HospitalInspections.org

Based on staff interview and record review, the hospital Emergency Department (ED) failed to demonstrate evidence in the electronic medical record (EMR) of the utilization of a transfer form, as required, to assure both the physician and nursing completed the necessary documentation related to the patient transfer and the patient and/or individual legally responsible had also signed the consent for transfer to a receiving hospital for 2 of 2 applicable records. (Patients # 17 & 19) Findings include:

1. Patient #17 received treatment in the ED on 9/14/16 thru 9/15/16 for a psychiatric diagnosis. Shortly after admission to the ED the patient was screened by a crisis clinician and it was determined Patient #17 was in need of in-patient psychiatric hospitalization. On 9/15/16 Patient #17 was transferred to an inpatient psychiatric unit at an acute care hospital. Per review of the EMR and confirmed on 10/13/16 at 10:00 AM by the ED Nurse Manager, the Patient Transfer Form utilized by the hospital was not included/retained in the EMR.

2. Patient # 19 was transferred from a acute care hospital to the ED on 8/31/16 for further evaluation and testing after experiencing extremity weakness. After completion of extensive testing and further diagnosis, it was determined Patient #19 could return to the originating hospital where s/he would be admitted. Although there was evidence of communication between both hospitals related to the transfer of Patient #19, the Patient Transfer Form was not included in the EMR. By this omission, there was a failure to demonstrate evidence of physician and nursing documentation, noting patient's condition, benefits of transfer along with the patient's consent for transfer. Per interview on 10/13/16 at 10:05 AM, the ED Nurse Manager confirmed the form was not included as part of the EMR.