HospitalInspections.org

Based on a review of medical records, review of policies and procedures, and interviews with key personnel on December 4, 2013 at approximately 1615, it was determined that the facility failed to provide the required written risks and benefits of transfer to the patient's guardian prior to transfer.

The findings include:

1. 42 CFR 489.24(e)(1)(ii)(A) states: "...The request must be in writing and indicate the reasons for the request as well as indicate that he/she is aware of the risks and benefits of the transfer..."

2. TAMC EMTALA policy states: "TAMC may not transfer or discharge the patient unless: ...the patient ...is aware of the risks and benefits of transfer, must be filed in the patient's medical record ..."

3. A review of Record U was conducted on December 4, 2013, and it was determined that the record failed to contain the required documentation.

4. During an interview with the Emergency Department Director at 1530, following his review of the patient ' s medical record, he stated: "I'm not seeing where the risks and benefits were explained to the mother ...I looked in the dictation ...It's not there ..."