HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 21 patients, the hospital failed to ensure compliance with 489.24 in that the hospital failed to document stability of patient at the time of transfer and failed to complete physician certification documentation with explanation of risks and benefits of the transfer prior to transfer.

Findings include:

1. See findings cited at 489.24 (c) (1-2).

Based on document review and staff interview, the facility failed to document patient stability at time of transfer for 2 of 16 transferred patients (patients #2 and #15) and failed to complete physician certification documentation with explanation of risk and benefits of the transfer for 1 of 16 patients transferred (patient #15).

Findings include:

1. Review of patient #2 medical record indicated the following:
(A) He/she presented to the ED on 11/25/10 with weakness in his/her leg and was treated by M.D. #4. A CT scan revealed a brain mass and the patient was transferred to another acute care facility.
(B) Document titled "EMTALA TRANSFER FORM," section "PATIENT STATUS at TRANSFER" lacked documentation of the patient's status at the time of the transfer.

2. Review of patient #15 medical record indicated the following:
(A) He/she presented to the ED on 1/20/11 with injuries sustained in a motor vehicle accident (MVA) and was treated by M.D. #4. He/she was transferred to another acute care facility.
(B) Document titled "EMTALA TRANSFER FORM," section "PATIENT STATUS at TRANSFER" lacked documentation of the patient's status at the time of the transfer. Additionally, section "Physician Certification" indicating the risk and benefits of a transfer was left blank.

3. Review of quality assurance (QA) transfer documentation statistics for each physician indicated that M.D. #4 failed to document patient stability for one (1) patient and explanation of risk/benefits of the transfer for five (5) patients for October through December 2010. There was no documentation that the identified problem had been addressed with the physician.

4. Facility policy titled "Admission of patients to ED," last reviewed/revised 10/10 stated on page 2:
10. If a patient is to be transferred for medical necessity, the following guidelines must be followed: a. A physician certification that the risk of transferring the patient is outweighed by the potential benefits. The individual risks and benefits must be documented and the patient's medical record must support these....."

5. Medical staff rules and regulations stated on page 9: "2. An appropriate medical record shall be kept for every patient receiving emergency service and be incorporated in the patient's Hospital record, if such exists. The record shall include.....(g) Condition of the patient on discharge or transfer....."

6. Staff member #1 verified medical record documentation as indicated above at 3:15 p.m.