St Joseph’s Hospital Health Center

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 46619 Based on document review, medical record (MR) review, and interview, in one of five MRs there was no documented evidence that the laboratory was notified by facility staff when a patient (Patient #1) had a suspected transfusion reaction. Findings include: -- Per review of facility policy and procedure (P&P) titled “Blood Transfusion Reaction,” last revised 7/2025,it indicated, allergic reaction occurs when antibodies in the patient’s blood react to allergens in the donor’s blood. Symptoms may include itching, hives, nausea, vomiting, wheezing, and in severe cases, anaphylaxis. In the event of a possible transfusion such as this, the registered nurse (RN) should notify the provider and Transfusion Services immediately. Staff should continue to monitor and treat the patient, and complete the Adverse Reaction to Blood/Blood Products Report and order a Transfusion Reaction Workup in the MR. The blood product and blood tubing should be returned to the laboratory with the completed report. An incident report should be entered electronically. -- Per review of the MR, Patient #1 presented to the emergency department (ED) on 4/2/2026 at 3:46 pm indicating that they were sent to the ED by their primary care doctor who identified that their hemoglobin and hematocrit (lab values that indicate a patient’s red blood cell count) were critically low and they had to get a transfusion. Patient #1 indicated that they have anemia but have never required a transfusion prior. Patient #1 indicated they were feeling short of breath, were having palpitations, and were dizzy. Labs were drawn and confirmed that the patient was anemic with hemoglobin of 5.3 g/dL (12-16 is the normal range) and hematocrit of 21.7 % (36 - 47 is normal range). Patient #1 was triaged on 4/2/2026 at 4:11 pm and vital signs (V/S) were as follows: blood pressure (B/P) 128/76, pulse (P) 84, respirations (R) 18, temperature (T) 98.2 degrees Fahrenheit (F), oxygen saturation (SpO2) 100%. Orders were placed by the doctor to transfuse 2 units of packed red blood cells at 8:30 pm. V/S at 9:54 pm were as follows: B/P 104/52, P 84, R 18, T 99.5 degrees F, SpO2 100%. The first transfusion was started at 9:56 pm. An RN documented that consent for the transfusion was obtained, and transfusion-related education was provided to the patient. V/S at 10:19 pm were as follows: B/P 112/54, P 90, R 18, T 100.0 F, SpO2 100%. V/S at 12:12 am on 4/3/2026 were as follows: B/P 104/52, P 84, R 18, T 99.5 degrees F, SpO2 100%. An RN documented that the first unit of blood was finished transfusing. At 12:17 am the second transfusion was started. V/S at 12:17 am were as follows: B/P 112/54, P 87, R 18, T 99 degrees F, SpO2 100%. At 12:30 am an RN documented that the patient reported hives to their face but denied chest pain, shortness of breath, nausea, or vomiting and the doctor came to the bedside to reevaluate. V/S were as follows: B/P 112/56, P 79, R 18. The doctor placed an order for Benadryl 25 milligrams (a medication used to treat the hives) to be given intravenously (IV) at 12:37 am. This medication was documented as administered at 12:38 am. V/S at 12:45 am were as follows: B/P 140/61, P 81, R 19, T 98.7 degrees F, SpO2 96%. V/S at 3:00 am were as follows: B/P 104/51, P 81, R 18, T 100 degrees F, SpO2 96%. V/S at 3:10 am were as follows: B/P 109/53, P 80, R 18, T 100.0 F, SpO2 98%. The RN documented at this time that the second unit of blood was transfused. Lungs remained clear. No transfusion reaction was suspected. On 4/3/2026 at 3:25 am an RN documented that the patient was discharged in good condition, was ambulatory, and that the patient understood all discharge instructions. The patient denied any pain. -- Per interview of Staff A, Clinical Staff, on 6/8/2026 at 1:40 pm they stated Patient #1 came in with low hemoglobin and it was their first time getting a blood transfusion. Staff A stated they noted Patient #1 was very nervous as they went through the consent but Patient #1 did consent to the transfusion after discussion with the physician. Staff a stated they started the blood transfusion and Patient #1 started getting hives on their face. Staff A called the doctor and put the blood on hold. When the doctor arrived at the bedside the doctor ordered Patient #1 Benadryl, the hives lessened, and the doctor instructed Staff A to continue the blood transfusion and to