HospitalInspections.org

Based on clinical record review and review of facility documents, hospital staff failed to ensure the transfer authorization documentation was completed for 5 (five) of 5 (five) patients included in the sample who were transferred to another facility. Patient #'s 18, 19, 23, 24 and 25.

The findings are:

Surveyor review of the clinical records was conducted on 6/15/2021 and 6/16/2021 with the assistance of a navigator Staff Member (SM) #1. The hospital's "Transfer/EMTALA Form" was completed for each patient transferred. The "Transfer/EMTALA Form" is a two page paper document completed by the transferring physician and scanned into the medical record.

Patient #18 was transferred on 5/13/21. Review of the transfer form found the following omissions: The physician failed to designate patient as stable or unstable, failed to document a preliminary diagnosis on the "Transfer/EMTALA Form" and failed to designate what documentation (medical records) should be sent to the receiving hospital when the patient was transferred. Therefore it cannot be assumed that a preliminary diagnosis was documented and/or that hospital staff sent medical records related to the individual's emergency medical diagnosis to the receiving hospital.

Patient #19 was transferred 2/15/21. The physician failed to complete the certification for transfer including the preliminary diagnosis, whether the patient was stable or unstable, the benefits and risks to the patient, and the physician's dated and timed signature. Hospital staff failed to designate what documentation should be sent to the receiving hospital when the patient was transferred. Therefore it cannot be assumed that a preliminary diagnosis was documented and/or that hospital staff sent medical records related to the individual's emergency medical diagnosis to the receiving hospital.

Patient #23 was transferred 5/2/21. Hospital staff failed to designate what documentation should be sent to the receiving hospital when the patient was transferred. Therefore it cannot be assumed that a preliminary diagnosis was documented and/or that hospital staff sent medical records related to the individual's emergency medical diagnosis to the receiving hospital.

Patient #24 was transferred 1/29/21. Hospital staff failed to designate what documentation should be sent to the receiving hospital when the patient was transferred. Therefore it cannot be assumed that a preliminary diagnosis was documented and/or that hospital staff sent medical records related to the individual's emergency medical diagnosis to the receiving hospital.

Patient #25 was transferred on 1/11/21. Hospital staff failed to designate what documentation should be sent to the receiving hospital when the patient was transferred. Therefore it cannot be assumed that hospital staff sent medical records related to the individual's emergency medical diagnosis to the receiving hospital.

The above findings were confirmed by SM #1 at the time of discovery. Review of hospital policy "Transfer EMTALA" last updated 08/2020 read in part as follows: "5. ...the ED or on-call Physician will complete the Transfer/EMTALA form which must include a summary of the risks and benefits of transfer" and "7. Copies of the Patient's medical record, including, but not limited to , symptoms, preliminary diagnosis, treatment provided, test results, and informed written consent or transfer certification, will be sent with the Patient to the receiving hospital."

The failure to complete transfer paperwork in it's entirety was discussed with hospital management prior to exit on 6/16/2021.