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Based on interview and record/document review, Hospital A failed to maintain documented evidence of an appropriate inter-facility transfer for 6 of 21 sampled patients (1, 2, 5, 8, 11 and 12). Documentation of Patient 1's re-assessment after a change of condition, a transfer summary report and evidence of informed consent for the transfer were not available in the patient's medical record. In addition, Patient 2, Patient 5 and Patient 11's transfer summaries and informed consent for transfer were not available in the patients' medical records. In addition, Patient 8 and Patient 12's transfer summaries were not available in the patients' medical record. The omission of the patients' transfer summaries and informed consents, failed to ensure evidence of the required physician attestation of patient stability, informed consent and appropriateness for the inter-facility transfers.

Findings:

1. Patient 1 was admitted to Hospital A's Emergency Department (ED) via paramedics on 12/24/15 at 7:34 A.M. per the Assessment History Report. Patient 1's family members stated the the patient was observed with new onset difficulty speaking and weakness. A "Code Stroke" protocol (a specific set of laboratory, radiology and neurological screening examinations used in the diagnosis and treatment a suspected stroke, which is an emergent brain disorder which can cause permanent disability and/or death) was initiated upon the patient's arrival in the ED.

During an interview and joint record review, on 2/2/16 at 11:30 A.M., Medical Doctor (MD) 2 recalled Patient 1 and reviewed Patient 1's ED progress notes, dated 12/24/15. MD 2 stated that he examined the patient upon the patient's arrival in the ED. MD 2 stated Patient 1 was aphasic (unable to speak) and demonstrated decreased right sided grip strength. MD 2 stated that a head CT (computerized tomography; a specialized radiology examination used in the diagnosis of brain disorders) was completed and reviewed by the neurologist (physician specialist in nerve and brain disorders). MD 2 stated that Patient 1's aphasia and grip improved after the CT and during the on call neurologist examination. MD 2 stated that he consulted with a physician at the patient's HMO (Health Maintenance Organization) primary care hospital (Hospital B), "felt the patient was stable" and proceeded with transfer arrangements (prior to 10:00 A.M.). MD 2 recalled registered nurse (RN) 1 reported an increased facial droop and change in condition "around 10 am". MD 2 stated he re-examined the patient and spoke to the patient/family members, but acknowledged that he did not document the patient re-examination or the discussion with the patient/family members regarding the risks/benefits of the planned transfer. In addition, MD 2 stated that he had not communicated or re-consulted,with the on call neurologist, after the reported re-occurrence of the patient's symptoms.

During an interview and joint record review of nurse notes, on 2/3/16 at 7:45 A.M., RN 1 recalled Patient 1 and reviewed nurse notes, dated 12/24/15. RN 1 stated that Patient 1 was admitted as a "Code Stroke" and that he was assigned to the patient throughout the patient's ED visit. RN 1 stated that the patient's initial aphasia and right sided weakness improved after the patient returned from the initial CT exam, at approximately 8:17 A.M. RN 1 stated he then conducted a nursing assessment, assisted with the on call neurologist consultation and monitored the patient's status. RN 1 stated Patient 1's family members stated the patient was "nearly back to normal around 9:30". RN 1 stated at 10:03 A.M., he informed MD 2 of the patient's "reappearing symptoms, right side weakness, and return of facial droop." RN 1 stated he conducted a nursing re-assessment, but acknowledged that he did not document the re-assessment in the patient's medical record. RN 1 acknowledged that the next nursing note documentation occurred at 11:32 A.M. The nursing documentation indicated that the patient was transferred at "1215 (12:15 P.M.)" to the patient's primary care hospital. RN 1 acknowledged that the nursing notes did not include further nursing assessments or vital sign documentation after the change in the patient's condition at 10:03 A.M.

During an interview on 2/3/16 at 8:00 A.M., the Emergency Department Director (EDD) stated a handwritten ED Transfer Form should be completed on each patient transferred from the hospital ED to other facilities. The EDD stated the ED Transfer Form provided information regarding the patient condition at the time of discharge/transfer and included both nursing and physician summaries. The EDD stated Patient 1's ED Transfer Form was not available for review as it could not be located in Patient 1's medical record.

