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.

Based on interview, record review, and review of hospital policies and procedures, the hospital failed to implement policies and procedures for transfer of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to provide an RN-to-RN report when patients are transferred places patients at risk for medical errors and adverse patient outcomes due to lack of care continuity.

Findings included:

Cross Reference A2409 Requirements of an Appropriate Transfer
Based on interviews, review of policies and procedures, and medical record review, the hospital failed to assure the safe transfer of 4 of 11 patients (Patients #1, #3, #8, and #11) who were transferred from the Emergency Department (ED) to other hospitals.

Failure to assure a safe hand off or transfer of care places patients at risk for harm and/or unmet care needs.

Findings included:

1. Review of the hospital's policy and procedure titled "Emergency Patients, Screening and Mental Health Patient Transfer (EMTALA)", policy # , approved 11/21/19, showed that when appropriate, staff would include a progress note containing documentation of a registered nurse (RN) to RN report between the transferring and accepting facilities.

Review of the hospital's policy titled "Hand Off Communication," policy # , approved 4/16/20, showed that when a patient is transferred to an outside facility, a hand off report to the direct care staff assuming care of a patient is required. The policy showed that the information for all hand offs is conveyed in either electronic/written communication or a verbal report, and an opportunity to ask questions following the given report will be provided.

2. Interviews with three ED registered nurses on 1/05/21 (Staff #1, #2, and #3), showed that when transferring patients from the ED to other hospitals or facilities, the primary RN is expected to call a report to the RN at the accepting facility. All staff interviewed (Staff #1, #2, and #3) stated that if the receiving RN is unable to take report at the time of the phone call, they will call back or give report to the charge nurse at the accepting facility.

3. On 1/05/21 at 1:00 PM, the investigator reviewed the medical records of 25 patients who received care in the ED. Eleven patients whose ED records were reviewed were transferred to other facilities. Medical records for 4 of the 11 patients, Patients #1, #3, #8, and #11, did not include documentation that a RN to RN report occurred between the transferring and accepting facilities as required by hospital policy.

4. The above findings were confirmed by the Chief Nursing Officer (Staff #4) and the Regional Director of Emergency Services (Staff #5) at the time of the record review.