HospitalInspections.org

Based on document review and interview, the facility failed to comply with 489.24 for 1 of 20 Emergency Department (ED) medical records (MR) reviewed (1).

Findings include:

1. See under tags 2406 (489.24 (c) & (r) ) and 2409 (489.24 (e)).

Based on interview and document review, the facility failed to maintain medical records (MR) related to individuals transferred from the hospital for a period of 5 years from the date of the transfer for 1 of 12 Emergency Department transferred MRs reviewed (1).

Findings include:

1. On 03-04-10 at 1155 hours, staff #42 confirmed that patient #1 presented to the facility on 01-31-10 and there was no MR of patient #1's visit.

2. On 03-04-10 at 130 hours, staff #44 confirmed that patient #1 was brought into the facility Emergency Department via ambulance. Staff #44 told ambulance personnel that MD #1 wanted the patient to go to facility #2 and the ambulance personnel agreed and rolled the patient out of the Emergency Department. Staff #44 confirmed that MD #1 did not see the patient in the Emergency Department.

3. Review of the New Albany Fire Department documentation dated 01-31-10 indicated the ambulance arrived at the facility with patient #1 on 01-31-10 at 1930 hours and indicated the following:
Upon arrival at facility #1, control stated immediate transfer to facility #2. The New Albany Fire Department documentation indicated the ambulance left with the patient on 01-31-10 at 1930 hours and arrived at facility #2 on 01-31-10 at 1954 hours.

Based on interview and document review, the facility failed to to maintain a central log on each individual who comes to the emergency department, seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 of 20 Emergency Department medical records (MR) reviewed (1).

Findings include:

1. Review of the Emergency Department Patient Log Book indicated lack of documentation that patient #1 was recorded as presenting to the facility Emergency Department on 01-31-10 at 1930 hours and the disposition of the patient.

2. On 03-04-10 at 1155 hours, staff #42 confirmed that patient #1 presented to the facility on 01-31-10 and there was no MR of patient #1's visit.

3. On 03-04-10 at 130 hours, staff #44 confirmed that patient #1 was brought into the facility Emergency Department via ambulance. Staff #44 told ambulance personnel that MD #1 wanted the patient to go to facility #2 and the ambulance personnel agreed and rolled the patient out of the Emergency Department.

4. Review of the New Albany Fire Department documentation dated 01-31-10 indicated the ambulance arrived at the facility with patient #1 on 01-31-10 at 1930 hours and indicated the following:
Upon arrival at facility #1, control stated immediate transfer to facility #2.

Based on interview and document review, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists for 1 of 20 Emergency Department medical records (MR) reviewed (1).

Findings include:

1. Review of policy/procedure E-3, Screening, Stabilization, and Transfer of Emergency Patients, indicated the following:
Responsibilities
II. Physician
a. Medical screening exam, medical stabilization, and determination of the need for transfer to another facility. Medical stabilization may include performing specific tests critical to treatment and stabilization of patient and will be determined by the treating physician.
This policy/procedure was last reviewed/revised on 03/05.

2. On 03-04-10 at 1155 hours, staff #42 confirmed that patient #1 presented to the facility on 01-31-10 and there was no MR of patient #1's visit.

3. On 03-04-10 at 130 hours, staff #44 confirmed that patient #1 was brought into the facility Emergency Department via ambulance. Staff #44 told ambulance personnel that MD #1 wanted the patient to go to facility #2 and the ambulance personnel agreed and rolled the patient out of the Emergency Department. Staff #44 confirmed that MD #1 did not see the patient in the Emergency Department.

4. Review of the New Albany Fire Department documentation dated 01-31-10 indicated the ambulance arrived at the facility with patient #1 on 01-31-10 at 1930 hours and indicated the following:
Upon arrival at facility #1, control stated immediate transfer to facility #2. The New Albany Fire Department documentation indicates the ambulance left with the patient on 01-31-10 at 1930 hours and arrived at facility #2 on 01-31-10 at 1954 hours.

5. There was no written evidence that a medical screening exam was performed by a physician on patient #1.

Based on document review and interview, the facility failed to ensure an appropriate transfer for 1 of 12 Emergency Department (ED) transfer medical records (MR) reviewed (1).

Findings include:

1. Review of policy/procedure E-3, Screening, Stabilization, and Transfer of Emergency Patients, indicated the following:

Responsibilities
II. Physician
a. Medical screening exam, medical stabilization, and determination of the need for transfer to another facility. Medical stabilization may include performing specific tests critical to treatment and stabilization of patient and will be determined by the treating physician.
c. Sign a transfer consent certification form that is based on available information at the time of transfer stating that the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the risks to the individual from the transfer. This must include a summary of the benefits and risks of such a transfer.
d. Discuss directly with the patient and/or family the risks, benefits, or alternatives of transfer.
f. Communicate directly with receiving physician and facility to give report of the patient needs and condition and to acquire acceptance of the transfer.

III. Registered Nurse
d. Ensure that appropriate patient information accompanies the patient:
i. Transfer form for Emergency Room Patients.
e. Ensure that an accepting physician at the receiving facility has been obtained.
f. Notify the receiving facility and ensure agreeability of transfer and bed availability.
This policy/procedure was last reviewed/revised on 03/05.

2. On 03-04-10 at 1155 hours, staff #42 confirmed that patient #1 presented to the facility on 01-31-10 and there was no MR of patient #1's visit.

3. On 03-04-10 at 130 hours, staff #44 confirmed that patient #1 was brought into the facility Emergency Department via ambulance. Staff #44 told ambulance personnel that MD #1 wanted the patient to go to facility #2 and the ambulance personnel agreed and rolled the patient out of the Emergency Department. Staff #44 confirmed that MD #1 did not see the patient in the Emergency Department.

4. Review of the New Albany Fire Department documentation dated 01-31-10 indicated the ambulance arrived at the facility with patient #1 on 01-31-10 at 1930 hours and indicated the following:
Upon arrival at facility #1, control stated immediate transfer to facility #2. The New Albany Fire Department documentation indicated the ambulance left with the patient on 01-31-10 at 1930 hours and arrived at facility #2 on 01-31-10 at 1954 hours.

5. There was no written evidence that the ED MD signed a transfer consent certification form, that the risks and benefits were discussed with the patient and/or responsible party, that the ED MD communicated with the receiving physician, that the receiving facility had accepted patient #1, and the required documentation was sent to the receiving facility.