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SACRED HEART HOSPITAL
COMPLIANCE WITH 489.24
Tag No.: A2400
Based on MR review, in 20 of 20 MR (1 through 20), tour and observation, the facility failed to ensure transfer forms are complete and including Pt specific risk of transfer, MD to MD contact, and EMTALA signs are missing.
Findings include:
In 1 of 1 tour, the facility failed to ensure an EMTALA sign is in the patient/family waiting room, and signs are posted in languages to meet the community population. See Tag A2402.
In 2 of 2 MRs, the facility failed to ensure the transfer form and/or MR includes: documentation of MD to MD contact, date and time of transfer consent, and risks of transfer specific to the Pt condition. See Tag A2409.
The cumulative affect of these deficiencies potentially affect all 91 ED and Urgent Care Pts seen during survey.
POSTING OF SIGNS
Tag No.: A2402
Based on 1 of 1 tour of the facility's ED and 1 of 1 interview with staff (D) the facility failed to ensure EMTALA signs are posted in waiting areas and are in languages of the high populations.
Findings include:
Per tour of the facility ED on 4/8/13 at 2:00 PM, there are no EMTALA signs in the waiting area. Per interview with ED Dir D on 4/8/13 at 2:00 PM, the community has a high Hispanic and Hmong population. ED Dir D pointed out an EMTALA sign written in Spanish in the Triage area, but there are no other Spanish or Hmong EMTALA signs in the ED. ED Dir D stated there are no EMTALA signs in the ED waiting area.
APPROPRIATE TRANSFER
Tag No.: A2409
Based on MR review and interview with staff (C and D) in 2 of 2 transfer records (7 and 12) reviewed out of a total of 20 MRs reviewed, the facility failed to ensure the transfer documentation is complete including times, risks, destination and accepting physician.
Findings include:
Pt #7's MR review on 4/8/13 at 4:45 PM revealed Pt #7 arrived in the ED with a complaint of hyporthermia on 1/2/13. Pt #7 was transferred to another facility for pediatric specialists. The Physician Certification for Transfer: Orders/Consent does not have a time the family member signed the transfer consent; there are no risks specific to the Pt's condition, including transport by private car; the destination hospital is not documented on the transfer form and the accepting MD and time contacted are not documented on the transfer form to ensure the receiving facility accepted the Pt. This is confirmed in interview with ED Dir D on 4/8/13 at 4:45 PM, stating the document should be complete.
Pt #12's MR review on 4/9/13 at 7:40 AM revealed Pt #12 arrived in the ED with a complaint of chest pain on 12/5/12. Pt #12 was transferred to another facility for a specialist evaluation. The Physician Certification for Transfer: Orders/Consent does not have a date and time Pt #12 signed the consent to transfer; there are no risks specific to the Pt's condition; and there is no accepting MD contact time documented on the transfer form to ensure the receiving facility accepted the Pt. This is confirmed in interview with QCC C and ED Dir D on 4/9/13 at 7:40 AM, stating the document should be complete.