HospitalInspections.org

Based on policy review and medical record review, the hospital staff failed to document communication with the power of attorney (POA) regarding transfer to a higher level of care for 1 of 3 (Patient #1) sampled emergency department (ED) patients.

The findings included:

1. Review of the hospital's "Transfer Policy" applicable to the ED, dated 08/01/1987 and revised 7/17/2014, revealed, "PURPOSE: To provide guidelines for treatment and medically appropriate transfers based on state and federal laws...PROCEDURE:...E. Transfer papers will be completed...the patient/guardian must sign to accept the transfer..."

2. Medical record review for Patient #1 revealed a 79 year old female who presented to the ED on 4/6/2022 at 8:22 AM with complaints of weakness and recent falls, with a possible urinary tract infection. Patient #1 was transported to the ED via emergency medical services (EMS), but her spouse accompanied her to the ED via private car. At 12:45 PM, the ED Nurse documented, "Husband has left to run an errand, will admit to this facility..." During the process of the medical screening exam, Patient #1 tested positive for COVID-19 and chest Xray results revealed "very poor expansion the lungs with resulting accentuation of lung makings soft tissue artifact but no acute pulmonary processes otherwise..." Lab results revealed slightly elevated troponin, elevated lactic acid, elevated white blood cells, and elevated creatinine. The ED Physician initiated a transfer to a higher level of care for further evaluation and treatment via EMS on 4/6/2022 at 5:25 PM. There was no documentation Patient #1's spouse was notified of the transfer. There was no documentation of staff attempts to reach Patient #1's spouse via telephone to inform him Patient #1 required a higher level of care and was not being admitted to this hospital.

3. In an interview on 5/23/2022 at 10:00 AM, the ED Nursing Director verified there was no documentation the spouse was informed prior to the transfer. The ED Nursing Director stated, "Not charted, not done." The ED Nursing Director stated the correct procedure was to document a verbal consent or telephone call with family/POA at the top of the transfer form. She verified for Patient #1 the nurse documented "unable to sign" at 4:25 PM.