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Based on review of the Dedicated Emergency Department (DED) and Obstetrical (OB) logs, medical records, policies and procedures, and interviews, it was determined the hospital failed to require the hospital staff implement the EMTALA transfer policies and procedures as evidence by:


A2409 489.24(e)(1)-(2): An Appropriate Transfer. The hospital failed to require:

a) one (1) transfer medical record did not have a signed certification by the physician, outlining the medical benefits of the transfer (Patient # 35); and

b) one (1) transfer medical record did not include documentation the patient's medical records were provided to the receiving hospital, at the time of transfer (Patient #35).

Based on a tour of the Emergency Department (ED), review of policies and procedures, and interview, it was determined the hospital failed to post signs in the ED "pending results" room that specified the rights of individuals to receive an examination and treatment for emergency medical conditions, and for women in labor; and to inform the public that the facility participates in the Medicaid program.

Findings include:

The hospital's policy "EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening Examination and Stabilization Treatment" requires: "...Signage specifying:...the rights of individuals with Emergency Medical Conditions and women in labor and...Whether the hospital participates in the applicable state Medicaid program must be posted in a place...likely to be noticed in the Dedicated Emergency Department...and in such other locations where individuals are waiting from examination and treatment...."

On 04/12/10, the Director of ED conducted a tour with a surveyor, and the Director confirmed the ED consists of 54 beds/bays, and of those are 6 intake rooms.

On 04/12/10, "quick look" triage Registered Nurse (RN) # 5 stated if a patient is a ESI of 4 or 5 the patient is taken to an intake room, for a complete RN assessment, and a medical screening exam (MSE) by a physician. He stated if the 6 intake rooms are full, then the patient is placed in either a Green Zone bed or into the "pending results" room located in the middle of the Green Zone.

On 04/12/10, during a tour of the Green Zone, a glass enclosed "pending results" room located in the center of the Green Zone was identified by the Director of ED as a room for patients to wait for: 1) an ED bed to become available, 2) for a Physician's MSE 3) test results, and/or 4) receive ordered treatments.

The Director of the ED confirmed the pending results room had no signs posted informing the public of the right to receive a medical examination, receive treatment for the emergency medical condition, and for women in labor, and that the facility participates in the Medicaid program.

Based on review of the Emergency Department (ED) Transfer Logs, Obstetrical (OB) logs, medical records, policies and procedures, and interviews, it was determined:

one (1) transfer medical record did not have a signed certification by the physician, outlining the medical benefits of the transfer (Patient # 35); and

one (1) transfer medical record did not include documentation the patient's medical records were provided to the receiving hospital, at the time of transfer (Patient #35).

Findings include:

The hospital policy "EMTALA - Medical Screening Examination and Stabilization Treatment" requires: "...Transfer of the patient is accomplished as follows: a). The form 'Request for Transfer/Consent to Transfer/Certification for Transfer' is fully completed...c). The transfer is effected through appropriate means consisting of the necessary, qualified personnel and transportation equipment including the use of life support measures. d). Copies of all medical records related the Emergency Medical Condition are sent with the patient to the accepting facility...."

On 04/13/10, the Director of the ED and the Interim Director of Labor and Delivery (L&D) confirmed that every ED and OB patient must have a Request for Transfer/Consent to Transfer/Certification for Transfer Form completed prior to transfer to another acute care facility.

Patient #35 presented to Labor and Delivery from her physician's office on 3/31/10, at 0951, to rule out pre-term labor. The patient was transferred to an acute care facility on 3/31/10, for pre-term (30 weeks) labor.

On 04/14/10, the Interim Director of L&D confirmed Patient #35's Request for Transfer/Consent to Transfer/Certification for Transfer form had no documentation by the physician, as to the medical benefits expected at the receiving hospital, or that the patient's medical record were provided at the time of the transfer.