HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interview, the facility failed to implement its policy and procedure related to completion of medical record entries specific to transfer order and physician authentication of entries for one of twenty (N1) closed patient medical records reviewed and completion of transfer forms for nine of twenty (N4-N6, N8, N12, N15, N17, N19 and N20) closed patient medical records reviewed.

Findings:
1. Medical Staff Bylaws, Policies, and Rules and Regulations, reviewed on 3/16/10 at 2:10 PM, indicated on pg. 111, point A. Transfer of Patient to Another Hospital/Facility, "Transfer of the patient to another hospital or facility requires a written order for transfer..."

2. Review of closed patient medical records on 3/15/09 at 2:00 PM indicated patient N1:
A. per Physician's Orders dated 3/1/10:
a. at 10:15 AM, "Discharge patient, have patient follow-up care with own physician [D4]."
b. at 1:01 PM, "Transfer patient to [receiving facility]." This order was crossed out and error written above it by R.N.
c. at 1:10 PM, "Patient may be discharged to follow-up at [receiving facility] with [D4]."
d. lacked a physician's order to transfer patient to another acute care facility.

3. Review of closed patient medical records on 3/16/09 at 10:00 AM indicated lack of documentation on Patient Transfer Form for patient:
A. N4, time of acceptance by physician at receiving facility and time of discharge vitals.
B. N5, patient's representative signature is present with one witness signature, but lacked date and time in space provided.
C. N6, date and time of acceptance by physician at receiving facility, discharge vitals, and patient's representative signature is present with one witness signature, but lacked date and time in space provided.
D. N8, patient's representative signature is present with one witness signature, but lacked date and time in space provided.
E. N12, date of physician authentication on certification statement of risks versus benefits of transfer.
F. N15, name of ambulance service contracted, time, ETA (estimated time of arrival), and date on lines provided and patient's representative signature is present with one witness signature, but lacked time in space provided.
G. N17, time of acceptance by physician at receiving facility and patient's representative signature is present, but lacked witness signature and date and time in space provided.
H. N19, reason for transfer and patient's signature is present, but lacked date and time in space provided.
I. N20, who contacted transport service, time, ETA, and date on lines provided.

4. Review of closed patient medical records on 3/15/09 at 2:00 PM indicated patient N1, Consent for Surgical, Special Diagnostic or Therapeutic Procedures dated 3/1/10, listed "Induction of labor with Cytotec, Cervidil, and/or Pitocin" as the procedure to be performed; lacked physician authentication and date and time of Physician Attestation Statement explaining and discussing the indications, risks, benefits, complications, alternatives and/or limitations of the procedure with the patient or their representative.

5. Personnel P9 was interviewed on 3/15/10 at 3:42 PM and indicated:
A. N4-N6, N8, N12, N15, N17, N19 and N20 patient medical records lacked complete documentation on the Patient Transfer Record and are to be completed, with all options filled-in and/or checked off appropriately by staff prior to transfer. This is required per facility policy and procedure.
B. Consents for Surgical, Special Diagnostic or Therapeutic Procedures are to be completed and the Physician Attestation Statement to be signed, dated, and timed by the physician.
C. a transfer order from the patient's physician must be obtained prior to transfer.

Based on clinical record review, a review of the Hospital's Rules and Regulations, policy and procedure review, medical record review, and interview, it was determined that in 1 in 20 (N1) records reviewed of patients who presented to the facility requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide an appropriate transfer.

Findings:

1. Please see findings cited at 489.24(e)(1)-(2) A2409.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to provide an appropriate transfer/discharge according to facility policy and procedure for one of twenty (N1) closed patient medical records reviewed.

Findings:

1. Patient Rights and Responsibilities, Policy No.: CORP_02, reviewed on 3/16/10 at 1:45 PM, indicated on pg. 1, point 3. and 4., "You have the right to be informed and make informed decisions about your care, including treatment, medical/surgical interventions, pain management, patient care issues and discharge planning. You have the right to be informed of your health status (diagnoses and prognoses) and any unanticipated outcome. You have the right to consent, request or refuse care or treatment..."

