HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital (A) failed to ensure that the accepting Hospital (B) has agreed to accept the patient for appropriate medical care and treatment.

See deficiency at A - 2409.

Based on document review and interview, it was determined that for 1 of 11 (Pt #1) clinical records reviewed for patients' who were transferred to another Hospital, the Hospital (A) failed to ensure that the accepting Hospital (B) has agreed to accept the patient for appropriate medical care and treatment.

Findings Include:

1. The Hospital's policy entitled, "Emergency Medical Treatment and Labor Act (EMTALA)," (posting date 10/31/2014) included, " ...Appendix B: Transfer to another Facility ...C. The transfer is to a higher level or to specialty care not available at CCHS (Cook County Health and Hospital System). Note: If CCHS does not have capacity to treat a patient due to lack of space ...2. Staff determines that the receiving Facility has available space and qualified personnel for treatment of the individual, and agrees to accept transfer of the patient ...3. Staff documents in the medical record, the above information ...The Patient Transfer Form and Physician Certificate for Transfer (Form #1450) are completed. 4. Staff sends copies of all medical records related to the emergency condition for which the individual presented ..."

2. The clinical record of Pt #1 was reviewed on 1/7/2020. Pt #1 was a 57 year old who presented to the Hospital's Emergency Department (ED) on 12/4/2019 at 9:05 PM with complaints of altered mental status and tracheostomy (a breathing tube in the wind pipe) tube evaluation. Nursing documentation dated 12/5/19 at 2:20 AM included, "(EMS #2) arrived for patient transport, patient leaving in stable condition. ED Addendum: Patient taken to (Hospital B)." Physician documentation dated 12/4/19 at 11:50 PM included, " ...patient is a resident of (Long Term Care - LTC). He reportedly displayed violent behavior ...and was intended to be transferred to (Hospital B) for involuntary admission. However, EMS brought him to (Hospital A) ..." Pt #1 received a medical screening exam, that included, systems assessment, blood work, urinalysis, chest x ray, and an electrocardiogram.

Physician documentation dated 12/5/19 at 1:02 AM included, "Pt transferred to (Hospital A) erroneously. Was meant to go to (Hospital B) for psychiatric evaluation. Resident d/w (discussed with) (Hospital B) and transfer facilitated."

Physician documentation dated 12/5/19 at 4:58 AM included, "Patient sent back from (Hospital B) without evaluation. They state they did not accept the patient ..."

Pt #1's clinical record did not contain the required Patient Transfer Form #1450. The form required the following documentation: Patient Information; Chief Complaint; treatments at time of transfer; vital signs; allergies; mode of transfer and name of transport agency; what copies of medical records were sent with the patient; receiving physician, facility, address, and name of Nurse that report was given to; Medical clearance; risk and benefits; name of accepting physician; and name of transferring physician.

3. On 1/7/2020 at approximately 12:30 PM, during an interview, the Nurse Clinician from the ED (E #1) stated, "There should be a transfer form in the patient's chart but there is not one, to be found."

4. During an interview on 1/8/2020 at approximately 11:40 AM, The Attending Physician (MD #3), who took over Pt #1's care stated "I wrote an order to transfer the patient to (Hospital B). The Resident Physician (MD #4) informed me that she called the Nursing Home to find out what happened and why he came here. When the patient came back from (Hospital B), (MD #4) told me (MD #3) that she did not talk to (Hospital B), she talked to the Nursing Home and was told that they (Nursing Home) would notify (Hospital B), of the patient being transferred from (Hospital A) to (Hospital B). All of the Residents in the ED receive EMTALA training."

5. The Resident Physician (MD #4), working on 12/5/19 was interviewed on 1/9/2020 at approximately 10:40 AM. MD #4 stated, "(MD #3) was my attending physician. This patient was endorsed to me from the previous shift Resident (MD #5 - unavailable for interview). When I called the Nursing Home (NH), to inquire as to why this patient was here, I was told that he was supposed to go to (Hospital B) for a psychiatric evaluation. The NH stated that they had received prior approval to send the patient to (Hospital B). I did not call the receiving Hospital (B)..."