During a record review on 2/22/16 at 2:00 P.M., Patient 1's medical record at Hospital B was reviewed. Patient 1 was admitted to the ED of Hospital B on 12/24/16 at 12:23 P.M. after arriving by Critical Care Transport (CCT). A "Stroke Code" was also initiated on Patient 1 at Hospital B. The nursing assessment dated/timed 12/24/16 at 12:37 P.M., included the presence of right sided weakness, aphasia and right sided facial drooping. A review of Hospital B's neurology consultation note, dated 12/24/15 at 1:13 P.M., included "[Patient 1] presented with right sided weakness, facial droop and slurred speech...resolved at 0930 (9:30 A.M.)...started again at about 1030 (10:30 A.M.)...Symptoms worsened in the ambulance." In addition, Patient 1's ED Transfer Form, initiated at Hospital A, was found at Hospital B and reviewed. The Physician Summary area on the ED Transfer Form had not been completed in a thorough manner and omitted information such as a diagnosis and physician orders for transport. The Physician Summary included a checklist for "Reason for Transfer (include risk and benefit)" and "Insurance Request" checkbox had been marked with an "x". An area on the form for the physician's signature attestation for the transfer had been left blank. In addition, the Nursing Summary area on the ED Transfer Form had not been completed with regard to patient/representative transfer acknowledgements, hand off report to the receiving facility and the time of recorded vital signs. Furthermore, an attached Transfer Consent form, which indicated a patient/representative acknowledgment of explanation and acceptance of the transfer, had been left blank and unsigned.

An interview with MD 3 was conducted on 2/24/16 at 8:30 A.M. MD 3 stated he was the Tele-neurologist on call and consulted by MD 2 (the Emergency Department physician) when Patient 1 presented to the Emergency Department (ED) , on 12/24/15, with symptoms of a stroke. MD 3 stated that since Patient 1 had unknown onset of her stroke symptoms greater than 4 hours and that Patient 1's head CT (computed tomogram - a scan of the brain) was negative for bleeding or blockage of large vessels, that Patient 1 would not be a candidate for TPA (tissue plasminogen activator- a medicine that breaks down blood clots). MD 3 stated his management plan was that Patient 1 was stable for transfer to a hospital that was part of Patient 1's HMO insurance plan for further management. MD 3 stated that during his evaluation of Patient 1 that he observed her to "wax and wane" or slightly improve and worsen in her stroke symptoms; however MD 3 stated that Patient 1 did not have worsening symptoms than when Patient 1 presented to the ED. MD 3 stated that he did not have an expectation that the hospital would contact him if Patient 1 had slightly worsening symptoms as this was normally seen in this type of stroke patient. However, MD 3 stated that determination would be dictated by the hospital polices. MD 3 acknowledged that MD 2 should have documented an examination of Patient 1 after the reported change of condition and prior to transfer and that MD2 should have signed the physician attestation that Patient 1 was stable for transfer.
A second interview with MD 2 was conducted on 2/24/16 at 9:20 A.M. MD 2 stated he was the Emergency Department (ED) physician who provided care for Patient 1. MD 2 stated Patient 1 presented with signs and symptoms of a stroke and that the onset of these symptoms was unknown, but greater than the 4 hour window to treat with TPA. MD 2 stated that he consulted MD 3 who was the tele-neurologist on call and that MD 3 advised him to obtain an emergent CTA (computerized tomography angiogram- a scan of the brain and blood vessels) which was negative for any blockage of large blood vessels. MD 2 stated that MD 3 advised him that Patient 1 would be stable for transfer to a hospital that is part of her HMO health insurance plan for further management. MD 2 stated that prior to transfer of Patient 1 that he was notified by RN 1 that Patient 1 was developing facial droop and right sided weakness and that MD 2 examined Patient 1 but he did not document his physical assessment of Patient 1. MD 2 stated he did not consult MD 3 about Patient 1's worsening of stroke symptoms because Patient 1's symptoms were not worse than her "baseline" or level of presenting symptoms. MD 2 stated that Patient 1 was still not a candidate for the TPA treatment and the minor worsening of symptoms would not change the plan for transfer. MD 2 stated he discussed the transfer with Patient 1's family and that the family was in agreement, however, MD 2 stated that he did not document his conversation with the family. MD 2 acknowledged that he should have documented his physical examination of Patient 1 after the change in her condition prior to transfer. MD 2 also acknowledged that he should have documented his conversation with Patient 1's family regarding the transfer. MD 2 stated he did not recall whether he signed the physician attestation that Patient 1 was stable for transfer.
A review of the hospital policy and procedure entitled Code Stroke, dated "10/15" included "ED Procedure...Continue to monitor neurological status. Notify Neurologist STAT (immediately) of any changes."