2. EMTALA (Emergency Medical Treatment and Active Labor Act), Policy No.: RM_20, reviewed on 3/16/10 at 1:11 PM, indicated on pg. 7:
A. section B. Transfer of Unstable Individual, point 1. "An individual with an emergency medical condition that has not been, or cannot be stabilized may not be transferred by the Hospital unless...i. The individual, or his/her legal representative, after being informed of the Hospital's EMTALA obligations and the risk of the transfer, requests the transfer and completes the TRANSFER REFUSAL/REQUEST form; ii. A physician signs the TRANSFER CONSENT/PHYSICIAN CERTIFICATION form to the effect that, based upon the reasonable risk and expected benefits to the individual and based upon information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweighs the increased risks to the individual and, in the case of a woman in labor, to the unborn child from being transferred..."
B. point C., "Prior to any transfer, the individual's medical record must reflect the chronology of events that occurred and what measures or treatments were implemented..."
C. point D., "Acceptance of the transfer will be documented on the PATIENT TRANSFER RECORD which identifies the individual, receiving facility, the consenting party's name and position or responsibility, and the date and time of the acceptance."
D. point E., "An individual will be transferred upon his/her legal representative's request, the attending physician's request...An individual who is in active labor and cannot be safely transferred will not be transferred unless the individual requests the transfer..."
E. point G., "Hospital staff or the physician will notify the receiving facility of the transfer and report/document the following...2. The condition of the individual...4. If the receiving facility is given medical information regarding the individual by someone other than the person who requested the receiving facility to accept the individual--both party's names must be documented."
F. point J., "The physician designates the method of transport and his/her designation is documented on the PATIENT TRANSFER RECORD form."

3. Review of closed patient medical records on 3/15/09 at 2:00 PM indicated patient N1:
A. presented to ED and was sent directly to the Labor & Delivery Department and was admitted as outpatient observation status on 2/28/10 at 18:00 PM due to 37 weeks gestation and chief complaint of "nausea and vomiting and increased blood sugar in a.m. of 490."
B. per Obstetric Admission Nursing Data Base (NDB) dated 2/28/10 at 18:00 PM, no fetal heart tones (FHT) 2 days ago; no contractions; no vaginal bleeding; cervical exam of station -3, thick effacement, and closed dilatation; and dull back/abdominal pain of 6 on 0-10 scale that comes and goes.
C. per Ante/Intrapartal Progress Notes Flowsheet dated 2/28/10:
a. at 18:20 PM, "Uterine Activity per TOCO (Tocodynamometer) external monitor: zero frequency, zero duration, zero intensity, rest/tone soft and non-tender; Fetal Assessment per Ultrasound external monitor: no fetal heart rate noted."
b. at 22:40 PM, "Cytotec 100 mcg inserted to posterior fornix of vagina [per physician's orders]; patient instructed on usage, verbalizes understanding."
c. at 23:30 PM, "Uterine Activity per TOCO external monitor: occasional frequency, irregular duration, mild intensity, rest/tone soft and non-tender."
D. per Ante/Intrapartal Progress Notes Flowsheet dated 3/1/10 at:
a. 2:40 AM, "Cytotec 100 mcg given vaginally [per physician's orders], cervix 1 cm, 50%, TOCO adjusted, contracting every 2-3 minutes."
b. 3:30 AM, "Uterine Activity per TOCO external monitor: 3-4 frequency, 70 duration, mild intensity, rest/tone soft and non-tender."
c. 6:40 AM, "cervix 1-2 cm, thick, presenting part unknown, -2 [station], Cytotec placed [per physician's orders]."
d. 7:30 AM to 11:18 AM, "Uterine Activity per TOCO (Tocodynamometer) external monitor: zero frequency, zero duration, zero intensity, rest/tone soft and non-tender."
e. 10:15 AM, "Spoke with [D3, physician from transferring facility] about patient's plan of care. Gave history of transient patient of [D4, physician from receiving facility], Type II diabetic, hypertension, on Magnesium Sulfate, fasting blood sugar 120, blood pressure 129/81. Orders received to discharge patient. [D3] also aware [Cytotec initiated] and has already received 3 doses. Aware spontaneous vaginal exam 1 cm, 100%, -2."
f. 11:30 AM, "Rechecked 2 cm, 100%, -1."
E. per Patient Progress Record dated 3/1/10 at:
a. 1:10 PM, "[R.N. (Registered Nurse)] spoke with [D3 who spoke with D4]. Made aware of patient situation. [D3] states [D4] will accept care at [receiving facility]."
b. 4:20 PM, "SVE (spontaneous vaginal exam) 3/100%/-1 [dilated 3cm, 100% effaced, station -1], unchanged from previous exam. Patient expresses pain with irregular contracting...ambulance on its way."
c. 4:25 PM, "Ambulance personnel at bedside, patient transferred to cart."
F. lacked documentation of vaginal exam and/or uterine activity after exam at 11:30 AM to exam at 4:20 PM.
G. per Patient Transfer Form dated 3/1/10, under section:
a. 1. C., "Patient is pregnant with contractions." Discharge vitals at 4:00 PM: blood sugar 81; blood pressure 155/85; respirations 20; pulse 94; and temperature 99.4 degrees Fahrenheit (F).
b. 1. C., lacked physician authentication and date on certification statement of risks versus benefits of transfer.
c. 7., transfer form had 2 boxes that could be checked to indicate whether or not the patient consented or refused transfer, but neither box was checked off. Patient's signature is present with two witness signatures, but lacked date and time in space provided.
d. lacked documentation of a written request for transfer.

