The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|UNIV. OF VERMONT - FLETCHER ALLEN HEALTH CARE||111 COLCHESTER AVE BURLINGTON, VT 05401||Oct. 13, 2016|
|VIOLATION: APPROPRIATE TRANSFER||Tag No: A2409|
|Based on staff interview and record review, the hospital Emergency Department (ED) failed to demonstrate evidence in the electronic medical record (EMR) of the utilization of a transfer form, as required, to assure both the physician and nursing completed the necessary documentation related to the patient transfer and the patient and/or individual legally responsible had also signed the consent for transfer to a receiving hospital for 2 of 2 applicable records. (Patients # 17 & 19) Findings include:
1. Patient #17 received treatment in the ED on 9/14/16 thru 9/15/16 for a psychiatric diagnosis. Shortly after admission to the ED the patient was screened by a crisis clinician and it was determined Patient #17 was in need of in-patient psychiatric hospitalization . On 9/15/16 Patient #17 was transferred to an inpatient psychiatric unit at an acute care hospital. Per review of the EMR and confirmed on 10/13/16 at 10:00 AM by the ED Nurse Manager, the Patient Transfer Form utilized by the hospital was not included/retained in the EMR.
2. Patient # 19 was transferred from a acute care hospital to the ED on 8/31/16 for further evaluation and testing after experiencing extremity weakness. After completion of extensive testing and further diagnosis, it was determined Patient #19 could return to the originating hospital where s/he would be admitted . Although there was evidence of communication between both hospitals related to the transfer of Patient #19, the Patient Transfer Form was not included in the EMR. By this omission, there was a failure to demonstrate evidence of physician and nursing documentation, noting patient's condition, benefits of transfer along with the patient's consent for transfer. Per interview on 10/13/16 at 10:05 AM, the ED Nurse Manager confirmed the form was not included as part of the EMR.