HospitalInspections.org

Based on medical record review and staff interview, the facility failed to ensure that the intended receiving facility was contacted prior to the transfer of a patient. This is evident in one (1) of 20 medical records reviewed. (Patient #7).

Findings include:

Review of the medical record for Patient #7 identified: the patient presented to the Emergency Department (ED) on 8/11/18 at 7:24 PM. The patient complained that she was suicidal and has taken unknown medications in unknown amounts. She was examined and diagnosed with suicide attempt and ideations with the physician's determination to transfer the patient to a psychiatric hospital.

On 8/12/18 at 2:29 AM the physician documented that the patient was stable and ready for transfer to the receiving facility and at 4:19 AM on 8/12/18, the patient was transferred to the receiving facility. Upon reaching the facility, it was discovered that the receiving facility had not received any prior communication about the transfer from the transferring facility.

During interview with the physician on 8/22/18 at 11:45AM, the physician revealed that the transfer communication was inadvertently made with another facility but not with the intended facility.