HospitalInspections.org

Based on record review, policy review, and interview, the provider failed to ensure transfer consent certification forms with risks and benefits were performed for two of four sampled patients (20 and 31) who were transferred. Findings include:

1. Review of patient 20's medical record revealed:
*He was admitted on 1/15/17 at 4:00 a.m. with diagnoses of auditory hallucinations, anxiety, bipolar, depression, and schizophrenia.
*A petition for emergency commitment listed the nature of the danger as "voices telling him to hurt himself or others."
*A certification of qualified mental health professional or physician was completed by qualified mental health professional D.
*A mental illness hold was placed on patient 20 on 1/15/17 at 11:31 a.m.
*A discharge order was done at 10:54 a.m.
*Human Services Center (HSC) accepted the patient for transfer at 11:40 a.m.
*Transfer communication provided to HSC was:
-Pre-transfer information.
-Medication information.
-Procedures and tests.
-Patient identification.
-Physician information.
-Vital signs.
-Care summary.
*The patient was discharged to law enforcement for transfer to HSC at 11:55 a.m.
*The discharge destination was marked as "yes" for transfer of continued care to an acute care facility.
*No transfer consent certification form was documented.

Review of the provider's undated Steps to a Committal (adult: 18 and older) policy revealed:
*Provider would contact HSC and notify them of a possible transfer.
*After reviewing all paperwork, the HSC would notify the provider if the patient was accepted.
*Patient would be discharged to a law officer for the patient going to HSC.
*Law officer would sign discharge paperwork and paperwork would have been sent with that officer.

Interview on 5/2/17 at 2:10 p.m. with vice president of patient care B revealed:
*For patients sent to HSC the behavioral health procedure was to discharge the patient the patient to the law officer.
*No transfer consent certification form would have been filled out for a patient transferred to HSC.



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2. Review of patient 31's medical record revealed:
*He had been admitted on 1/31/17.
*A 2/15/17 at 12:41 p.m. physical therapy contact note "Pt [patient] d/c'ing [discharging] to Avera McKennan this afternoon with his wife for gallbladder surgery and further care."
*A 2/15/17 at 1:30 p.m. nurses note "[Physician's name] called to McKennan to see about patient leaving today. Talked to [name] and she states she will not know about a bed until around 1500 [3 p.m.] [Physician's name] instructed this nurse to call back and talk to [name] at 1500 as patient's wife would like to be gone around 1530 [3:30 p.m.] so she does not have to drive in the dark or during rush hour."
*A 2/15/17 at 5:23 p.m. emergency department departure data follow-up appointments and examinations (exam) "Go to Avera McKennan to be admitted there."
*A 2/15/17 at 5:30 p.m. nurses note "Received a call from the Avera transfer center. They state they are able to take patient tonight. Family is in aberrance with the patient going to McKennan. Discharge will be started so they can head to Avera McKennan."
*A 2/15/17 at 5:50 p.m. emergency department departure data follow-up appointments and exams "Go to Avera McKennan to be admitted there."
*A 2/15/17 at 5:50 p.m. nurses note "Talked to [name] at Avera McKennan 1 West. Gave report on patient. Let her know that patient just left and they will be there in about 2 hours. [Name] was told to call with any questions."
*Certified nurse practitioner's 2/15/17 discharge summary noted:
-Gallstone ultrasound showed impression of one large right and small left pleural effusion.
-"The patient was discharged to Avera McKennan for further evaluation of concerns noted with his gallbladder ultrasound."
*No transfer consent certification form had been completed.

Interview on 5/3/17 at 9:45 a.m. with director of patient care A confirmed the patient transfer sheet should have been completed prior to discharge.

3. Review of the provider's January 2017 Transfer Procedure policy revealed a transfer consent must be completed when a patient was transferred.

Review of the provider's January 1993 Transfer Consent Certification Form revealed the form contained:
*The reason, risk, and benefits of transfer were included.
*The mode of transfer included car, ground ambulance, and air ambulance.
*A place for the patient or their representative to sign.
*A place for the physician authorizing transfer to sign.

Based on record review, interview, and policy review, the provider failed to ensure:
*Five of five sampled surgical patient's (21, 22, 23, 24, and 25) history and physicals had been timed.
*One of five sampled surgical patient's (25) consent form had been dated and timed.
Findings include:

1. Review of patient 21's medical record revealed:
*She had a left carpel tunnel release on 3/23/17.
*The history and physical had not been timed when it had been completed.

2. Review of patient 22's medical record revealed:
*She had a colonoscopy done on 4/6/17.
*The history and physical had not been timed when it had been completed.

3. Review of patient 23's medical record revealed:
*He had a colonscopy with hemorrhoid banding done on 3/2/17.
*The history and physical had not been timed when it had been completed.

4. Review of patient 24's medical record revealed:
*He had a colonoscopy with biopsies done on 3/2/17.
*The history and physical had not been timed when it had been completed.

5. Review of patient 25's medical record revealed:
*She had an esophagogastroduodenoscopy (EGD) done on 2/2/17.
*The history and physical had not been timed when it had been completed.
*The consent form for the surgical procedure had not been dated and timed when signed by the physician.

6. Interview on 5/2/17 at 3:00 p.m. with director of surgical services C regarding the above patients revealed her expectations would have been for the:
*History and physicals for patients 21, 22, 23, 24, and 25 to have been timed when done.
*The physician to have dated and timed the surgical consent form for patient 26.

Interview on 5/3/17 at 8:35 a.m. with the vice-president of patient care services B and the director of patient care services A regarding the above revealed their expectations would have been for the:
*History and physicals for patients 21, 22, 23, 24, and 25 to have been timed when done.
*The physician to have dated and timed the surgical consent form for patient 26.

Review of the provider's April 2017 Pre-Operative Patient Preparation policy revealed: "K. All entries (not in meditech) will have signatures, dates, and times."