HospitalInspections.org

Based on interviews, policy and procedure review, and documentation it was determined the hospital failed to follow its EMTALA policy regarding documentation that copies of the patient's ED records for 1 of 3 ED patients with an EMC were sent with the patient who was transferred to another medical facility (refer to Tag C2409).

Based on review of policies and procedures and medical record review, it was determined that in 1 of 3 medical records of patients (Patient #24) who presented with an EMC and were transferred to other medical facilities the hospital failed to enforce its EMTALA policies and procedures related to patient transfer.

Findings include:

1. Review of a policy titled "Inter-Hospital Transfer," effective 12/20/2012 reflected "5. Transferring patients out...The Nursing Administrative Supervisor will be called by the unit Charge Nurse upon determination of transfer of patients with the following conditions: 1. Emergency Department...1.3 Unstabilized medical condition...Contact Nursing Administrative Supervisor who will: 1. Complete Inter-Hospital Transfer Form with the referring physician and the ED staff...3. Deliver yellow copy of Inter-Hospital Transfer Form to Risk Management Services...4. Notify Ambulance Company or helicopter of transfer. F. Copy all pertinent medical records to be sent to receiving institution. 6. Clothing and valuables accounted for and disposition noted on medical record."

2. Review of documentation revealed that the hospital had developed a transfer form titled, "Inter-Hospital Transfer Form" that addressed all elements of an appropriate transfer.

3. Review of the medical record for Patient #24 reflected a 70 year old (male/female) patient who presented to the ED on 03/20/2012, escorted by family to the ED with complaint of "chest pain to back [for] 30 min." The ED staff obtained an electrocardiogram (EKG). The ED physician, P1, documented "[third degree heart block] - [inferior ST elevated myocardial infarction]" as the diagnosis on the "Chest Pain" T-system documentation form.

P1 signed the "Emergency Department STEMI Orders" form per ED protocol then consulted with a cardiologist. Sacred Heart University District did not have a cardiac care unit nor an interventional cardiac catheter lab capability. P1 determined that the cardiac condition of Patient #24 required a higher level of care at another facility so he/she transferred the patient. P1 fully completed the "PHYSICIAN" portion of the "Inter-Hospital Transfer Form" per hospital policy.

Nursing personnel partially completed the "NURSING" portion of the "Inter-Hospital Transfer Form" but neglected to check the designated "boxes" under the heading "ACCOMPANYING DOCUMENTATION." A thorough review of the medical record revealed it lacked documentation that nursing personnel sent copies of the patient's ED record to the receiving medical facility. The patient's medical records should have included physician and nursing assessment of the patient, test results, medications and treatments provided per this regulation.

4. The ED Nurse Manager, I4, and the Director of Risk Management & Organizational Integrity, I7, were informed of the incomplete transfer form found in the medical record of Patient #24 on 05/22/2013. Both individuals reviewed the medical record and agreed that the entire ED medical record, including the transfer form lacked documentation confirming copies of the patient's medical record related to the patient's medical condition, available history, results of diagnostics studies and stabilizing treatment were sent to the receiving hospital per this regulation.

5. An interview with Quality Resources manager, I8, on 05/22/2013 at 1040 reflected that the medical center did not collect quality data confirming ED physician and staff compliance with routine completion of the "Inter-Hospital Transfer Form" used when transferring patients to other facilities.