HospitalInspections.org

25730

Based on interview and record review, the facility failed to complete the "Patient Transfer: Physician Certification and Assessment" form for two of the twenty sampled patients when the attending physicians did not sign this form for Patient 72 and Patient 80.

Findings:

1. Record review indicated Patient 72 was seen in the hospital's Emergency Department (ED) on 10/1/15 for a chief complaint of cough and shortness of breath. During the Medical Screening Examination, the ED Physician (MD 6) determined that Patient 72 had bilateral pneumonia and needed to be transferred to a higher level of care. MD 6 and the attending Registered Nurse (RN 2) completed the necessary steps to make this transfer occur but MD 6 failed to sign the form "Patient Transfer: Physician Certification and Assessment."

During an interview on 10/12/15 at 3:45 PM, the hospital's ED Director reviewed Patient 72's ED record and confirmed that MD 6 had not signed the Physician Certification form.

The hospital's Policy and Procedure titled Transfer of Individuals with Emergency Medical Conditions, dated 9/14, stated "The individual may be transferred if a physician has documented in the 2 page form , 'Patient Transfer: Physician Assessment & Certification' that the transfer shall not create a medical hazard for the individual."

MD 6 did not comply with this policy and procedure when he did not sign this form for Patient 72.


26616


2. Record review indicated Patient 80 was seen in the hospital's ED on 9/1/15, brought in by his parents who were concerned about the patient been crying and not getting enough milk from mother who was breastfeeding him. The patient was a 2 (two) days old baby. MD 7 (ED Physician) seen and examined Patient 80 which the Doctor Notes indicated, "I do not think that this child is critically ill, but is hungry and mother is unable to produce milk or colostrum (mother's first milk). He (receiving physician at another hospital) will arrange direct admission to the NICU (Neonatal Intensive Care Unit)." MD 7 completed the form "Patient Transfer: Physician Assessment and Certification", however, the Section 3: Physician Certification MD Signature was not signed by MD 7.

During an interview on 10/13/15 at 9:45 AM, the ED Director verified the "Patient Transfer: Physician Assessment and Certification" form was not signed by MD 7. ED Director stated the form had to be signed by MD 7.



27921