HospitalInspections.org

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that medical records were complete and consistent with hospital policies and procedures for three of four transfer records reviewed (MR19, MR20, and MR47).

Findings include:

Review of facility policy and procedure "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated December 30, 2011, revealed "V. Procedure ... 5. ... If the hospital determines that it does not have appropriate medical and/or staffing resources to properly stabilize the patient, transfer to an appropriate facility may be made if a physician certifies in writing that the medical benefits of the transfer are expected to outweigh the risks of transfer; or if a QMP(Qualified Medical Person) certifies in writing that the benefits of transfer are expected to outweigh the risks of transfer, and such certification is co-signed by a physician."

1) Review of MR19, MR20, and MR47 revealed no documentation that a physician certified, in writing, that the medical benefits of the transfer were expected to outweigh the risks of transfer; or if a QMP(Qualified Medical Person) certified in writing that the benefits of transfer were expected to outweigh the risks of transfer, and such certification was co-signed by a physician.

Interview with EMP3 on July 18, 2012, at approximately 2:30 PM confirmed the above findings and revealed "It's on the transfer form, but it's(transfer form) not there."

2) A transfer policy was requested on July 19, 2012, from the facility and was not produced.

Interview with EMP1 on July 19, 2012, at approximately 3:00 PM confirmed the above findings and revealed "No, we don't have a transfer policy."