HospitalInspections.org

Based on interview, medical record review, and document review, it was determined the facility failed to ensure an appropriate transfer by not including the "Patient Transfer Order and Certificate" (EMTALA certification) form for one (1) of the five (5) patients reviewed in the transferred patient sample selection.

The findings included:

The surveyor selected a patient sample based on, but not limited to, the following reasons: transferred to another facility, left against medical advice (AM), left without being seen, and returned to the emergency department (ED) within 48 hours.

On 3/8/2022, the surveyor reviewed the selected patients medical records with Staff Members (SM) #2 and #4. It was discovered that Patient #1 was triaged on December 1, 2022 at 12:37 a.m. in the emergency department (ED) for labor pain. At 1:17 a.m. on December 1, 2021, Patient #1 was transferred from the ED to another facility for appropriate care. SM #2 and #4 searched the medical record for documentation of the "Patient Transfer Order and Certificate" and any documentation from the transport service. The staff members were unable to locate the documentation. SM #2 said when a patient is transferred the form is a requirement and (SM #2) would "look into further to see if it could be located".

A review was conducted of the facility's policy titled, Admission/Discharge/Transfer, which read in part: "...I. SCOPE/PURPOSE... To define the process for the safe admission, discharge and transfer of patients between hospital units and between medical facilities... II. POLICY... A. The admission, discharge, or transfer of patients requires a valid order from a Licensed Practitioner or acceptance by a provider of a transferred patient from another facility... C. INTERFACILITY TRANSFERS (Transfer to another FACILITY) 1. Inter-facility transfer requires physician to physician consultation and acceptance of the patient by the receiving physician and the receiving facility. 2. NH Patient Transfer Order and Certificate will be completed in Dimensions prior to transfer... The patient should be stabilized prior to transfer per EMTALA - Emergency Medical Treatment and Labor Act - NH-PC-CC-1132... 4. Communication hand off will occur that includes: a. Interactive communication between caregivers during a patient's transition that allows for accurate, relevant, effective information to be exchanged promoting the continuity of care and the opportunity to ask questions. b. Communication handoff is documented including full name of receiving nurse, date and time on the NH Patient Transfer Order and Certificate...".

On 3/9/2022, SM #3 informed the surveyor that Patient #1's transfer documentation could not be located in the medical record.

During the exit conference on 3/9/2022, the finding was reviewed again with SM #3.