HospitalInspections.org

Based on record review and interview, the hospital failed to ensure transfer documents are completed with risks of transfer unique to the patient. This deficiency potentially affects all patients treated at the facility.

Findings include:

The hospital failed to ensure that physician certification documentation of transfer risks was specific to the patient's condition. See tag C-2409

Based on record review and interview, the facility failed to ensure that physician certification documentation of transfer risks was specific to the patient's condition, in 7 of 15 medical records of transferred patients (9, 10, 14, 15, 17, 18 and 20), out of a total 20 medical records reviewed.

Findings include:

Per review of facility policy titled Transfers, Emergency (Hospital to Hospital), dated 6/2007, it states under F "...All patients being transferred will be informed of the risks and benefits of the transfer."

Patient #9's medical record review revealed Patient #9 was in the emergency room on 7/12/16 with a diagnosis of anemia (low hemoglobin or oxygen in the blood) due to a gastrointestinal bleed. Patient #1 receives dialysis which is not available at the facility. Patient #1 was transferred to an acute care hospital to be treated for anemia and receive dialysis. The Authorization of Transfer form completed on 7/12/16 states under Risks "none", rather than a condition specific risk.

Patient #10's medical record review revealed Patient #10 was in the emergency room on 7/3/16 with a diagnosis of right femur (upper leg bone) fracture. Patient #10 was transferred to an acute care hospital for orthopedic care that is not available at the facility. The Authorization of Transfer form completed on 7/3/16 states under Risks "ambulance" rather than a condition specific risk.

Patient #14's medical record review revealed Patient #14 was in the emergency room on 7/13/16 with a diagnosis of suicide attempt. Patient #14 was transferred to a hospital for psychiatric care, via police, that is not available at the facility. The Authorization of Transfer form completed on 7/14/16 states under Risks "suicide/car transfer", rather than risks of transfer specific to Patient #14's condition, and/or non-medical assisted transfer.

Patient #15's medical record review revealed Patient #15 was in the emergency room on 7/3/16 with a diagnosis of myocardial infarction (heart attack). Patient #15 was transferred to an acute care hospital for cardiology not available at the facility. The Authorization of Transfer form completed on 7/3/16 states under Risks "ambulance", rather than a condition specific risk.

Patient #17's medical record review revealed Patient #17 was in the emergency room on 7/16/16 with a diagnosis of fractured pelvis. Patient #17 was transferred to an acute care hospital for trauma surgery not available at the facility. The Authorization of Transfer form completed on 7/16/16 states under Risks "helicopter/trauma", rather than a condition specific risk.

Patient #18's medical record review revealed Patient #18 was in the emergency room on 7/3/16 with a diagnosis of unstable angina (chest pain). Patient #18 was transferred to an acute care hospital for cardiology not available at the facility. The Authorization of Transfer form competed on 7/3/16 states under Risks "ambulance/MVA (motor vehicle accident)", rather than a condition specific risk.

Patient #20's medical record review revealed Patient #20 was in the emergency room on 7/8/16 with a diagnosis of Subdural Hematoma (blood under skull and outside the brain). Patient #20 was transferred to an acute care hospital for neurological care not available at the facility. The Authorization of Transfer form completed on 7/8/16 states under Risks "Subdural Hematoma" rather than risks of transfer specific to Patient #20's condition.

The above is confirmed in interview with Director of Emergency Services C during record reviews on 7/25/16 between 11:00 AM and 2:00 PM, who agreed the risks should be patient condition specific.