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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the responsible adult relationship was noted on the discharge instructions for two out of two applicable medical records (MR43 and MR44).

Findings include:

A request was made on March 16, 2017, for a facility policy and procedure for staff to follow for the completion of the discharge instruction form. There was no policy and procedure provided.

Interview with EMP3 on March 17, 2017, at 1:00 PM, confirmed there was no facility policy and procedure for staff to follow for the completion of the discharge instruction form.

Review on March 16, 2017 of the facility form "Geisinger GBH-Geisinger Bloomsburg Hospital ... Discharge Instructions" revealed an area noting that if the patient is unable to sign: followed by a space for the signature of the Responsible Adult Date [and] Time and a space to document the Relationship to Patient.

Interview with EMP1 and EMP2 on March 16, 2017, at 3:00 PM, confirmed facility practice if the patient was unable to sign the discharge instruction was to have the area of the Discharge Instructions completed by the responsible adult at the time of discharge.

Review on March 16, 2017, at approximately 1:00 PM, of MR43 revealed the patient was a four year old admitted for surgery December 16, 2016. The discharge instructions form was signed by the responsible adult. There was no documentation noted of this person's relationship to the patient.

Review on March 16, 2017, at approximately 2:00 PM, of MR44 revealed the patient was a four year old admitted for surgery March 9, 2017. The discharge instructions form was signed by the responsible adult. There was no documentation noted of this person's relationship to the patient.

Interview with EMP1 and EMP2 on March 16, 2017, at 3:00 PM, confirmed MR43 and MR44 discharge instruction forms were signed by the responsible adult. There was no documentation noted of the responsible adults' relationship to the patients.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure medical records of patients transferred from the Emergency Department to an outside facility contained a physician order for the transfer, the patient's consent for transfer, and documentation the patient's medical record was sent to the receiving hospital to ensure continuity of care for three of four applicable medical records reviewed (MR24, MR25 and MR28).

Findings include

Review on March 13, 2017, of the facility's "EMTALA Memorandum of Transfer" form, last approved February 2015, revealed sections for the physician to document the patient's diagnosis, if the patient was stable or unstable and to sign, date and time. There was an area for the transferring physician's signature, date and time. There were sections for the facility staff to document the accompanying documentation sent at the time of the transfer, and the patient's consent to the transfer.

Review of MR24 on March 13, 2017, revealed the patient was admitted to the Emergency Department (ED) on September 7, 2016, for evaluation and treatment of a psychiatric disorder. The facility transferred the patient to a facility outside the health system. There was no documentation the facility completed an EMTALA Memorandum of Transfer form or that a physician order for transfer was obtained. There was no documentation the patient consented to the transfer and no documentation indicating what part of the medical record was sent with the patient to ensure continuity of care.

Interview with EMP4 and EMP5 on March 13, 2017, at approximately 1:00 PM confirmed MR24 was a patient in the ED for evaluation and treatment of a psychiatric disorder, and the patient was transferred to a facility outside the health system. EMP4 and EMP5 confirmed there was no documentation the facility completed an EMTALA Memorandum of Transfer form or that a physician order for transfer was obtained. EMP4 and EMP5 confirmed there was no documentation the patient consented to the transfer and no documentation indicating what part of the medical record was sent with the patient to ensure continuity of care.

Review of MR25 on March 13, 2017, revealed the patient was admitted to the ED on October 10, 2016, for evaluation and treatment of a psychiatric disorder. The facility transferred the patient to a facility outside the health system. There was no documentation the patient consented to the transfer and no documentation indicating what part of the medical record was sent with the patient to ensure continuity of care.

Interview with EMP4 and EMP5 on March 13, 2017, at approximately 1:15 PM confirmed MR25 was a patient in the ED for evaluation and treatment of a psychiatric disorder and the facility transferred the patient to a facility outside the health system. EMP4 and EMP5 confirmed there was no documentation the patient consented to the transfer and no documentation indicating what part of the medical record was sent with the patient to ensure continuity of care.

Review of MR28 on March 13, 2017, revealed the patient was admitted to the ED on December 28, 2016, for evaluation and treatment of a burn. The facility transferred the patient to a facility outside the health system. There was no documentation the patient consented to the transfer and no documentation indicating what part of the medical record was sent with the patient to ensure continuity of care.

Interview with EMP4 and EMP5 on March 13, 2017, at approximately 2:00 PM confirmed MR28 was a patient in the ED for evaluation and treatment of a burn and the facility transferred the patient to a facility outside the health system. EMP4 and EMP5 confirmed there was no documentation the patient consented to the transfer and no documentation indicating what part of the medical record was sent with the patient to ensure continuity of care.

Interview with EMP4 on March 13, 2017, at approximately 2:10 PM revealed it was facility policy that an EMTALA Memorandum of Transfer form be completed on all patient transfers.