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Based on interview, record review and a review of facility documentation, the facility failed to ensure the performance of appropriate transfers through the completion of documentation in the medical record to indicate the reasons for the requests for transfer, as well as indications as to whether or not the patient is aware of the risks and benefits of the transfer and the inclusion of physician-signed a certifications that, based upon the information available at the time of transfers, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweighed the increased risks to the individual or, in the case of a woman in labor (#1), to the woman or the unborn child, from being transferred in five of twenty sampled patients (#1, #7, #8, #13 & #18).

Findings:


A review of policy "Interfacility Transfer from a Health First Hospital to an Outside Facility" revealed the following, "Documentation forms: Patient Consent/Request/Refusal to transfer. ... Provide the patient and/or legal representation with information regarding the reason for transfer and the risks associated with the transfer." The second page of this document, as referenced in the policy, addresses reasons for the transfer, patient awareness of the risk and benefits of a transfer and a physician certification that the benefits of a transfer to another facility outweighs the risks.

During an interview of the Emergency Department (ED) Manager on 9/03/20 at 11:50 AM, she stated that the process in the ED is for the Health Unit Coordinator (HUC) to print out blank transfer documentation, including the "Patient Consent/Request/Refusal to Transfer" form and bring it to the nurse for eventual completion, including physician's signature. She then brings the completed documents back to the HUC.

1. A review of the medical record of patient #1 was performed. The patient was triaged on 7/27/20 at 5:35 PM. A physician's note of 7/27/20 at 5:44 PM, which covers events through 6:01 PM on the same day, read, "Progress and Procedures: Course of care: Helicopter transport unavailable due to bad weather. ... 911 called and is coming with lights and sirens to transport to L&D (labor and delivery) at HRMC (Holmes Regional Medical Center). ... Discussed case with on-call health care provider .... Agreed upon treatment plan. Health care provider will see patient in hospital .... Disposition ...Transferred to another Health First facility. Physician orders of 7/27/20 at 6:01 PM read, "Discharge to other HF (Health First) facility." The record did not have the "Patient Consent/Request/Refusal to Transfer" form.

On 9/02/20 at 3:32 PM, the ED physician for patient #1 stated that the patient was discharged in a stable condition when discharged and that she needed to go. He stated that Viera Hospital does not have obstetric (OB) capabilities. He stated that they always complete the "Patient Consent/Request/Refusal to Transfer" form but he could not recall specifics of this form with patient #1.

On 9/02/20 at approximately 3:48 PM, registered nurse (RN) A stated that she remembered patient #1. She could not recall any specifics regarding the "Patient Consent/Request/Refusal to Transfer" form. She stated that the HUC prints the form out and that it was the primary nurse's responsibility to get it signed.

On 9/02/20 at approximately 3:57 PM, RN B stated that she could not recall whether or not the "Patient Consent/Request/Refusal to Transfer" form was completed for patient #1.

On 9/02/20 at approximately 2:55 PM, RN C stated that she remembered the patient. She stated that she was not involved in assessing or caring for the patient. She stated that she could not remember whether the "Patient Consent/Request/Refusal to Transfer" form was completed and placed in the record. She stated that day, during the involved time period, she had to assume the HUC role because the assigned person was absent that day.

2. A review of the medical record of patient #7 was performed. The patient was triaged on 7/22/20 at 1:19 AM. A physician note of 7/22/20 at 3:30 AM read, "Reviewed CT (Computed Tomography) results, will transfer patient to HRMC as a trauma transfer. Transfer Center called. ... Disposition: Transferred to another Health First Facility." Orders for the transfer were placed at 3:31 AM on 7/22/20. The record did not have the form "Patient Consent/Request/Refusal to Transfer.

3. A review of the medical record of patient #8 was performed. The patient was triaged on 7/24/20 at 10:06 AM. A physician's note of 7/24/20 at 10:56 AM read, "Course of Care: 10:56. .... Transfer to Holmes. Physician orders of 7/24/20 at 11:04 AM read, "Discharge to other HF facility." A physician's note of 7/24/20 at 11:06 AM read, "Holmes will accept pt." The record did not have the "Patient Consent/Request/Refusal to Transfer" form.

4. A review of the medical record of patient #13 was performed. The patient was triaged on 7/26/20 at 12:59 PM. A physician's note of 7/26/20 at 4:16 PM read, "Dr. (prior shift physician) decided to transfer patient to facility with oral maxillofacial surgeon in for IV (intravenous) antibiotics. I agree with this plan having assessed the patient myself. ... Disposition: Transferred to Acute Hospital." Physician's orders of 7/26/20 at 2:37 PM read, "Discharge to other HF (Health First) facility." A physician's note at 4:55 PM on 7/26/20 read, "Patient will be transferred ground emergent ..." The record did not have the form "Patient Consent/Request/Refusal to Transfer" form.

5. A review of the medical record of patient #18 was performed. The patient was triaged on 7/06/20 at 2:44 PM. Physician's orders of 7/06/20 at 5:12 PM read, "Discharge to other HF facility." A physician's note of 7/06/20 at 7:39 PM read, "Transferred to Acute Hospital." The record did not have the "Patient Consent/Request/Refusal to Transfer" form.

The medical records for patients #1, #7, #8, #13 and #18 did not contain the completed "Patient Consent/Request/Refusal to Transfer" form, signed by the physician, which indicates the reason for a transfer request, patient awareness of the risk and benefits of a transfer and physician certification that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual, or, in the case of a woman in labor, patient #1, to the woman or the unborn child, from being transferred.