Baptist Medical Center East

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 30952 Based on review of hospital policy and procedure, medical records (MR), and staff interviews, it was determined the facility failed to ensure emergency department (ED) staff followed the facility policy and procedure and conducted a comprehensive pain assessment, initiated care to manage moderate and severe pain, and reassessed patient’s pain. This affected Patient Identifier (PI) # 5, PI # 6, PI # 7, PI # 2 and PI # 10, in five of ten ED records, and had the potential to negatively affect all patients treated in the ED. Findings include: Facility Policy and Procedure Pain Management Guidelines Revision Dates: 05/2022 ...I. Purpose: The purpose of this policy is to provide guidelines for ensuring safe and effective pain control. III. ...C. Pain: an unpleasant sensory and emotional experience arising from actual or potential tissue damage D. Pain scales: tools used to rate or quantify a patient’s perceived level of pain ...F. Moderate pain: pain rated on a numeric scale as four (4) to seven (7); distracting, cannot be ignored for more than a few minutes; interferes with daily living activities G. Severe pain: pain rated on a numeric scale as eight (8) to ten (10); disabling, dominates the senses; significantly limits the ability to perform normal daily activities... IV. Policy: A. A comprehensive pain assessment should be conducted... as appropriate to the patient’s condition and the scope of the care, treatment, and services provided. D. Pain management interventions should be appropriate... E. The physician attending of the patient is responsible for developing an appropriate pain management plan for the patient. ...V. Procedure: A. Patients will have their pain assessed... utilizing methods that are appropriate to the patient’s age and/or abilities. 2. The pain assessment should include, but is not limited to: a. Pain history b. Previously used methods for pain control c. Whether the pain is acute or chronic d. Pain intensity using a pain scale e. Location, onset, duration, and quality of pain f. Acceptable level of the pain (the patient’s comfort zone) 3. If pain management is indicated, the nurse should determine if appropriate pain management...or modalities have been ordered or if...communication with the attending physician is indicated to develop and initiate the pain management plan. ...5. Pain interventions should be documented... 6. Pain assessments/reassessments should be documented... 1. PI # 5 presented to the ED on 2/10/26 with a chief complaint of generalized abdominal pain. Review of the ED Triage performed on 2/10/26 at 11:20 PM revealed PI # 5 complained of middle back pain, generalized abdominal pain that started yesterday, and the pain rating was 6 (moderate on 1-10 scale). There was no documentation on previously used methods for pain control, the quality of pain, and an acceptable level of pain per the facility policy. Further review of the MR revealed no documentation PI # 5’s pain was re-assessed for worsening/improvement, and no documentation actions to alleviate and/or manage the pain was provided. Record review revealed on 2/11/26 at 4:05 AM, four hours forty-five minutes later, ED staff called the patient with no answer. On 2/11/26 at 4:37 AM, the ED record documentation revealed the patient left without notifying ED staff. PI # 5 returned to the ED on 2/12/26 at 5:54 AM. At 7:55 AM, the patient’s pain was rated a 10 (severe on 1-10 scale). The patient was transferred to a higher level of care for a surgical procedure at 7:05 PM. An interview was conducted on 4/2/26 at 11:00 AM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed ED staff failed to follow the facility pain management guidelines for pain assessment and pain re-assessment. 2. PI # 6 presented to the ED on 11/4/25 at 3:34 AM with a chief complaint of upper abdominal pain. Review of the ED Triage conducted on 11/4/25 at 3:37 AM revealed PI # 6 complained of increasing abdominal pain, had been diagnosed on 9/21 (2025) with necrotic pancreas, and had a stent placed in October 2025. Further review of the ED Triage pain assessment documentation revealed the location of the pain was the left lateral abdomen, the pain quality was sharp, and the pain was rated 8 (severe on a 1-10 scale). There was no documentation of previously used methods for pain control, whether the pain is acute or chronic, and no acceptable level of pain. There was no documentation ED staff notified the ED provider of the severe pain assessment rating, and no documentation interventions/actions were taken to address/alleviate PI # 6’s severe pain. Record review revealed on 11/4/25 at 5:21 AM, PI # 6 informed ED staff he/she was departing the ED without a physician’s examination. PI # 6 returned to the ED on 11/5/26 at 3:08 AM. Review of the ED Triage dated 11/5/25 at 3:12 AM revealed the patient reported abdomen pain rated a 10 (severe on 1-10 scale). There was no documentation of previously used methods for pain control, whether the pain is acute or chronic, the quality of the pain, and no acceptable level of the pain. Review of an ED Adult Assessment dated 11/5/25 at 3:47 AM revealed an acute pain assessment, pain location was abdomen, and pain was rated 7 (moderate on 1-10 scale). There was no documentation of previously used methods for pain control, whether the pain is acute or chronic, the quality of pain, and no acceptable level of the pain. An interview was conducted on 4/2/26 at 11:39 AM with EI # 1, who confirmed ED staff failed to follow the facility pain management guidelines for pain assessment. 