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Based on document review, record review and staff interview it was determined the facility failed to monitor incomplete documentation of Emergency Department (ED) transfers of unstable patients. This deficient practice was identified in two (2) records reviewed of unstable patient transfers (Patients #4 and 8). This failure leads to missed opportunities to identify problems in high-risk areas and possible improvement of hospital services.

Findings include:

1. Facility policy entitled, "Emergency Medical Treatment and Active Labor Act", last reviewed 1/14, states, in part: "Transfers: Appropriate transfers must be carried out through the use of qualified personnel and transportation equipment, including those life support measures that may be required during transport."

2. Patient # 4's medical record was reviewed on 4/26/16. Review of the ED Provider Note revealed the patient presented to the ED on 3/9/16 with a diagnosis of "acute CVA" (cerebro-vascular accident/stroke). Care was provided and a decision was made to transport the patient. Under the heading "Disposition" was the entry: "Patient Condition: guarded, Patient Improvement: Deteriorated". No documentation was found in the record of arrangements/orders for the care of the patient during transport.

3. Patient #8's medical record was reviewed on 4/26/16. Review of the ED Provider Note revealed the patient presented to the ED on 4/17/16 with a diagnosis of a perforated colon. Care was provided and a decision was made to transport the patient. Review of the Patient Disposition Note revealed the entry: "Patient Condition: guarded, Patient Improvement: Deteriorated". No documentation was found in the record of arrangements/orders for the care of the patient during transport.

4. An interview was conducted with the ED Nurse Manager on 4/26/16 at 2:10 p.m., at which time the above findings were reviewed. She stated the ED physicians verbally communicate their orders to the transport teams, and agreed there was no documentation of these orders in the medical records. She stated she does review the medical records of all transported patients for completeness, but stated she does not review for physician's orders for transport of the patient. She stated some of the ambulance teams utilize their own paper forms for orders, but this document goes with the team and does not become a part of the medical record. She stated her record reviews are reported monthly to Administration, the Surgery Department and the Trauma Department.

5. An interview was conducted with the Director of Quality on 4/27/16 at 8:45 a.m. He stated he receives a monthly report of the total number of transfers from the ED, but does not receive a detailed report of the chart audits conducted by the ED Nurse Manager. He stated the only time he receives information related to ED transfers is if they are "unusual enough to be documented on an Incident Report". He stated the transfer of an unstable patient from the ED is not, in itself, considered an "unusual" event; therefore, he does not review those cases. Upon questioning, he did agree the transport of an unstable ED patient would be considered a high-risk procedure.

Based on document review, record review and staff interview it was determined the facility failed to ensure Emergency Department (ED) medical staff arranged for safe transport of unstable patients, per policy, for two (2) of two (2) transferred patients deemed unstable (Patients # 4 and # 8). This failure can lead to unsafe and/or inappropriate care of patients during transport, with possible negative outcomes.

Findings include:

1. Facility policy entitled, "Emergency Medical Treatment and Active Labor Act", last reviewed 1/14, states, in part: "Transfers: Appropriate transfers must be carried out through the use of qualified personnel and transportation equipment, including those life support measures that may be required during transport."

2. Patient # 4's medical record was reviewed on 4/26/16. Review of the ED Provider Note revealed the patient presented to the ED on 3/9/16 with a diagnosis of "acute CVA" (cerebro-vascular accident/stroke). Care was provided and a decision was made to transport the patient. Under the heading "Disposition" was the entry: "Patient Condition: guarded, Patient Improvement: Deteriorated". No documentation was found in the record of arrangements/orders for the care of the patient during transport.

3. Patient #8's medical record was reviewed on 4/26/16. Review of the ED Provider Note revealed the patient presented to the ED on 4/17/16 with a diagnosis of a perforated colon. Care was provided and a decision was made to transport the patient. Review of the Patient Disposition Note revealed the entry: "Patient Condition: guarded, Patient Improvement: Deteriorated". No documentation was found in the record of arrangements/orders for the care of the patient during transport.

4. An interview was conducted with the ED Nurse Manager on 4/26/16 at 2:10 p.m., at which time the above findings were reviewed. She stated the ED physicians verbally communicate their orders to the transport teams and agreed there was no documentation of these orders in the medical record.

5. An interview was conducted with the Director of the Department of Emergency Medicine on 4/27/16 at 8:10 a.m. He stated he is unable to print out orders for transport from the computer system and stated he and the rest of the ED medical staff give verbal orders to flight crews and ambulance crews as needed. He agreed the orders are not documented in the medical record.