A review of the hospital policy and procedure entitled EMTALA Compliance, dated "02/14" included "Continuous Monitoring: The medical screening examination is a continuous process reflecting ongoing monitoring in accordance with an individuals needs. Monitoring will continue until the individual is stabilized or appropriately transferred. Reevaluation of the patient must occur prior to discharge or transfer."

A review of the [name] Hospital Rules and Regulations, approved 9/18/15, included "Emergency Service Medical Record...An appropriate medical record shall be kept for every patient receiving emergency service and be incorporated in the patient's hospital record...The record shall include...Condition of the patient on discharge or transfer."

An interview with MD 1 was conducted on 2/24/16 at 9:30 A.M. MD 1 stated he is the Medical Director for the Emergency Department (ED). MD 1 stated that Patient 1 presented to the ED with an unknown onset of stroke symptoms and during the course of her ED visit, Patient 1's symptoms improved and slightly worsened but never got worse than her baseline. MD 1 stated Patient 1 was not a candidate for the TPA treatment and that she was deemed stable for transfer to the hospital that was part of Patient 1's HMO health insurance plan for supportive care. MD 1 acknowledged that MD2 should have documented Patient 1's physical assessment prior to transfer. MD 1 also acknowledged that the ED Transfer Form, discussion with patient 1's family and Transfer Consent form should have been documented by MD 2.
A review of the hospital policy and procedure entitled Contents of the Medical Record, dated "7/2015" included "Emergency Department...ED Reports must include...condition...Support that any transfer was warranted (not arbitrary). Name of receiving hospital and documentation that accompanied."

A review of the hospital policy and procedure entitled Inter-Facility Transfer, dated "8/13" included "Nursing should complete the Patient Transfer form and ensure that physician orders are present...Emergency Department transfers will be reviewed and coordinated by the ED Physician in accordance with EMTALA guidelines and [Hospital Name] Emergency Transfer Policy."

During a second interview on 2/24/16 at 1:00 P.M., RN 1 recalled that he became aware of Patient 1's plan for transfer after 9:00 A.M. RN 1 stated it was part of his responsibilities to prepare necessary forms and confirm physician orders and consent signatures. RN 1 stated that the ED Charge Nurse had final oversight of each patients' ED Transfer Forms and Transfer Consents.

During a joint interview and record review on 2/24/16 at 3:00 P.M., the EDD and Charge Nurse (CN) 2 stated that the ED/CN was responsible for oversight of the completion of the ED Transfer Form and the Transfer Consents, by the physicians and nurses. CN 2 stated that she had not maintained oversight of the completion of the ED Transfer Form and Transfer Consents prior to Patient 1's transfer.

During a joint interview on 2/25/16 at 9:15 A.M., the hospital Chief Nursing Officer (CNO) and Administrator (ADM) acknowledged that re-assessment of Patient 1's changes in condition were not documented and acted upon in accordance with the hospital policy and procedure. In addition, the CNO and ADM acknowledged that the patient's medical record had not been maintained in a manner that ensured documentation of condition stability and of an informed consent for transfer.

