HospitalInspections.org

Bringing transparency to federal inspections

100 ST LUKE'S LANE

STROUDSBURG, PA 18360

NON-PARTICIPATING HOSPITALS, EMERGENCIES

Tag No.: A0001

APPROPRIATE TRANSFER

Tag No.: A2409

Based on review of facility documentation, medical records (MR) and staff interviews (EMP) it was determined the facility failed to document the condition of transferred patients in two of 20 medical records reviewed (MR1 and MR19); to ensure the receiving facility had available space and qualified personnel for the treatment of a transferred patient in two of 20 medical records reviewed (MR1 and MR19); failed to obtain approval from an accepting physician prior to transferring patients in two of 20 medical records reviewed (MR1 and MR 19) and failed to ensure copies of the transferring patients' medical records were sent to the receiving hospital for nine of 20 medical records reviewed (MR1, MR3, MR4, MR5, MR12, MR13, MR14, MR15, and MR19).

Findings include:

Review on September 17, 2019, of facility policy "EMTALA - Medical Screening Examination and Stabilization Treatment (#241), dated July 7, 2018, revealed "B. Procedure. ... c. QMP [Qualified Medical Professional] or other Hospital staff effectuating the transfer will contact the receiving facility via telephone and document the date and time of the communication with the receiving facility, and the name of the person accepting the transfer, in the Patient Transfer Form. d. The Hospital will send to the receiving facility all medical records (or copies of these records) related to the EMC [Emergency Medical Condition] that have been transcribed and are available at the time of transfer ..."

Review on September 17, 2019, of facility form "EMTALA/Acute Care Transfer" revealed "Provider Certification ... Patient Condition: ___ ... Transfer Requirements: Facility ___ ... Agreed to accept transfer and to provide adequate appropriate medical treatment as acknowledged by ___ Appropriate medical records of the examination and treatment of the patient are provided at the time of transfer STAFF INITIAL WHEN COMPLETED ___ ..."

Review on September 17, 2019, of MR1, revealed this patient was transferred to another acute care hospital on August 9, 2019. There was no documented evidence on the transfer form of the patient's condition (whether stable or unstable). There was no documented evidence that the receiving facility had available space and qualified personnel for the treatment of the patient. Further review revealed there was no documented evidence on the transfer form that the receiving facility was contacted via telephone; that the date and time of the communication with the receiving facility was documented; and that the name of the person accepting the transfer was documented. Further review of MR1 revealed there was no documented evidence that any medical records related to the EMC were sent to the receiving hospital.

Review on September 18, 2019, of MR3, revealed this patient was transferred to another acute care hospital on February 3, 2019. Further review revealed there was no documented evidence in MR3 that any medical records related to the EMC were sent to the receiving hospital.

Review on September 18, 2019, of MR4, revealed this patient was transferred to another acute care hospital on May 22, 2019. Further review revealed there was no documented evidence in MR4 that any medical records related to the EMC were sent to the receiving hospital.

Review on September 18, 2019, of MR5, revealed this patient was transferred to another acute care hospital on May 7, 2019. Further review revealed there was no documented evidence in MR5 that any medical records related to the EMC were sent to the receiving hospital.

Review on September 18, 2019, of MR12, revealed this patient was transferred to another acute care hospital on September 2, 2019. Further review revealed there was no documented evidence in MR12 that any medical records related to the EMC were sent to the receiving hospital.

Review on September 18, 2019, of MR13, revealed this patient was transferred to another acute care hospital on July 16, 2019. Further review revealed there was no documented evidence in MR13 that any medical records related to the EMC were sent to the receiving hospital.

Review on September 18, 2019, of MR14, revealed this patient was transferred to another acute care hospital on June 7, 2019. Further review revealed there was no documented evidence in MR14 that any medical records related to the EMC were sent to the receiving hospital.

Review on September 18, 2019, of MR15, revealed this patient was transferred to another acute care hospital on June 18, 2019. Further review revealed there was no documented evidence in MR15 that any medical records related to the EMC were sent to the receiving hospital.

Review on September 18, 2019, of MR19, revealed this patient was transferred to another acute care hospital on February 16, 2019. There was no documented evidence on the transfer form of the patient's condition (whether stable or unstable). There was no documented evidence that the receiving facility had available space and qualified personnel for the treatment of the patient. Further review revealed there was no documented evidence on the transfer form that the receiving facility was contacted via telephone; that the date and time of the communication with the receiving facility was documented; and that the name of the person accepting the transfer was documented. Further review of MR19 revealed there was no documented evidence that any medical records related to the EMC were sent to the receiving hospital.

Interview with EMP1, on September 18, 2019, at 2:12 PM, confirmed there was no documented evidence in MR1 and MR19 on the transfer forms of the patients' condition (whether the patient was stable or unstable for transfer), that the receiving facility had available space and qualified personnel for the treatment of the patients; and the receiving facility was contacted via telephone; that the date and time of the communication with the receiving facility was documented; and that the name of the person accepting the transfer was documented. Further interview with EMP1 confirmed there was no documented evidence that any medical records related to the EMC were sent to the receiving hospitals for MR1, MR3, MR4, MR5, MR12, MR13, MR14, MR15, and MR19.