Baylor Scott & White Emergency Hospital

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by:”

“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: 45847 . Based on record review and interview the facility failed to abide by the provider’s agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on a record review of 20 patients and interview, it was discovered that Facility A failed to provide a complete and accurate medical screening examination (MSE) for 1 of the 28 (Patient #1) whose records were reviewed. Patient #1 is a 31-year-old male patient with a history of diabetes mellitus and anxiety. Patient #1 presented on 12/07/2024 at 3:11 PM with complaints verbalized by Patient #1 as dizziness and confusion. Facility A failed to medically assess Patient #1 or provide screening of his blood glucose levels. Facility A failed to follow its policy regarding MSEs. . Cross refer A2406. .”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 45847 . Based on record reviews and interviews, Facility A failed to maintain a written policy for On-Call Providers that outlined: 1. How emergency services would be available to meet the needs of individuals with emergency medical conditions (EMCs). 2. It is not documented whether the hospital permits on-call providers to have simultaneous duties. If so, a clear delineation of on-call physician responsibilities should be documented. . Findings: Document Review: A review of Facility A’s Medical Staff Rules and Regulations, last reviewed and implemented on 02/22/2024 had one mention of “on-call physicians” found on page 21 of 21: “ ...C. Consultations in the Emergency Department: The ER physician may request consultation with various specialties on the Medical Staff as needed. When a request for consultation to the ER is made, the on-call physician should respond to the emergency department within 60 minutes of the request ...” . There was no mention of “on-call physicians” found during a review of Facility A’s Medical Staff Bylaws, last reviewed and implemented on 02/22/2024. . Policy Review: A review of the facility policies revealed that Facility A does not have an On-call Policy and referred this surveyor to its “EMTALA” and “Scope of Service - Emergency and Inpatient Services” policies. They read as follows: . Facility A’s Scope of Service - Emergency and Inpatient Services policy, last reviewed and effective on 10/2023, stated on page 1 of 7: “ ...An on-call list of Internal Medicine Physicians and/or Hospitalists is maintained for inpatient admissions ...” . Facility A’s EMTALA Policy, last reviewed and effective on 09/2023, stated on page 9 of 13: “ ...H. Physicians On-Call 1. The Hospital must maintain a list of physicians who are on-call for duty after the initial medical screening examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. The list must include the names of individual physicians on call; the name of a physician group or practice is not sufficient. . 2. The Hospital has the discretion to maintain the on-call list in accordance with the resources available to the Hospital, including the availability of on-call physicians. In determining on-call responsibilities, the Hospital will consider all relevant factors, including the number of physicians on staff in a particular specialty, other demands on these physicians, and the frequency with which individuals typically require services of on-call physicians. . 3. A determination as to whether an on-call physician must physically assess the individual in the emergency department is the decision of the treating Emergency Department physician. . 4. If a physician on the on-call list is called by the Emergency Department physician to provide emergency screening or treatment, the physician must respond within a reasonable time in accordance with the time established in the Hospital Medical Staff by-laws. If the physician refuses or fails to arrive within the required response time the chain of command should be initiated in an effort to obtain treatment for the emergency patient. If the individual is required to be transferred as a result of the on-call physician’s failure to appear, the Hospital is required by EMTALA to document in the medical record the name and address of the physician who failed to appear. See Reporting Obligations section. Transfers that result from an on-call physician refusal shall be referred to peer review for evaluation in accordance with the Hospital Medical Staff by-laws ...” . Interviews: On 02/03/2025 at 3:59 PM, Facility A’s Market Chief Executive Officer (CEO), Staff #4, was asked about On-call Policies. Staff #4 stated that there were no policies for on-call physicians at this facility. Staff #4 stated that the facility had specialists on duty 24/7 that could be conferred with if needed, but only have Internal Medicine or Hospitalists on-call for emergent coverage as needed. This was confirmed by Facility A’s Hospital Compliance Officer, Staff #3. . On 02/04/2025 at 7:43 AM, Staff #4 was asked again to clarify if the facility had an On-Call Policy. This Surveyor was directed to a paragraph in the EMTALA Policy regarding on-call and a sentence in the Scope of Service - Emergency and Inpatient Services Policy. Staff #4 stated that there was no separate On-Call policy. This was again confirmed by Staff #3. .”

