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Based on document review and interview, it was determined that the facility failed to have policies and procedures in effect to ensure compliance with 42 CFR 489.24 and the related provisions at 42 CFR 489.20.

Findings include:

Review of Emergency Department medical records indicated the facility did not comply with all of the requirements of an appropriate transfer.

Please see Tag # 2409

Based on medical record review and interview, the facility has not ensured the individual has been advised of the medical risks associated with transfer for 9 of 21 patients transferred to a higher level of care.

Findings Include:

Review on 5/30/13 of policy " COBRA POLICY " last reviewed 1/2010 revealed the EMTALA requirements per the omnibus budget reconciliation act of 1989. Reasons for the transfer and the potential risks and benefits of the transfer must be discussed with the patient or legal representative and consent for transfer obtained. This should be documented on the transfer form.

Review on 5/30/13 of Emergency Department medical records revealed that 9 of 21 patients transferred to a higher level care lacked documentation of the risk of transfer specific to their current health problem. (Patient # 2, 3, 11, 23, 24, 25, 26, 27 and 29).

These findings were verified on 5/30/13 at 3:00pm with the Nursing Administrator.