HospitalInspections.org

Based on record review and interview, the facility failed to ensure all patients transferred from another facility were accompanied with transfer forms, evidence of a medical screening exam and accepted by a facility physician, in 1 of 1 received transfer record reviewed. The effect of this deficiency potentially affect all patients transferred to the facility from another hospital for treatment.

Findings include:

The facility failed to ensure patients received from other hospitals were accepted and accompanied with evidence of a medical screening exam, transfer documents and physician to physician contact. See tag C2411.

The facility failed to ensure patients received from other hospitals were accepted and accompanied with evidence of a medical screening exam, transfer documents and physician to physician contact, in 1 of 1 received transferred patient record reviewed (1). This deficiency potentially affects all patients transferred from another facility without transfer documents for medical treatment.

Findings include:

Per review of Patient #1's obstetric triage and labor documentation, Patient #1 arrived at the facility on 2/19/17 at 12:31 AM, in labor accompanied by a midwife who believed the patient may have a breech presentation and needed a cesarean section. Per the Delivery Record, at 2:02 AM Patient #1 delivered an infant vaginally. The infant was not in breech position. The patient was triaged at 12:31 AM, delivered vaginally and discharged at 4:10 AM. This was confirmed in interview during record review with Quality Compliance Coordinator E on 2/27/17 at 9:30 AM.

Per interview with Registered Nurse Legal Counsel B on 2/28/17 at 9:01 AM, s/he was made aware of Patient #1 arriving at the facility from another Eau Claire hospital on 2/19/17, and contacted the other hospital to confirm. Nurse B said after discussion with the other legal counsel they decided to report the inappropriate transfer, due to Patient #1 not having a Medical Screening Exam, proper transfer forms completed or physician to physician contact for acceptance.

Per interview on 2/28/17 at 9:25 AM with Privacy Officer C, s/he provided a copy of an email she sent to a State Agency contact, on 2/22/17 at 2:46 PM, reporting the inappropriate transfer, and requested a "read receipt:" Officer C said s/he received a relayed receipt from Mail Delivery System on 2/22/17 at 3:08 PM, that stated "Delivery to these recipients or groups is complete, but no delivery notification was sent by the destination server..." Officer C said s/he believed the email was received because the MAILER-DAEMON message said it was complete. Per Officer C, s/he never received a read receipt. Officer C was unaware that notifications from MAILER-DAEMON usually means it was not delivered.

Review of the email sent on 2/22/17 by Privacy Officer C had an obsolete email address for the State Agency contact.

Per email confirmation on 2/28/17 at 9:41 AM the intended recipient at the State Agency confirmed the email was not received.