“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: 45847 . Based on record review and interview, Facility failed to maintain a complete and accurate central log and follow its policy when their December 2024 ED Log/Transfer Log was reviewed and it was discovered that of the 715 patients, there were 9 patients (Patient #1 and Patients #21 through #28) did not have a documented time of arrival and 2 of the 9 patients (#28 and #29) had no date documented. . Findings: Document Review: The December 2024 ED Log/Transfer Log was reviewed in detail. There were 715 Patients listed on the December 2024 log. Of the 715 patients, there were 9 patients (Patient #21 through #29) noted to have “LWBS (left without being seen) Before Triage”. Of the 9 patients who “LWBS Before Triage”, there were 5 (Patient #1, #22, #23, #24, #25, and #28) who did not have a documented time of arrival. Of the 9 patients who “LWBS Before Triage”, there were 2 patients (#28 and #29) who had no date documented. These findings are also contrary to Facility A’s EMTALA Policy. For 2 of the 9 patients (Patient #26 and #27) who “LWBS Before Triage”, there was no documentation in a medical record, but a “ED Central Log” portion was attached by Facility A to the medical record. . Policy Review: Facility A’s EMTALA Policy, last reviewed and effective on 09/2023, stated on page 2 - 3 of 13: “ ...D. “Central Log” is a documented list of each individual who comes to the emergency department seeking assistance, whether or not that person refused treatment, was refused treatment, or was transferred, admitted and treated, stabilized and transferred or discharged. E. “Dedicated Emergency Department”(DED) is defined as any department or facility of the Hospital, regardless of whether it is located on or off the main Hospital campus, that meets at least one of the following requirements: 1. It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department; 2. It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously schedule appointment; or 3. During the calendar year immediately preceding the calendar year in which a determination under this Section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment ...” . and on page 6 - 7 of 13: “ ...B. Central Log 1. The Hospital must maintain a central log of individuals who come to the emergency department seeking examination and/or treatment for an emergency medical condition (including psychiatric conditions). All individuals who present for examination or treatment in the emergency department must be entered into the Central Log, even if they leave prior to triage or MSE. 2. The log shall include the individual’s name, date, time, chief complaint/diagnosis, and their disposition, which should indicate if the patient was: a. Admitted b. Discharged c. Transferred d. Refused MSE or stabilizing treatment e. Was refused treatment f. Left without being seen (LWBS/LWOBS) g. Eloped or Left Against Medical Advice (NOTE: Documentation should indicate if the emergency medical condition was stabilized or was unstabilized upon admission, discharge, or transfer.) 3. If a presenting individual left prior to completing the initial registration, an ED staff member should document, if the individual’s first and last name and DOB is not known, a description of the individual into the designated event/incident reporting system. 4. The Hospital may keep its central log in an electronic format but has the discretion to maintain the central log in a form that best meets the needs of the Hospital. 5. The central logs must be available in a timely manner for surveyor review and must be kept as required in the Records Retention Schedule, but not less than five (5) years from the date of disposition of the individual who sought examination or treatment for a medical condition from the DED. 6. The central log should also include any additional information as required by state law ...” . Interview: On 02/06/2025 at 10:04 AM, Facility A’s Market Chief Executive Officer (CEO), Staff #4, was asked if the December 2024 ED/Transfer Log was complete as provided to the Surveyors. Staff #4 confirmed that it was. .”