2. Patient 2 was admitted to the hospital ED on 8/17/15 at 8:47 P.M. with suicide ideation per the Assessment History Report.

A review of the ED physician summary included the treatment plan for patient transfer to a higher level of care at an inpatient psychiatric hospital. An addendum to the ED summary indicated that Patient 2 was transferred on 8/17/15. Patient 2's medical record did not include documented evidence of the physician attestation of the patient's stability or patient consent for the transfer. The ED Transfer Form and the Transfer Consent form were not found in the patient's medical record.

During an interview on 2/24/16 at 9:35 A.M., MD 1 stated that expectation of documented attestation of patient stability and completion of informed consents for patients transferred from the ED to other hospitals for continued treatment.

A review of the [name] Hospital Rules and Regulations, approved 9/18/15, included "Emergency Service Medical Record...An appropriate medical record shall be kept for every patient receiving emergency service and be incorporated in the patient's hospital record...The record shall include...Condition of the patient on discharge or transfer."

A review of the hospital policy and procedure entitled Inter-Facility Transfer, dated "8/13" included Nursing should complete the Patient Transfer form and ensure that physician orders are present...Emergency Department transfers will be reviewed and coordinated by the ED Physician in accordance with EMTALA guidelines and [Hospital Name] Emergency Transfer Policy.

A review of the hospital policy and procedure entitled EMTALA Compliance, dated "02/14" included "Continuous Monitoring: The medical screening examination is a continuous process reflecting ongoing monitoring in accordance with an individuals needs. Monitoring will continue until the individual is stabilized or appropriately transferred. Reevaluation of the patient must occur prior to discharge or transfer."

During a joint interview and record review on 2/24/16 at 3:00 P.M., the EDD and Charge Nurse (CN) 2 stated that the ED/CN was responsible for oversight of the completion of the ED Transfer Form and the Transfer Consents, by the physicians and nurses.

During a joint interview on 2/25/16 at 9:15 A.M., the hospital Chief Nursing Officer (CNO) and Administrator (ADM) acknowledged Patient 2's medical record had not been maintained in a manner that ensured documentation of condition stability and of an informed consent for transfer.

3. Patient 5 was admitted to the hospital ED on 12/21/15 at 5:24 A.M., after a spontaneous birth per the Assessment History Report.

A review of the ED physician summary included the treatment plan for patient/mother transfer to a higher level of care at hospital which offered obstetrics and pediatric services. Patient 5's medical record did not include documented evidence of the physician attestation of the patient's stability or patient consent for the transfer. The ED Transfer Form and the Transfer Consent were not found in the patient's medical record.

During an interview on 2/24/16 at 9:35 A.M., MD 1 stated that expectation of documented attestation of patient stability and completion of informed consents for patients transferred from the ED to other hospitals for continued treatment.

A review of the [name] Hospital Rules and Regulations, approved 9/18/15, included "Emergency Service Medical Record...An appropriate medical record shall be kept for every patient receiving emergency service and be incorporated in the patient's hospital record...The record shall include...Condition of the patient on discharge or transfer."

A review of the hospital policy and procedure entitled Inter-Facility Transfer, dated "8/13" included Nursing should complete the Patient Transfer form and ensure that physician orders are present...Emergency Department transfers will be reviewed and coordinated by the ED Physician in accordance with EMTALA guidelines and [Hospital Name] Emergency Transfer Policy.

A review of the hospital policy and procedure entitled EMTALA Compliance, dated "02/14" included "Continuous Monitoring: The medical screening examination is a continuous process reflecting ongoing monitoring in accordance with an individuals needs. Monitoring will continue until the individual is stabilized or appropriately transferred. Reevaluation of the patient must occur prior to discharge or transfer."

During a joint interview and record review on 2/24/16 at 3:00 P.M., the EDD and Charge Nurse (CN) 2 stated that the ED/CN was responsible for oversight of the completion of the ED Transfer Form and the Transfer Consents, by the physicians and nurses.

