HospitalInspections.org

Based on document review and interview it was determined that in 1 (patient 18) of 21 medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 42 CFR 489.24 in that the facility failed to provide an appropriate transfer.

Findings Include:

1. See findings cited at 42 CFR 489.24, C2409

Based on document review and interview, the facility failed to provide a proper transfer for 1 of 6 emergency department transfer records reviewed. (P18)

Findings include:

1. Facility policy titled, " Transfer Of The Emergency Department Patient To Another Health Care Facility", last revised 05/2024, under Procedure: C. No patient will be transferred arbitrarily. The ED physician shall determine when transfer to another health facility is indicated. If transfer is indicated, the physician shall determine to whom the patient shall be transferred (physician) and to which health facility. It is the responsibility of the attending physician to contact the receiving physician. No patient will be transferred without acceptance by the receiving facility and/or physician (this is to be a Physician to Physician acceptance & hand-off of care).

2. P18 was treated at F1(Critical Access Facility) on 12/03/24 at approximately 12:48 am and was transferred to F2 (Psychiatric Facility) at approximately 4:55 am. P18's MR's lacked documentation of physician order for transfer and transfer form.

3. In interview on 12/13/24 at approximately 3:35 pm, N1 (Registered Nurse, Emergency Department Manager) and A1 (Quality Manager) confirmed P18's MR lacked documentation of transfer order and transfer form.

4. In telephone interview on 12/16/24 at approximately 11:43 am to 11:53 am, N2 (Registered Nurse, Emergency Department) indicated EDO (Emergency Detention Order) transfers are handled differently from other transfers as the nurse makes all the contact to find a receiving facility and sends the patient information. N2 confirmed the transfer document used in other transfers is not used in an EDO transfer.

5. In telephone interview on 12/17/24 at approximately 2:00 pm to 2:05 pm, C1 (complainant) indicated F2 has a 24-hour Emergency Solutions Call Service accessed by an 800 number, and a physician is always on-call for contact with new admissions, questions, or changes to patient status. C1 indicated an emergency admission always requires physician contact and he/she was notified of P18's need for admission to F2 when patient arrived on F2's door-step in the early morning hours on 12/03/24. C1 confirmed no physician hand-off was received from F1 regarding P18 prior to patient's arrival at F2.