Memorial Hospital

“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: 47234 Based on document review, record review, policy review and interview the Critical Access Hospital (CAH) failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to 1. ensure a central log was maintained for each individual; 2. perform an appropriate medical screening exam (MSE); and 3. appropriately transfer patients who presented to the emergency department seeking emergency medical care. Failure to perform an appropriate MSE and an appropriate transfer places patients at risk for unidentified emergency medical conditions resulting harm and injury up to an including death. Findings Include: Review of CAH policy titled “EMTALA Policy” approval date 09/05/20 showed, “Purpose: The purpose of this policy is to establish clinical guidelines for medical screening exams, stabilization and safe appropriate transfer of patients to other facilities in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) ... Policy/Procedure/Guidelines: Any person presenting himself or herself to the hospital’s Emergency Department requesting examination or treatment for a medical condition ... “comes to the hospital for emergency care” must receive a Medical Screening Exam (MSE) to determine if they have an Emergency Medical Condition (EMC) in accordance with EMTALA regulations. ...Provide safe and appropriate transfer if either, the individual requests the transfer or the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC ... Appropriate Transfer: 1. 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;... ...Guidelines: ... 2. A quick registration process will be performed ... ...Transfer Process- EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC are applicable in any departments of the hospital located on hospital property. 1. ...The patient or surrogate must be provided with information regarding the risks and benefits of transfer. This shall be documented on the Transfer form ... d. Enter/document a transfer order that includes:...the medical benefits reasonably expected from the transfer outweigh the increased risks to the individual. If the physician is not physically present at the time of transfer, a physician’s assistant or nurse practitioner may sign the certification after consultation with the physician. The physician must cosign the certification within 72 hours... G. Central Log - the Central Log includes,...ED log of patients that ask for assistance yet decline to be registered and log of patients from Labor and Delivery where an individual may present for emergency services or receive a medical screening examination ... Review of CAH policy titled “Triage, Assessment and Reassessment of patients seeking care in the Emergency Department Area: Injury, Illness or Accident (All Ages)” origination date 01/2022 showed ...Policy/Procedure/Guidelines: ... 2. Register the patient in Meditech ...Patients who refuse treatment as an ED patient; Any patient that has not been registered should be entered in the Failure to Check in log located at the nurse’s station computer with their full name (or Jane/John Doe if their name was not obtained prior to the patient leaving), DOB, Chief Complaint and Reason for Leaving ...” Review of hospital policy titled “Documentation Charting” revised July 2022 showed “ ...POLICY: ...Medical Staff, Mid-levels, Residents, Students, any [Hospital B] Employee providing care or a service to the patient will have access to make entries in the patient medical record to support the care or service provided. 2. A medical record will be maintained for every inpatient and/or outpatient evaluated or treated in the hospital and/or associated hospitals and clinics. 3. The required elements of documentation are based on the process of assessment, treatment, goal setting, planning, implementation, and evaluation of the patient ...” 1. The CAH failed to ensure a central log was maintained for each individual who presented to the emergency department (ED) seeking emergency medical care. (Refer to C2405) 2. The CAH failed to ensure an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists was completed for 1 of 21 patients (Patient 21) who presented to the Hospital seeking emergency medical care. (Refer to C2406) 3. The CAH failed to ensure an appropriate transfer of a patient with an emergent medical condition (EMC). (Refer to C2409)”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 47234 Based on policy review, hospital documents, interviews, and video review the Critical Access Hospital (CAH) failed to ensure a central log was maintained for each individual who presented to the emergency department (ED) seeking emergency medical care for 1 of 21 patients (Patient 21) reviewed. This failure has the potential to effect all patients presenting to the ED. Findings Include: Patient 21 Review of the hospital document titled “EM [Emergency] Daily LOG” dated 01/24/24 to 06/24/24 showed Patient 21 failed to be entered on the log upon arrival to the hospital on 06/08/24 at 4:40 AM. Review of Hospital documents titled “Failure to Check In - 2024” showed “ ...date 06/08/24; Time 449 [4:49 AM]; Name unknown - adult female; DOB [Date of Birth] unknown; Chief complaint labor contractions; Reason for leaving; Found out we didn’t have OB monitoring and wanted to leave and travel