Erlanger Behavioral Hospital, LLC

“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: 30553 Based on review of facility policy, medical record review, and interviews, the facility failed to provide an appropriate transfer for 1 patient (#6) who presented to the Emergency Department with Suicidal Ideations (SI) of 20 records reviewed. The findings include: Patient #6 was admitted on 9/20/2025 with SI. The patient was a walk-in to the facility’s intake unit. She had been discharged from the facility on 9/19/2025. The patient was evaluated and a medical screening examination was provided. The facility did not have an open adult bed for the patient. In the medical screening documentation, there was documentation the patient would be transferred to Facility D. On the transfer from, there was documentation the patient was going to Facility C but then crossed out and documented as Facility B. There were no risks and benefits of transfer documented. There was no documentation of a receiving physician for the transfer. There was no medical record for Patient #6 at Facility B on 9/20/2025. On 9/20/2025 the patient presented to Facility D at 5:29 PM where a medical screening examination was completed. The patient was placed under a Certificate of Need (CON). Psychiatry was consulted who agreed the patient should be placed under a CON and transferred to an inpatient psychiatric facility. The patient was admitted to Facility E on 9/21/2025. Cross Refer to A-2409.”

“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: 30553 Based on review of facility policy, medical record review, and interviews, the facility failed to provide an appropriate transfer for 1 patient (#6) who presented to the Emergency Department (ED) with Suicidal Ideations (SI) of 20 records reviewed. The findings include: Review of facility policy EMTALA (Emergency Medical Treatment and Labor Act), last revised 1/2026, showed “...a physician will sign a certification that based upon the information at the time of the transfer, the medical benefits reasonably expected from the provision of emergency medical treatment at another facility outweigh the increased risk to the individual...if a physician is not physically present in the facility at the time an individual is transferred, a qualified medical person may sign the certification after the physician, in consultation with the qualified medical person, had made the determination...and subsequently countersigns the certification...Transfer: before a hospital may transfer an individual, the hospital must satisfy the following conditions: risk minimized...the transferring physician or registered nurse has notified a physician at the receiving facility and had obtained consent to the transfer and confirmation that the individual meets the facility’s admissions criteria related to appropriate bed, personnel and equipment necessary to treat the individual...a transfer summary signed by the transferring physician and or qualified medical person and which contains relevant information pertaining to the individual’s condition. At a minimum the transfer summary must contain...the name and address of the transferring physician, the name of the of the physician at the receiving hospital consenting for transfer...” Review of the ED Central logs showed Patient #6 was admitted to Facility A on 9/20/2025 and transferred to Facility D. Medical record review showed Patient #6 was admitted on 9/20/2025 at 2:20 PM with SI and Auditory Visual Hallucinations. The patient was a walk-in. The patient had been discharged from Facility A on 9/19/2025. She presented with a plan to “run her car off the road”. The facility did not have any open female beds and was unable to admit the patient. Medical record review of an EMTALA Request/Consent for Transfer form dated 9/20/2025 showed the patient was to be transferred. The consent form stated the patient would be going to Facility C. Further review showed Facility C was crossed out and documented the patient would be transferred to Facility B. Review of an EMTALA Memorandum of Transfer form dated 9/20/2025 at 4:13 PM showed the receiving hospital was Facility B. There was no documentation related to accepting physician. Medical record review of a Physician Certificate for Transfer dated 9/20/2025 at 4:30 PM showed no documentation of the Risk and Benefits were explained to the patient and the physician had not signed the Certificate for Transfer. The receiving hospital was not documented on the form. Medical record review of an Emergency Medical Service Certificate of Medical Necessity for Ambulance Services dated 9/20/2025 showed the patient was to be transported to Facility B. There was no medical record for the patient at Facility B which was documented on the transfer form and the Certificate of Medical Necessity for Ambulance Services at Facility A. The patient was admitted to Facility D’s ED on 9/20/2025 at 5:29 PM. There was no documentation the patient was accepted or transferred to Facility D in Facility A’s medical record on 9/20/2025. Medical record review showed the patient arrived at Facility D on 9/20/2025 at 5:35 PM with SI. She had been discharged from Facility A on 9/19/2025. A medical screening examination was completed. Psychiatry was consulted who recommended involuntary commitment and transfer to an inpatient psychiatric facility. A Certificate of Need (CON) for Emergency Involuntary Commitment was signed on 9/20/2025 at 6:24 PM. She was diagnosed with SI and depression. The patient was transferred to Facility E on 9/21/2025. Facility A’s Director of Quality Management sent an electronic intake report on 10/7/2025 at 5:24 AM related to Patient #6. The referral showed the patient was admitted to Facility A on 9/20/2025 but not admitted to the facility. Later the intake report showed a referral from Facility D was requested. The patient was accepted at Facility E on 9/20/2025. During an interview on 10/1/2025 at 2:30 PM, Registered Nurse (RN) #1, confirmed there was no documentation of a physician who accepted the patient; it was not clear where the patient was transported to; and the Risk and Benefits of transfer was not documented. During an interview on 10/1/2025 at 3:00 PM, RN #2 confirmed there was no documentation of the Risk and Benefits of transfer and there was documentation of the provider who accepted the patient. She confirmed the transfer paperwork indicated the patient would be transferred to Facility B but the patient was transferred to Facility D. The ED Central log showed the patient was transferred to Facility D.”