HospitalInspections.org

Based on document review and interview the Discharging Physician failed to abide by the facility policy and assess the patient and document that the patient was stable for discharge in 1 of 20 medical records reviewed (#2), resulting in the potential for an unstable discharge. Findings include:

On 3-4-2013 at approximately 1100 during review of the policy titled" EMTALA: Treatment of Emergency Medical Conditions and Patient Transfers" dated "4-20-2012" it was stated on page 7 under "4.9.2. Discharge certification statement, attesting that the patient is stable for discharge, in the Discharge Progress Note or Case Summary for all patients presenting to the Emergency Department with an Emergency Medical Condition and admitted to the hospital."

On 3-4-2013 at approximately 1400 during review of the medical record for patient #2 it was revealed that the patient came to the hospital on 9-1-2012 via ambulance for Headache, Weakness, confusion and altered LOC (level of consciousness). The patient was a 24-year-old female with a history of "multifocal neurologic complaints." Physician staff E documented at 2150 "To be transferred. Patient transferred to [Hospital B] per patient and mom's request. Discussed transfer with [Physician A] who accepted transfer. Transfer documentation forms were reviewed and signed. Condition at disposition - stable."Also documented by staff E on the Physician Certification Statement for Non-Emergency Ambulance Services form under the section titled: "Section ll - Medical Necessity Questionnaire: #2. Describe the PHYSICAL or MENTAL CONDITION of this patient AT THE TIME OF AMBULANCE TRANSPORTATION that requires the patient to be transported on a stretcher in an ambulance and why transport by other means is contraindicated by the patient's condition: Mentation Changes. #4 Patient is confused, combative, lethargic, or comatose."

On 3-4-2013 at approximately 1400 during review of the medical record for patient #2 it was revealed in the nursing notes that at 2324 nurse staff L documented "Patient cleared to go to [Hospital B] via private auto per [physician staff F]." No documentation could be found in the medical record indicating that staff F had assessed the patient. There was no documentation in the medical record of vitals signs after 2142. No evidence of care being given to the patient after 2142 was evident in the medical record. In the mecical record it was documented by staff L that the patient's mother/guardian decided to sign the patient out Against Medical Advice (AMA) after a physical/verbal altercation with staff. The decision was then made to transfer the patient via private vehicle (a taxi). The patient was documented to have left at 2335 after not having received any documented care for a period of approximately 2 hours.

On 3-4-13 at approximately 1445 the above information (policy and medical record review) was confirmed with staff A.