HospitalInspections.org

Based on clinical record review and interview, it was determined the Facility failed to inform five of five (#16-#20) patients the risks of being transferred to another Facility specific to their diagnosis and failed to have three (#16, #17 and #18) of five (#16-#20) patients sign the acknowledgement of the risks and benefits of the transfer. The failed practice did not ensure the patients were aware of or accepted the risks or benefits of the transfer specific to their diagnosis. The failed practice had the potential to affect all patients presenting with an emergency medical condition that was transferred to another Facility. The findings follow:

A. Review of Patient #16's clinical record on 09/29/14 revealed the patient's clinical impression was "Traumatic brain injury with brief (less than 1 hour) loss of consciousness and closed head injury with petechial brain hemorrhage, initial encounter." The patient was transferred to another Facility from the Emergency Department. Risks of Transfer revealed, "Worsening of patient EMC (emergency medical condition) or death en route." There was no evidence the risks of the transfer specific to the patient's condition were listed so the patient/patient representative was aware of the risks of the transfer. There was no evidence the patient/patient representative acknowledged the risks or benefits of the transfer.

B. Review of Patient #17's clinical record on 09/29/14 revealed the patient's clinical impression was "Asthma exacerbation, moderate persistent and respiratory distress". The patient was transferred to another Facility from the Emergency Department. Risks of Transfer revealed, "Worsening of patient EMC (emergency medical condition) or death en route." There was no evidence the risks of the transfer specific to the patient's condition were listed so the patient/patient representative was aware of the risks of the transfer. There was no evidence the patient/patient representative acknowledged the risks or benefits of the transfer.

C. Review of Patient #18's clinical record on 09/29/14 revealed the patient's clinical impression was "Seizure". The patient was transferred to another Facility from the Emergency Department. There was no evidence the risks of the transfer specific to the patient's condition were listed so the patient/patient representative was aware of the risks of the transfer. There was no evidence the patient/patient representative acknowledged the risks or benefits of the transfer.

D. Review of Patient #19's clinical record on 09/29/14 revealed the patient's clinical impression was "Suicidal behavior". The patient was transferred to another Facility from the Emergency Department. Risks of Transfer revealed, "Worsening of patient EMC (emergency medical condition) or death en route." There was no evidence the risks of the transfer specific to the patient's condition were listed so the patient/patient representative was aware of the risks of the transfer.

E. Review of Patient #20's clinical record on 09/29/14 revealed the patient's clinical impression was "Behavior disorder". The patient was transferred to another Facility from the Emergency Department. Risks of Transfer revealed, "Other (Specify in comments)". There was no evidence of "other comments". There was no evidence the risks of the transfer specific to the patient's condition were listed so the patient/patient representative was aware of the risks of the transfer.

F. The findings were confirmed in an interview with the Emergency Room Director on 09/30/14 at 1215.