“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: 45847 . Based on a record review of 20 patients and interview, it was discovered that Facility A failed to provide a complete and accurate medical screening examination (MSE) for 1 of the 28 (Patient #1) whose records were reviewed. Patient #1 is a 31-year-old male patient with a history of diabetes mellitus and anxiety. Patient #1 presented on 12/07/2024 at 3:11 PM with complaints verbalized by Patient #1 as dizziness and confusion. Facility A failed to medically assess Patient #1 or provide screening of his blood glucose levels. Facility A failed to follow its policy regarding MSEs. . Findings: Medical Record Review for Patient #1 at Facility A: Patient #1 is a 31-year-old patient with a history of diabetes mellitus and anxiety. A patient record was provided for Patient #1 with the date (12/17/2024), time (9:11 AM), and attending Emergency Department (ED) physician (Staff #5) name documented. There were no assessments or treatments documented. The ED Registered Nurses (RNs) on duty at the time Patient #1 presented were (Staff #6) and (Staff #4). Patient #1 is documented on the ED Log with a disposition of “LWBS (left without being seen) Before Triage”. . Medical Record Review for Patient #1 at Facility B: A patient record was provided for Patient #1. The record stated that Patient #1 arrived on 12/17/2024 at 9:36 AM by car. The triage notes at 9:42 AM reflected that “Pt (Patient #1) reports history of sleep apnea and did not wear machine last night and reports he woke up having dizziness and disoriented. Pt (Patient #1) reports was seen at (Facility A) and was “kicked out” because of his dog. Pt (Patient #1) reports dizziness and anxiety.” . Medical provider notes at 9:57 AM stated “(Patient #1) is a 31 y.o. male with anxiety who presents to the ED c/a dizziness and panic attack. Patient (#1) states he has a history of sleep apnea and did not wear machine last night and reports being dizzy and disoriented. Patient (#1) reports he was seen at (Facility A) but was kicked out because of his dog. Patient (#1) states that he takes Propranolol. Patient voices no other complaints at this time.” The notes reflected a review of systems and physical exam that reflected that Patient #1 had normal attention and perception and a mood and affect that were normal. The Differential Diagnosis included acute anxiety, panic attack, and dehydration. . The review of Patient #1’s medical history documented anxiety, depression, and diabetes mellitus. . At 10:42 AM documentation of a recheck on Patient #1 by the medical provider stated “Upon patient reassessment, patient is feeling better and resting comfortably in no distress. Discussed findings and reviewed discharge instructions with patient. Discussed follow-up and return precautions. Patient understands and is agreeable to the plan.” The final diagnosis was acute anxiety. . At 10:06 AM, Patient #1 received Ativan 2mg orally. Patient #1 was discharged from the ED at 11:22 AM. . Policy Reviews: Facility A’s STAT Light Policy, last reviewed and implemented on 07/2024, stated on page 2 of 3: “ ...B. Examples of presenting patient complaints/conditions and/or obvious signs that shall dictate when the STAT Light is to be used (not an all-inclusive list): 1. Stroke a. Weakness b. Numbness c. Tingling to one side of the body d. Dizziness e. Difficulty speaking/ slurred speech f. Sudden/ severe headache g. Sudden changes in vision ...” . and on page 2 of 3: “ ...6. Other a. Confusion or changes in mental function ...” . and on page 3 of 3: “ ...C. Upon activation of the STAT Light by staff in the front-office, the device will emit an audible and visual indicator in the Emergency Department clinical area. It will remain active until clinical personnel have arrived to the patient in distress, for an immediate assessment(s) and interventions. D. The STAT light shall not be discontinued until appropriate clinical staff have responded to the patient in need ...” . Facility A’s Medical Staff Rules and Regulations, last reviewed and implemented on 02/22/2024, stated on page 14 of 21: “ ...A medical screening examination sufficient to detect the presence of an emergency medical condition or active labor will be performed by qualified medical personnel, which will be a Doctor of Medicine or osteopathy, nurse practitioner, or physician assistant. The attending physician is ultimately responsible for screening examinations. If, after the screening examination, in the best medical judgment of the provider, the patient is not in active labor and no emergency medical condition is present, the patient will be treated, referred or transferred according to internal Emergency Department or Ambulatory Services procedures and appropriate standards of medical practice. Where the patient is transferred to another facility, appropriate documentation will be sent with the patient ...” . Facility A’s EMTALA Policy, last reviewed and effective on 09/2023, stated on page 1 of 13: “ ...The purpose of this policy is to set forth policies and procedures for the Hospital’s use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA), as noted in Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. Section 1395dd, which obligates hospitals to provide medical screening, stabilizing treatment and transfer of individuals with emergency medical conditions or women in labor regardless of ability to pay ...” . and on page 2-3 of 13: “ ...DEFINITIONS ... C. “Comes to the Emergency Department.” For purposes of this policy, an individual is deemed to have “come to the emergency department” if the individual: 1. Presents to the “Dedicated Emergency Department”, or on the “Hospital Property”, and: a. requests examination or treatment for a medical condition; or b. has such a request made on their behalf of the individual; or c. In the absence of such a request by or on behalf of the individual, the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed examination or treatment for medical condition; ...” . and on page 3 of 13: “ ...1.”Medical Screening Examination” or “MSE” means the screening process required to determine with reasonable clinical confidence whether an “emergency medical condition” does or does not exist ...” . Interviews: On 02/04/2025 at 9:53 AM, the assigned Emergency Department Registered Nurse (ED RN) (Staff #6) during Patient #1’s visit on 12/17/2024 confirmed that Facility A’s process should have included a medical screening on all patients who presented to the Emergency Department (ED). Staff #6 confirmed that Facility A’s process was not followed for Patient #1. . On 02/04/2025 at 9:43 AM, another ED RN (Staff #10) on duty during Patient #1’s visit on 12/17/2024 confirmed that Facility A’s process should have included a medical screening on all patients who presented to the Emergency Department (ED). Staff #10 confirmed that Facility A’s process was not followed for Patient #1. . On 02/04/2025 at 10:45 AM, Facility A’s Medical Director (Staff #8) confirmed that Facility A’s process should have included a medical screening on all patients who presented to the Emergency Department (ED). Staff #10 confirmed that Facility A’s process was not followed for Patient #1. .”

