HospitalInspections.org

Based on interviews and documentation review, it was determined the Hospital failed to conduct a timely comprehensive review of possible issues related to Patient 16's transfer from the Hospital's Emergency Department (including a possible EMTALA compliance issue).

Findings included:

ED Staff RN #1 was interviewed in person at 3:10 PM on 7/15/10. She reported notifying the Nursing Supervisor of Patient #16's ED presentation and transfer and that the transfer was probably not in compliance with EMTALA regulations shortly after the Patient's transfer to Hospital #2.

ED Physician #1 was interviewed in person at 1:50 PM on 7/15/10. She reported notifying the ED Medical Director of Patient #16's ED presentation and transfer and that the transfer might not have been in compliance with EMTALA regulations; the day of the Patient's transfer.

The ED Nurse Manager and the Vice President of Quality Systems and Managed Care were interviewed in person throughout the EMTALA Survey. The Nurse Manager said she was notified of a possible EMTALA regulation violation in relation to Patient #16's care/transfer on the day of the Patient's transfer to Hospital #2. The Vice President said she was notified of a possible EMTALA regulation violation in relation to Patient #16's care/transfer 2 days following the Patient's transfer and a Hospital Internal Investigation was initiated.

A review of the Hospital Internal Investigation related to Patient #16's care and transfer 19 days following the transfer revealed the Patient's medical record had been reviewed and ED Physician #1 had been interviewed. No other interviews had been conducted, the sequence of events related to the Patient's care and transfer had not been determined, and the Patient's care had not been thoroughly analyzed/evaluated.

The Vice President of Quality Systems and Managed Care said the Hospital Internal Investigation was ongoing and had not (yet) determined if Patient #16's care/transfer were appropriate and/or if the Patient was transferred to Hospital #2 in compliance with EMTALA regulations.

Based on documentation review, it was determined Patient #16's medical record was not accurately written.

Findings included:

Patient #16's Ambulance Trip Report indicated he/she arrived at the Hospital at 1:03 PM, departed the Hospital for Hospital #2 at 1:07 PM and arrived at Hospital #2 at 1:37 PM.

Documentation in Patient #16's Hospital medical record indicated he/she arrived in the ED and was registered at 3:51 PM.

ED Physician #1 said Patient #16's medical record was created and medical record documentation was completed; after the Patient was transferred to Hospital #2.

Continued review of medical record documentation revealed it indicated Patient #16: was visited by a radiology technician at 4:02 PM; the Patient left the ED at 4:56 PM and; Physician R at Hospital #2 was contacted regarding Patient transfer at 5:16 PM.