Northfield Hospital

“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: 47264 Based on interview and document review, the facility failed to adequately document the transfer for 2 of 20 patients (P7, P9) reviewed. The transfer documentation for P7 lacked a destination facility or the name of the accepting provider, did not indicate if P7 consented to transfer, and did not contain P7’s signature. P9’s transfer form did not indicate a destination facility or the name of the accepting provider. Findings Include: P7 was a 19-year-old female who presented to the ED on 1/8/25 at 12:03 a.m. by self for self-induced lacerations on the left forearm. P7’s past medical history included anxiety, depression, nonepileptic seizures, and post-traumatic stress disorder (PTSD) with a previous history of hospitalization for mental health concerns. A provider note dated 1/8/25 at 12:07 a.m. indicated P7 received sutures on the dorsal surface of her left arm for these lacerations. P7 endorsed suicidal thoughts and two intentional overdose attempts within the last six months. The provider recommended inpatient treatment due to P7’s escalating symptoms, who agreed. An authorization for transfer form dated 1/8/25 at 4:25 a.m. indicated P7 required transfer to another facility via basic life support ambulance transport for treatment and services not provided by the hospital. The authorization form indicated P7 was discharged at 1:50 p.m. The authorization form did not indicate a destination facility or the name of the accepting provider. The authorization form did not indicate if P7 consented to transfer, and did not contain P7’s signature. A physician certification statement dated 1/8/25 at 8:25 a.m. indicated P7 was transferring to “Mayo - Albert Lea.” The certification statement indicated P7 required continuous monitor for her own safety for a mental health crisis. P7’s ambulance run sheet dated 1/25/25 at 3:10 a.m. indicated P7 left the facility ED on 1/8/25 at 2:10 p.m., and arrived at her destination on 1/8/25 at 3:20 p.m. The run sheet indicated P7 was transferred to Mayo Albert Lea inpatient psychiatric unit. P9 was a 40-year-old male who presented to the ED on 2/14/25 at 5:38 p.m. via ambulance for stroke-like symptoms. A document titled Stroke Protocol Stroke Code Team Activation Gray Matter Matters indicated P9 arrived in the ED on 2/14/25 at 5:30 p.m. and was seen by a provider at 5:34 p.m. The document indicated a neurology contact was placed via phone at 5:43 p.m., and connected with the provider at 5:55 p.m. A provider note dated 2/14/25 at 5:39 p.m. indicated P9 was initially assessed to have left-sided facial drooping and slurred speech. The note indicated P9 was sent to computed tomography (CT) for immediate imaging. The note indicated preliminary CT results indicated occlusions of the right internal carotid artery and the right middle cerebral artery trifurcation; however no acute intracranial processes were identified. The note indicated an unspecified intensivist was contacted and recommended transfer to a neurological step-down unit. An authorization for transfer form dated 2/14/25 at 11:10 p.m. indicated P9 required transfer to “Abbot NW” via advanced life support ambulance for treatment and services not provided by the hospital, and a higher level of neurological care. The form indicated there was a risk of worsening neuromuscular condition and the patient may be at risk for deterioration from/during transport. The form was signed by P9 on 2/14/25 at 11:10 p.m. The authorization form did not indicate a destination facility or the name of the accepting provider. P9’s ambulance run sheet dated 2/16/25 at 12:25 a.m. indicated P9 left the facility ED on 2/14/25 at 11:39 p.m. The run sheet indicated P9 was transferred to Abbott Northwestern Hospital on 2/15/25 at 12:33 a.m. During an interview on 4/9/25 at 10:33 a.m., registered nurse (RN)-A stated the decision to transfer a patient to another hospital is determined by the provider. RN-A stated the nursing staff or unit coordinator will coordinate a call between the providers, who then complete the paperwork. During an interview on 4/9/25 at 10:49 a.m., RN-B stated ED transfers are a provider-initiated process. RN-B stated providers complete the “Authorization for Transfer” paperwork. During an interview on 4/9/25 at 11:04 a.m., RN-C stated the doctor makes the decision if an ED patient needs to transfer to another facility. RN-C stated the unit coordinator will reach out to hospitals and connect the doctors to speak over the phone. During an interview on 4/10/25 at 2:40 p.m., the medical director of the ED stated the ED’s transfer forms are the “Authorization for Transfer” forms and are specific for EMTALA regulations. The medical director stated the authorization transfer form is separate from the “Physician Certification Statement,” is a separate document, and information there does not replace what is noted on the “Authorization for Transfer” form. The medical director stated all areas of the authorization of transfer form must be completed, or it is inaccurate. The medical director stated the name of the accepting provider, and the hospital should always be on the form. During an interview on 4/10/25 at 3:43 p.m., medical doctor (MD)-A stated if a patient needs a transfer, the physician must call the receiving facility. MD-A stated the accepting provider must verbalize their acceptance and this is documented in the EMTALA form. MD-A stated providers are responsible for filling out all portions of the form except for the vital signs, which is the nurse’s responsibility when the patient discharges. MD-A stated he gives the completed form to the nurse or the unit coordinator, who then scan it into their electronic medical record system. MD-S stated a provider cannot complete the transfer process without this form being completed. A facility policy titled “Transferring patients to an Outside Hospital other than trauma patient,” dated 9/12/22 indicated the physician must complete the Authorization for Transfer form and the Physician Certification Statement.”