transfuse the second unit of blood. The doctor told Staff A it was not a transfusion reaction but was more likely anxiety as the patient was very nervous about getting the blood transfusion. Staff A noted Patient #1 had no symptoms of a reaction when the second unit of blood was transfused. -- Per interview of Staff B, Clinical Staff, on 6/8/2026 at 2:25 pm they stated Patient #1 was very concerned and anxious prior to the transfusion and they had a long conversation with Patient #1 about the blood transfusion, including the risks, when obtaining consent for the blood transfusion. Once the transfusion was started the nurse alerted Staff B to a possible transfusion reaction that Patient #1 was having. Staff B responded by going to the bedside to evaluate and indicated Patient #1 had only mild itchiness. Staff B stated they gave Patient #1 Benadryl to subdue the itchiness. Staff B stated they did not recall there being any additional concerns. Staff B stated it was a very mild reaction and not a classic reaction and there was no indication that the transfusion could not continue. -- Per interview of Staff C, Non-clinical staff, on 6/8/3036 at 3:17 pm, they stated that when a complaint came in regarding Patient #1’s blood transfusion reaction, the specimen had already been discarded. Staff C stated that if a transfusion reaction is suspected the first step is to alert the physician and the second step is to contact the blood bank. Staff C stated that not every call they get regarding a reaction is a true reaction, but they work up all calls as if they are a reaction. -- Per interview of Staff D, Clinical Staff, on 6/8/2026 at 3:17 pm and 6/9/2026 at 11:19 am, they stated that if a patient develops hives during a blood transfusion it isn’t absolutely necessary to stop the transfusion, however, the transfusion reaction protocol should still be followed. Staff D stated that hives should be recorded as a transfusion reaction, and the transfusion reaction form should be filled out and submitted to the blood bank. Staff D acknowledged the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 49512 Based on document review, medical record review, and interview, in 1 of 5 medical records reviewed (Patient #3) of patients placed in restraints, staff secured a patient’s wrist restraints to the wheelchair handles (used to push the wheelchair) resulting in the patient’s hands being restrained over their head. This could potentially injure a patient and cause untoward patient outcomes. Findings include: -- Review of the facility’s policy and procedure titled, “Restraints: Application & Removal Standard Precautions Exposure Category 1,” last revised 10/2022, indicated staff should never restrain a patient with their arms positioned over their head. -- Per medical record review, Patient #3 presented to the emergency department (ED) on 3/21/2024 accompanied by law enforcement with chief complaint of homicidal statements and need for a psychiatric health evaluation. Medical screening exam was completed and revealed patient had bipolar affective disorder with severely manic psychotic features. Patient was very agitated and had to be physically and chemically restrained. The psychiatrist on the comprehensive psychiatric emergency program (CPEP) unit was consulted and Patient #3 was accepted for evaluation. Patient was transported to CPEP on 3/21/2024 at 5:55 am. A late entry in the medical record on 3/21/2024 at 9:31 pm, documented that a security officer and a patient care technician wrapped bilateral wrist restraint straps around the wheelchair handles (used to push the wheelchair) to restrain Patient #3. This resulted in his hands being positioned above his head after he slid down in the wheelchair. --Per interview of Staff A, Security Guard on 4/18/2024 at 7:00 am, after Patient #3 was assisted into a wheelchair for transport from the ED to the CPEP unit, he became very agitated, was kicking, and yelling. Staff A decided to wrap the bilateral wrist restraint straps around the wheelchair handles (used to push the wheelchair) to try and prevent Patient #3 from flailing and potentially hitting staff. -- Per interview of Staff B, Patient Care Technician on 4/17/2024 at 11:30 am, once Patient #3 was placed in a wheelchair for transport from the ED to the CPEP unit, he became combative and was grabbing at staff. Staff B wrapped the straps from the wrist restraints around the handles (used to push the wheelchair) in order to prevent staff from getting hit by Patient #3. -- Per interview of Staff C, Registered Nurse on 4/19/2024 at 12:20 pm, nursing does not have input into the decision regarding the patient’s transfer from the ED to the CPEP unit; this is controlled by the doctors. Patient #3 was medically cleared and in need of a behavioral health assessment. -- During interview of Staff D, Registered Nurse Coordinator on 4/16/2024 at 1:05 pm, he/she/they acknowledged the above findings.