HospitalInspections.org

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined that the facility failed to follow their policy and failed to execute an appropriate transfer to another facility for two of twenty medical records reviewed, MR10 and MR13.

Findings:

Review of policy "Cobra EMTALA Policy Statement Effective Date: 11/12/2021 I. Policy Statement: It is the policy of the hospital to comply with the requirements of the Emergency Medical Treatment and Active Labor Act as enumerated in the Consolidated Omnibus Budget Reconciliation Act ... Policy: ... C. Patient Transfers and Stabilization: Patient transfers (whether the patient is stable or not) MUST be done in accordance with the Transfer Policy in the Administrative Manual. A patient's informed consent must be obtained prior to transfer ..."

Policy review of "Transfer of ED cases Beyond the Capacity - Specialty Present Facility Effective Date: 2/22/2022: The provider, on behalf of the patient, may direct that a patient be transferred to another health care facility specially selected for diagnostic or medical reasons ... Procedure: ... 2. Document that the risks of transfer have been explained. 3. Notify the receiving hospital and document the name of accepting provider and institution ... 6. When stable, arrange transportation and nurse, if appropriate, to accompany the patient unless otherwise designated by the provider. 7. Transferring provider must complete the transfer form. A printed copy of the ER electronic record will be sent with the patient if transferring out of Crozer Heath Facility. The Transfer checklist must be completed .... "

Medical record review on August 17, 2022, of MR10 revealed the facilities "Patient Transfer Form Physician Certificate For Transfer (must be completed) ... " showed no documentation that risks were documented, that the medical record went with the patient, or that transportation was arranged to accepting hospital.

Medical record review on August 17, 2022, of MR13 revealed the facilities "Patient Transfer Form Physician Certificate For Transfer (must be completed) ... " indicated no documentation that Emergency Medical Condition has been stabilized, medical record went with the patient and transportation was arranged to accepting facility.

Interview with EMP1 on August 17, 2022, at approximately 3:00 PM confirmed that the Patient Transfer Form Physician Certificate for Transfer had documentation missing for MR10 and MR13.