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Based on record review and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer (A2409).

Based on medical record review and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer for five of five medical records of transferred patients reviewed (Patient #5, #6, #7, #8, and 11). A total of 20 medical records were reviewed. The hospital registered 36,128 patients in the emergency department in the preceding eight months prior to the survey.

Findings include:

Review of the "Transfer Summary and Consent" form revealed the non-medical risks of transfer were pre-printed on the form. The form contained a space to list the medical risks of transfer. The form also contained a check box next to "Medical Transfer: Based upon reasonable risks and benefits to the patient, and upon information available at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual's medical condition from effecting the transfer."

1. Review of the medical record for Patient #5 revealed an arrival date of 06/04/21 at 6:30 PM to the emergency department. The medical record contained documentation the patient was having seizures. The medical record contained documentation the patient was transferred to a pediatric facility where his/her neurologist practiced on 06/04/21 at 11:58 PM. The "Transfer Summary and Consent" form signed by the physician lacked documentation of the medical risks of transfer and the check box was empty next to "Medical Transfer".

2. Review of the medical record for Patient #6 revealed an arrival date of 07/03/21 at 10:35 AM to the emergency department. The medical record contained documentation the patient was brought to the emergency department for stroke symptoms. Diagnostic testing revealed a large right frontal lobe mass with edema and evidence of subfalcine herniation. The medical record contained documentation the patient was transferred to another facility for a neurosurgery consult on 07/03/21 at 3:30 PM. The "Transfer Summary and Consent" form signed by the physician lacked documentation of the medical risks of transfer and the check box was empty next to "Medical Transfer".

3. Review of the medical record for Patient #7 revealed an arrival date of 11/01/21 at 6:35 PM to the emergency department. The medical record contained documentation the patient was brought to the emergency department by ambulance and police for abnormal psychotic behavior. The patient had an "Application for Emergency Admission" form stating the patient represented a substantial risk to self and would benefit from treatment in a hospital for mental illness. The medical record contained documentation the patient was transferred to a psychiatric facility on 11/02/21 at 6:42 AM. The "Transfer Summary and Consent" form signed by the physician lacked documentation of the medical risks of transfer and the check box was empty next to "Medical Transfer". In addition the "Reason for Transfer" section was marked insurance.

4. Review of the medical record for Patient #8 revealed an arrival date of 04/17/21 at 5:41 AM to the emergency department. The medical record contained documentation the patient was brought to the emergency department for psychotic behavior. While in the emergency department, the physician and physician assistant were in the room trying to talk the patient into getting back in bed for an assessment. The patient sat on the floor with his/her hands over his/her face and his/her back to the medical staff. The patient used his/her hands to remove both of his/her eyes from their sockets. The medical staff and security quickly held the patient down, sedated the patient and controlled the bleeding, as well as placed the eyes into saline. Another facility's trauma service was called and transfer was arranged. The medical record contained documentation the patient was transferred to another facility for trauma services on 04/17/21 at 10:42 AM. The "Transfer Summary and Consent" form signed by the physician lacked documentation of the medical risks of transfer and the check box was empty next to "Medical Transfer".

5. Review of the medical record for Patient #11 revealed an arrival date of 04/06/21 at 12:39 AM to the emergency department. The medical record contained documentation the patient was brought to the emergency department by ambulance and police for paranoid behavior. The patient had an "Application for Emergency Admission" form stating the patient represented a substantial risk to self or others and would benefit from treatment in a hospital for mental illness. The medical record contained documentation the patient was transferred to a psychiatric facility on 04/06/21 at 11:14 AM. The medical record lacked documentation of a physician signed transfer form including a summary of the risks and benefits of the transfer. On 12/01/21 at 3:33 PM, Staff A verified a transfer form could not be located for this patient.

In an interview on 12/01/21 at 1:30 PM, Staff B verified staff did not always write in the medical risks of transfer or check the box next to "Medical Transfer" on the "Transfer Summary and Consent" form.