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 21072 Based on document review and interview, in 2 of 3 investigations reviewed the facility failed to thoroughly investigate the events and failed to implement corrective actions (Patient #1 and Patient #3). These failures could put patients at risk for injury and lead to poor patient outcomes. Findings pertinent to Patient #1 include: -- Review of a facility investigation report entered on 3/12/2024 revealed a patient (Patient #1) fell during a transfer. It was stated in the report that Patient #1 did not have a fall bracelet (armband) on. (A fall bracelet is placed on a patient who is identified as a high risk for falling) The report was reviewed by the manager of the department where the fall occurred. He/she/they closed the investigation with the status documented as “No further follow-up necessary.” -- The facility’s investigation did not address the concern that the patient, who was at high risk for falls, was not wearing a fall bracelet (armband). No corrective actions were implemented. Findings pertinent to Patient #2 include: -- Review of a facility investigation report entered on 3/21/2024 revealed a patient (Patient #3) was inappropriately restrained while being transported in a wheelchair. -- The facility’s investigation identified concerns related to this event. The investigation did not address all the concerns identified or implement corrective actions for all the concerns identified. -- Per interview of Staff G, Regional Director Clinical Risk on 5/10/2024 at 9:00 am, he/she/they acknowledged the above findings.”

“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: 36617 Based on document review, medical record review and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, 1) In 2 of 21 (Patient #2 and Patient #4) medical records reviewed the hospital failed to provide an appropriate medical screening exam to patients who presented to the emergency department for evaluation to determine if an emergency medical condition existed. 2) In 1of 4 (Patient #3) medical records reviewed of patients who required a transfer to a higher level of care, it lacked documentation of an appropriate transfer. This could lead to untoward patient outcomes. Please reference findings at Tag 2406 and Tag 2409.”

“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: 36617 Based on document review, medical record review and interview, in 2 of 21 (Patient #2 and Patient #4) medical records reviewed, the hospital failed to perform an appropriate medical screening exam to determine if an emergency medical condition existed. This could lead to untoward patient outcomes. Findings include: -- Review of the hospital’s policy and procedure titled, “Emergency Patient Medical Screening Guidelines,” revised 4/2023, indicated according to emergency medical treatment and labor act (EMTALA), if any individual comes to the hospital emergency department and requests examination or treatment for a medical condition the hospital must provide, without discrimination, an appropriate medical screening exam to determine whether an emergency medical condition exists. -- Review of Patient #2’s (15-day-old female) medical record revealed, she presented to the emergency department on 12/25/2023 at 1:56 am with a chief complaint of a cough. The patient was triaged at 2:59 am (no triage level was assigned). Nursing documentation revealed, Patient #2 arrived with parents. Per patient’s father, she has had an intermittent cough at home since Friday (12/22/2023). Patient #2 may have been exposed to a febrile illness. “Patient was asleep on initial observation. Responds to tactile stimuli and is alert once awake. She does have a decreased response to painful stimuli as in she stops crying quickly without soothing. Patient is moving all extremities. Blood glucose 74 (normal 40 - 99) via heel.” 3:04 am - Initial vital signs at were as follows: temperature 100.2 Fahrenheit (rectally), heart rate 168, respirations 42 and oxygen