somewhere else ...” Review of hospital video footage from 06/08/24 at 4:40:16 AM showed Patient 21 arriving at the ED and presenting to the registration desk. At 4:41:14 AM, Patient 21 then is seen walking into triage room with Staff M, CNA (Certified Nursing Assistant), and followed by Staff H, RN (registered nurse) then exiting the triage room followed by Staff M, CNA, Staff H RN and Staff B, RN, ED Manager to the ER entrance hallway. The patient then is seen exiting the ED at 4:43:17 AM. During an interview on 06/26/24 at 3:40 PM Staff B, RN, ED Manager, states “Staff H, RN told patient that we don’t [fetal] monitor. When I saw the patient, I told her that we would check her in. She is an example of patient’s coming in and asking us to [fetal] monitor, are we supposed to lie and say we can do it when we don’t’.” During an interview on 06/27/24 at 8:11 AM Staff M, CNA, stated that, when a patient arrives, we do a quick registration asking name, date of birth and chief complaint. The patient came to the triage room [Staff H, RN] was asked by patient if we could do fetal monitoring and [Staff H, RN] told her no we do not do fetal monitoring, since the computer was running slow, we did not register the patient and she left. During an interview on 07/02/24 at 1:02 PM, Staff D, RN, CNO (Chief Nursing Officer) stated “ ...The patient [patient 21] was not on the ER log, no documentation of patient in triage room having vital signs, medical screening exam, that the provider was notified or signing an AMA form. A request for review of Patient 21’s ED medical record showed the hospital had no documentation concerning her ED visit on 06/08/24.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 47234 Based on record review, policy review, document review and interview the Critical Access Hospital (CAH) failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 21 patients (Patient 21) who presented to the Hospital seeking emergency medical care. The hospital’s failure to perform an appropriate MSE has the potential for patients to be discharged with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person’s condition, including harm and death. Findings Include: Patient 21 Review of video footage showed Patient 21, unknown age female, presented to the [Above Named Hospital] on 06/08/24 at 4:40 AM for labor contractions. Review of Hospital documents titled “Failure to Check In - 2024” showed “ ...date 06/08/2024; Time 449 [4:49 AM]; Name unknown - adult female; DOB [Date of Birth] unknown; Chief complaint labor contractions; Reason for leaving; Found out we didn’t have OB monitoring and wanted to leave and travel somewhere else ...” Review of hospital video footage from 06/08/24 at 4:40:16 AM showed Patient 21 arriving at the ED and presenting to the registration desk. At 4:41:14 AM, Patient 21 then is seen walking into triage room with Staff M, CNA (Certified Nursing Assistant), and followed by Staff H, RN (registered nurse) then exiting the triage room followed by Staff M, CNA, Staff H RN and Staff B, RN, ED Manager to the ER entrance hallway. The patient then is seen exiting the ED at 4:43:17 AM. During an interview on 06/25/24 at 9:00 AM Staff B, RN, ED Manager, stated that, for obstetrical patients we have a handheld doppler that helps us count the fetal heart tones. We have a fetal monitor and [Staff K, MD] can fetal monitor patients since she is trained. During an interview on 06/26/24 at 11:38 AM Staff H, RN, stated “ ...If someone is in labor it’s emergency. We have a fetal monitor, but the doctor does the fetal monitoring, since we are not trained.” During an interview on 06/26/24 at 3:40 PM Staff B, RN, ED Manager, states “Staff H, RN told patient that we don’t [fetal] monitor. When I saw the patient, I told her that we would check her in. She is an example of patient’s coming in and asking us to [fetal] monitor, are we supposed to lie and say we can do it when we don’t’.” During an interview on 06/26/24 at 3:35 PM, Staff H, RN, stated that pregnant female had come to ER requesting to be put on a fetal monitor and “we told her that we didn’t [fetal] monitor and she left since she couldn’t be [fetal] monitored.” During an interview on 06/27/24 at 8:11 AM Staff M, CNA, stated that, when someone arrives to ER we cannot turn them away. The patient came to triage room [Staff H, RN] was asked by patient if we could do fetal monitoring and [Staff H, RN] told her no we do not fetal monitoring, since the computer was running slow, we did not register the patient and she left and since she wasn’t checked in she was not given AMA papers to sign.” During an interview on 07/02/24 at 1:02 PM, Staff D, RN, CNO (Chief Nursing Officer) stated “ ...The patient [patient 21] was not on the ER log, no documentation of patient in triage room having vital signs, medical screening exam, that the provider was notified or signing an AMA form. When I interviewed the nurse, she stated patient wanted fetal monitoring and told her that we would check her in and see about her baby, but she left since we were not able to do fetal monitoring...” Request for review of Patient 21’s medical record showed the hospital had no documentation concerning her ED visit on 06/08/24 and failed to show documentation of medical screening examination to determine if an emergency medical condition exists.”

