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CHRISTUS ST VINCENT REGIONAL MEDICAL CENTER 455 ST MICHAEL'S DRIVE SANTA FE, NM 87505 July 29, 2014
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on record review, interviews, and document review, the transferring hospital failed to ensure that all clinical records related to the patient's emergency medical condition, including the hospital transfer form, were available at the time of transfer to the receiving hospital for 11 of 20 sampled emergency department (ED) patients (Patient #1, 6, 7, 8, 9, 10, 11, 15, 16, 17, and 18) (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20) identified by the Vice President-Compliance Officer/Privacy Officer as patients who were transferred to another hospital provided on 07/29/14. This deficient practice resulted in the delay of the receiving hospital's physicians ability to diagnose and treat the patient, thus putting the patient's health and safety in jeopardy. The findings are:

A. Record review of the letter from the receiving hospital revealed the following: "On 07/08/14 at 9:57 pm, the [name of hospital] received a call from a physician from the transferring hospital requesting a transfer of Patient #1. The reason stated for the request to transfer was 'urinary retention, needs suprapubic catheter.' The patient was accepted in transfer by an Emergency Medicine physician.

The letter further stated that Patient #1 arrived via ambulance at the receiving hospital's ED on 07/09/14 at 12:04 am; that no medical records were sent with Patient #1, who had significant heart disease; and that the hospital did not receive a transfer form, although the ED Charge Nurse called the transferring hospital multiple times in an effort to obtain the medical records and the transfer form.

The letter quoted the ED Provider note dictated on 07/09/14 at 1:25 am as stating, "No records sent with patient and have not been received via fax for further history yet. The ED Charge Nurse called the [transferring hospital's name] multiple times, finally talked to the Admin Supervisor since the documents we received were only the discharge instructions, no provider note or documentation of ER visit or transfer order. Admin supervisor stated that they 'didn't have any other documentation available.'" The receiving hospital's letter additionally stated, "Given long cardiac history, we also requested his most recent cardiology note or procedure as the patient was found to have an elevated Troponin (a cardiac enzyme)[level]. At 4:15 am, records finally arrived from the transferring hospital with cardiology notes and an old electrocardiogram (EKG). Patient's Trop[onin] [level] #2 reported at approximately the same time was more elevated than the first. Cardiology paged at 4:25 am after patient [was] guaiaced (patient stool tested for hidden blood) and heparin ( a blood thinner medication) ordered...Emergent medical condition exits..."

B. On 07/29/14 at 11:30 am, during interview, the Chief Medical Officer at the transferring hospital indicated that he had reviewed Patient #1's emergency record dated 07/08/14. He stated that he did not find the transfer form in the chart.

C. On 07/29/14 at 12:45 pm, during interview, the Clinical Manager of the ED at the transferring hospital confirmed after reviewing Patient #1's emergency record dated 07/08/14, that the transfer form was not found in the chart.

D. Record review of the emergency records of Patient #6, 7, 8, 9, 10, 11, 15, 16, 17, and 18 revealed no evidence of a transfer form in their charts.

E. On 07/29/14 at 4:00 pm, during interview, the Vice President - Compliance Officer/Privacy Officer confirmed the lack of documented evidence of a transfer form in the emergency records of Patient #6, 7, 8, 9, 10, 11, 15, 16, 17, and 18.

F. Record review of the hospital's policy #107.0, effective date 05/14/12, last reviewed/revised 09/14/12 titled "Emergency Department Patient Inter-facility Transfers" revealed the following: "5. The following transfer forms must be completed prior to transferring the patient: a. Patient's request/refusal/consent to transfer form. b. Physician assessment and certification or the Emergency Treatment Record. 6. The original forms are retained in the patient's medical record and copies are sent to the receiving hospital with the patient. 7. A copy of medical records, lab results, radiology results, and/or any other pertinent information from the medical record will be sent to the receiving hospital with the patient...9. Prior to transferring the patient to the receiving hospital the following should be documented:
a. Report given to transport team
b. Report given to receiving hospital
c. Condition of patient at time of transfer
d. Current vital signs."

G. Record review of the hospital's "EMTALA (Emergency Medical Treatment and Labor Act) Transfer" policy with an effective date of 01/01/84 and last reviewed/revised 10/01/06 revealed the following: "...Necessary medical records must accompany individuals being transferred to another hospital. If a transfer is in an individual's best interest, it should not be delayed until records are retrieved or test results come back from the laboratory. Whatever medical records are available at the time the individual is transferred should be sent to the receiving (recipient) hospital with the patient. Test results that become available after the individual is transferred should be communicated to the recipient hospital in a manner consistent with HIPAA (Health Insurance Portability and Accountability Act) provisions on the transmission of data...The sending hospital is ultimately responsible for ensuring that the transfer is affected appropriately...Certification of the risks and benefits of transfer must be placed in the patient's medical record."