HospitalInspections.org

Based on interview and record review, the facility failed to ensure physician certifications for transfers were complete for the timeframe of July 2017-January 2018. The facility failed to ensure physicians signed transfer certifications and indicated if the patients were stable or unstable prior to transfers.

This deficient practice had the likelihood to cause harm to all patients needing to be transferred.

Findings include:

Review of Memorandum of Transfers (MOT) revealed patient transfer certifications were not signed off by the physician on the following:

Patient #64 and #65 (01/23/2018);
Patient #63 (01/20/2018);
Patient #62 (01/18/2018):
Patient #66 (01/09/2018);
Patient #67 (01/07/2018);
Patient #41 (12/26/2017):
Patient #40 (08/23/2017);
Patient #39 (08/12/2017);
Patient #38 (08/07/2017);
Patient #68 (07/29/2017);
Patient #69 (07/18/2017);
Patient #35 (07/11/2017);
Patient #36 (07/09/2017);
And Patient #37 (07/07/2017).

Review of the MOT's revealed no documentation as to if the patients had been determined to be stable or unstable prior to transfer by a physician on the following:

Patient #70 (01/18/2018);
Patient #71 (01/19/2018);
Patient #72 (01/26/2018);
Patient #50 (12/18/2017);
Patient #51 (12/18/2017);
Patient #52 (12/19/2017);
Patient #53 (12/26/2017);
Patient #54 (12/29/2017);
Patient #55 (12/31/2017);
Patient #56 (11/20/2017);
Patient #57 (10/18/2017);
Patient #58 (10/31/2017);
Patient #57 (09/04/2017);
Patient #57 (09/23/2017);
Patient #48 (08/30/2017);
Patient #47(08/30/2017);
Patient #49 (08/21/2017);
Patient #46 (08/07/2017);
Patient #45 (07/04/2017);

During an interview on 02/27/2018 after 10:20 a.m., Staff #'s 5 and 9 confirmed the missing physician signatures certifying the transfer and the missing documentation as to if the patients were stable or not. Staff #'s 5 and 9 confirmed they were not checking the forms to make sure they were completed timely and accurately.

Review of the facility's policy named "Patient Transfers- Hospital to Hospital-1.080" dated 03/23/2016 revealed the following:

"VI. Memorandum of Transfer:..
B. The Memorandum of Transfer will be signed by the transferring physician or, if not present, a hospital staff member acting under the physician's order if a delay in transferring has been determined to be detrimental to the patient. If a patient with an emergency medical condition which has not been stabilized is transferred, the transferring physician shall complete, or have completed by a qualified person at the hospital, if the physician is not physically present in the emergency department at the time of the transfer, on the Memorandum of Transfer a certification statement that the medical treatment at another facility outweigh the increased risks of the transfer to the patient and in the case of labor, the unborn child. The physician shall countersign the certification as soon as possible if initially completed by hospital personnel. The Memorandum of Transfer must also be signed by a hospital administration representative ...."

Based on interview and record review the facility failed to ensure physician certifications for transfers were complete for the timeframe of July 2017-January 2018. The facility failed to ensure physicians signed transfer certifications and indicated if the patients were stable or unstable prior to transfers.

This deficient practice had the likelihood to cause harm to all patients needing to be transferred.

Findings include:

Review of Memorandum of Transfers (MOT) revealed patient transfer certifications were not signed off by the physician on the following:

Patient #64 and #65 (01/23/2018);
Patient #63 (01/20/2018);
Patient #62 (01/18/2018):
Patient #66 (01/09/2018);
Patient #67 (01/07/2018);
Patient #41 (12/26/2017):
Patient #40 (08/23/2017);
Patient #39 (08/12/2017);
Patient #38 (08/07/2017);
Patient #68 (07/29/2017);
Patient #69 (07/18/2017);
Patient #35 (07/11/2017);
Patient #36 (07/09/2017);
And Patient #37 (07/07/2017).

Review of the MOT's revealed no documentation as to if the patients had been determined to be stable or unstable prior to transfer by a physician on the following:

Patient #70 (01/18/2018);
Patient #71 (01/19/2018);
Patient #72 (01/26/2018);
Patient #50 (12/18/2017);
Patient #51 (12/18/2017);
Patient #52 (12/19/2017);
Patient #53 (12/26/2017);
Patient #54 (12/29/2017);
Patient #55 (12/31/2017);
Patient #56 (11/20/2017);
Patient #57 (10/18/2017);
Patient #58 (10/31/2017);
Patient #57 (09/04/2017);
Patient #57 (09/23/2017);
Patient #48 (08/30/2017);
Patient #47(08/30/2017);
Patient #49 (08/21/2017);
Patient #46 (08/07/2017);
Patient #45 (07/04/2017);

During an interview on 02/27/2018 after 10:20 a.m., Staff #'s 5 and 9 confirmed the missing physician signatures certifying the transfer and the missing documentation as to if the patients were stable or not. Staff #'s 5 and 9 confirmed they were not checking the forms to make sure they were completed timely and accurately.

Review of the facility's policy named "Patient Transfers- Hospital to Hospital-1.080" dated 03/23/2016 revealed the following:

"VI. Memorandum of Transfer:..
B. The Memorandum of Transfer will be signed by the transferring physician or, if not present, a hospital staff member acting under the physician's order if a delay in transferring has been determined to be detrimental to the patient. If a patient with an emergency medical condition which has not been stabilized is transferred, the transferring physician shall complete, or have completed by a qualified person at the hospital, if the physician is not physically present in the emergency department at the time of the transfer, on the Memorandum of Transfer a certification statement that the medical treatment at another facility outweigh the increased risks of the transfer to the patient and in the case of labor, the unborn child. The physician shall countersign the certification as soon as possible if initially completed by hospital personnel. The Memorandum of Transfer must also be signed by a hospital administration representative ...."