“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: 45847 . Based on interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on record review and interview, the Facility failed to provide an appropriate transfer when the Memorandum of Transfer (MOT) for nine of nine patients (Patient #2, #4, #5, #7, #10, #11, #12, #16, and #20) whose records were reviewed failed to contain completed or signed physician certifications that listed the medical benefits or potential risks to the individual upon transfer. . Cross reference to Tag A2409 CFR §489.24(a) and §489.24(c).”

“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: 45847 . Based on record review and interview, the Facility failed to provide an appropriate transfer when the Memorandum of Transfer (MOT) for nine of nine patients (Patient #2, #4, #5, #7, #10, #11, #12, #16, and #20) whose records were reviewed failed to contain completed or signed physician certifications that listed the medical benefits or potential risks to the individual upon transfer. . Findings: There were 20 randomly selected patient records chosen from the ED and Transfer Logs, to include nine transferred patient records. The MOTs for each were reviewed. It was noted that for nine of nine patients (Patient #2, #4, #5, #7, #10, #11, #12, #16, and #20) whose records were reviewed the MOTs failed to contain signed physician certifications that listed the medical benefits or potential risks to the individual upon transfer. One of nine (Patient #4) did not contain a signed consent to transfer. Three of nine (Patient #10, #16, and #20) transferred via private vehicle and did contain a signed transfer refusal. Three of nine (Patient #2, #5, and #11) were transferred with advanced life support. Three of nine (Patient #4, #7, and #12) were transferred with basic life support. The detailed findings are as follows: . Patient #2: Date of ED admission 06/17/2024 at 2143 PM with chief complaints of snake bite; triage began at 2150 PM; medical screening exam began at 2150 PM; treatments: vital signs monitored, Zofran was given, history reviewed, exam; diagnosis at disposition: snake bite; transferred for a higher level of care at 2207 PM. MOT reviewed and found to not contain an explanation of risks or benefits or a physician’s signed certification. The MOT did contain a signed consent for transfer and a “Patient Condition for Transfer” statement signed by a physician, which did not explain risks and benefits of the transfer. The transfer was completed via EMS with advanced life support in place. . Patient #4: Date of ED admission 02/12/2024 at 1204 PM with chief complaints of abdominal pain; triage began at 1205 PM; medical screening exam began at 1206 PM; treatments: vital signs monitored, labs obtained, CT of the abdomen and pelvis - acute appendicitis, uncomplicated, no abscess; diagnosis at disposition: acute appendicitis; transferred at 1638 PM. MOT reviewed and found to not contain an explanation of risks or benefits or a physician’s signed certification. The MOT did not contain a signed consent for transfer. A “Patient Condition for Transfer” statement was signed by a physician, but no reason was indicated, and it did not explain risks and benefits of the transfer. The transfer was completed via EMS with basic life support in place. . Patient #5: Date of ED admission 02/12/2024 at 1418 PM with chief complaints of abdominal pain; triage began at 1446 PM; medical screening exam began at 1447 PM; treatments: vital signs monitored, labs obtained, CT abdomen and pelvis - no acute findings, moderate stool, meds given, indwelling foley placed; diagnosis at disposition: stercoral colitis; transferred to a higher level of care on 02/13/2024 at 0607 AM. MOT reviewed and found to not contain an explanation of risks or benefits or a physician’s signed certification. The MOT did contain a signed consent for transfer and a “Patient Condition for Transfer” statement signed by a physician, which did not explain risks and benefits of the transfer. The transfer was completed via EMS with advanced life support in place. . Patient #7: Date of ED admission 02/13/2024 at 1906 PM with chief complaints of throat pain; triage began at 1929 PM; medical screening exam began at 1938 PM; treatments: vital signs monitored, CT soft tissue neck - showed several bilateral tonsilitis with left peritonsillar abscess, meds given; diagnosis at disposition: left peritonsillar abscess; transferred on 02/14/2024 at 0201 AM. MOT reviewed and found to not contain an explanation of risks or benefits or a physician’s signed certification. The MOT did contain a signed consent for transfer and a “Patient Condition for Transfer” statement signed by a physician, which did not explain risks and benefits of the transfer. The transfer was completed via EMS with basic life support in place. . Patient #10: Date of ED admission 02/15/2024 at 1317 PM with chief complaints of a fast heartbeat and chest pressure; triage began at 1318 PM; medical screening exam began at 1324 PM; treatments: vital signs monitored, labs obtained, EKG obtained, exam; diagnosis at disposition: light headedness, heart palpitations; transferred at 1539 PM. The MOT did contain a signed consent for transfer and a “Patient Condition for Transfer” statement signed by a physician, which did not explain risks and benefits of the transfer. The transfer was completed via private vehicle as the patient refused to consent to transfer. The refusal is signed. . Patient #11: Date of ED admission 02/15/2024 at 2018 PM with chief complaints of feeling like he had a stroke; triage began at 2034 PM; medical screening exam began at 2056 PM; treatments: vital signs monitored, CT of head, neck, and brain - shows atherosclerotic plaque, no acute herniation or hemorrhage; diagnosis at disposition: transient ischemic attack (TIA); transferred on 02/16/2024 at 0231 AM. MOT reviewed and found to not contain an explanation of risks or benefits or a physician’s signed certification. The MOT did contain a signed consent for transfer and a “Patient Condition for Transfer” statement signed by a physician, which did not explain risks and benefits of the transfer. The transfer was completed via EMS with advanced life support in place. . Patient #12: Date of ED admission 02/16/2024 at 1317 PM with chief complaints of nausea, vomiting and diarrhea; triage began at 1326 PM; medical screening exam began at 1335 PM; treatments: vital signs monitored, labs obtained, x-ray abdomen- shows bilateral clear lungs, mild to moderate stool burden, flu positive; diagnosis at disposition: influenza, myositis, rhabdomyolysis; transferred at 1655 PM. MOT reviewed and found to not contain an explanation of risks or benefits or a physician’s signed certification. The MOT did contain a signed consent for transfer and a “Patient Condition for Transfer” statement signed by a physician, which did not explain risks and benefits of the transfer. The transfer was completed via EMS with basic life support in place. . Patient #16: Date of ED admission 02/19/2024 at 0946 AM with chief complaints of abdominal pain; triage began at 1114 AM; medical screening exam began at 1120 AM; treatments: vital signs monitored, labs obtained, CT abdomen and pelvis - active GIB arising from diverticula and aortic aneurysm, admitted observation at 1838 PM; diagnosis at disposition: abdominal pain, alcohol use; transferred at 1719 PM. MOT reviewed and found to contain an explanation of risks and benefits and physician’s signed certification. The MOT did contain a “Patient Condition for Transfer” statement signed by a physician, which did not explain risks and benefits of the transfer. A signed consent for transfer was completed. The transfer was completed via private vehicle for patient’s refusal of ambulance transportation. The refusal of transfer form was signed. . Patient #20: Date of ED admission 04/01/2024 at 2040 PM with chief complaints of shortness of breath; triage began at 2042 PM; medical screening exam began at 2044 PM; treatments: vital signs monitored, labs obtained, CT of the chest, rule out pulmonary embolus (PE) - PE was seen, CT abdomen - showed right sided pleural effusion with atelectasis, US of the abdomen - negative, meds given, antibiotics given; diagnosis at disposition: pulmonary embolism; transferred on 04/02/2024 at 0213 AM. MOT reviewed and found to not contain an explanation of risks or benefits or a physician’s signed certification. The MOT did contain a signed consent for transfer and a “Patient Condition for Transfer” statement signed by a physician, which did not explain risks and benefits of the transfer. The transfer was completed via private vehicle for the patient’s refusal of ambulance transportation. The refusal of transfer form was signed. . In interviews on June 18, 2024, and the morning of June 19, 2024, Staff #1 (Nurse Manager) & Staff #2 the staff members were asked, “Are all of your MOTs like these nine (referring to the MOTs reviewed during patient record reviews) and void of a physicians certification, risks and benefits?” . Staff #2 replied, “Yes, they have a patient signature stating that the risks and benefits of the transfer were explained to them. The certification is no longer needed as the patient was stabilized prior to transfer.” .”