HospitalInspections.org

Based on interview, record review and review of policy and procedure, the hospital failed to ensure that patients received care in a safe setting by not assuring a safe hospital-to-hospital transfer for 1 of 11 patients whose records were reviewed (Patient #1).

Failure to ensure a safe hospital-to-hospital transfer places patients at risk of harm due to placement in a hospital that cannot meet their health care needs.

Findings included:

1. On 03/25/19, at approximately 3:00 PM, the Manager of Patient Safety and Risk Management (Staff #2) stated that the hospital followed EMTALA policy, and followed the "Emergency Department Standards of Care" guidelines, when transferring/discharging patients from the ED to other facilities.

2. Record review of the hospital's policy and procedure titled, "EMTALA: General Guidelines to Examination, Treatment and Transfer of Patient," Policy #5922818, reviewed 02/19, showed that the receiving facility must have available space and personnel for the care of the patient, and must agree to accept the transfer of the patient.

a. Record review of the "Emergency Department Standards of Care" guidelines, policy #5871821, last reviewed 01/19, showed that on page 3 of 5 staff were directed to complete documentation per the EMTALA guidelines. The policy stated under #4 that report was to be communicated to the accepting RN and LIP [licensed independent practitioner] by the ED LIP, ED RN and the ED Crisis Counselor as indicated.

3. Review of Patient #1's medical record showed:

a. Patient #1 was transferred from the hospital's ED to a behavioral health hospital on 04/03/18, 04/24/18, 05/28/18, 06/19/18 and 06/28/18.

b. There was no documentation that showed that the receiving hospital had agreed to accept transfer of the patient or provide the appropriate and necessary medical care for Patient #1 on 4 of 5 transfer dates (04/03/18, 04/24/18, 05/28/18, and 06/19/18).

c. There was no documentation that showed that the sending ED RN had communicated report to the RN at the receiving hospital on 1 of the 5 dates the patient was transferred (04/03/18).

d. There was no documentation that showed that there had been physician/LIP to physician/LIP communication on 4 of the 5 dates the patient was transferred (04/03/18, 04/24/18, 05/28/18 and 06/19/18).

4. The above findings were confirmed with the Director of Compliance and Accreditation (Staff #1) and the Manager of Patient Safety and Risk Management (Staff #2) on 03/28/19 at 4:45 PM.