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INDIANHEAD MEDICAL CENTER SHELL LAKE
COMPLIANCE WITH 489.24
Tag No.: C2400
Based on record review, observation and interviews, the facility failed to ensure there are complete transfer forms with Pt specific benefits for transfer, and/or the transfer forms are retained in the MR, in 2 of 10 MRs reviewed (3 and 4).
Findings include:
The facility failed to ensure transfer forms are complete for Pt specific benefits of transferring to another facility, and retained in the MR, in 2 of 5 transfer MRs out of a total 10 MRs reviewed (3 and 4). See Tag C2409.
The affect of this deficiencies potentially affect all ED Pts treated at the facility. There were 4 pts seen in the ED during the survey.
APPROPRIATE TRANSFER
Tag No.: C2409
Based on record review and interview the facility failed to ensure EMTALA transfer forms are complete and retained in the MR, in 2 of 5 transferred Pt MR reviewed (3 and 4).
Findings include:
Review of facility policy on 4/7/15 titled EMTALA transfer form completion, dated 1/11/15, states "...Indication of transfer will be filled out including patient specific risks and benefits documented."
Pt #3's MR reviewed on 4/6/15 at 12:00 PM revealed Pt #3 arrived in the ER on 2/27/15 at 3:29 PM with a complaint of chest pain. The MR nursing documentation showed Pt #3 has been treated at another facility for a lung infection, and requested transfer to that facility. The ER report by the MD stated the other facility would like Pt #3 transferred to them. There are no transfer forms in the MR to indicate Pt #3's request and consent for transfer. This is confirmed in interview with DON A on 4/6/15 at 12:00 PM, stating they discovered the consent was sent with Pt #3. When the receiving facility was contacted to send the form or a copy back, the receiving facility had already destroyed the document.
Pt #4's MR reviewed on 4/6/15 at 12:15 PM revealed Pt #4 arrived in the ER on 3/19/15 at 1:05 PM with a complaint of weakness and pain. The MR documentation states Pt #4 has shortness of breath, chest pain, fatigue, edema, acute renal failure and anemia. The transfer form completed on 3/19/15 at 1:35 PM does not state the patient specific benefits for the transfer. This is confirmed in interview with DON A on 4/6/15 at 12:15 PM, who stated the benefits should have been listed.