HospitalInspections.org

16790

Based on staff interview, review of medical records and hospital policy, it was determined that the facility failed to ensure that each patient transferred from the Emergency Department (ED) to another facility for continued care has a signed physician certification that includes a summary of the risks and benefits upon which the transfer was based. This deficiency was noted in 3 of 3 applicable medical records reviewed (MRs #1, #2 & # 3).
Findings include:
Review of MR # 1 on 9/24/2013 at approximately 12:30 PM documents that this 14 year old presented to the facility's Emergency Department (ED) on 3/3/2013 15:35 with a chief complaint of weakness. Past medical history includes obesity. The patient's glucose was elevated; Glucometer reading - 412mg/dl (Normal glucose 70-120mg/dL). After medical evaluation, the patient was transferred to another hospital.
The "Consent to Transfer and Physician Certification" form noted the risks and benefits of the proposed transfer as "deterioration and road conditions" . The physician failed to include in the physician certification, the benefits of the transfer to the patient's medical treatment and the risks to the patient.
In addition, the Physician Certification form under section (2) - "Benefits and Risks of Transfer and Hospital's Obligation to Treat" failed to indicate if the patient's Emergency Medical Condition (EMC) has been stabilized prior to the transfer.
Review of MR # 2 on 9/24/2013 at approximately 1:00 PM documents that this 12 year old patient presented to the facility's ED, on 5/6/2013 at 12:14, with a chief complaint of abdominal pain associated with tongue rash and generalized malaise/weakness. The patient was found with glucose and ketones in urine; and her finger stick revealed elevated glucose. The patient was diagnosed with diabetic ketoacidosis and transferred to another hospital after stabilization treatment.
The Consent to Transfer and Physician Certification form for this patient noted the benefit of the transfer was "specify care", and the risk was "motor vehicle accident". The risk and benefit documented by the physician were not related to the patient's medical condition/diagnosis and continued treatment. The "Benefits and Risks of Transfer and Hospital's Obligation to Treat" section of the form that required the physician to document that the patient's EMC has been stabilized was not completed.
Review of MR#3 documents a 4-year-old who was evaluated in the ED on 03/01/13 and found to have an acute exacerbation of Asthma. The patient was transferred to another facility on 03/01/13 for continued treatment of his medical condition.
The physician certification indicted the risks and benefits of the proposed transfer were "deterioration and road hazards".
The review of the facility's policy titled Emergency Department Treatment and Transfer of Patients, Policy No: A2-115 on 9/24/2013 revealed physicians are responsible for completing the "Consent to Transfer and Physician Certification". This policy was not implemented.
During interview with the Director of the Emergency Department on 9/24/13 at 14:05 (2:05 PM), the Consent to Transfer and Physician Certification forms for medical records #1, #2 & #3 were brought to his attention. The Director of the ED stated that the treating physicians did not correctly document on each patient what the risks and benefits were, and also did not indicate on the Physician Certification that patients' medical condition had been stabilized prior to the transfer of the patients.