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Based on observation, record review and interview the facility failed to ensure compliance with EMTALA Regulation 489.24 in that the facility failed to appropriately transfer 2 of 20 patients (Pt. #1 and Pt. #2). Failure to appropriately transfer has the potential to affect all patients presenting in an emergency.


See findings:

The hospital failed to appropriately transfer. See A 2409.

Based on record review and interview the facility failed to ensure appropriate transfer of patients. In 2 of 20 records reviewed (#1 and #2) the receiving hospital was not contacted before transfer. This deficiency has the potential to affect all patients served by the emergency department.

Findings include:

Hospital policy entitled; "Transfer Guideline for Patient Transfer to Another Facility- Sparta" dated 02/11/15 states;
"Provider responsibilities:
a. The provider initiating the transfer must contact the receiving facility to obtain consent for transfer and determine an accepting provider.
i. No patient is transferred until receiving facility consents to accept the patient.
ii. The provider documents the information on the Physician Certification of Need for Transfer form."

Per review of the MR of pt. #1 and #2 on 06/22/15 at 11:00 AM both pt. #1 and pt. #2 presented with road rash from a motorcycle crash. Pt. #1 and #2's injuries were the equivalent of second degree burns. MD A completed transfer forms dated 06/12/15 at 7:40 PM for both pt. #1 and pt. #2, the receiving facility is documented as "Madison Regional Burn Center" and the accepting physician is documented as Dr. B. There is no phone number of the receiving facility listed on either transfer form although a space is designated for this phone number.

According to the ambulance report for pt. #1's trip from the sending hospital to the receiving hospital there was no contact between the two hospitals. The ambulance report narrative states; "Upon arrival at (the receiving hospital), ER (emergency room) charge nurse advised that there was no records of patient any where in the (hospital's) system. EMS provided charge RN with name of accepting provider. ER charge RN advised that no such provider existed any where in the (receiving) hospital system.".... "EMS called (sending hospital's) ER in attempt to problem solve the situation. ER RN provided EMS with number that ER MD (A) had used to arrange for an accepting physician. Upon looking up phone number, it was learned that phone number was for the Burn Center at (another hospital). Upon further investigation by ER charge RN it was learned that at (this other hospital) there was a burn physician (B) with the name listed on EMS paperwork. EMS advised (receiving hospital) ER staff that there was a second patient (pt. #2) coming in another ambulance that was in the same dilemma. ER staff advised that they would see and evaluate patient's and treat and manage them appropriately."

Per phone interview with MD A on 06/23/15 at 4:00 PM A asked the operator to be connected the burn unit at the receiving hospital. A stated A was connected with another hospital and neither A or the physician at the other hospital realized they were talking to the wrong physician at a completely different hospital.