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RAPIDES REGIONAL MEDICAL CENTER
APPROPRIATE TRANSFER
Tag No.: A2409
Based on record review and interview, the hospital failed to ensure the Emergency Department Physicians informed Patient #2, or a legally responsible person acting on the patient's behalf, in writing of the risks and benefit of the transfer as evidenced by failure to have documented evidence that 1 (#2) of 20 ED patients (#1-#20) (or their responsible party) transferred were informed of the risks and benefits of transfer in writing.
Findings:
Patient #2 presented to the ED 11/04/2023 at 12:00 p.m. via ambulance.
A review of Patient #2's medical record revealed he presented to the Emergency Department after a motor vehicle accident with open deformity to the medical aspect of the right foot or ankle.
CT of right ankle completed 11/4/2023 at 12:59 p.m. showed a severely comminuted open fracture involving the calcaneus. Fracture extends into the subtalar joint and calcaneal cuboid articulation. Fragments are displaced upwards of 2.5 cm. There are bone fragments seen at the skin surface posteriorly. There is punctuate debris in the wound association. Soft tissue gas is also seen within the ankle joint and anterior soft tissues. Marked soft tissue swelling is also noted.
Patient #2 Diagnosis: motor vehicle collision, right femoral fracture, abrasions to multiple sites, open fracture of calcaneus, right pneumothorax, compression fracture of T9 vertebra, fracture of sternum with retrosternal contusion, bilateral pulmonary contusion.
Transfer request time: 3:05 p.m. 11/04/2023.
Transfer accepted: 4:16 p.m. 11/04/2023 for orthopedics higher level of care.
Departed 11/04/2023 at 6:52 p.m.
Further review failed to reveal the Emergency Department Physicians informed Patient #2, or a legally responsible person acting on the patient's behalf, in writing of the risks and benefit of the transfer and request for the transfer.
In an interview on 11/8/2023 at 12:00 p.m. S3RM and S4VPRQ reviewed and verified the certified medical record for Patient #2 did not contain required transfer documentation and consent.