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Based on record review and interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer. In the last six months, the facility saw 15,140 patients and 371 patients were transferred to other facilities.

See A2409

Based on record review and interview, the facility failed to ensure individuals who were transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer. This affected five (Patients #6, #7, #8, #9, and #11) of six medical records of transferred patients reviewed. In the last six months, the facility saw 15,140 patients and 371 patients were transferred to other facilities.

Findings include:

1. Review of the medical record for Patient #6 revealed an arrival date of 06/27/24 at 7:53 PM to the emergency department. The medical record contained documentation the patient had a displaced femur fracture and was transferred to a higher level of care. The "Transfer Summary" form signed by the physician lacked documentation of patient specific risks and benefits of the transfer.

2. Review of the medical record for Patient #7 revealed an arrival date of 07/14/24 at 12:43 PM to the emergency department. The medical record contained documentation the patient had a non-traumatic subarachnoid hemorrhage and was transferred to a higher level of care for neurosurgical evaluation by air ambulance. The "Transfer Summary" form signed by the physician lacked documentation of patient specific risks and benefits of the transfer.

3. Review of the medical record for Patient #8 revealed an arrival date of 07/04/24 at 9:14 PM to the emergency department. The medical record contained documentation the patient was suicidal and was transferred to an inpatient psychiatric facility. The "Transfer Summary" form signed by the physician listed only "psych" in the patient specific risks and benefits of the transfer.

4. Review of the medical record for Patient #9 revealed an arrival date of 10/12/24 at 10:14 PM to the emergency department. The medical record contained documentation the patient was suicidal and was transferred to an inpatient psychiatric facility. The "Transfer Summary" form signed by the physician lacked documentation of patient specific risks and benefits of the transfer.

5. Review of the medical record for Patient #11 revealed an arrival date of 09/28/24 at 4:31 PM to the emergency department. The medical record contained documentation the patient had displaced fractures of the tibia, fibula, and humerus and was transferred to a higher level of care. The "Transfer Summary" form signed by the physician lacked documentation of patient specific risks and benefits of the transfer.

Review of the "Transfer Summary" form revealed three sections, Patient Transfer Request, Physician Certification, and Transfer Information. Under the Physician Certification section, there was a pre-printed section that stated: "Risks of all transfers include the possibility that the patient's condition may worsen en route; patient may be injured by a vehicular accident or equipment failure; and if the patient is in labor, she may progress to delivery while en route. Summary of additional risks/benefits:".

During an interview on 12/11/24 at 2:07 PM, Staff B and Staff C verified the above findings.