HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined the facility failed to ensure that the staff explained the risks and benefits of transfers, and send copies of the patient ' s medical records when they were transferred to another hospital. This was found in 2 of 5 medical records (MR # 48 and MR # 52).

Findings include:

MR #48 was reviewed on 9/5/13 at 11:30 a.m. The record revealed that this thirty-six year old patient presented to the facility on August 30, 2013 at 4:22 PM for a possible allergic reaction. Upon arrival the patient had intermittent chest tightness.

On August 30, 2013 an Electrocardiogram was done which revealed 116 beats per minute with ST depression. The patient was transferred to another hospital at 12:24 AM on August 31, 2013 while she was receiving 2 Liters of oxygen.

There was no documentation in the medical record that the staff explained the risks and benefits of transfer to the patient or whether a copy of the medical record was sent with the patient to the recipient hospital.

During staff interview conducted on September 5, 2013 at approximately 3:00 PM, Staff #7, the Director of Patient Services, stated that the facility always sends a copy of the medical record with the patient. Staff #7 also stated that the risks and benefits are explained to the patient prior to transfer,


MR #52 was reviewed 9/5/13 at 2 p.m. A review of the medical record revealed that the patient was a seventy-two year old patient who was brought to the hospital by ambulance on September 6, 2013 at 12:33 AM with a history of altered mental status after he had eloped from another hospital. The patient was unable to sign admitting forms upon arrival "due to medical reasons."

Blood tests were abnormal and the patient was transferred from the hospital at 6:17 AM that morning to another acute care hospital.

There was no evidence in the medical record that a copy of the patient's medical record including labs and chest x-ray results were sent along with the patient to the recipient hospital.

The facility's policy titled "Transfer Of Patient For Evaluation/Admission To Another Facility" was reviewed on 9/6/13 at 2 p.m. This policy was revised March 16, 2012 and it stated a "transfer summary (including pertinent lab and x-ray reports, legal papers and EMTALA Inter-Intuitional Transfer Form" "must be completed." The policy does not state a copy of the medical record should be sent with the patient

During staff interview conducted on September 5, 2013 at approximately 3:00 PM, Staff #7, the Director of Patient Services, stated that the facility always sends a copy of the medical record with the patient. Staff #7 also stated that the risks and benefits are explained to the patient prior to transfer.