HospitalInspections.org

Based on interview and record review, the facility failed to ensure physician certifications for transfers were completed for the time frame of April 1, 2018 to April 30, 2018. The facility failed to ensure that the physician signed the Memorandum of Transfer (MOT) Physician certification indicating risks and benefits of transfer and was explained to the patient for one (#45) of 35 patients reviewed. Also, the facility failed to ensure the physician indicated if patients were stable or unstable prior to transfers for 35 patients (#26, #27, #28, #29, #30, #31, #32,
#33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59 and #60) of 35 patients reviewed.

This deficient practice had the likelihood to cause harm to all patients needing to be transferred.


Findings include:

Review of Memorandum of Transfer (MOT) for Patient #45 revealed that the patient transfer certification was not signed off by the physician and the physician did not indicate if the patient was stable or unstable prior to transfer.

Review of the MOT's revealed no documentation that the patient had been determined to be stable or unstable prior to transfer by a physician on the following patients:

Patient #26 (4-5-2018);
Patient #27 (4-7-2018);
Patient #28 (4-8-2018);
Patient #29 (4-10-2018);
Patient #30, Patient #31 (4-11-2018);
Patient #32, Patient #33, Patient #34, Patient #35, (4-12-2018);
Patient #36 (4-13-2018);
Patient #37, Patient #38, Patient #39, Patient #41(4-16-2018)
Patient #40, Patient #42, Patient #43, (4-17-2018)
Patient #44, Patient #47, Patient #49 (4-21-2018)
Patient #46 (4-20-2018);
Patient #48, Patient #50, Patient #51 (4-22-2018);
Patient #52, Patient #53, Patient #54, Patient #57 (4-25-2018);
Patient #55, Patient #56, (4-26-2018);
Patient #58 (4-29-2018);
Patient #59, Patient #60 (4-30-2018).

On May 22, 2018 at 1127 AM during an interview, Staff #1 confirmed the above findings. Staff #1 was asked if the facility reviewed the completed MOTs. Staff #1 stated, "the house supervisors review the MOTs at the time of transfer when they sign as approval for administration".


Review of facility policy, "RIGHT AND ORGANIZATIONAL ETHICS -EMTALA-TRANSFER POLICY" with a review date of October 15 revealed the following:

...7. Physician Certification of Risks and Benefits. A physician must sign an express written
certification that, based on the appropriate information available at the time of transfer, the
medical benefits reasonably expected from the provision of appropriate medical treatment at
another medical facility outweighs the increased risks to the individual or, in the case of a
woman in labor, to the unborn child, from being transferred. The certification should meet
the following requirements:

o The certification should be specific to the condition of the patient upon transfer.

o The certification must contain a complete picture of the benefits to be expected from
appropriate care at the receiving facility as well as a summary of the material risks
associated with the transfer, including the time away from an acute care setting
necessary to affect the transfer.

o The certification must state the reason(s) for transfer. This rationale may be
documented on the certification form or elsewhere in the medical record.

o The date and time of the physician certification should closely match the date and
time of the transfer ...."