3. PI # 7 presented to the ED on 12/16/25 with a chief complaint of nausea, vomiting, and fevers for 24 hours. Review of the ED record revealed ED Triage documentation dated 12/16/25 at 5:26 PM that PI # 7 complained of generalized pain rated 5 (moderate on 1-10 scale). Record review revealed a general pain assessment dated 12/16/25 at 5:54 PM which revealed the pain location was the head, and the pain was rated 7 (moderate on 1-10 scale). Review of the ED Adult Assessment dated 12/16/25 at 6:01 PM revealed the pain location was the head rated as 10 (severe on 1-10 scale), and at 8:14 PM the pain location was the head rated as 7 (moderate on 1-10 scale). There was no documentation of previously used methods for pain control, whether the pain is acute or chronic, the quality of pain, and no acceptable level of the pain. There were no pain re-assessments after 8:14 PM, and the patient was discharged at 9:37 PM. The pain assessments were not comprehensive according to the facility Pain Management Guidelines policy and procedure. An interview was conducted on 4/2/26 at 11:25 AM with EI # 2, Accreditation Coordinator, who reported an action plan is in work, and EI # 2 confirmed ED staff failed to follow the facility pain management guidelines for pain assessment. 46293 4. PI # 2 presented to the ED per Emergency Management Systems (EMS), on 2/14/26 at 1:37 PM with the chief complaint of general malaise and fever for two days. ED record review revealed a general pain assessment dated 2/14/26 at 1:44 PM noted pain was generalized and rated an eight, (severe on the 1-10 pain scale). There was no documentation ED staff notified the ED provider of the severe pain assessment rating and no documentation interventions/actions were taken to address/alleviate PI # 2s’ severe pain. There was no documentation of previously used methods of pain control, whether the pain was acute or chronic, the quality of the pain, or an acceptable level of pain for this patient. Review of the ED Adult Assessment dated 2/14/26 at 1:53 PM revealed Acute Pain Assessment of zero without any interventions documented to decrease the 8/10 pain in a nine-minute time span. There was no other pain assessments documented. Review of the ED provider note dated 2/14/26 at 2:45 PM in the Rationale portion of documentation revealed “The patient stated that he/she was aching all over, coughing and vomiting.” The patient was discharged on 2/14/26 at 6:12 PM. PI # 2 returned to the ED per EMS, on 2/15/26 at 12:02 AM with a chief complaint of vomiting blood. Review of the ED triage documentation dated 2/15/26 at 12:05 AM revealed complaints of vomiting blood, fever, and chills. ED record review of the ED Adult Assessment dated 2/15/26 at 12:53 AM revealed an Acute Pain Assessment of eight with the location of pain as generalized. There was no documentation ED staff notified the ED provider of the severe pain assessment rating and no documentation interventions/actions were taken to address/alleviate PI # 2s’ severe pain. There was no documentation of previously used methods of pain control, whether pain was acute or chronic, quality of pain or what level of pain was acceptable for this patient. There were no pain reassessments documented from 12:53 AM to 4:29 PM when patient was admitted to the hospital. The pain assessments were not comprehensive according to the facility Pain Management Guidelines policy and procedure. An interview was conducted on 4/2/26 at 12:16 PM with EI # 2, who confirmed ED staff failed to follow the facility policy pain management guidelines for pain assessment. 5. PI # 10 presented to the ED on 12/26/25 at 9:22 AM with a chief complaint of nausea, unable to eat for couple of weeks, and a low-grade temperature. ED record review of the ED Adult Assessment dated 12/26/25 at 1:55 PM revealed an Acute Pain Assessment Score as 10 (severe on the 1-10 pain scale) for greater than one week in his/her lower back. Review of the ED Provider Note dated 12/26/25 at 2:09 PM revealed “the patient stated that (she/he) was hurting in (his/her) lower back but that this was relieved with sitting up.” There was no documentation of previously used methods of pain control, whether the pain was acute or chronic, the quality of the pain, or an acceptable level of pain for this patient. There were no other pain re-assessments documented after 1:55 PM until the patient was discharged home at 6:29 PM. PI # 10 returned to the ED per EMS, on 12/27/25 at 5:44 AM with a chief complaint of bilateral lower extremity pain. Review of the ED triage documentation dated 12/27/25 at 5:44 AM with complaints of lower extremity pain for two weeks and a pain assessment of 7 (moderate on the 1-10 pain scale) in