HospitalInspections.org

Based on medical record review, it was determined that the facility did not effectively ensure that all transfer requirements were met.

Findings include:

Review of medical record MR #7 noted that the patient presented to the hospital's ED on 6/14/12 with chief complaint of fever, sore throat, difficulty swallowing and swelling of the throat. Patient's medical condition was evaluated by the ED physician whose impression was tonsillar abscess and discharge disposition was noted as transfer to LIJ. There was no transfer paper located in the patient's medical record to indicte the reason for the transfer, the accepting hospital, that the family consented to the transfer, or that the risk and benefits of the transfer was explained to the patient.

Review of medical record MR #8 on 7/19/12 noted that the patient presented to the hospital's ED on 5/12/12 with chief complaint of fever, and blisters to lower lips. The patient's medical condition was evaluated by the ED physician whose impression was stomatitis, gingivitis, dehydration and fever. Discharge disposition was noted as transfer to Cohen's hospital. There was no transfer paper located in the patient's medical record to indicate the reason for the transfer, the accepting hospital, that the family consented to the transfer, or that the risk and benefits of the transfer was explained to the patient.

Review of the MR #9 on 7/19/12 noted that this patient presented to the ED on 6/27/12 with complaint of infection in nose not getting any better. The patient was seen and evaluated by the physician and diagnosed with nasal cellulitis, nasal abscess. Discharge disposition was noted as transfer to LIJ. There was no transfer paper to indicate that the risk / benefits of the transfer were explained to the patient.