HospitalInspections.org

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Based on interview and document review, the hospital failed to implement their policies and procedures for transferring patients to another acute care facility in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA).

Failure to ensure patients receive safe transfer risks poor health care continuity, outcomes, injury and death.

Findings included:

1. The hospital failed to complete the required EMTALA transfer documentation in the medical record of 2 of 3 patients (#6 and #24).

Cross-reference: Tag A-2409
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Based on record review and review of hospital policies and procedures, the hospital failed to provide evidence that a) patients were informed of the risks and benefits of transfer if stabilizaiton was not possible; b) the hospital ensured there was an accepting physician and hospital prior to transferring the patient; c) the hospital ensured patients were appropriately monitored during transport; and d) the hospital sent copies of all medical records pertaining to the patient's emergency care to the receiving facility when patients were transferred to another hospital as demonstrated by 2 of 3 patient records reviewed (Patient #6, #24).

Failure to transfer patients between acute care facilities without ensuring EMTALA requirements are met risks poor health outcomes, injury and death.

Findings included:

1. Review of the Multicare Deaconess Hospital policy and procedure titled, "Emergency Medical Treatment and Active Labor Act (EMTALA), Compliance With," dated 04/18, no policy number, showed that the facility will comply with EMTALA obligations including written consent to transfer, physician certification of benefits outweigh risks of transfer, receiving facility has available space and personnel, an accepting physician, and that copies of all medical records available at the time of transfer related to the emergency medical condition are sent and that the transfer is effected using appropriate personnel, equipment, life support measures,and vehicle.

2. Review of the Multicare Deaconess Hospital policy and procedure titled, "Patient Transfer & Transport to Another Facility," dated 11/19, no policy number, showed documentation on the Patient Transfer Consent Form (Form # 88-2141-5), is required by the provider, and registered nurse (RN). Elements included on the Patient Transfer Consent include physician certification, method of transportation, receiving facility acceptance, physician-to-physician and nurse-to-nurse handoff and provision of medical record copies.

3. Review of the medical records for Patient #6 showed that the patient presented to the Emergency Department (ED) on 12/09/20 after suffering a ground level fall resulting in nasal bone fracture, facial hematoma and lacerations. Patient was transferred because there was no plastic surgeon on call. The medical record did not include evidence of the organization's form # 88-2141-5, Patient Transfer Consent Form which contains the elements listed as required by the hospital policy.

4. Review of the medical records for Patient #24 showed that the patient presented to the ED on 08/04/20 with shortness of breath and subsequent cardiac arrest. The patient was transferred to a facility with an available critical care bed. The medical record did not include evidence of the organization's form #88-2141-5, Patient Transfer Consent Form which contains the elements listed as required by the hospital policy.