his/her lower legs. Record review of the ED Adult Assessment dated 12/27/26 at 6:27 AM revealed Acute Pain Assessment of 10, (severe on the 1-10 scale), greater than one week, aching, in his/her right ankle. There was no documentation ED staff notified the ED provider of the severe pain assessment rating and no documentation interventions/actions were taken to address/alleviate PI # 10s’ severe pain. There was no documentation on previously used methods for pain control, the quality of pain, and an acceptable level of pain. The pain assessment was not performed as per policy and procedure. Further review of the MR revealed no documentation of a pain reassessment for worsening/improvement from 12/27/26 at 6:27 AM until 12/28/25 at 8:00 AM, over 24 hours later. The pain assessments were not comprehensive according to the facility Pain Management Guidelines policy and procedure. An interview was conducted on 4/2/26 at 12:25 PM with EI # 2, who confirmed ED staff failed to follow the facility policy Pain Management Guidelines for pain assessment.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 40119 Based on review of the hospital A’s (Baptist Medical Center East) policies and procedures, medical records (MR), and interviews with staff it was determined the hospital failed to: 1. Inform the patient of the risk and benefits of leaving prior to the medical screening examination (MSE) and stabilizing treatment and failed to document what was refused by the patient when he/she left without being seen (LWBS). 2. Ensure a hospital policy was developed which included the provision of a description of the MSE and stabilizing treatment refused, informing the patient of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment, and steps to secure the patient’s written informed refusal when LWBS. 3. Provide an appropriate transfer that included signed certification by the physician that the medical benefits of treatment at another hospital outweighed the risks of being transferred. 4. Ensure the patient and/or caregiver consented to the transfer to another hospital. 5. Ensure the patient transfer was effected through qualified personnel and transportation equipment. 6. Send to the receiving facility, all medical records related to the emergency condition which the patient had presented. This deficient practice affected two of five MRs reviewed who LWBS, including Patient Identifier (PI) # 1 and PI # 10, and two of three transferred MR’s, including PI # 13 and PI # 15, and had the potential to affect all patients served by the hospital ED. Findings Include: Cross Refer to A 2406 and A 2409 for findings.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 40119 Based on review of the hospital policy, medical records (MR), and interviews with staff it was determined the hospital failed to: 1. Inform the patient of the risk and benefits of leaving prior to the medical screening examination (MSE) and stabilizing treatment and failed to document what was refused by the patient when he/she left without being seen (LWBS). 2. Ensure a hospital policy was developed which included the provision of a description of the MSE and stabilizing treatment refused, informing the patient of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment, and steps to secure the patient’s written informed refusal when LWBS. This deficient practice affected two of five MRs reviewed who LWBS, including Patient Identifier (PI) # 1 and PI # 10, and had the potential to affect all patients served by the hospital Emergency Department (ED). The findings included: Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy Policy Number: Not documented Reviewed Date: 4/24 I. Purpose: The purpose of this policy is to set forth guidelines to comply with the requirements of the EMTALA including, but not limited to the performance of MSE, patient stabilization... III. Definition of Terms: ...B. MSE: the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the patient has an emergency medical condition or not... D. Stabilization...no material deterioration of the condition is likely, within reasonable medical probability, to result... E. Emergency Medical Condition... A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in either: a. Placing the health of the patient...in serious jeopardy; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part... 1. PI # 1 presented to the hospital ED on 1/4/25 at 12:13 AM with a chief complaint of bleeding at the surgical site following the removal of tonsils and adenoids on 1/3/25. Review of the Triage Assessment dated 1/4/25 at 12:33 AM revealed the patient had experienced bleeding at the surgical site around 11 PM on 1/3/25 with throat and ear pain. Further review revealed there was no active bleeding during triage and pain in the mouth at an 8 on a 1 to 10 scale. Review of the ED Depart (Departure) Nursing Note dated 1/4/25 at 3:24 AM revealed the patient left with caregivers per registration. Review of the MR revealed no documentation of a description of the MSE and stabilizing treatment refused by the patient and/or caregiver and the patient and/or caregiver was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment. Review