HospitalInspections.org

Based on medical record review, review of facility policy and procedures, and staff interview, the facility failed to ensure a physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual. The certification must contain a summary of the risks and benefits upon which it is based. This affected one (#1) of seven patients reviewed for transfers. A total of 20 medical records were reviewed.

See A2409

Based on medical record review, review of facility policy and procedures, and staff interview, the facility failed to ensure patients transferred to another hospital had appropriate transfers which included a summary of the risks of the transfer. This affected one (#1) of seven patients reviewed for transfers. A total of 20 medical records were reviewed.

Findings include:

Review of the medical record for Patient #1 revealed the patient presented at the facility's emergency department on 03/08/23 at 7:02 PM with multiple complaints of weakness,abdominal pain with nausea and vomiting, and let calf pain. The medical record contained documentation the patient was transferred to a higher level of care for an aortic dissection on 03/09/23 at 12:39 AM. Review medical record and the transfer document revealed the form lacked documentation of the risks of transfer.

Review of the facility policy titled "EMTALA - Transfer CP77 (Emergency Medical Treatment and Labor Act)," last revised 09/2020, directed a physician certifies and documents that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred.

Interview with Staff C on 5/23/23 at 3:00 PM confirmed the facility was unable to provide documentation the risks of transfer were explained and documented on the transfer document.