HospitalInspections.org

Based on medical record review and interview, the facility failed to ensure 2 of 20 (Patient #2 and #12) sampled patients transferred to a higher level of care had a physician order for the transfer and documentation of medical records sent to the receiving facility.

The findings included:

1. Medical record review for Patient #2 revealed nurse's notes dated 8/9/15 that documented the patient was sent to an acute care hospital for emergent dialysis due to low urine output and fluid overload. There was no physician order for the transfer to the higher level of care. Further review revealed no documentation of the medical records sent to the receiving hospital to ensure continuity of care.

2. Medical record review for Patient #12 revealed Physician progress notes dated 9/28/15 that documented the patient was sent to an acute care hospital for a reaction to medication on 9/20/15. There was no physician order for the transfer to the higher level of care facility. Further review revealed no documentation of the medical records sent to the receiving hospital to ensure continuity of care.

During an interview on 9/29/15 at 1:30 PM in the Nurse Manager's office, the Nurse Manager verified there was no physician order for the patient's transfer.

3. During an interview in the conference room on 9/28/15 at 9:10 AM, the Nurse Manager stated, "We didn't do as well [documenting] if transfer...an emergent issue. The doctor was notified patient was sent to [named hospital] for emergent dialysis..."

During an interview in the conference room on 9/30/15 at 8:33 AM, the Nurse Manger stated the information sent to the receiving hospital was not documented in the medical record. She stated the staff completed a checklist of items sent but the checklist was not part of the medical record.

During an interview in the conference room on 9/30/15 at 8:55 AM, the Chief Clinical Officer stated a policy had been written as a result of the Joint Commission survey in August. He stated prior to the new policy, there was not a written protocol on transfers to acute facilities. He verified the new policy was approved by Quality Council on 9/21/15 and was not implemented until 9/24/15.