“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: 47234 Based on record review, policy review, document review and interview the Critical Access Hospital (CAH) failed to ensure an appropriate transfer of patients with an emergent medical condition (EMC) for 6 of 7 patients (Patient 4, 5, 6, 7, 8 and 16) transferred. Failure to ensure an appropriate transfer puts patients at risk for an unsafe transfer and deterioration person’s condition, including harm and death. Findings Include: Patient 4 Review of Patient 4’s medical record showed a 59-year-old who presented to the emergency department (ED) on 03/22/24 at 2:48 PM by POV (private vehicle) with her son. Patient 4 was triaged at 2:48 PM. Her chief complaint was “Piece of meat stuck in throat.” The “MDM [medical decision making] -Ingestion FB [foreign body]” showed “ ...3:41 PM ...patient will be transferred by private vehicle for ER to ER acceptance with anticipation that patient will go to special procedures for a foreign body esophageal removal. Patient is advised, IV (soft flexible tube placed inside a vein) left in place and Ace wrap will be applied...” Review of “EMTALA PLUS FORM- KANSAS” dated 03/22/24 at 2:48 PM showed “ ...Reason for Transfer of Unstable Patient; Higher Level of care is required/sending hospital lacks capacity (complete Physician/QMP [Qualified Medical Person] certification below. Obtain patient consent to transfer, if possible) ...” During an interview on 06/26/24 at 11:54 AM Staff L, Advance Registered Nurse Practitioner (APRN) stated “ ...There are very few reasons I would let a patient go POV (private vehicle) to another hospital. If it was medical emergency and they refused EMS (emergency medical service (ambulance) for transfer, I would document refused EMS.” During an interview on 06/26/24 at 12:23 PM, Staff D, Registered Nurse (RN), Chief Nursing Officer (CNO) stated, “[Patient 4] the doctor did not sign the EMTALA Plus form. It is the responsibility of provider and nurse to make sure that the form is filled out correctly before the patient leaves the facility.” During an interview on 06/26/24 at 1:02 PM Staff A, Chief Executive Officer (CEO), stated that, If patient is being transfer to higher level of care should go by land or air transfer. Refusing transfer by ambulance then its considered AMA [Against Medical Advice]. The record failed to show ambulance transport was considered or that the patient representative refused or signed a refusal of ambulance transfer. There was no “Countersignature of Physician that QMP certified” on the certification of transfer, within 72 hours specified by the hospital rules or regulations, as directed by the hospital’s “EMTALA (Emergency Medical Treatment and Labor Act) Policy.” Patient 5 Review of Patient 5’s medical record showed a 19-year-old who presented to ED on 03/31/24 at 9:04 PM by private vehicle. Patient 5 was triage at 9:04 AM. His chief complaint was testicular pain. The “ ...GU [Genitourinary] Male” Note showed “ ...trying to manipulate the testicle in attempt to partially relieve or relieve the torsion (twisting of male organ that makes hormones or sperm) ...patient does not have a ride and does not want to be transported by ambulance ... The right testicle is absent from previous orchiectomy (surgical procedure to remove one or both testicles) ...” Review of patient 5’s “ED Discharge Comments” showed “ ...Education provided on reason for transfer and importance of follow up. Patient verbalizes understanding and agrees with POC [Plan of Care]. ambulated out of the facility/declined WC [Wheelchair]. Transfer packet given to patient. Patient left via private car with father as driver ...” Review of “EMTALA PLUS FORM- KANSAS” dated 03/31/24 at 9:04 AM showed “ ... I have been offered and received medical screening