HospitalInspections.org

Based on medical record review, document review and interview, it was determined that in 1(patient #1) of 20 records reviewed of patients who presented to the hospital requesting emergency services , the facility failed to ensure compliance with 489.24 in that the facility failed to provide an appropriate transfer.

Findings include:

1. See findings cited at 489.24 (e) A2409.

Based on medical record review, document review and interview, the facility failed to follow its policy on patient transfers to another facility and failed to provide an appropriate transfer for 1 of 5 Emergency Department (ED) patients transferred to another acute care facility (Patient #1) in that the facility lacked documentation of a signed physician certification which included risk and benefits, lacked documentation of communication with the receiving facility to indicate that the facility had accepted the patient and lacked any evidence that the required medical record information was sent to the receiving facility.


Findings include:

1. Review of policy/procedure Immediate Transfer of the Emergency Services Patient to Another Facility, indicated the following:

"Policy
1. An Emergency Physician will perform a medical screening exam, treat and stabilize the patient and initiate transfer.
2. The patient family must be notified immediately of transfer. Risks and benefits of transfer will be reviewed by the physician.
4. An Emergency Physician will order the method of transportation considering patient's condition.
5. The transferring physician must consult with the receiving physician and document acceptance of the patient.
6. Immediate Transfer Form #503712 must be completed and signed by the patient or family member, physician and nurse.
7. The patient's primary nurse will report clinical information to the receiving facilities nurse."
This policy/procedure was last reviewed/revised on 01/09.

2. Review of patient #1's MR indicated the patient presented to the facility Emergency Department (ED) on 04-07-11 at 1602 hours with a triage complaint of "I'm feeling anxious and suicidal today." The ED physician ordered a psychiatric evaluation. The Psych Evaluation dated 04-07-11 at 1828 hours written by staff #45 indicated the following; "Pt triaged states she feel off the cliff and into deep pool and can't get out. States calmly she's having suicidal thoughts of jumping off G Street bridge... Called [MD #2] and [staff #43] suggested to call [facility #2] to see if any available beds since patient is with [Faciliy #4] and pt has been here several times. Pt has never been to [facility #2] may be better fit for pt. [Facility #2] had 2 female beds open. [Staff #53] from[ facility #4] said will take pt to[ facility #2] to get pt admitted to adult unit pt agreed and left with [staff #53] to be admitted to[ facility #2] Adult Psych unit." The Emergency Services Physician Orders/Disposition indicates the patient was released per psych services on 04-07-11 at 1835 hours.

3. There was no written evidence that the ED MD and patient signed the Immediate Transfer Form #503712 as required per policy. There was no evidence of a signed physician certification documenting the risks and benefits of the transfer. There was no documentation of the condition on disposition of the patient, no documentation that the ED MD communicated with the receiving physician, no documentation that the receiving facility had accepted patient #1, and there was no evidence to indicate the required medical record information was sent to the receiving facility.

4. On 04-18-11 at 1150 hours staff #43 confirmed that staff #45 should have documented the discharge instructions or if patient was being transferred to another facility, he/she should have documented this on the Emergency Services Physician Order Sheet and then should have contacted the ED MD.