HospitalInspections.org

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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to implement policies and procedures for evaluation, treatment, and transfer of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to send copies of medical records to the receiving hospital when patients are transferred places patients at risk for medical errors and adverse patient outcomes due to lack of care continuity.

Findings included:

The hospital failed to provide evidence that emergency department staff members sent copies of all medical records pertaining to the patient's emergency care to the receiving facility when patients were transferred to another hospital (Cross Reference C2409).
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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed to 1) ensure ED staff members completed "Authorization for Transfer" forms, including certification that the patient was either stable or unstable at the time of transfer; and 2) provide evidence that emergency department staff members sent copies of all medical records pertaining to the patient's emergency care to the receiving facility when patients were transferred to another hospital, as demonstrated by 6 of 17 patients reviewed (Patient #1, #2, #3, #4, #5, #6).

Failure to send completed transfer documents and copies of all medical records pertaining to the patient's emergency care to the receiving facility when patients are transferred from one hospital to another risks medical errors and adverse patient outcomes due to lack of care continuity.

Findings included:

1. Review of the hospital's policy and procedure titled "Transfer of Patient to Another Facility", Policy #7579519 reviewed 01/20, showed when patients were transferred from the emergency department (ED) ED staff would complete an "Authorization for Transfer" form. The procedure stated that copies of all medical records pertaining to the patient's emergency condition would be sent to the receiving hospital.

2. On 01/30/20 at 10:40 AM, the investigator interviewed the hospital's ED nursing director (Staff #1) regarding what medical records were to be sent to the receiving hospital when the patient was transferred to another hospital. The director stated the records were to include demographic information ("face sheet"), the "Authorization for Transfer" form, nursing notes, the patient's history and physical examination, diagnostic test results, and the ED provider progress notes.

3. On 01/30/20, the investigator reviewed the records of 17 patient who came to the the hospital's ED between 08/04/19 and 01/14/20 and were transferred to another hospital.

a. The review showed that 4 records contained incomplete "Authorization for Transfer" forms (Patients #1, #4, #5, #6). Missing information included the name of the receiving facility; the receiving physician; the staff member who gave provider-to-provider report; the staff member at the receiving hospital who received the nursing report, including the date and time of the report; the mode of transfer; the patients primary diagnosis; who accompanied the patient during the transfer; documentation that an "appropriate medical screening examination" had been done or refused by the patient; and whether the patient was stable or not stable when transferred.

b. The review also showed that 5 records lacked evidence that the patient's ED records were sent to the receiving facility when the patients were transferred to another hospital (Patients #1, #2, #3, #4, #5).

3. On 01/30/20 at 3:45 PM during an interview with the investigator, the hospital's emergency department nursing director (Staff #1) confirmed that the hospital's transfer policy and procedure had not been followed for the patients identified above.
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