HospitalInspections.org

Based on document review and interview, it ws determined that for 1 of 3 (Pt.#1) clinical records reviewed for nursing services, the hospital failed to ensure that the nurse notified and obtained a physician's order for transfer of a patient and failed to ensure that the tranfer certification form was completed by the physician.

Findings include:

1. The hospital's policy titled, "Discharge of a Patient" (revised 04/04/23) was reviewed and required, "Discharge to another Hospital ... I. LIP (licensed independent practitioner) completes discharge order ... II. LIP or RN contacts consultants as appropriate to obtain clearance for discharge of patient ... "

2. The hospital's "Job Description for Registered Nurse" (effective 04/22/2019) was reviewed and included, "Serves as a primary coordinator of all disciplines for well-coordinated patient care. Notes and carries out physician and nursing orders. Assesses and coordinates patient's discharge planning needs with members of the healthcare team.

3. The clinical record for Pt.#1 was reviewed. Pt.#1 was admitted to the hospital on 06/06/24 and was discharged/transferred per family request on 06/09/24. The clinical record included the following; however, the clinical record lacked an order for discharge/transfer from the physician:

-History and Physical (MD#1), dated 06/07/24 at 10:52 AM, " ... (Pt.#1) admitted for evaluation of stroke ... Neurology has been consulted. (Pt.#1) to undergo all the imaging study protocol for stroke."

-Physician Report Stroke Progress Note (MD#2/Neurologist), dated 06/08/24 at 12:53 PM, "There were no acute events overnight ... All 3 daughters are present today ... discussing the patient's (Pt.#1's) rehabilitation options ... asked many questions about (Pt.#1's) TEE (Transesophageal Echocardiogram-used to visualize detailed close-up view of heart) and diagnostic cerebral angiogram (diagnostic procedure that shows images of blood vessels) that is planned for 6/10/24. All questions were answered."

-Nurse Note, dated 06/09/24 at 10:39 PM, "(Pt.#1's) daughter contacted Charge RN to state concerns regarding I/O (intake and output), patient turning Q2 (every 2 hours) ... daughter stated to Charge Nurse she wants all procedures stopped and will be transferring (Pt.#1) out 6/10. (Pt.#1) was made aware of daughters call with staff ..."

-Discharge Summary/Provider (MD#1) dated (07/12/24 at 7:02 AM) actual date of discharge was 06/10/24. "Clinically stable. Foley catheter in place for Urinary Retention. Family wants patient transferred to another Facility. D/W (discussed with) Hospitalist at length - not sure if they are accepting." The Discharge Summary did not indicate the name of the physician or hospital that MD#1 spoke to and did not indicate that (Pt.#1) was accepted prior to transfer. The clinical record did not include a discharge/transfer physician order.

-Patient Transfer Certification/Consent Form, dated 06/10/24 at 1400 (2:00 PM), included, "Name/Signature of Physician Transferring Patient: (name of MD #1) ... Name of Physician and Hospital Contacted/Accepted Patient's Transfer: (left blank) Date and Time Contacted: (left blank) ... Section To Be Completed by Patient (check one of the following) After being provided an appropriate medical screening examination based upon the information available at the time of the examination and being informed of the risks, benefits, and alternatives ... the risks involved in a transfer to another institution and the options available ... I do hereby: Accept responsibility and agree to transfer (is checked). Signature of Patient (left blank) ... witness (signed by discharge nurse E#11)." The form was not signed by the Transferring Physician and or (Pt.#1) or healthcare power of attorney. The form lacked documentation of the name of accepting physician and hospital.

4. An interview was conducted via phone with the Attending Physician (MD#1) on 11/20/24 at 12:43 PM. MD#1 stated that for pts requesting transfer to another hospital for same level of care the family needs to provide the name of the accepting physician and hospital. The physician will reach out to that hospital's accepting physician and provide the information required. The Physician would contact the accepting physician then provide the transfer or discharge order. Documentation of communication with the accepting Physician should be included in the clinical record to indicate that the patient has been accepted by the other facility.