saturation 98%. “Patient #2 is readily responsive to painful/noxious stimuli on assessment, but quiets quickly without being soothed. Last full feeding was around 6:00 pm last night, per her parents. Patient then fell asleep and on waking, patient’s father stated that she didn’t eat much and fell back to sleep. Wetting diapers per normal. Full term, uncomplicated vaginal delivery 12/10/23. She is receiving breast milk every 1.5 - 2 hours per father. Patient offered Pedialyte and latched to bottle nipple without difficulty but did gag frequently while eating. Patient does have an occasional, wet cough. Lung sounds clear on auscultation. The parents spoke with the provider and will be transporting the patient to another hospital emergency department with pediatrics at this time. Patient discharged at 3:18 am. Disposition set to discharge.” Provider documentation (on 12/31/2023 at 10:16 pm - 6 days after discharge) revealed, “Patient was seen, found to be mildly hypoglycemic. Given sugar water by nurse. Considering that patient was born at gestational age, but is within 15 days, there is concern that patient needs inpatient care at least for couple of days for observation. Shared decision making was made with family members, will likely need to be transferred to Hospital B as we do not have inpatient pediatric floors. Family members found it easier to go to Hospital B’s emergency department, and get evaluated there, and to be transferred to floors by there.” History and Physical Review of Systems (blank) Physical Exam Vitals and nursing note reviewed. Constitutional: General: She is active. Appearance: Normal appearance. She is not diaphoretic. Comments: Crying but consoled by mother HENT: Head: Normocephalic. Eyes: General: Right eye: No edema or discharge. Left eye: No edema or discharge. No periorbital edema or erythema on the right side. No periorbital edema or erythema on the left side. Extraocular Movements: Extraocular movements intact. Cardiovascular: Pulses: Normal pulses. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. Skin: General: Skin is cool. Findings: There is no diaper rash. Comments: No rashes noted Neurological: Mental Status: She is alert. The facility failed to do a complete and comprehensive medical screening exam to determine if the patient had an emergency medical condition requiring a higher level of care. -- Per interview of Staff A, Emergency Department Medical Director on 4/10/2024 at 12:30 pm, Staff A indicated Patient #2 had a fever and needed a sepsis workup, viral panel, lumbar puncture, etc. Staff A received notification that there was only a progress note written for Patient # 2 in the chart, and that their needed to be a full note with system review and full assessment completed. The physician involved in the care of Patient #2 had gone to the waiting room and explained to Patient # 2’s parents what would need to be done. The patient’s mother did not want to stay. The physician explained to the parents the risks of leaving, however, the mother still wanted to leave. Staff A discussed that a Leave Against Medical Advice form should have been completed prior to Patient #2 and her parents leaving the emergency department. Staff A indicated all emergency department physicians have been educated on EMTALA and that training occurred two times in the last year. -- Per interview of Staff B, Registered Nurse on 4/10/2024 at 12:55 pm, Patient #2 was 15 days old and was seen on 12/25/2023. Patient #2 was very sick and had a cough, fever and was excessively crying. Staff B was not working triage on that day but does recall an emergency department provider seeing her in triage. The parents wanted to leave and go to another facility and that the provider spoke with the parents about the risks of leaving. -- Review of Patient #4’s medical record revealed, he presented to the emergency department on 12/5/2023 at 4:05 pm via emergency medical services with a chief complaint of constipation x 1 week. Prehospital vital signs as documented by emergency medical services were as follows: blood pressure 147/91, pulse 103, respirations 16, oxygen saturation 95%. 4:48 pm - Nursing documented, “Patient #4 had been locked in the bathroom for some time. Once the door was opened, Patient #4 was found to be smoking crack in the bathroom.” 