HospitalInspections.org

Based on review of records, policy, procedures, and interview SMH failed to notify receiving hospital of patient arrival and no Doctor to Doctor communication was made resulting in an inappropriate transfer of 1 (patient #08) out of 20 reviewed.

This failed practice had the potential for possible deterioration of health due to the lack of confirming capability and capacity at receiving hospital to provide needed care.

FINDINGS:
Review of the SMH Policy EMD-105 Titled EMTALA - Medical Screening and Treatment of Emergency Medical Conditions
Page 10 Transfers A#1(c) defines that if no EMC exist a "Transfer Certificate for Stable Patients" is completed if the patient is transferred to another medical facility. Page 12. (D) Internal Procedures for Transfer #1(a) contact the receiving facility who will be responsible to assume care of the patient and assure the receiving facility has the capacity to care for the patient. #2(d) provide the receiving facility with a telephone report of the patient's condition.

Review of patient#08 record noted the following. Patient #08 presented to SMH ED by private vehicle on 10-06-23 at 5:33 p.m. with a traumatic amputation of the distal tuft to the third digit distal phalanx. Documented by Staff A a finger block of left third digit with 2% Lidocaine for pain control. Wound cleaned and dressing applied. Staff A documented in patient #08 chart on 10-06-23 at 6:38 p.m. patient would likely need either general surgery or hand surgeon to repair finger. At this time Staff A also documented that patient #08 refused transfer by EMS. Patient #8 was discharged with instructions to follow up at Chickasaw Nation, in Ada, OK today. Medical Records, X-Ray results and Disc where sent with patient. Staff A documented on 10-06-23 at 6:38 p.m. that Ada Hospital ER notified that patient will be heading their way via private vehicle. No documentation found in patient #08 chart stating who at receiving Ada Hospital was contacted, date or time.

Summary of Interviews:


10-25-23 at 9:00 a.m. Staff A stated that when a patient needs a higher level of care and refused an EMS transport the receiving facility should be called by the nurse to give them a heads up.

10-25-23 at 1:30 p.m. Staff D was asked what should be done when sending a patient out for a higher level of care? Staff D stated that a consultation should be made with the receiving facility to make sure there is no delay of care.

10-25-23 at 9:20 a.m. Staff F states that they asked Staff A if they needed to call Ada Hospital and they were told no.