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AKRON CHILDREN'S HOSPITAL

1 PERKINS SQUARE

AKRON, OH 44308

COMPLIANCE WITH 489.24

Tag No.: A2400

Based on medical record review, policy review, and staff interview, the facility failed to ensure a physician signed the certification for patient transfer (A 2409).

APPROPRIATE TRANSFER

Tag No.: A2409

Based on medical record review, policy review, and staff interview, the facility failed to ensure a physician signed the certification for patient transfer for three of four transfer records reviewed (Patients #6, #7 and #9). A total of 20 medical records were reviewed.

Findings include:

Review of the facility policy titled, EMTALA Policy, current effective date 06/29/20, stated under Required Elements of an "Appropriate Transfer" that the physician has signed a certification that, based on information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual (and, in the case of a woman in labor, also to the unborn child). The certification must: a) Be in writing; b) Include a summary (specific to the patient) of the risks/benefits upon which the certification is based (including time away from an acute care setting necessary to effect the transfer) (or in medical record); and c) Dated, timed, and signed by the physician.

1. Review of the medical record for Patient #6 revealed the patient was transferred to a different facility on 02/23/23 for a diagnosis of Suicidal Ideation. The medical record did not contain a signed physician certification for the transfer.

2. Review of the medical record for Patient #7 revealed the patient was transferred to a different facility on 01/11/23 for a diagnosis of Suicidal Ideation. The medical record did not contain a signed physician certification for the transfer.

3. Review of the medical record for Patient #9 revealed the patient was transferred to a different facility on 03/30/23 for a diagnosis of Chest Pain. The medical record did not contain a signed physician certification for the transfer.

On 06/12/23 at 7:19 AM, the findings were shared with Staff F and Staff G and confirmed.