College Hospital Costa Mesa

“TRANSFER PROTOCOLS CFR(s): Effective July 1, 2025, the hospital must have written policies and procedures for transferring patients under its care (inclusive of inpatient services) to the appropriate level of care (including to another hospital) as needed to meet the needs of the patient. The hospital must also provide annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to follow its P&P for transferring one of two sampled patients (Patient 1) to another acute care hospital (Hospital 1). This failure had the potential to compromise continuity and safety of care. Findings: During a review of the hospital’s P&P titled, “Transfer of Patient or Temporary Release,” reviewed on 10/24, the P&P showed transfers are made when medically permissible and after the patient or their legal guardian has received complete information and explanation concerning the need for alternatives to the transfer. The transfer must be acceptable to the receiving health care facility. Appropriate documentation and transfer of records will be completed. Patients may be transferred to another facility for the following reasons: the specialized services required which are not offered or available at (hospital’s name). The transferring physician will determine whether patient is medically appropriate to transfer. The transferring physician will document and authenticate order for transfer in the patient’s medical record, and will complete and sign the “Physician Certification” form. The Attending Physician or his/her designee will contact the facility to which the patient is being transferred and make arrangements for admission to such facility. The patient should be given a complete explanation of the need for the transfer and of the alternatives to such transfer as well as adequate information regarding the proposed transportation plan. The “Consent to Transfer for Medical Treatment” form should be completed by hospital staff and signed by the patient or his representative unless the patient’s medical condition precludes such. The hospital maintains current inter-facility transfer agreements to ensure appropriate care for patients. If the patient will not return to the transferring hospital and is required to be admitted to the receiving hospital, the patient should be discharged at the time of transfer. During a review of the hospital’s P&P titled, “Discharge Planning and Discharging the Patient,” reviewed 3/24, the P&P showed discharging the patient from the hospital is an inter-disciplinary process that ensures the following: it is based on the patient’s assessed needs and provides the appropriate exchange of information for continuity of care. The social worker will provide a specific assessment of the patient’s discharge planning needs as part of every psychosocial assessment. The social worker will get consent to obtain additional relevant psychosocial information from the treatment providers. This information will also be incorporated in the patient’s treatment and discharge plan. The discharge plan will demonstrate a clear understanding of the impact of illness on both patients and families. The discharge plan will be reassessed, with the patient’s input, as the patient’s status or discharge needs change. Appropriate information is exchanged in a language the patient comprehends. The charge nurse or designated RN is responsible for completing the Nursing Discharge Summary Form, which is to include the following information: the condition of the patient on discharge (i.e. assessment of the symptoms for which the patient was hospitalized). Social worker or Nursing staff will provide the following: provide the patient with teaching as needed regarding the patient’s continuing care plan; staff will obtain consents necessary and facilitate the necessary and appropriate exchange of information with the receiving treatment provider, including the reason for referral; and complete the Aftercare Form, staff will provide this form as well as the executed Informed Consent Form to the patient upon discharge. During a review of the hospital’s P&P titled, “Charting Guidelines,” reviewed on 7/25, the P&P showed if it is necessary to correct an entry in the hard copy of the patient’s medical record, the method to be used is to line out the incorrect entry with a single line in ink, leaving the original writing legible. The person should note the reason for the change (i.e. error), the date of strike and sign the correction. During a review of the hospital’s P&P titled, “Abbreviations,” reviewed on 7/25, the P&P showed to improve patient safety, avoid misinterpretation, the hospital has developed the abbreviations list attached there is a “DO NOT USE THESE ABBREVIATIONS” list as well as appropriate use of abbreviations. During a concurrent interview and record review on 12/5/25 at 1025 hours, with the DON and QIRM Manager, Patient 1’s medical record was reviewed. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 10/24/25. Review of the History and Physical electronically signed on 10/28/25 at 1535 hours, showed Patient 1 was admitted for opiate dependency and recent alcohol abuse. The patient had right knee and femur fracture, with orthopedic recommendation of right knee brace and delay of surgery. The plan included follow-up with orthopedics for fracture. During a review of the Discharge Summary, signed on 10/28/25 at 1703 hours, the Discharge Summary showed Patient 1 was stable, improved, and was transferred to another acute care hospital (Hospital 1) and then to a rehabilitation facility. During an interview with SW 1 on 12/5/25 at 1102 hours and 1341 hours, SW 1 stated that there was no communication with Hospital 1 regarding agreed and acceptance of Patient 1. During an interview with RN 2 on 12/5/25 at 1110 hours, RN 2 stated there was no confirmation from Hospital 1 about accepting Patient 1, but the transfer was reported to the Hospital 1’s ED RN. During a review of the “Reason for Transfer,” dated 10/28/25 at 1423 hours, the Reason for Transfer form showed RN 1 documented that the receiving hospital had agreed to accept the transfer, provide appropriate medical treatment; and the transferring hospital had, within its capacity, provided medical treatment. During an interview with RN 1 on 12/5/25 at 1121 hours, RN 1 stated there was no information confirming Hospital 1 had agreed to accept Patient 1 before the transfer. During an interview with MD 1 on 12/5/25 at 1157 hours, MD 1 stated they could not recall any communication with Hospital 1 regarding the transfer and noted the absence of documentation of the patient’s worsening condition. During a concurrent interview and record review on 12/5/25 at 1341 hours, with the DON and QIRM Manager, the DON and QIRM Manager stated the transfer was not reviewed or discussed by the management team. The QIRM Manager and the DON confirmed there was no documented evidence of a transfer agreement with Hospital 1, as required by the hospital’s P&P. The DON and QIRM Manager also identified errors in the Consent to Transfer document, including documentation errors and the use of unapproved abbreviations. They further stated that the Physician Certification form for the transfer was incomplete.”