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RIVER FALLS AREA HOSPITAL 1629 E DIVISION ST RIVER FALLS, WI 54022 Dec. 20, 2018
VIOLATION: RECORDS SYSTEM Tag No: C1102
Based on record review and interview, the facility failed to ensure compliance with their policy by failing to fully complete the Inter-Facility Transfer Form per policy in 6 of 10 patients transferred (Patients #2, 7, 10, 16, 18 and 19) in a total of 20 charts reviewed.

Findings include:

Review of policy System-wide Procedure: "EMTALA Transfer" # SYS-PC-EMCC-001.P1 revealed under Procedure A. "Transferring Physician or Qualified Medical Person will...5. Complete the following sections of the Allina Inter-Facility Transfer Form...[1] Patient Condition: Select all that apply... [2] Reason for transfer: select all reasons that apply. If the second and/or third boxes are checked, section 5 "Transferring Physician Certification" must be completed... [4] Medical Risks of Transfer - Concise summary of the medical and other risks of transfer discussed with patient... [5] Transferring Physician Certification - This section must be completed whenever the second or third boxes are checked in section [2]... [6]...indicate the time that the acceptance was obtained... B. Transferring Nurse will...4. Complete the following areas [6] Indicate who gave nurse to nurse report, the name of the nurse who accepted the report at the receiving facility and the time it was completed... [8] Documentation - Specify the documents sent with patient at time of transfer... [10] Notification of family - Indicate whether family was notified, was in attendance or if the hospital was not able to contact the family... [11] Signatures - The patient, of the legally responsible representative acting on behalf of the patient must sign and indicate the date and time."

Medical record review of "Inter-Facility Transfer Form" for Patient # 2 with Emergency Department (ED) Manager C revealed under Patient Condition #1: no documentation, the space was blank, under "name of Nurse accepting report" #6: no documentation the space was blank and no times were documented. Under #11: no times or date of signature of witness to consent was not documented.

Medical record review of "Inter-Facility Transfer Form" for Patient #7 with ED Manager C revealed under "Medical Risks of Transfer" #4: no documentation, the space was blank, under "Facility Acceptance" #6: time was not documented. Under "Notification of Family" #10: no documentation, nothing was marked or filled in.

Medical record review of "Inter-Facility Transfer Form" for Patient #10 with ED Manager C revealed under "name of Nurse accepting report" #6: no documentation, the space was blank and no time was documented.

Medical record review of "Inter-Facility Transfer Form" for Patient #16 with ED Manager C revealed under "Receiving Physician" #6: no time documented, under "Documentation" #8: no documentation, the space was blank. Under "signature of patient or legal responsible individual" #11: no time or date was not documented.

Medical record review of "Inter-Facility Transfer Form" for Patient #18 with ED Manager C revealed "Transferring Physician Certification" #5 time was not documented.

Medical record review of "Inter-Facility Transfer Form" for Patient #19 with ED Manager C revealed "receiving facility who agreed to accept patient" #6: no time was documented and "signature of patient or legally responsible individual" #11: time was not documented.

On 12/20/2018 at 10:26 AM during interview with ED Manager C and Quality Manager A, Quality Manager A stated the "System-wide Procedure: EMTALA Transfer" policy requires the form to be filled out completely when patients are transferred to another facility and confirmed the Inter-Facility Transfer Forms were not fully completed in the medical records that were reviewed (Patients #2, 7, 10, 16, 18 and 19).