4:52 pm - Nursing documented, “Patient #4 found with drugs in the bathroom, escorted out by security.” There is no documentation that a medical screening exam was performed or if the patient requested to be seen or to leave the facility. -- Per interview of Staff C, Registered Nurse on 4/10/2024 at 12:05 pm, Patient #4 arrived by ambulance and he was a lower acuity patient. When an emergency medical services patient has a lower acuity, they go through the regular triage process (to waiting room. then triaged as soon as possible). -- Per interview of Staff A on 4/10/2024 at 12:30 pm, Staff A was aware of Patient #4 being in the bathroom. A lot of patients use emergency medical services as a taxi. Providers are all educated on EMTALA and were made aware patients need a medical screening exam. The facility instituted the MDE code (call a provider to see a patient before leaving) for that reason to ensure patients receive an exam before leaving the facility. Staff A acknowledged the above findings. -- Per interview of Staff D, Registered Nurse on 4/11/2024 at 2:50 pm, Staff D recalled Patient #4 and when first calling him for triage there was no response. Staff D went back to the waiting room again to get the patient and he/she/they could still not find him. There was someone in the bathroom. The patient said he couldn’t come out. After a significant amount of time and the fact other patients needed to use the bathroom, he/she/they contacted security. When security opened the door there was aluminum foil with a white substance on it. Security then escorted the patient out of the facility. -- During interview of Staff E, Accreditation Specialist on 4/10/2024 at 3:00 pm, he/she/they acknowledged the above findings.”

“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: 36617 Based on medical record review, document review and interview, in 1 of 4 (Patient #3) medical records reviewed of patients who were transferred to a higher level of care, it lacked documentation of the physician certification for transfer or risks and benefits certification of transfer specific to the patient’s medical condition. This could lead to patients not being informed of potential risks and benefits related the transfer. Findings include: -- Per review of Patient #3’s (7-year-old female) medcial record, she presented to emergency department on 1/2/2024 at 9:44 am with a chief complaint of generalized weakness. Per mother she was seen in the emergency department 3 days prior and was becoming weaker and won’t eat or drink much. The patient was triaged was at 9:56 am and the patient was assigned an Emergency Severity Index level of 2 (on a scale of 1 -5, [1 being resuscitation and 5 non-urgent]). Vital signs were as follows: temperature 99.4 degrees Fahrenheit, blood pressure 105/69, heart rate 94, respirations 20 and oxygen saturation 100%. Multiple laboratory studies were performed for example, complete blood count, blood glucose, magnesium, hepatic (liver) function panel, sedimentation rate, metabolic profile, venous blood gas, etcetera. Intravenous fluids were initiated, blood cultures obtained. Glucose was 110 (normal 65-99). Blood urea nitrogen/creatinine level 36 (normal 10.0-20.0 [elevated level can indicate dehydration]), white blood cell 22.7 (normal 4.5-14.5). 12:49 pm - Transfer center request ordered. Reason for transfer, higher level of care for pediatrics. 1:47 pm - Provider documented, “Patient meeting systemic inflammatory response syndrome (SIRS) criteria with fever of unknown origin. She has been given intravenous fluids and have started on intravenous antibiotics. The patient will need to be admitted and unfortunately, we do not have pediatric support here at the hospital. Hospital B’s transfer center was contacted, they will check bed availability and call back.” 3:05 pm - Provider documented, “given that patient has continued to look ill, has had worsening symptoms over the last 2 weeks with ongoing fevers, and workup concerning for leukocytosis, I reached out to Hospital B who connected me to their pediatrics department. I spoke with a provider who accepted the patient in transfer/admission to their pediatrics unit. Awaiting bed assignment from the facility. Clinical Impressions: systemic inflammatory response syndrome and fever of unknown origin.” 3:59 pm - Patient transferred to another facility by ambulance. Nurse to nurse report given. There was no documentation of certification for transfer or the risk and benefits of such transfer. -- During interview of Staff E, Accreditation Specialist on 4/10/2024 at 3:30 pm, he/she/they acknowledged the above findings.”