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PECONIC BAY MEDICAL CENTER
COMPLIANCE WITH 489.24
Tag No.: A2400
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Based on medical record (MR) review and document review, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA).
Findings:
The hospital failed to ensure that the "Interhospital Transfer" form, documented the benefits and risks associated with the patient's transfer and were specific to the patient's medical condition.
See Tag A-2409
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APPROPRIATE TRANSFER
Tag No.: A2409
Based on medical record (MR) review and document review, in one (1) of eight (8) medical records MRs reviewed, the hospital failed to ensure that the "Interhospital Transfer" form, documented the benefits and risks associated with the patient's transfer and were specific to the patient's medical condition.
This failure places all patients are risk for not being informed of potential risks and benefits related to the transfer.
Findings include:
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Review of the hospital's policy and procedure (P&P) titled, "Transfer of Patients Inter-Facility," reviewed 10/2016, stated the following: "The transferring physician will complete appropriate sections of the inter-hospital transfer form. Transferring physician is responsible for explanation and documentation of the risks and benefits of transfer."
Review of Patient #1's MR identified the following information: On 6/28/2023, the patient was brought to the Emergency Department with a chief complaint of falling through a glass table and cutting his left arm. The patient was diagnosed with Injury of Ulnar [forearm] Artery, Left Forearm Laceration and the physician determined that the patient needed to be transferred to another hospital.
The "Interhospital Transfer" form, dated 6/29/2023, stated the following: "My medical condition has been explained to me by the physician. The risk of transfer, such as motor vehicle accident, traffic delays, or in the case of helicopter-air crash, have been made clear. However, the following benefits have been explained to me:" This section of the form was blank.
The benefits and risks associated with the transfer and specific to the patient's medical condition were not documented.