HospitalInspections.org

Based on review of facility documents, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure emergency room staff included a transfer sheet containing patient consent for transfer and copies of all pertinent medical or diagnostic information to accompany the patient on transfer to other facilities in 14 of 16 applicable medical records reviewed (MR3, MR5, MR6, MR7, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR18, MR19, and MR20).

Findings include:

Review on September 21, 2010, of facility policy "Transfer-Emergency Department Transfers" last reviewed February 2009, revealed, "8. An Acute Care Transfer form (MR 485) will be completed. A. The physician will document the reason for transfer. B. The accountable nurse will assure the completion of the remainder of the checklist. C. The original form will remain with the patient's medical record; a copy of the form will accompany the patient to the receiving facility. D. The patient or Power of Attorney must sign consent for transfer."

1) Review on September 21, 2010, of MR3, MR5, MR6, MR7, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR18, MR19, and MR20 revealed that the facility transferred the patients to other facilities. Further review revealed that emergency room staff failed to complete a transfer sheet including the patient's written consent for transfer or provide copies of all pertinent medical or diagnostic information.

2) An E-mail from EMP1 on September 23, 2010, at 5:51 PM confirmed that MR3, MR5, MR6, MR7, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR18, MR19, and MR20 did not contain a transfer sheet which included the patient's written consent for transfer and copies of all pertinent medical or diagnostic information.