HospitalInspections.org

Based on staff interview and record review, the facility failed to provide 2 of 21 patients (Patients 15, 19) who presented to the emergency department between 4/1/11 and 9/23/11 a Transfer Summary that included evidence a physician:
1. Had certified, based on information available at the time of transfer, that the medical benefits outweighed the risks of transfer, and
2. Provided a written summary of the risks and benefits of transfer patients who presented to the Emergency Department (ED).

Findings:

On 10/20/11 at 12 p.m., the medical records of 21 patients who presented to the ED between 4/1/11 and 9/23/11 were reviewed. Twenty patients were triaged as Level 3 (Urgent), Level 2 (Emergent) or Level 1 (Critical) and were transferred to acute care facilities for a higher level of care. In a review of each patient's Transfer Summary, a document completed by the physician and nurse prior to transfer, the following was noted:


1. Patient 15, a 53 year old, presented to the ED on 6/4/11 at 7:07 p.m. with chest pain and was triaged as Level 2 (Emergent). Patient 15 was transferred to an acute care facility on 6/5/11 at 12:45 a.m.

In review of the Transfer Summary, the box that indicated the physician had examined Patient 15 and determined the medical benefits outweighed the risks of transfer had not been checked.

2. Patient 19, a 50 year old, presented to the ED on 7/24/11 at 1:23 a.m. with an altered level of consciousness, facial droop and lower extremity weakness. Patient 19's family member stated Patient 19 had a headache for several hours and was found unresponsive at home. Patient 19, triaged as Level 2 (Emergent), was transferred to an acute care facility on 7/24/11 at 3:25 a.m.

In review of Patient 19's Transfer Summary, the area denoted for the physician's written summary of the risks and benefits of transfer was left blank.


In review of a facility policy titled EMTALA: Transfer and Discharge of Emergency Patients revised 12/08, there was stipulation "The transfer of a "stable" patient must comply with the standards for the transfer of a patient with an emergency medical condition." and "the same EMTALA certification and records requirements are to be followed for these transfers. This includes: ....... 3) The individual's informed written request to transfer or the certification of the physician or qualified medical personnel that the benefits of transfer outweigh the risks".

In an interview with the Vice President/Chief Nurse Executive and the Director of Quality Care Management on 10/20/11 at 3 p.m., they acknowledged a significant number of the Transfer Summary documents were incomplete and the physician should have written a summary of the risk and benefits of the transfer.