HospitalInspections.org

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Based on interview and document review, the hospital failed to implement their policies and procedures for the transfer of a patient to another hospital for care that could not be provided at the hospital where the patient presented for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to complete a discharge transfer sheet to be sent with the patient at the time of transfer puts patients for risk for delays in receving care at the accepting hospital.

Findings included:

The hospital failed to complete a discharge transfer sheet to be sent with the patient's medical records at the time of transfer.

Cross reference: C-2409

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Based on interview and document review, the hospital failed to implement its policies and procedures to ensure the patient's transfer paperwork was completed before sending the patient to the receiving hospital in accordance with the Emergency Medical Treatment and Labor Act (EMTALA) for 1 of 25 patient records reviewed (Patient #1).

Failure to send the completed transfer paperwork with patients at time of transfer puts patients at risk for delays in receiving care when they arrive at the accepting hospital.

Findings included:

1. Document review of the hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA), updated 03/16, showed that when transferring a patient to another hospital, staff were to send the patient with a completed demographics facesheet, which summarized care provided along with corresponding labs, provider notes, documentation of contact with receiving hospital, and signature of the patient consenting to transfer.

2. Document review of Patient #1's medical record showed that:

a) Patient #1 presented to the emergency department on 06/05/22 for emergency care. The hospital provided a medical screening exam and stabilizing treatment. The patient required further care that the hospital could not provide.

b) The hospital contacted another hospital that was able to provide the level of care the patient required. The accepting hospital agreed to accept the patient. On 06/06/22 at 12:59 AM, the hospital contacted the specialist on call that agreed to accept the patient. The hospital contacted the accepting hospital supervisor about the transfer and that the patient would be coming by private car to the emergency department.

c) The paperwork was sent with the patient in a sealed envelop with copies of the completed medical screening exam and lab work. c The paperwork did not include the completed demographics facesheet.

3. On 07/06/22 at 12:45 PM, the investigator interviewed Patient #1. Patient #1 stated that the hospital sent her with a sealed envelop of the lab tests and medical screening exam that she gave to the emergency department staff. The patient stated that she remembered the emergency department staff was upset that the packet did not have the completed transfer facesheet but the staff contacted the physician that had accepted her for care and she received the care she required.

4. On 07/06/22 at 9:10 AM, the investigator interviewed a registered nurse (Staff #2). Staff #2 stated that a completed demographics facesheet needed to be completed at the time of transfer and sent along with labs, tests and the medical screening exam results to the accepting hospital. The facesheet summarized what physician had accepted the patient for treatment along with a signature from the patient stating they were informed of the risks and benefits of the transfer and consented to the transfer.

5. On 07/06/22 at 9:30 AM, the investigator interviewed a registered nurse (Staff #3). Staff #3 verified that at the time of transfer a completed demographics face sheet needed to be completed. The facesheet summarized the physician accepting the patient for treatment and the patient signed the facesheet showing the patient had been informed of the risks and benefits of the transfer and consented to the transfer.

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