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MARSHFIELD MEDICAL CENTER - RICE LAKE 1700 WEST STOUT STREET RICE LAKE, WI 54868 Jan. 15, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and interview, facility staff failed to complete transfer forms per the guidance on the form, regulatory guidance, and/or facility policy in 17 of 20 medical records reviewed (Patient # 1, 2, 4, 5, 6, 7, 8, 9, 11, 12,13,15,16,17,18,19, and 20).

Findings include:

Facility staff failed to complete transfer forms per the guidance on the form and/or facility policy. See tag A2409.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on record review and interview, staff failed to accurately complete the patient transfer form information in 17 of 20 medical records reviewed of patients transferred to other facilities (Patient # 1, 2, 4, 5, 6, 7, 8, 9, 11, 12,13,15,16,17,18,19, and 20) and failed to obtain physician co-signatures on the transfer form for 4 of 4 patients transferred by mid-level providers (Patient #2, 6, 8, and 11) out of a total of 20 medical records reviewed.

Findings include:

The facility Physician Certification for Transfer form was reviewed on 1/16/2019 at 9:00 AM. The form had 5 sections. Section I, titled Medical Condition, asked for diagnosis, and had check boxes for if the patient had an emergent condition, if the patient was stable or unstable. Section II, titled "Risk and benefit for Transfer," revealed, "(Required: Check all that apply and add case-specific information.)" Section III, titled Mode/Support/Treatment during transfer as determined by physician, asked for transport information. Section IV, titled Receiving facility and individual, asked for the name of the receiving facility, receiving facility representative accepting the transfer and the time, the name of the accepting physician and the time, and the transferring physician's name, date and time. Section V, titled Patient consent to :Medically Indicated" or "Patient Requested" transfer, had check boxes for if the transfer was medically indicated or if it was a patient request, and an area for the patient and witnesses to sign.

The facility policy titled, "[Acronym for facility] EMTALA (emergency medical treatment and labor act): Screening, Stabilization, and Transfer," dated October 5, 2017, was reviewed on 1/15/2019 at 9:00 AM. The policy revealed in part, "D. Transfer or Discharge 1. Stable Patient Transfer Only a physician may transfer a stable patient from [acronym for facility] to a receiving facility for ongoing care if ALL of the following requirements are met:..." The policy goes on to reveal the requirements for facility staff to transfer a patient.

On 1/15/2019 at 10:45 AM a policy or protocol for completion of the Physician Certificating for Transfer form was requested. Per interview with Emergency Department Manager C at the time of the request, Manager C stated that there was no separate policy, only the EMTALA policy.

A review of Patient #1's medical record was conducted on 1/15/2019 at 10:30 AM accompanied by Emergency Department Manager C who confirmed the following findings per interview: Patient #1 was transferred to an alternate acute care facility on 1/5/2019. In section V of the Physician Certification for Transfer form, the physician/nurse did not check if the transfer was medically indicated or patient request.

A review of Patient #2's medical record was conducted on 1/15/2019 at 10:52 AM accompanied by Emergency Department Manager C who confirmed the following findings per interview: Patient #2 was transferred to an alternate acute care facility on 1/2/2019. In section II the Physician Certification for Transfer form does not specify what the medical benefits or risks are, specific to Patient #2's needs. Also in section II the form does not identify specialty resources required. In section IV the transfer form was signed by a Nurse Practitioner and not co-signed by a physician indicating there was a consultation and agreement prior to the transfer.

A review of Patient #4's medical record was conducted on 1/15/2019 at 11:23 AM accompanied by Emergency Department Manager C who confirmed the following findings per interview: Patient #4 was transferred to an alternate acute care facility on 1/3/2019. In section II of the Physician Certification for Transfer form, the specific benefits and risks for Patient #4 were not listed. In section IV of the form there was no time that the receiving facility was contacted/accepted Patient #4, and there was no time the physician signed the form. In section V the physician/nurse did not check if the transfer was medically indicated or patient request.

A review of Patient #5's medical record was conducted on 1/15/2019 at 11:40 AM accompanied by Emergency Department Manager C who confirmed the following findings per interview: Patient #5 was transferred to an alternate acute care facility on 1/3/2019. Section II of the Physician Certification for Transfer form was incomplete with unchecked applicable boxes. The specific medical risks for Patient #5 were entered as "transfer."

A review of Patient #6's medical record was conducted on 1/15/2019 at 11:47 AM accompanied by Emergency Department Manager C who confirmed the following findings per interview: Patient #6 was transferred to an alternate acute care facility on 1/4/2019. Section II of the Physician Certification for Transfer form does not specify the medical risks of transfer specific to Patient #6. There was no mode of transportation indicated in section III of the form. In section IV of the form there was no time that the physician assistant signed the form and there was no co-signature from a physician. In section V the physician assistant/nurse did not check if the transfer was medically indicated or patient request.

