Bringing transparency to federal inspections
Tag No.: A0131
Based on interviews, review of medical records, and review of facility documents, the facility, for 1 of 20 sampled patients (#10) who were transferred, did so without a consent to transfer. In the case of 3 of the 20 patients (#1, 2, and 3), the facility conducted the transfer without the approval of the designated patient representative or required Power of Attorney (POA). The consents for transfer for all of the 20 patients (#1 - 20), moreover, were witnessed and obtained by the emergency department unit secretary whether the patients were diagnosed as mentally altered or not, rather than a mid-level practitioner, registered nurse or physician. These failed practices exposed patients to the potential dangers of inappropriate transfers. The findings are:
A. Review of the medical record for Patient #10 revealed no "consent to transfer" form signed or unsigned. Yet the patient was transferred.
B. Review of Patient #1's transfer form from the facility revealed that the patient was "unable to sign" on the patient signature line and that the consent was witnessed by the emergency department unit secretary. The reason identified on the form for the patient's inability to sign was "mental status." It was not signed by his POA nor was there any note of a consent obtained by the staff via phone.
1. On 08/28/14 at 4:15 pm, during interview, the Physician Assistant (PA) making the transfer for Patient #1 confirmed she made the transfer without informing the POA of the change in destination hospital, mode of transfer or the reasons for the changes. The PA also confirmed the conversation with the POA in which the POA specifically requested her father not go to the hospital where Patient #1 ultimately was transferred.
2. On 08/28/14 at 3:30 pm during interview, the POA confirmed that she was not informed of the changes in hospital destination, the mode of transportation or the reasons for the changes.
C. Review of Patient #2's consent to transfer form revealed that it was signed by the patient and was witnessed by the emergency department unit secretary, despite evidence from multiple notations in Patient #2's medical record that the patient was assessed as being "mentally altered," having slurred speech and an "abnormal gaze."
D. Review of Patient #3's consent to transfer form revealed that the patient was "unable to sign" on the signature line and that the consent was witnessed by the emergency department unit secretary. In the nursing notes mental status was indicated as "unresponsive." No notes were found in the medical records to indicate that a family member or POA was contacted to give consent. Admitting diagnoses for Patient #3 were "acute upper gastrointestinal bleed" and "aspiration into airway."
E. On 08/28/24 at 4:30 pm the ED Director confirmed Patient #10 had no consent to transfer form in the record. He also confirmed that the consents to transfer forms for Patients #1-3 should have been witnessed by the appropriate patient representative or documented consent via phone.
F. Review of the consent to transfer forms for Patients #4-20 revealed witness signatures by the emergency department unit secretary.
G. On 08/28/14 at 5 pm during interview, the Medical Director of the Emergency Department reviewed the form and agreed that it would be more appropriate for a registered nurse, mid-level practitioner or physician to obtain the consent for transfer. He also agreed that mentally altered patients should have a patient representative, family member or POA sign for the patient.
H. Review of the facility's policy titled "ACCESS - General Consent for Treatment - Patient Access" (dated 08/06/13) revealed the following: "It is the responsibility of the Patient Access Representative to document such consent by having the patient or his or her legal representative (i.e., patient's surrogate, parent, custodian, guardian or Health Care Agent...) sign the General Consent form. It is important to note that general consent to treatment is not the same as informed consent, which must be obtained by a licensed medical professional."
G. Review of the facility's policy titled "EMTALA Transfer" (dated 11/08/06) revealed the following: "Each facility must have written guidelines outlining the requirements for an appropriate transfer to another facility in accordance with federal and state laws. Any transfer of an individual with an emergency medical condition must be initiated either by the written request of the patient or the legally responsible person acting on the patient's behalf for such transfer or by a physician order with the appropriate physician certification."