Based on record review and interview staff failed to ensure compliance with EMTALA (Emergency Medical Treatment and Labor Act) 42 CFR 489.24, in 1 of the 11 required areas (A2409--Appropriate transfer). Findings include: Staff failed to ensure 3 of 20 patients receiving treatment in the Emergency Department were appropriately transferred; this failure potentially allowed for a delay in patients receiving additional stabilizing treatment (Reference A 2409).

Based on record review and interview, staff failed to address the risks and medical benefits and provide clinical indications when transferring patients who present with an Emergency Medical Condition in 3 of 13 Emergency Department (ED) transfer records (2, 3, 4) in a total 20 records reviewed. Findings Include: 1. Review of the policy titled "EMTALA Screening, Treatment & Transfer of Patients" last reviewed 8/23/2016 states, "(Hospital) will not delay the medical screening examination or stabilizing treatment to inquire about the patient's method of payment or insurance status or to engage in debt collection efforts. No financial discussions with patient may occur before screening or before stabilization treatment as been initiated; provided, however, that the patient may be asked basic insurance information as part of the hospital's normal registration process; as long as the inquires do not delay screening or treatment." 2. Record review on 7/17/17 beginning at 1:20 PM of Patient 2's Emergency Department (ED) "Events" log dated 4/4/17, revealed Patient 2 arrived in the ED on 4/4/17 at 6:23 AM and was transferred to acute care hospital on [DATE] at 10:16 AM. Physician D's "ED Provider Notes" dated 4/4/17 at 7:07 AM revealed the following, "Per security, patient was found wandering around on the loading dock with an unsteady gait. (Patient 2's) car was noted to still be in drive wedged into the loading dock. (Patient 2) states (Patient 2) woke up at 3:30 this morning and normally wakes up very early and states (Patient 2) felt (Patient 2's) gait was unsteady and (Patient 2) felt foggy. (Patient 2) states she was having trouble remembering things. (Patient 2) states (Patient 2's) vision also seemed blurred when trying to use (Patient 2's) cell phone. Patient history of binge drinking. (Patient 2) was discharged yesterday (4/3/17) after being admitted 2 days ago (4/2/17) for alcohol-induced hepatitis, metabolic acidosis." Physician D's "ED Course" documented on 4/4/17 at 7:07 am revealed diagnostic testing was performed including a CT (computed tomography) of the head, EKG (electrocardiogram), and lab tests. Physician D's "ED Provider Notes" dated 4/4/17 at 9:59 AM revealed, "On reexam...(Patient 2) has continued unsteady shuffling gait and is not able to ambulate independently...(Patient 2) also has to be continually reminded by Registered Nurse that (Patient 2) is unsafe to drive and that (Patient 2) hit the dock and car was still parked in drive." Physician D's documentation on 4/4/17 at 9:59 AM, of Patient 2's "Clinical Impression" revealed "Confusion, Need for assistance due to unsteady gait, and History of Alcohol Abuse". Physician D's "ED Provider Notes" dated 4/4/17 at 9:59 AM revealed, "Discussed the patient, symptoms, and ER workup with the hospitalist service at (receiving hospital)...Patient's insurance dictates that (Patient 2) either be admitted to (2 other acute care hospitals)...cannot be admitted to (transferring hospital) per staff." Review of Patient 2's "Authorization for Transfer" form dated 4/4/17 at 10:06 AM revealed in "Section 2 Reasons For Transfer", "Confusion, unsteady gait, HO (history) ETOH (alcohol) abuse." is documented in the "Risk/Benefits of Transfer" section. "Risk/Benefits of Transfer" section does not include documentation of medical rationale addressing the risks and medical benefits of transferring Patient 2 to a different acute care hospital. Review of Patient 2's ED record shows no documented evidence explaining the clinical indications for Patient 2's transfer to a different acute care hospital. Per Physician D's above documentation, "insurance dictates" where Patient 2 could be admitted . 