HospitalInspections.org

Based on document review, patient interview, and staff interview, it was determined that for 2 of 10 patients (Patients # 5 and 7) in the sample the facility failed to complete required documentation when transfering a patient from the facility ED to another facility. Findings include:

Hospital policy titled "Emergency Medical Treatment & Labor Act (EMTALA)" with a last review date of August 29, 2022, stated, " ...An EMTALA Transfer must comply all with the following requirements: ... The transferring hospital sends all medical records related to the EMC (Emergency Medical Condition) available at the time of transfer ... The transferring hospital sends a Physician Certification or the patient's written request for a transfer, as applicable ...Any EMTALA Transfer to another hospital shall be based on either: ... A written physician order and patient consent, accompanied by a Physician Certification that the benefits of the Transfer outweigh the risks ... References: ChristianaCare's Request for Patient Transfer/Transfer Checklist (Form 19284) ..."

Hospital Form titled "Request for Patient Transfer/Transfer Checklist (Form 19284)" contains fields for the provider to identify if the patient is stabilized to the best ability of the hospital, to outline the risks and benefits of transfer, a copy of the medical record was sent with the patient, and request for transfer by the patient or permission obtained from the patient for transfer.

Hospital Medical-Dental Staff Rules with a last review date of September 18, 2023, stated, " ...A patient with an incompletely stabilized emergency medical condition may either be ... Transferred to another facility outside of the Christiana Care Health System, if ... the treating physician certifies that the benefits of transfer outweigh the risks, and the patient consents to the transfer ..."


Medical record review for Patient #5 revealed:

Patient #5 presented to the DED on 12/5/23 at 10:36 PM with a complaint of fever and cough.

Pediatric Emergent Physician Note dated 12/06/23 at 12:23 AM stated, " ...patient appears to have failure to thrive. Discussed with in-house hospitalist who recommended transfer to [children's acute care hospital] for workup and greater access to subspecialists. D/w (discussed with) Dr. [name], [children's acute care hospital] Hospitalist who recommended transfer to the [children's acute care hospital] ER [emergency room] for workup rather than the inpatient floor ... Discussed with Access Center to arrange for EMS (Emergency Medical Services) transport to the [children's acute hospital] ... Dr. [name] accepted the patient and EMS to arrive in 20 mins to transport patient ... Patient remained hemodynamically stable and in no acute respiratory distress at the time of transfer ..."

Surveyors requested to see the Request for Patient Transfer/Transfer Checklist (Form 19284) for this patient from Employee #1 on 12/6/23 at 3:26 PM. On 12/7/23 at 9:31 AM, Employee #1 confirmed that the facility was unable to produce this form.

No evidence of medical records related to the EMC (Emergency Medical Condition) being sent to the receiving hospital.

No evidence of Physician Certification that the benefits of the transfer outweigh the risks.

No evidence of written patient consent for the transfer.



Medical record review for Patient #7 revealed:

Patient #7 presented to the DED (Dedicated Emergency Department) on 10/28/23 at 10:37 AM with a complaint of wheezing and retractions.

Pediatric Emergent Physician Note dated 10/28/23 at 11:03 AM stated, "...transport center was called and PICU (Pediatric Intensive Care Unit) transfer to [children's acute care hospital] was coordinated. Accepting physician is Dr. [name]. Parents have been updated on planned of care, all questions answered ..."

Surveyors requested to see the Request for Patient Transfer/Transfer Checklist (Form 19284) for this patient from Employee #1 on 12/6/23 at 3:26 PM. On 12/7/23 at 9:31 AM, Employee #1 confirmed that the facility was unable to produce this form.

No evidence of medical records related to the EMC being sent to the receiving hospital.

No evidence of Physician Certification that the benefits of the transfer outweigh the risks.

No evidence of written patient consent for the transfer.

The findings above were confirmed with Employee #1 on 12/7/23 at 9:31 AM.