HospitalInspections.org

Based on document review and interview, it was determined that 1 in 25 patients who presented to the Emergency Department requesting medical services, the facility failed to ensure compliance with 489.24 in that the facility failed to stabilize patient #25 prior to transfer to the receiving hospital.

Findings include:

1. See findings at 42 CFR 482.24 (e) (1-2)

Based on document review and interview, the facility failed to ensure communication with an accepting physician prior to transfer and completion of certification of risks and benefits form prior to transfer for 1 of 25 patients. (patient #25).

Findings included:

1. Review of patient #25's Medical Record Admission Log on 3/3/2019, indicated patient arrived at facility #1's Emergency Department (ED) at 0159 hours, via Emergency Medical Services (EMS) ambulance. EMS personnel had called report to ED personnel, stroke protocol initiated, and patient taken directly to Computerized Tomography (CT) upon arrival at ED.
2. Review of CT head/brain scan by Qualified Medical Professional (QMP) #3, MD, Radiologist, on 3/3/2019 indicated: Impression: Significant intraventricular hemorrhage throughout the right lateral ventricle.
3. Review of MR lacked documentation of communication with an accepting physician prior to the transfer and lacked documentation of completion of certification of risks and benefits form.