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Based on review of documents, medical records and staff interview, it was determined the facility failed to obtain the written and informed refusal of an appropriate transfer in four (4) of twenty (20) medical records reviewed (#2, 7, 10 and 19). This has the potential to negatively impact all patients when they are not informed of the risks associated with an in-appropriate transfer in an emergency medical condition.

Findings include:

1. Hospital Policy titled Inter-Hospital Transfer of Patient, last reviewed 11/13, states in part: "Transfers are achieved through a mutual agreement between the transferring physician and the receiving physician. The transferring physician must receive acceptance from receiving facility and physician and document on the transfer order. If patient (or representative) refuses stabilizing treatment or transfer after hospital offers treatment or transfer and hospital discloses risks and benefits, the hospital takes all reasonable steps to obtain written refusal."

2. Review of Patient #2 medical record revealed the patient was being transferred to a higher level of care. The patient wanted to transport themselves in their private owned vehicle (POV). Further review of the record revealed the Transfer Request Form was incomplete upon transfer. The form lacked important information regarding acceptance of the patient by the receiving hospital, if report was given to the receiving hospital and what documents (tests, treatment notes, x-rays etc) were sent with the patient.

3. Review of Patient #7 medical record revealed the physician was transferring the patient to a higher level of care. The patient's mother was transporting the patient by POV. Further review of the medical record revealed the Informed Refusal Form was incomplete upon transfer. The physician documented the patient's mother had signed the refusal form. Review of the form revealed the mother's signature was not present on the Informed Refusal Form.

4. Review of Patient #10 medical record revealed the physician wanted to transfer the patient to a higher level of care. The patient's mother wanted to transport the patient in her private POV. There was not a Transfer Request Form or Transfer Orders in the patient's medical record. No documentation was present by the physician indicating the patient's mother refused the transfer with the risks and benefits being explained to the patient.

5. Review of Patient #19 medical record revealed the physician was transferring the patient to another ED for further evaluation of a right wrist injury. The patient wanted to transport themselves in their POV. Further review of the record revealed no Transfer Request Form or Transfer Orders by the physician. The physician failed to document education or instruction to the patient detailing the risks of traveling in POV.

6. These medical records were reviewed with the Medical Director of the ED on 10/9/14 at 4:00 pm. She agreed the required transfer forms were not present or completed properly. She also agreed the physician failed to document according to hospital policy regarding the transfer of a patient in a POV.

Based on review of documents, medical records and staff interview it was determined the facility failed to ensure the Request for Transfer Forms were completed appropriately in one (1) of seven (7) medical records reviewed (# 3) for patient request for transfer. This has the potential to negatively affect all patients, leaving them unaware of the risks associated with a transfer.

Findings include:

1. Hospital policy titled Inter-Hospital Transfer of Patient, last reviewed 11/13 states in part: "Transfer to another healthcare facility should be considered if: Patient/family requests transfer (risk must be explained to patient)."

2. Patient #3 presented to the Ed with complaints of increased knee pain after total knee surgery. The Medical Screening Exam (MSE) revealed the patient had an infection in her right knee. The patient requested a transfer. The physician called the receiving facility who accepted the transfer. The Request for Transfer form was not filled out by the physician indicating the patient's reason for transfer and the associated risks with using their Private Owned Vehicle (POV). No documentation was present in the medical record to indicate any education or reasons related to the transfer.

3. This medical record was reviewed with the Medical Director of the ED on 10/9/14 at 4:00 pm. She concurred with these findings.