3. Review on 7/17/17 beginning at 1:45 PM of Patient 3's ED "Events" log dated 5/10/17 revealed Patient 3 arrived in the ED on 5/10/17 at 12:02 PM and was transferred on 5/10/17 at 5:48 PM. Physician C's provider note dated 5/10/17 at 12:21 PM revealed, "Patient reports that (Patient 3's) sore throat has become progressively worse. Patient reports that (Patient 3) was seen at (acute care hospital) 2 days ago (5/8/17) and diagnosed with Mono (mononucleosis)...Patient currently rates throat pain a 10 out of 10. (Patient 3) reports that it is very painful to swallow. (Patient 3) is having difficulty swallowing saliva." Per review of Patient 3's "ED Course" dated 5/10/17 at 4:26 PM, Physician C revealed, "Patient reports that (Patient 3) continues to have difficulty swallowing and therefore we discussed (Patient 3's) admission to the hospital for IV fluids and further medical care." Review of Patient 3's "Authorization for Transfer" form dated 5/10/17 at 5:25 PM revealed Physician C documented "Insurance Requirement" under "Reasons for Transfer". "Risk/Benefits of Transfer" section does not include documentation of medical rationale addressing the risks and medical benefits of transferring Patient 3 to a different acute care hospital. Review of "Call Schedule" for ENT (Ear, Nose, and Throat) physician, revealed ENT physician was on call at transferring hospital on [DATE]. Review of Patient 3's ED record revealed no documented evidence explaining the medical benefits and clinical indications for Patient 3's transfer to a different acute care hospital. Per Physician C's above documentation, Patient 3 is being transferred due to an "Insurance Requirement". 4. Review on 7/17/17 beginning at 2:00 PM of Patient 4's ED "Events" log dated 5/24/17, revealed Patient 4 arrived in the ED on 5/24/17 at 7:36 AM and was transferred to a different acute care hospital on [DATE] at 10:45 AM. Physician C's "ED Provider Notes" on 5/24/17 at 7:57 AM revealed, "...chest pain intermittently for the past 3 weeks. Patient reports the chest pain is substernal in nature with radiation to left chest. Patient currently rates pain 2/10. However (Patient 4) reports yesterday the chest pain was much worse. Patient describes chest pain as being sharp at times." Review of Patient 4's "ED Course" dated 5/24/17 at 10:12 AM, Physician C documented, "Patient was informed of the need for admission for further evaluation and testing. However due to the patient's medical insurance (Patient 4) could not be admitted here at (transferring hospital) and therefore needs to be transferred to another medical facility. This is based on (Patient 4's) medical insurance." Review of Patient 4's "Authorization for Transfer" form dated 5/24/17 at 10:40 AM, revealed Physician C documented "Medical Insurance Mandate" under "Reasons for Transfer". "Risk/Benefits of Transfer" section does not include documentation of medical rationale addressing the medical risks and benefits of transferring Patient 4 to a different acute care hospital. Review of Patient 4's ED record revealed no documented evidence of the clinical indications for Patient 3's transfer to a different acute care hospital. Per Physician C's above documentation, Patient 4 is being transferred due to a "Medical Insurance Mandate". Review of the "Cardiology Consult Schedule" for May 2017, shows on 5/24/17 a Cardiologist was on call at the transferring hospital. 5. Per interview with Physician E on 7/18/17 beginning at 1:13 PM, Physician E revealed when an ED patient needs to be admitted to the hospital, ED staff contact Admissions/Registration department and determine if the patients insurance will cover admission to the hospital. If the patient's insurance does not cover an inpatient stay at this hospital, Physician E informs the patient and gives other options for admission to hospitals that are covered under the patient's insurance. The patient is given a choice to be admitted to this hospital or transferred to a different hospital covered by insurance. 6. Per interview with Physician C (ED Medical Director) on 7/18/17 beginning at 1:35 PM, Physician C revealed when an ED patient needs to be admitted the unit clerk contacts the Admissions/Registration department to determine if the patient's insurance covers admission to this hospital. If not, Physician C gives the patient options to stay at this hospital and incur a bill or be transferred to hospital where insurance is covered. Physician C stated, "They don't have to go but the patient knows they will get a huge bill if they stay". Physician C stated ED physician's would never transfer a patient if they are not stable just because of insurance coverage. Physician C stated the ED physician's do not explicitly document if a patient is having an Emergency Medical Condition; this is addressed throughout the physician documentation.