4. Personnel P9 was interviewed on 3/15/10 at 3:42 PM and indicated:
A. N1 patient medical record lacked complete documentation on the Patient Transfer Record of physician authentication and date on certification statement of risks versus benefits of transfer; lacked documentation of a written request for transfer and is to be completed, with all options filled-in and/or checked off appropriately by staff prior to transfer. This is required per facility policy and procedure.
B. personnel should have documented assessments of this patient that included vaginal exams and uterine activity on the Ante/Intrapartal Progress Notes Flowsheet at least every hour and this was not done after the vaginal exam at 11:30 AM until the next one at 4:20 PM.

5. Review of closed patient medical record from receiving facility on 3/15/10 at 10:20 AM indicated patient N1:
A. was admitted to receiving facility on 3/1/10 at 18:04 PM via transfer for treatment of labor.
B. per Admit Report dated 3/1/10, arrived at 17:32 PM, gestational age by EDC was 38 weeks and 3 days; uterine contraction evaluation: intensity was strong, membranes intact, dilation complete, effacement 100%, station +2, thick meconium fluid present, and presentation vertex.
C. per Nurses' Notes Log dated 3/1/10:
a. at 17:30 PM, "contracting every 2-3 minutes per patient. Vaginal exam: dilatation 10.0 cm, effacement 100%, station 2."
b. at 18:00 PM, "blood pressure 185/106 mm/Hg."
c. at 18:05 PM, "[physician] unable to deliver shoulders and body. Decision for delivery to continue in Operating Room under anesthesia."
D. per Intraoperative Record dated 3/1/10, "vaginal delivery of still born female at 18:40 PM".
E. per History and Physical dictated 3/1/10 at 18:57 PM, "Today I received a phone call from [transferring facility] where the patient had apparently been hospitalized for greater than a day. They reported that the patient requested transfer to our facility. I pointed out to them that there was not any special expertise here beyond what was available at their hospital. However, if the patient arrived at our hospital, I would care for her as part of my on-call obligation. The communications between the nurses suggest that the patient has received magnesium sulfate, and the patient suggests that there may have been some intravaginal medication placed last night to try to induce labor. Report from the attending physician at [transferring facility] was that the patient was requesting transfer because she considered herself to be my patient and that the patient was not in labor, that her blood pressure and blood sugar were normal and stable. On arrival, in fact, the patient was noted to have the infant head on the perineum and the head pushed out. There was severe shoulder dystocia which could not be released in labor and delivery. It is elected to bring the patient to surgery for Anesthesia to employ shoulder dystocia release maneuvers."

6. Medical record for Patient N1 at transferring facility lacked documentation of an appropriate transfer for patient in active labor as determined by receiving facility's documentation to indicate that labor had been induced with medication prior to patient's transfer and patient was having contractions on transfer. Also, there was a lack of documentation of a vaginal exam and/or uterine activity for approximately 4 hours and 50 minutes, from 11:30 AM to 4:20 PM. Upon arrival at the receiving facility, it was indicated patient was completely dilated, 100% effaced, at +2 station and the infant head was pushed out. Furthermore, there was a lack of documentation on the Patient Transfer Record of the physician's authentication and date on the certification statement of risks versus benefits of transfer. This form also lacked documentation of a written request for transfer and it had 2 boxes that could be checked off to indicate whether or not the patient consented or refused transfer, but neither box was checked off.