HospitalInspections.org

Based on interviews and a review of documentation, the governing body failed to be responsible for all services furnished in the hospital.

Findings were:

Facility policy 1.018 titled Transfer of Patient to Another Facility states, in part, "POLICY ...3. The physician will be responsible for securing a receiving physician and a receiving hospital that will be appropriate to the medical needs of the patient and that will accept responsibility for the patient ' s medical treatment and hospital care ...PROCEDURE...6. Make sure you have an accepting physician at the accepting facility. 7. Pertinent paperwork should be sent with the patient, including the following: a. Memorandum of Transfer (per Texas State Law) i. Should be signed by transferring physician ...b. Consent and Request with Risks and Benefits (per COBRA Law) ...c. Physician Assessment and Certification (per COBRA Law) ...e. Hospital Patient Transfer Form.

Although a review of the clinical record for patient #20 revealed a memorandum of transfer, it was incomplete with regard to the signature of the transferring physician. The diagnosis was listed as " bilateral lower extremity cellulitis " . There was no time noted at which an accepting physician was secured. No " Consent and Request with Risks and Benefits " , " Physician Assessment and Certification " or " Hospital Patient Transfer Form " was present in the clinical record.

In an interview with staff #2 on 2-4-13 at 1300, when asked if he had secured and spoken with a receiving physician at BSSH prior to the transfer of the patient, he stated that he didn ' t know he was supposed to.

The above was confirmed in a meeting with the Chief Nursing Officer on the afternoon of 2-4-13 in the CEO's office.

Based on a review of the clinical record and an interview with staff, the hospital failed to meet the requirements of an appropriate transfer.

Findings were:

During a review of the clinical record for patient #20, the following requirements of an appropriate transfer were not met:
- The memorandum of transfer was not signed by the transferring physician.
- No evidence of a Consent and Request with Risks and Benefits was found in the clinical record.
- No evidence of a Physician Assessment and Certification was found in the clinical record.
- No evidence of a Hospital Patient Transfer Form was found in the clinical record.

In an interview with staff #2 on 2-4-13 at 1300, when asked if he had secured and spoken with a receiving physician at BSSH prior to the transfer of the patient, he stated that he didn't know he was supposed to.

The above was confirmed in a meeting with the Chief Nursing Officer on the afternoon of 2-4-13 in the CEO's office.