HospitalInspections.org

Based on interviews and record review, the facility failed to ensure appropriate transfers were conducted in 3 out of 20 patients (patients #11, #14 and #19) when:

1. Memorandum of Transfers (MOT) did not include benefits and risks of transfers or a summary of the transfer.
2. Physician Certification Statements (PCS) and were not signed or countersigned by a physician.
3. Bylaws did not determine the definition of a qualified medical person who may sign in the absence of the physician in the emergency department.

The findings are as follows:

Record Review

Record Review of Patient #11 shows the patient presented to the Emergency Room (ER) on 8/11/2023 via Emergency Medical Services (EMS) for a suicide attempt and was on emergency detention. On 8/12/2023, Patient #11 was found to be a danger to self and others, on emergency detention, and was transferred via EMS to a mental health facility. The Physician's Certification Statement was signed by a Registered Nurse (RN) and did not reflect a physician's signature or countersignature in the patient's medical record. The MOT did not include the reason for the transfer, including risk and benefits, or a summary of the transfer.

Record Review of Patient #14 shows the patient presented to the ER on 10/17/2023 with altered mental status (AMS) and cough. On 10/18/2023, the patient was transferred to the VA hospital due to insurance coverage while on supplemental oxygen with diagnoses of complicated UTI and pneumonia. Patient #14 required an EMS transport due to the continued use of supplemental oxygen. A Care Coordinator signed the Physician's Certification Statement and did not reflect a physician's signature or countersignature in the patient's medical record. The MOT did not include risks and benefits or a summary of the transfer.

Record Review of Patient #19 shows the patient presented to the ER via EMS on 09/25/2023 from another hospital after a fall and was diagnosed with T-11 and T-12 fractures. Due to the O-arm a surgical imaging system being nonfunctional (a necessary part of the surgical equipment), Patient #19 was transferred to another facility for surgery. The Physician's Certification Statement was signed by a Registered Nurse (RN) and did not reflect a physician's signature or countersignature in the patient's medical record. The MOT did not include the reason for the transfer, including risk and benefits, or a summary of the transfer.

The facility's "Medical - Dental Staff Bylaws", last revised and effective on 05/23/2017, stated on page 59:
" ...Every practitioner providing clinical services at University Health systems facilities by virtue of Staff appointment or otherwise shall be entitled to exercise only those clinical privileges specifically granted by the Board of Managers ...."

The Facility's policy titled "Emergency Medical Treatment and Patient Transfer", last revised and effective on 10/22/2018, defines an emergency medical condition (EMC) on page 5 as follows:
" ... I. Emergency Medical Condition (EMC) - A medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:

1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

2. Serious impairment to bodily functions; or

3. Serious dysfunction of any bodily organ or part ..."

Interviews

Interview with Staff #19, Interim Director of Care Coordination, indicated her team oversees transfers for patients at the hospital. Staff # 19 indicated physicians notate the patient records indicated the patient was cleared for transfer and would complete a signature via a doctor's order in the patient record. Staff #19 stated the physician would only sign off on a PCS if the transfer was considered urgent. Staff # 19 indicated a social worker or RN will then sign off subsequently and their signature is reflected on the PCS. Staff #19 indicated physicians are not required to provide a countersignature since they sign first and notate the patient record designating medical clearance for transfer.

Interview with Staff #12, ER RN, indicated the providers, "can sign off as a witness but the healthcare provider still signs off on it. The doctors are adding in the discharge summary or their last note indicating the patient is medically cleared to transfer." Staff #12 confirmed the PCS form did not include a physician's signature and attributed it to an issue with the Electronic Medical Record (EMR) system.