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Based on review of facility documents, and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure adopted policies were followed related to the transferring of patients to a receiving facility, failed to ensure that all pertinent medical and social information was sent with the patient upon transfer, and failed to ensure that the patient's physical condition was documented in the medical record upon discharge.

This is not met as evidenced by:

Based on a review of medical records (MR) and facility documentation and staff interviews (EMP), it was determined that the facility failed to notify the receiving hospital prior to transfer and to send the patient's medical record for one of 13 medical records reviewed (MR1).

Findings included:

Review of facility policy "Transfer Policy" reviewed August 2010 revealed "...F. The Emergency Department physician at the receiving facility must be notified by the transferring physician. A report between the two physicians must be initiated prior to transfer...G. Copies of Medical Records, related to the emergency condition , which are available at the time of transfer, must accompany the patient...A. Physician responsibility...2. For a transfer to another facility...Makes a physician to physician call to receiving facility to assure acceptance of patient...B. Registered Nurse responsibility...2. For transfer to another facility...Assure that a copy of patient's record and testing accompany patient..."

1) Review of the Emergency Room Clinical Facesheet revealed that MR1 presented to the facility's Emergency Department on July 16, 2011 at 6:15 PM with a complaint of "visual disturbances."

2) Review of physician's documentation dated July 16, 2011 at 6:15 PM revealed and dictated on July 16, 2011 at 7:18 PM revealed "...Medical Decision Making: ... presents with acute visual disturbances...spoke with Dr. ... on call for ophthalmology who suggested transfer to (receiving facility) for a thorough ophthalmologic evaluation including retinal exam. I presently have a call out to (receiving facility) ophthalmology and am awaiting call back...Disposition: Transfer to (receiving hospital)..."

3) Review of Patient Discharge Instructions dated July 16, 2011 at 7:16 PM revealed "...The following note(s) should be read carefully: Go to (receiving hospital's) ER now..."

4) Review of Emergency Department Order/Flow Sheet dated July 16, 2011 revealed "...Nurse's Summary 7:25 sent to (receiving hospital's) ER (Emergency Room).

During interview on August 10, 2011 at approximately 10:30 AM EMP1 revealed "...pt was released concurrently when a page went out to (receiving hospital's) ER...I made a note and realized later that the (receiving hospital) had not called...patient was already at the ER before I spoke to the ER..."

During interview on August 10, 2011 at approximately 11:00 AM EMP2 confirmed that the medical record did not accompany MR1 to the receiving hospital's ER and revealed "...On a transfer we transfer everything with the patient...yes the medical record should have gone with the patient..."

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Based on a review of facility policy, medical records (MR), and staff interview (EMP), it was determined that the emergency department staff failed to record that all pertinent medical and social information of a patient was sent to the receiving hospital for eleven of eleven medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10,and MR11).

Findings include:

Review of facility policy "Transfer Policy" dated August 2011, revealed "G. Copies of Medical Records, related to the emergency condition, which are available at the time of transfer, must accompany the patient."

1) Review of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10,and MR11, revealed no documented evidence that the patient's pertinent medical and social information was sent to the receiving hospital.

Interview with EMP2 on August 10, 2011, at approximately 12:30 PM confirmed the above findings and revealed "It wouldn't be documented in the medical record because the check list we use is not part of the medical record."
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Based on review of Medical Staff Rules And Regulations, medical records(MR), and staff (EMP) interview, it was determined that the facility failed to ensure the medical record included the condition of the patient at the time of discharge for five of 11 medical records reviewed (MR1, MR2, MR7, MR8, and MR10).

Findings include:

Review of "Medical Staff Rules And Regulations" dated February 3, 2011, revealed "Discharge Summaries ... (c) The discharge Summary shall include: ... (6) the condition of the patient at discharge"

1) Review of MR1, MR2, MR7, MR8, and MR10, revealed that these patients were discharged July 20, 2011, July 17, 2011, July 16, 2011, and July 15, 2011, respectively. Further review revealed no documented evidence of the patient's condition at the time of discharge.

Interview with EMP2 on August 10, 2011, at approximately 1:00 PM confirmed the above findings and revealed "It's(documentation of the patient's condition on transfer) is not there."