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Based on review of medical records, policies and procedures, committee meeting minutes, quality improvement/patient safety program, quality data and interviews with key personnel on September 28, 2010, it was determined that the facility failed to notify CMS or the State survey agency that it believed it received an individual who had been transferred with an unstable emergency medical condition. The evidence is as follows:

1. During a review of Patient F ' s Medical record on September 28, 2010, documentation from Calais Regional Hospital from the transferring physician ' s medical note stated, " Down East Community Hospital [accepting physician] will accept for Detox. Patient significant other will drive him/her there " . This documentation was timed at 1330.

2. In an interview on September 28, 2010, with the receiving physician, he stated that on September 13, 2010, at approximately 5:00 p.m., he had been requested by the transferring physician, to accept a stable patient in transfer for Detox. He stated that the transferring physician felt that the patient could be sent by private automobile. When the receiving physician was asked if he was concerned that the patient didn ' t arrive in a timely manner, he stated, " I was concerned that the transferring physician had called me, and the patient hadn't arrived, before I went into my meeting. " When asked if he questioned the mode of arrival, he stated, " I don ' Bt remember. " He said he was talking to [transferring physician] later, after the patient died, who said, 'Thank God I didn't send him by car.'"

3. In a telephone interview with the receiving nurse, at Down East Community Hospital [DECH] on September 28, 2010 she stated that she was told by the transferring nurse on September 13, 2010 at approximately 8:30 p.m.(2030), that patient F was " very shaky and would probably end up hurting him/herself. Transferring nurse said she was sending him/her via ambulance. " She also stated, " They told me he/she was stable. It sounded like he/she was being difficult, not unstable. "

4. On September 13, 2010, Patient F was transferred from Calais Regional Hospital [a Critical Access Hospital] to Down East Community Hospital [another Critical Access Hospital]. The Pre-hospital Care Report, documented by Calais Fire-EMS indicated that the time of transfer was 2105.

5. A Nursing Progress Note, dated September 13, 2010, documented that the patient was admitted via ambulance crew as a direct admit for alcohol detox. The patient was cyanotic and unresponsive, " no palpable pulses noted, one agonal breath noted then respiratory arrested. " Code called at 2215 as patient ' s code status was unknown.

6. A physician progress note, dated September 13, 2010 at 2250, " code Blue called at 2215, patient found apniac, unresponsive and pulseless ...ACLS protocol initiated ...TOD [time of death] 2238."

7. In an interview on September 28, 2010, with the Chief Nursing Officer/Quality Improvement Director (QID), when asked if she thought Patient F was stable for transfer, she stated, " My understanding is that [he/she] was stable. "

8. During interviews with key personnel and documentation review, there was no evidence to indicate the facility recognized that this patient had been transferred in an unstable emergency medical condition.

Based on review of medical records, policies and procedures and interviews with key personnel on September 28, 2010, it was determined that the facility failed to provide documentation of an appropriate medical screening examination, in one (1) of thirty-one (31) records reviewed. The evidence is as follows:

1. On September 28, 2010, a review of the medical record of Patient A, revealed that it failed to contain evidence that an appropriate medical screening examination was completed by the Emergency Department physician, when the patient was seen on September 24, 2010.

2. The DECH Policy #1157, titled " Medical Record Completion " , stated, " Late entries will be clearly designated as such, authenticated, dated and timed ...the emergency room medical record must be completed at the time of the patient ' s visit to include: ...documentation of findings and assessments, including time performed ... the conclusions or impressions after exam, assessment and treatment ... "

3. In an interview with the Director of Health Information Management, at 1220 on September 28, 2010, she stated, " I was unable to locate any physician dictation [physical examination] on [Patient A] ...I also checked with Eastern Maine Medical Center, and none was sent. "

4. On September 28, 2010, at 1900, in an interview with the Quality Improvement Reviewer, when presented with Patient A ' s " Emergency Physician Record " , she stated " ...I believe that all our patients get an appropriate medical screening, but you are right, there is no documentation. "

5. On September 28, 2010, the Emergency Department physician who examined Patient A on September 24, 2010, was requested by DECH to complete the " Emergency Physician Record Multiple Trauma " sheet. After completion of the form by the physician, the amended documentation was reviewed by the survey team . The form failed to indicate the date and time when the form was completed by the physician.