of the ED video footage on 1/15/25 revealed PI # 1 arrived with two caregivers on 1/4/25 at 12:02 AM, entered triage at 12:33 AM, exited triage at 12:38 AM, then remained in the ED waiting area. At 1:45 AM one of the caregivers went to the registration desk, spoke with Employee Identifier (EI) # 3, Patient Registration Specialist 1, walked to the ED badge registration desk, spoke with EI # 4, Patient Registration Specialist 2, then exited the ED with the patient at 1:48 AM. An interview was conducted on 1/16/25 at 7:42 AM with EI # 5, ED Triage nurse for PI # 1. EI # 5 verbalized registration would notify him/her if a patient wants or had LWBS, if the patient is still in the ED, then he/she would encourage the patient to stay and explain the risks and benefits of staying. If the patient had already LWBS then he/she would document the LWBS in a nurse’s notes. EI # 5 verbalized the patient would not sign anything related to the LWBS. An interview was conducted on 1/16/25 at 8:00 AM with EI # 3, who verbalized when a patient and/or caregiver notifies him/her of wanting to LWBS, he/she would tell them to knock on the triage door, give them your name, and tell them you’re leaving. An interview was conducted on 1/16/25 at 2:41 PM with EI # 4, Patient Registration Specialist 2, who verbalized when a patient and/or caregiver notified her/him of wanting to LWBS, she/he would make sure that’s what the patient wanted to do, she/he would document it in the comment section, and if there were any questions, she/he would refer them to the triage nurse. EI # 7 verbalized there was nothing the patient and/or caregiver signs. An interview was conducted on 1/16/25 at 10:08 AM with EI # 2, Vice President, Quality Management and Patient Safety, who verbalized a patient and/or caregiver LWBS is encouraged to stay but the hospital does not have the patient and/or caregiver sign anything since it usually occurs from the ED lobby. EI # 2 confirmed the hospital does not have a policy which includes the provision of a description of the MSE and stabilizing treatment refused, informing the patient of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment, and steps to secure the patient’s written informed refusal when LWBS. An interview was conducted on 1/16/25 at 10:32 AM with EI # 1, Accreditation Coordinator, who confirmed there was no documentation of a description of the MSE and stabilizing treatment refused and no documentation the patient and/or caregiver was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment. 2. PI # 10 presented to the hospital ED on 11/11/24 at 12:28 PM with a chief complaint of possibly swallowing one 20 mg (milligram) Telmisartan (medication used to treat high blood pressure). Review of the ED Depart Nursing Note dated 1/4/25 at 3:24 AM revealed the patient’s guardian notified the ED staff they were leaving. Review of the MR revealed no documentation of a description of the MSE and stabilizing treatment refused by the patient and/or caregiver and the patient and/or caregiver was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment. An interview was conducted on 1/16/25 at 10:21 AM with EI # 1 who confirmed there was no documentation of a description of the MSE and stabilizing treatment refused and no documentation the patient and/or caregiver was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 40119 Based on review of hospital policy and procedure, medical record (MR) reviews, and interview, it was determined the hospital failed to: 1. Provide an appropriate transfer that included signed certification by the physician that the medical benefits of treatment at another hospital outweighed the risks of being transferred. 2. Ensure the patient and/or caregiver consented to the transfer to another hospital. 3. Ensure the patient transfer was effected through qualified personnel and transportation equipment. 4. Send to the receiving facility, all medical records related to the emergency condition which the patient had presented. This deficient practice affected Patient Identifier (PI) # 13 and PI # 15, two of three transferred MR’s reviewed, and had the potential to affect all who require a transfer from this hospital. Findings include: Hospital Policy: Transfer Policy: Hospital to Other Facilities Policy Number: Not documented Reviewed Date: 5/23 I. Purpose: The purpose of this policy is to provide guidelines for the transfer...of patients from a Baptist Health hospital to a receiving facility. II. Scope: This policy applies to all Baptist health team members in any department that discharges or transfers patients to other facilities. ...V. Policy: A. The hospital should ensure that each patient (or legally responsible person acting on the patient’s behalf) is informed about and agrees with the facility-to-facility transfer. B. The transferring physician should inform the patient (or legal responsible person acting on the patient’s behalf) of the risks, benefits, and alternatives of the transfer. ...D. The hospital should provide...copies of the patient’s medical record to the receiving facility. E. Patient should be transferred to another facility with appropriate equipment in the care of a responsible family member/person, qualified ambulance attendant...as condition warrants based on physician order. ...I. Pediatric patients should be transferred from the Pediatric unit to another acute care setting...with the appropriate equipment and in the care (of) a qualified ambulance attendant... VI. Procedure: A. Transfer to Another Acute Care Hospital 1. Transferring Physician Responsibilities. ...b. Inform the patient (or legal responsible person acting in the patient’s behalf) of the risks and benefits of the transfer... 