A review of Patient #7's medical record was conducted on 1/15/2019 at 12:07 PM accompanied by Emergency Department Manager C who confirmed the following findings per interview: Patient #7 was transferred to an alternate acute care facility on 1/4/2019. In section I of the Physician Certification for Transfer form, there are no medical benefits or risks indicated for Patient #7's specific needs. In section IV there was no time the receiving facility was contacted/accepted the transfer, and there was no date or time the physician signed the form. In section V the physician/nurse did not check if the transfer was medically indicated or patient request and there was no relationship of the responsible person who signed the form (Patient #7 was unable to sign). In an interview with Manager C during the time of the record review regarding dates and times of signatures, Manager C stated, "Yes, it does have to have a date and time."

A review of Patient #8's medical record was conducted on 1/15/2019 at 12:20 PM accompanied by Emergency Department Manager C who confirmed the following findings per interview: Patient #8 was transferred to an alternate acute care facility on 1/5/2019. In section II of the Physician Certification for Transfer form, specialty resources needed were not listed. The mode of transportation in section III was not indicated. In section IV of the form there was no time that the physician assistant signed the form and there was no co-signature from a physician. In section V the physician assistant/nurse did not check if the transfer was medically indicated or patient request.

A review of Patient #9's medical record was conducted on 1/15/2019 at 12:33 PM accompanied by Emergency Department Manager C who confirmed the following findings per interview: Patient #9 was transferred to an alternate acute care facility on 1/5/2019. In section II of the Physician Certification for Transfer form, the medical benefits and risks for transfer specific to Patient #9's needs were not listed. In section IV of the form there was name of a receiving physician. In section V the physician/nurse did not check if the transfer was medically indicated or patient request.

A review of Patient #11's medical record was conducted on 1/15/2019 at 12:48 PM accompanied by Emergency Department Manager C who confirmed the following findings per interview: Patient #11 was transferred to an alternate acute care facility on 1/10/2019. In section II of the Physician Certification for Transfer form the medical risks for transfer specific to Patient #11's needs were not listed. The mode of transportation in section III was not indicated. In section IV of the form there was no time that the physician assistant signed the form and there was no co-signature from a physician. In section V the physician assistant/nurse did not check if the transfer was medically indicated or patient request.

A review of Patient #12's medical record was conducted on 1/15/2019 at 11:02 AM accompanied by Quality Manager B who confirmed the following findings per interview: Patient #12 was transferred to an alternate acute care facility on 10/04/2018. In section II of the Physician Certification for Transfer form the box indicating that benefits outweigh risks of transfer was not checked. In Section V of the same form the physician/nurse did not check if the transfer was medically indicated or patient request.

A review of Patient #13's medical record was conducted on 1/15/2019 at 11:19 AM accompanied by Quality Manager B who confirmed the following findings per interview: Patient #13 was transferred to an alternate acute care facility on 10/15/2018. In section II of the Physician Certification for Transfer form the box indicating that benefits outweigh risks of transfer was not checked. In Section V of the same form, the physician/nurse did not check if the transfer was medically indicated or patient request.

A review of Patient #15's medical record was conducted on 1/15/2019 at 11:39 AM accompanied by Quality Manager B who confirmed the following findings per interview: Patient #15 was transferred to an alternate acute care facility on 11/13/2018. In section II of the Physician Certification for Transfer form the box indicating that benefits outweigh risks of transfer was not checked. In Section V of the same form the physician/nurse did not check if the transfer was medically indicated or patient request nor was there a signature/name for patient or responsible person for consent to transfer.

A review of Patient #16's medical record was conducted on 1/15/2019 at 11:50 AM accompanied by Quality Manager B who confirmed the following findings per interview: Patient #16 was transferred to an alternate acute care facility on 11/23/2018. In section V of the Physician Certification for Transfer form the physician/nurse did not check if the transfer was medically indicated or patient request. Also in Section V of the same form there was not a witness signature.

A review of Patient #17's medical record was conducted on 1/15/2019 at 11:59 AM accompanied by Quality Manager B who confirmed the following findings per interview: Patient #17 was transferred to an alternate acute care facility on 11/29/2018. In section II of the Physician Certification for Transfer form the box indicating that benefits outweigh risks of transfer was not checked. Section V of the same form, the physician/nurse did not check if the transfer was medically indicated or patient request.

A review of Patient #18's medical record was conducted on 1/15/2019 at 12:35 PM accompanied by Quality Manager B who confirmed the following findings per interview: Patient #18 was transferred to an alternate acute care facility on 12/17/2018. In section II of the Physician Certification for Transfer form the box indicating that benefits outweigh risks of transfer was not checked.

A review of Patient #19's medical record was conducted on 1/15/2019 at 12:45 PM accompanied by Quality Manager B who confirmed the following findings per interview: Patient #19 was transferred to an alternate acute care facility on 12/23/2018. In section II of the Physician Certification for Transfer form the box indicating that benefits outweigh risks of transfer was not checked. In Section V of the same form the box indicating if the signature is that of the patient or responsible person is not checked.

A review of Patient #20's medical record was conducted on 1/15/2019 at 12:55 PM accompanied by Quality Manager B who confirmed the following findings per interview: Patient #20 was transferred to an alternate acute care facility on 12/28/2018. In section II of the Physician Certification for Transfer form the box indicating that benefits outweigh risks of transfer was not checked.