HospitalInspections.org

Based on review of documentation and interviews with the facility staff, the facility failed to ensure appropriate transfers were conducted in 1 out of 26 patients (Patient #1) as evidenced by the Memorandum of Transfer (MOT) not including the transfer risk specific to Patient #1.


The findings were:
The facility document titled, "EMTALA Registration Medical Screening Exam (MSE)," last updated 3/29/23, states, "When the Hospital transfers an individual with an unstabilized emergency medical condition to another facility, the transfer will be carried out in accordance with the following procedures ... The Hospital will send the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (2) records related to the individual's emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; and (8) a copy of the completed applicable sections of the Memorandum of Transfer (MOT) ..."


The complete medical record review of Patient #1's Emergency Department (ED) visit on 5/17/23 was performed on 9/6/23. It was noted:
The "Transfer Risk" section of the Memorandum of Transfer (MOT) form was left blank by the facility. This section states, "All transfers have inherent risk of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transport units that may limit care in the event of a crisis. In addition, specific risks of transfer to this patient may include: [blank]"


The surveyor interviewed Staff #7 (the ED physician that took care of Patient #1) via email:
Surveyor: Why was the patient transported by private vehicle to another hospital, instead of ambulance?

Staff #7: "In terms of method for transfer, my practice is to have a discussion with the patient and present all of the possible options, including risks and benefits of the various forms of transfer. If the patient was transferred by private vehicle, then the patient was a) stable for transfer by private vehicle, and b) chose that mode of transfer after discussion of risks/benefits."