3. Transferring RN (Registered Nurse) Responsibilities. ...c. Document the patient’s (or legally responsible person acting on the patient’s behalf) transfer consent and agreement to transfer to another acute care hospital on the Facility-to-Facility Transfer Record... f. Copy and send the following transfer documents to the receiving facility with the patient... medical record... lab and x-ray reports... 1. PI # 13, a 13-year-old patient, presented to the emergency department (ED) on 12/3/24 at 6:35 PM with a chief complaint of fever for one day. Review of the ED Triage note dated 12/3/24 at 6:35 PM revealed the patient had a fever of 102 with Tylenol administered prior to ED arrival and was receiving chemotherapy due to Hodgkin’s Lymphoma diagnosis. Further review revealed a temperature of 99.7 F (Fahrenheit), normal range 97.7 F - 99.5 F, heart rate of 132, normal range 60 - 100, respiratory rate of 22, normal range 16 - 22, and blood pressure of 91/65, normal range less than 120/80. Review of the ED Provider note dated 12/3/24 at 7:24 PM revealed the patient had a comorbid condition of Hodgkin’s Lymphoma, was administered chemotherapy earlier in the day, had an associated symptom of a headache, and the following abnormal laboratory results: Critical Low White Blood Cell count of 0.1 (reference range of 4.1 - 10.3). Low Red Blood Cell count of 3.14 (reference range of 4.04 - 5.48). Low Hemoglobin of 8.4 (reference range of 10.5 - 15.5). Low Hematocrit of 26.0 (reference range 10.5 - 15.5). Low Platelet count of 83 (reference range of 140 - 400). Critically Low absolute Neutrophil Count of 0 (reference range of 1.4 - 6.5). Low absolute lymphocyte count of 0.1 (reference range 1.0 - 4.8). Low absolute monocyte count of 0.0 (reference range of 0.1 - 0.6). Further review of the ED Provider note dated 12/3/24 at 7:24 PM revealed the provider spoke with the patient’s oncologist who stated the absolute neutrophil count, hemoglobin, and hematocrit had changed to the point where it was felt the patient required a transfer to another hospital. Further review revealed Cefepime (antibiotic) was administered in the ED, the patient’s fever had dropped, and the patient would be transferred by private vehicle (POV) to the receiving hospital. There was no documentation of the reason the patient would be transferred via POV instead of by emergency medical services (EMS) with a qualified ambulance attendant or the provider explained the risk and benefits of the transfer by POV to the patient and/or caregiver. Review of the vital sign documentation dated 12/3/24 at 8:45 PM revealed a temperature of 98.1, heart rate of 109, respiratory rate of 18, and blood pressure of 106/61. Review of the Facility-to-Facility Transfer Form dated 12/3/24 at 10:16 PM revealed the provider selected a non-emergent transfer to the receiving hospital. There was no documentation the patient and/or caregiver were explained the risk and benefits of the transfer, consented to the transfer, or acknowledged the mode of transport for the transfer. Review of the ED Depart (Departure) note dated 12/3/24 at 10:52 PM revealed the patient’s caregiver was provided the transfer paperwork, verbally acknowledged understanding of POV transfer instructions, and the patient ambulated from the ED. An interview was conducted on 1/16/25 at 10:22 AM with Employee Identifier (EI) # 1, Accreditation Coordinator, who confirmed there was no documentation the patient and/or caregiver consented to the transfer and no documentation the risks and benefits of the transfer were explained. An interview was conducted on 1/17/25 at 3:00 PM with EI # 6, Physician Assistant, who was the ED Provider for PI # 13. EI # 6 verbalized the patient’s caregivers had requested to be transferred by POV, instead of by EMS which is what is usually requested by the receiving hospital. EI # 6 verbalized after the caregiver’s request, he/she contacted the physician at the receiving hospital who approved the patient to be transferred by POV. EI # 6 verbalized he/she did not document the conversation with the caregivers or the approval by the receiving hospital’s physician for the patient to be transferred by POV. 2. PI # 15 presented to the ED on 12/13/24 at 7:34 AM with a chief complaint of a fall. Review of the MR revealed, PI # 15 was transferred to another facility with a diagnosis of Subarachnoid Hemorrhage. There was no documentation the patient’s MR was sent to the receiving hospital. An interview conducted on 1/16/25 at 10:11 AM with EI # 1 who confirmed there was no documentation the patient’s MR was sent to the receiving hospital.”