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BIG HORN HOSPITAL
APPROPRIATE TRANSFER
Tag No.: C2409
Based on record review and interview, facility staff failed to appropriately transfer 2 (#s 2 and 4) of 16 patients reviewed who were in active labor. The facility staff failed to complete and provide the required Transfer with a Physician Certification form for the receiving hospital. The facility staff did not provide a copy of the medical record to the receiving hospital.
Findings include:
1. On 4/21/15, patient #2 presented to the ED complaining of the onset of labor. The patient was 38 weeks pregnant. The EHR reflected her contractions were every 3-4 minutes. A QMP or provider did not present to the ED to complete a MSE. A phone call was received by a provider directing the nurse to send the patient to another hospital. The EHR did not reflect if the patient was stable to be transferred. The rationale as to why the patient was sent to another hospital was not reflected in the EHR. The patient did not request a transfer to another hospital. The EHR reflected a Physician Certification form was not completed. A copy of the medical record was not provided to the receiving hospital.
2. On 4/18/15, patient #4 presented to the ED complaining of being in active labor. The EHR reflected the patient was 39 weeks pregnant. The patient was dilated to 6 cm with 100 % effacement. Contractions were every 5-6 minutes. The QMP documented the patient was having active contractions and transferred the patient to another hospital. The EHR did not reflect the reason as to why the patient was transferred in an unstable condition. The patient did not request a transfer to another hospital. The EHR reflected a Physician Certification form was not completed. A copy of the medical record was not provided to the receiving hospital.
In an interview on 5/13/15 at 9:30 a.m., staff member A, DON, stated both patients should not have been transferred to another hospital. The condition of both patients were not stable enough to be transferred. Staff member A stated transfer paper work was not completed or provided to the receiving hospital for both patients.