and treatment by a physician or qualified medical person, and I have been informed and understand the reasons for my transfer. I hereby: [checked box] Consent to transfer ... Patient/Responsible Person Signature: [Patient 5] ...” During an interview on 06/25/24 at 9:00 AM Staff B, RN, ED Manager stated “ ...Testicular torsion is an emergency. [Patient 5’s] EMTALA Plus form does not show him refusing EMS as mode of transportation ...” During an interview on 06/26/24 at 8:06 AM, Staff G, APRN, stated that, [Patient 5] has had a testicular torsion in the past and presented with severe pain suggestive of a recurrent testicular torsion. Due to the lack of sonogram technician and the patient needing immediate imaging to rule out urological emergency, advised patient to go to [Hospital B]. [Patient 5] declined EMS transport. I contacted his father and instructed him to take [Patient 5] to [Hospital B] ER. Further stated , “I do go over the individualized benefits with the patient. I do not go over the risks with patients its absurd.” During an interview on 06/26/24 at 1:02 PM, Staff A, CEO, stated “ ...risks and benefits should be documented, if not documented then it wasn’t done ...” The record failed to show a statement informing of the risks and benefits, the reason for the refusal to consent to the transfer and signed a refusal of ambulance transfer. There was no “Countersignature of Physician that QMP certified” on the certification of transfer, within 72 hours specified by the hospital rules or regulations, as directed by the hospital’s “EMTALA (Emergency Medical Treatment and Labor Act) Policy.” Patient 6 Review of Patient 6’s medical record showed an 82-year-old the patient who presented to ED on 04/16/24 at 11:19 AM by private vehicle. Patient 6 was triage at 11:19 AM. His chief complaint was “collapsed suddenly and lost consciousness.” Review of Patient 6’s medical record dated 04/16/24 at 2:10 PM showed Patient 6 was transferred by ALS (Advanced Life Support) ground ambulance for diagnosis of non-ST elevation MI [Myocardial Infarction]( NSTEMI) (a type of heart attack). During an interview on 06/26/24 at 12:23 PM, Staff G, RN, CNO stated, “The EMTALA Plus forms are not being signed by a physician. HIM (Health Information Management) caught the oversight and educated her staff yesterday about making sure that it signed and complete.” There was no “Countersignature of Physician that QMP certified” on the certification of transfer, within 72 hours specified by the hospital rules or regulations, as directed by the hospital’s “EMTALA (Emergency Medical Treatment and Labor Act) Policy.” Patient 7 Review of Patient 7’s medical record showed a 34-year-old who presented to ED on 05/02/24 at 10:50 AM by private vehicle. Patient 7 was triage at 10:50 AM. Her chief complaint was thoughts of self-harm. Review of Patient 7’s medical record dated 05/03/24 at 1:50 AM showed Patient 7 was transferred by secure transport for diagnosis of Suicidal ideation (thinking about or planning suicide), Anxiety (feeling of fear, dread, and uneasiness), and Marijuana abuse. There was no “Countersignature of Physician that QMP certified” on the certification of transfer, within 72 hours specified by the hospital rules or regulations, as directed by the hospital’s “EMTALA (Emergency Medical Treatment and Labor Act) Policy.” Patient 8 Review of Patient 8’s medical record showed a 39-year-old the patient presented to ED on 05/02/24 at 10:50 AM by private vehicle. Patient 8 was triage at 12:01 PM. Her chief complaint was Suicidal Ideation (thinking about or planning suicide). Review of Patient 7’s medical record dated 05/03/24 at 1:50 AM showed Patient 8 was transferred by secure transport for diagnosis of Suicidal ideation, and Mental and behavioral problem in adult. There was no “Countersignature of Physician that QMP certified” on the certification of transfer, within 72 hours specified by the hospital rules or regulations, as directed by the hospital’s “EMTALA (Emergency Medical Treatment and Labor Act) Policy.” Patient 16 Review of Patient 16’s medical record showed an 81-year-old who presented to ED on 06/20/24 at 6:15 AM by wheelchair. Patient 16 was triage at 6:18 AM. His chief complaint was lower abdominal pain. Review of “Abdomen/Pelvis CT” on 06/20/24 at 6:27 AM showed “Impression: 1. An 8 X 6 mm obstructing calculus with the proximal right ureter (blockage in one or both tubes (ureters) that carry urine from the kidneys to the bladder) results mild hydronephrosis (urinating more frequently and an increased urge to urinate). 2. Multi calyceal caliculi (kidney stones that are hard deposits made of minerals and salts that form inside your kidneys) are present within the right kidney. 3. The appendix (a small finger shaped organ that comes out of the first part of the large intestine) appears suspiciously dilated and fluid-filled but without surrounding inflammatory changes ...” Review of “MDM [Medical Decision Making]-ABD Pain M [Male] 40 [Years] and Over” dated 06/20/24 at 8:15 AM showed “ ...Patient will be transferred by EMS due to age, amount of pain medication given and needing supplemental oxygen. Patient wears oxygen at night normally ...” 0830: The house supervisor called back and visited with the ED tech and they would like to have [Patient 16] come to ambulatory surgery around 11 am. I visited with the patient and advised him that if he requires additional pain medication and continues oxygen administration he will be transferred by EMS. If pain free and remains stable then he may go by POV. We will continue the IV fluids until leaving the ED. 1050[10:50 AM]: The patient has remained pain free. SpO2 (oxygen saturation is a measurement of how much oxygen your blood) mid to upper 90’s. Plan on patient to [Hospital B] ambulatory by POV. Review of “EMTALA PLUS FORM- KANSAS” dated 06/20/24 at 6:15 AM showed “” ... I have been offered and received medical screening and treatment by a physician or qualified medical person, and I have been informed and understand the reasons for my transfer. I hereby: [checked box] Consent to transfer ... Patient/Responsible Person Signature: [Patient 16] ...” During an interview on 06/26/24 at 8:06 AM, Staff G, Advanced Practice Registered Nurse (APRN) stated, “[Patient 16] had a large kidney stone, and fluid filled appendix with no surrounding inflammation. I visited with a doctor, they wanted him at 11:00 AM for special procedure, the surgeon didn’t think it was anything pressing. He was stable and wanted to go by POV. He didn’t refuse EMS, but he didn’t want to go by EMS. I told him the deal is if you have any more pain meds you are going by EMS. I always error on the side of caution if there is any question.” During an interview on 06/26/24 at 9:00 AM, Staff J, Registered Nurse (RN), stated “If someone refusing EMS for transfer, they sign out AMA ... [Patient 16] ambulatory services could take him at 11:00 AM. Since he was pain free, our provider said he didn’t need to go by EMS and could go by POV. [Patient 16] was not dismissed he was a transfer.” During an interview on 06/26/24 at 12:23 PM, Staff G, RN, Chief Nursing Officer (CNO) stated that , [Patient 16] chart reads that he needed to go by EMS due to his age and pain medications given him. The EMTALA Plus Form had it filled out for him to go by EMS then marked through it and put POV. There is no documentation of consent to transfer or refusal of transport ...” The record failed to show a statement informing of the risks and benefits, the reason for the refusal to consent to the transfer and signed a refusal of ambulance transfer.”