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Based on record reviews, policy and procedure reviews, and staff and family interviews, the facility failed to transfer 1 of 3 sampled patients (patient #2) to an appropriate facility that could meet the needs of the patient, which resulted in another transfer and delay of treatment.

The findings included:

Review of the medical record for patient #2 showed an emergency services run report, dated 9/2/2018 at 7:53PM, for transport to the facility.

A physician's note in the patient's chart indicated, "14 year old male presents to the emergency department (ED) for evaluation of burns to the face, torso and arms." Physician documentation also showed the patient had second degree burns on 31% of his total body surface and required intubation early in the course of his evaluation and treatment in the ED. It also stated that patient would require transfer to another hospital for more specialized care. The run report for transport from the facility, dated 9/3/2018 at 1:00AM, reflected a date of birth that would mean the patient was actually 12 years old, not fourteen as indicated by ED documetation. The date of birth on this run report was verified to be correct. Patient #2 was 12 years of age.

On 11/29/2018 at approximately 11:30AM, a phone interview was conducted with a family member of patient #2. She stated that patient #2 was transferred from the facility on 9/3/2018 and was transferred again after getting to the receiving facility because the receiving facility could not meet the needs of patient #2 based on his age. The family member stated that the sending facility was told the correct age of patient #2 during his evaluation in the emergency room.

A review of the facility Burn Management & Transfer Guidelines (PolicyStat ID: 4923120), with an origination date of 10/2013 and a most recent revision date of 09/2018, stated, "Written transfer agreements for burn care exist. See the attached phone tree for burn care referrals." Two phone trees were provided for review by the facility titled "Adult Burn Center Referral" and "Pediatric Burn Center Referral." The burn center that patient #2 was transferred to was listed on the adult burn center referral and not on the pediatric burn center referral.

On 11/30/2018 at approximately 3:47pm, an interview with staff A and Staff B indicated that patient #2 was incorrectly identified as a 14 year old, when in fact the patient was 12 years old. Staff A stated that demographic information for patients in the emergency department is only updated to correct inaccurate information if the patient is admitted to the facility, not if transferred or discharged from the emergency department.