HospitalInspections.org

Based on review of facility policy, medical records (MR) and interview with facility staff (EMP), it was determined the facility failed to ensure that all records related to the emergency condition were sent to the receiving hospital for four of 12 transfer medical records reviewed (MR1, MR2, MR3, and MR4) and failed to include a physician signed certification which include a summary of the risks and benefits for one of 12 transfer medical records reviewed (MR5).

Findings include:

Review on June 2, 2011, of the facility's "Medical Staff Rules and Regulations," last reviewed June 2010, revealed "Transfers In accordance with state law, patients will not be transferred unless it is medically necessary and appropriate. The medical risks and benefits of the transfer shall be explained to the patient or the patient's significant other. Forms to be completed: Physician Certification For Transfer, Consent to Transfer, When Appropriate Refusal To Consent To Treatment , Release From Responsibility For Discharge Against Medical Advice, Refusal To Consent To Transfer."

Review on June 2, 2011, of the facility's policy "Guidelines For Transferring Emergency Room Patients," dated 2007, revealed " ... 3. All transfers require completion of Consent to transfer form as well as copies of all necessary records. ..." Included with this policy was a two page transfer form which included the Physician Certification for Transfer and Consent to Transfer with an area for documenting what was sent to the receiving hospital.

1) Review on June 2, 2011, of MR1, MR2, MR3 and MR4 revealed the patients were transferred to another facility for a higher level of care. The transfer record in each of the medical records was not completed. There was no documentation on the Consent to Transfer that the medical record accompanied the patient at the time of transfer. In addition, there was no documentation in the nursing notes that the medical record was sent to the receiving facility at time of transfer.

Interview on June 2, 2011, with EMP1 at 11:00 confirmed that the transfer forms were not complete for MR1, MR2, MR3,and MR4. EMP1 confirmed there was no documentation that the patient's medical record was sent to the receiving facility at the time of transfer.

2) Review on June 2, 2011, of MR5 revealed the patient was transferred to another facility for a higher level of care. Continued review of MR5 revealed no documentation of a signed certification of transfer completed by the physician.

Interview with EMP1 on June 2, 2011, at 11:00 AM confirmed there was no documentation in MR5 of a signed certification of transfer completed by the physician.