on oxygen. Lab work was obtained and evaluated and a chest x-ray was completed which showed no acute pulmonary process. The patient was also placed on a nitroglycerin IV infusion. The physician documented the patient's cardiologist was at another facility and the reason for the transfer was availability of specialty care. The nurse documented the reason for the transfer was the cardiologist. The medical record contained documentation of communication with the accepting physician from the other facility. The patient was transferred by ambulance at 1:53 AM on 01/19/15. A "Critical Care Air/Ground Transfer Certification Form" was completed and signed by the physician. The form stated in "Section A: Reason for Transfer" was a higher level of care/diagnostic services or specialty consult - cardiology. "Section B: Risks and Benefits (COBRA - required for emergency and hospital to hospital transfers)" contained the risks of transfer, the benefits of transfer, and the patient consent or refusal for transfer, but was left blank. The medical record lacked documentation of the risks and benefits of the transfer or that the patient had been advised of the risks and benefits of the transfer. The medical record did not contain documentation the patient's condition was stabilized or that the emergency medical condition had resolved. 4. Review of the medical record for Patient #6 revealed the patient arrived to the emergency department on 12/07/14 for a psychiatric evaluation. The patient had a documented history of post traumatic stress disorder, bipolar and schizoaffective disorder. The patient reported being out of prescribed psychotropic medications and decompensated as a result. The medical record confirmed suicidal ideation with auditory hallucinations, self injurious behaviors that included cutting to the right wrist and right suprapubic areas. The medical record revealed the patient was placed on suicide precautions with a consult made to an outside crisis/intervention for an emergency mental health evaluation. The patient was evaluated and it was determined the patient represents a substantial risk of physical harm to harm self. Further, the patient would benefit from an emergency hospitalization admission (pink slip). The medical record failed to document the risks and benefits prior to the transfer to another facility. 5. Review of the medical record for Patient #8 revealed the patient (MDS) dated [DATE] at 5:40 PM for suicidal thoughts and a concrete plan. The patient had a history of psychiatric issues and prior suicide attempts. The patient had lab work including a drug screen which was negative. The patient was put on one to one observation by security while in the emergency department. The patient was given Ativan and Depakote when he/she reported to the staff that it felt like a seizure was coming on and seizure precautions were implemented. The patient was also given his/her regularly scheduled evening medications. The crisis/intervention team evaluated the patient and arranged for transfer and admission to another inpatient psychiatric facility with a bed available. The patient was transferred by ambulance on 04/28/15 at 4:38 AM. The medical record lacked documentation of the risks and benefits of the transfer or that the patient was advised of the risks and benefits of transfer. The medical record did not contain documentation that the patient's condition was stabilized or that the emergency medical condition had resolved. Staff A was interviewed on 06/11/15 at 1:35 PM. Staff A verified the risks and benefits of transfer were not documented on the medical records for Patients #1, #3, #6, and #8 and there was no documented evidence the patients were advised of these risks.