HospitalInspections.org

Based on review of policies and procedures, medical records review and interview the facility failed to ensure a physician has signed a certification that include all pertinent information (risks and benefits) to accompany patients being transferred to another facility in 3 out of 12 sampled patients (SP#1, SP#4, and SP#9).


(Refer to 2409)

Based on review of policies and procedures, medical records review and interview the facility failed to ensure a physician has signed a certification that include all pertinent information (risks and benefits) to accompany patients being transferred to another facility in 3 out of 12 sampled patients (SP#1, SP#4, and SP#9).


The findings:

1. Review of the sampled patient (SP) #4 medical record showed he was Baker Act on 10/10/2016 by the physician. The patient was medically cleared for transfer to a psychiatric facility. Review of facility record showed SP #4 was transferred to another hospital. There was no documentation that a physician had signed a certification that include all pertinent information (risks and benefits) prior to the transfer.

2. Review of the sampled patient #9 medical record showed he was Baker Act on 10/02/2016 by the physician. The patient was medically cleared for transfer to a psychiatric facility. Review of facility record showed SP # 9 was transferred to another hospital. There was no documentation that a physician had signed a certification that include all pertinent information (risks and benefits) prior to the transfer.

3. The medical record for Patient #1 was reviewed. On 11/9/2016 at 15:35 PM the ED record showed sample patient (SP) #1 presented to ED (Emergency Department) with unable to void since 3.30 hours ago as per patient. At 11/09/2016 at 17:50 PM a STAT (immediately) urology consult with named physician ref(reference): urinary retention, unable to place Foley. The ED physician's history and physical notes showed patient came to the ER (emergency room) with complaint of acute urinary retention and inability to urinate since the morning. (Positive) + bladder distention up to the umbilical area. The note further showed the urology call placed to named physician stat (immediately), he answered back at 7:30 PM and said he is not covering the ER anymore and recommend to transfer the patient to another hospital so the decision to transfer notified to nurse supervisor and ER nurse in charge. The Flowsheet Inquiry Report (ED Nursing Notes) showed at 20:26 PM note showed that at 19:31 PM the EDP (emergency department physician) decided to transfer to hospital for urology evaluation because there is no urology available at this moment. On 11/09/2016 at 21:32 PM another note showed the patient was transferred to Hospital #2. Review of the Consent to Transfer form dated 11/19/2016 was reviewed. The transfer from failed to state the reason/benefits of the transfer. The transfer form was not complete for patient #1 on 11/19/2016.

On 11/30/16 at 3:45 PM, the Risk Manager Coordinator in the presence of the CNO (Chief Nursing Officer) stated that the transfer form was not done on psyche pts (patients). because the Case Manager told her that pts who are involuntary status do not need the transfer form because they cannot sign.

The policy named "Transfer For Definitive Cases", revision date: 7/2015, state for transfer out of the emergency department: services not provided at this institution include psychiatry care. The procedure include: the appropriate transfer form is to be completed, and the nurse/ supervisor will obtain the patient consent for transfer.
The policy and procedure titled "EMTALA LAW" Policy #1000, Original date 7/13; Revision date-7/14; 7/15 was reviewed. The policy specified in part, E ...1 ... The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer, or; 2. A physician has signed a certification that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provisions of appropriate medical treatment at another medical facility outweigh the increased risk to the individual."