HospitalInspections.org

Based on interview and record review, it was determined that the hospital's dedicated Emergency Department (ED) failed to comply with the requirements for the Emergency Medical Treatment and Labor Act (EMTALA) at 42 CFR §489.20 (Patient Identifier #1).

Findings include:

The hospital failed to ensure appropriate transfers for 1 of 20 emergency room records reviewed. Refer to C2409: Appropriate Transfer.

47129


Based on interview and record review, it was determined that the hospital failed to send medical records related to the emergency condition available at the time of transfer for 1 of 20 patients reviewed presenting to the Emergency Department (ED) (Patient Identifier #1).

Findings include:

Review on 10/14/24 of Patient #1's medical record revealed that Patient #1 arrived at the ED by private vehicle and was admitted to the ED on 9/1/24 at 8:04 p.m. with hip pain (with redness and swelling). The patient was seen by multiple providers during the ED stay, including an orthopedic consult done on 9/2/24 at 9:01 a.m. Laboratory testing and a Computed Tomography (CT) scan were performed. The patient was started on antibiotics and other medications during the course of the ED visit.

Review on 10/14/24 of Patient's #1's "Notice of Risks and Benefits and Physician's Certificate to Transfer" revealed that the form was signed by the Ambulance Service on 9/2/24 at 11:01 a.m.

Review of the "EMS [Emergency Medical Services] Prehospital Incident Report...", dated 9/2/24 revealed that the patient arrived at the receiving hospital on 9/2/24 and care of the patient was transferred at 12:07 p.m.

Interview 10/16/24 at 9:50 a.m. with Staff M (EMS Coordinator) from the receiving hospital revealed that Staff M accepted the transfer of care from the ambulance service. Staff M stated that the ambulance service was given a transfer form but denied being given any medical records from the sending hospital at the time of transfer. Staff M called the sending hospital to request medical records.

Interview on 10/16/24 on 11:45 a.m. with Staff N (Emergency Medical Technician) from the transportation company revealed that Staff N provided all the documentation that was given to him/her from the sending hospital to the receiving hospital.

Interview on 10/14/24 at 1:00 p.m. with Staff A (Risk Manager) from the sending hospital revealed that he/she was notified by the receiving hospital on 9/4/24 that Patient#1 had been transferred without medical records. Staff A confirmed that Patient #1's medical record was faxed to the receiving hospital after the patient had arrived there.

Interview on 10/14/24 at approximately 2:30 p.m. with Staff C (Director of Compliance) revealed that they were aware of the above incident, but since the records had been sent to the receiving hospital, they did not believe there was any corrective actions necessary.