During a joint interview on 2/25/16 at 9:15 A.M., the hospital Chief Nursing Officer (CNO) and Administrator (ADM) acknowledged Patient 5's medical record had not been maintained in a manner that ensured documentation of condition stability and of an informed consent for transfer.

4. Patient 8 was admitted to the hospital ED on 6/1/15 at 8:26 P.M. with abdominal pain and vaginal bleeding per the Assessment History Report.

A review of the ED physician summary included the treatment plan for patient/mother transfer to a higher level of care level of care at hospital which offered obstetrics services. Patient 8's medical record did not include documented evidence of the physician attestation of the patient's stability for the transfer. The ED Transfer Form was not found in the patient's medical record.

During an interview on 2/24/16 at 9:35 A.M., MD 1 stated that expectation of documented attestation of patient stability for patients transferred from the ED to other hospitals for continued treatment.

A review of the [name] Hospital Rules and Regulations, approved 9/18/15, included "Emergency Service Medical Record...An appropriate medical record shall be kept for every patient receiving emergency service and be incorporated in the patient's hospital record...The record shall include...Condition of the patient on discharge or transfer."

A review of the hospital policy and procedure entitled Inter-Facility Transfer, dated "8/13" included Nursing should complete the Patient Transfer form and ensure that physician orders are present...Emergency Department transfers will be reviewed and coordinated by the ED Physician in accordance with EMTALA guidelines and [Hospital Name] Emergency Transfer Policy.

A review of the hospital policy and procedure entitled EMTALA Compliance, dated "02/14" included "Continuous Monitoring: The medical screening examination is a continuous process reflecting ongoing monitoring in accordance with an individuals needs. Monitoring will continue until the individual is stabilized or appropriately transferred. Reevaluation of the patient must occur prior to discharge or transfer."

During a joint interview and record review on 2/24/16 at 3:00 P.M., the EDD and Charge Nurse (CN) 2 stated that the ED/CN was responsible for oversight of the completion of the ED Transfer Form, by the physicians and nurses.

During a joint interview on 2/25/16 at 9:15 A.M., the hospital Chief Nursing Officer (CNO) and Administrator (ADM) acknowledged Patient 8's medical record had not been maintained in a manner that ensured documentation of condition stability for transfer.


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5. Patient 11 s medical record was reviewed on 2/24/16 at 11:30 A.M. Patient 11 presented to the emergency department (ED) in labor on 12/21/15. Patient 11 spontaneously delivered a female infant and Patient 11 was then transferred to a higher level of care because hospital A does not have OB/GYN (obstetrics and gynecology) or pediatric services to evaluate the infant. Patient 11's medical record did not contain documented evidence of a ED Transfer Form that is an attestation by the physician that the patient is stable for transfer. Patient 11's medical record did not contain documented evidence of a patient acknowledgement of risks and benefits and consent for transfer.

6. Patient 12's medical record was reviewed on 2/24/16 at 11:35 A.M. Patient 12 presented to the ED on 2/22/16 in labor. Patient 12 was transferred to higher level of care because Hospital A does not have OB/GYN services. Patient 12's medical record did not contain documented evidence that the patient ' s ED Transfer Form had been signed by the ED physician prior to the patient ' s transfer.

A review of the hospital policy and procedure entitled Contents of the Medical Record, dated "7/2015" included "Emergency Department...ED Reports must include...condition...Support that any transfer was warranted (not arbitrary). Name of receiving hospital and documentation that accompanied."

A review of the hospital policy and procedure entitled Inter-Facility Transfer, dated "8/13" included "Nursing should complete the Patient Transfer form and ensure that physician orders are present...Emergency Department transfers will be reviewed and coordinated by the ED Physician in accordance with EMTALA guidelines and [Hospital Name] Emergency Transfer Policy."


A concurrent interview with the Chief Nursing Officer (CNO) and the Emergency Department Director (EDD) was conducted on 2/25/16 at 9:30 A.M. The CNO and EDD acknowledged that the patient ED Transfer Form and patient acknowledgement and consent for transfer should have been included in the medical records for Patients 11 and 12.