HospitalInspections.org

Based on review of documents, medical records and staff interview, it was determined the facility failed to provide an appropriate transfer of a patient to a higher level of care in one (1) of twenty (20) medical records reviewed (patient #1). This has the potential to negatively affect all patient's presenting to the Emergency Department (ED) by delaying appropriate treatment in an emergency situation.

Findings include:

1. Hospital Policy titled Transfer of a Patient, last reviewed 1/10, states in part: "The physician must call the receiving physician to verify acceptance or transfer and document on the Certificate of Transfer Form section 1. If the patient refuses to consent to transfer, the hospital shall take all reasonable steps to secure the patients' written informed consent to refuse such transfer and the physician will document on the Certificate of Transfer Form section III. Section V is for patient Request for Transfer. It is the physician responsibility to complete the Certificate of Transfer Form..."

2. Review of Patient #1 medical record revealed the physician wanted to transfer the patient to a higher level of care. The patient wanted to transport themselves in their private owned vehicle (POV). There was not a Certificate of Transfer Form in the patient's medical record nor was there any documentation by the physician indicating the patient refused the transfer with the risks and benefits being explained to the patient.

3. During a telephone interview conducted on 2/5/14 at 1005 with the ED physician, he stated completion of these forms were a "gray area." He also revealed he told the patient if he wanted to be transferred, to return to the ED. He stated he did not call the recipient hospital to speak to the physician to determine capacity or capability for this patient.

4. These medical records were reviewed with the Clinical Nurse Manager of the ED on 2/5/14 at 1400 and she agreed the required transfer forms were not present or completed properly. She also agreed the physician failed to document according to hospital policy regarding the transfer of a patient in a POV.