Purpose: To describe how decisions occurred to transfer nursing home (NH) residents to emergency departments (EDs). Design: Three nursing homes (NHs) in Virginia were selected based on geographic and ownership variability. The phenomenon of concern was the decision-making process culminating in the transfer of NH residents to EDs. Sixteen transfers met the inclusion criteria and were analyzed. A minimum of two informants per transfer were interviewed, with a range of 2 to 4 interviews per transfer. All 42 respondents were asked to describe how the transfer decision was reached, to identify who participated in making the decision, and to describe any particular positive or negative aspects of reaching the transfer decision. Method: Data were analyzed with hermeneutic phenomenological methods. Journal writing, audit trails, informal and formal member checks, and expert consultation were used to control bias. Findings: The three main themes identified were Consensus, Conflict, and Cogency. Consensus, or agreement, occurred when all decision participants reported similar interpretations as to the severity and acuity of the presenting problem or had shared interpretations of the best interests of the elder. When decision participants held dissimilar interpretations, conflict occurred. Decision participants used cogency by persuading others, in order to reach consensus. Conclusions: The findings cannot be generalized to long-term care facilities across the US or to other countries, but they enhance understanding about some of the ways transfer decisions occur and the role of nurses in those transfers, especially when conflict arises. © 2007 Sigma Theta Tau International.