HospitalInspections.org

Based on document review and interview the facility failed to provide appropriate transfer for one (1) of ten (10) patients (P 10).

Findings include:

1. The hospital policy titled, "Memorandum of Transfer", no policy number, effective date 01/2021, indicated the following:

a. Prior to the transfer the transferring physician shall secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and hospital care.

b. Memorandum of Transfer must be completed for every patient transferred and must contain the following information:

i. The names, addresses's and telephone numbers of the transferring and receiving physicians.
ii. The time and date on which the transferring physician secured a receiving physician.
iii. The name, date, and time hospital administration was contacted in the receiving hospital.
iv. Signature, time and title of the transferring hospital administration who contracted the receiving hospital.


2. Review of P 10 medical record indicated the patient was a 38 y/o (year/old) admitted on 7/12/23 at 12:09 pm with the diagnosis including but not limited to, left foot GSW (gunshot wound) and open reduction internal fixation of left foot fracture. Presented to H # 2 (Psychiatric Hospital) from J # 1 (Jail/Correctional Facility) after being deemed incompetent to stand trail and was admitted to the Restorations Program. Final Ancillary Orders dated 7/25/23 at 8:00 am indicated a transfer to H # 3 (Acute Care Hospital) for an evaluation of the left foot surgical site. Memorandum of Transfer (MOT) dated 7/25/23 at 9:00 am indicated the reason for transfer was a need for an orthopedic referral. The MOT lacked names/addresses/ phone numbers of both transferring and receiving physicians, and date/time on which the transferring physician secured a receiving physician and the name/date/time the administration was contacted in the receiving hospital.

3. In interview on 8/14/23 at approximately 11:00 am with administrative staff member A 5 (Chief Medical Officer), confirmed that there was no communication between physicians at H # 2 and H # 3 prior to the transfer of P 10.

4. In interview on 8/14/23 at approximately 3:30 pm with staff member N 1 (Registered Nurse), confirmed that nurse to nurse report was conducted but failed to be documented properly.

5. In interview on 8/14/23 at approximately 4:00 pm with administrative staff member A 2 ( Chief Nursing Officer), confirmed this patient was treated as an emergent/urgent transfer, documentation was not completed properly, and there was no communication between H # 2 and H # 3 physicians prior to transfer of P 10.