HospitalInspections.org

Based on interview and review of patient medical records, it was determined that the hospital failed to comply with all requirements of 489.24.

Refer to citations and examples at:

Tag A 2409 Failure to assure appropriate transfers for all patients.

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Based on interview, review of medical records and review of policy, it was determined that the hospital failed to assure the safe transfer of 2 of 13 patients (Patients #6 and #10) who were transferred from the Emergency Department (ED) to other hospitals.

Failure to assure a safe transfer for all patients puts patients at risk for harm and/or unmet care needs.

Findings included:

1. Review of the hospital's policy and procedure titled "Transfers: Intercampus, Emergency Department, and Transfers to Other Healthcare Organizations", no number, approved 03/16, showed that before patients were discharged or transferred to another facility, staff would:

a. Assure that there was an admitting physician at the receiving facility

b. Assure that the accepting facility had capacity to receive and care for the patient

c. Document in the EMR (electronic medical record) the name and contact phone number for the representative from the receiving hospital

d. Report to the receiving hospital [per the transfer form, see below].

2. Review of the same policy showed that staff were directed to complete the "Consent to Transfer/Physician Certification to Transfer" form, and the form was to be scanned to the EMR. Review of the transfer form showed that there were fields to be completed for:

a. Accepting LIP

b. Name of RN calling report and name of RN receiving report

c. Mode of transport

d. Reason for transfer, and risks and benefits of transfer

e. Patient/representative consent for transfer

f. Physician's certification, which included a statement as to whether the patient was stable or unstable

3. Thirteen (13) of the patients whose ED records were reviewed had been transferred to other hospitals. Medical records for 2 of the 13 patients, Patients #6 and #10, did not include transfer forms.

4. The above findings were confirmed by the Medical Director of the Emergency Department (Staff #4), at the time of the record review.