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Based on review of facility documents, credential file (CF), medical staff bylaws, and interviews with staff (EMP), it was determined the facility failed to enforce the hospital's medical staff's bylaws and/or rules and regulations reviewed November 19, 2009, which reflect the requirements of 42 CFR ?489.24 and the related requirements 42 CFR ?489.20(l); adopt and enforce a policy to ensure compliance with the requirements of ?489.24, including but not limited to staff education.

Findings include:

On June 18, 2010, a review of the "Lancaster General Hospital's Staff Bylaws, reviewed November 19, 2009, revealed, "... Emergency call responsibilities as required by department and division rules and regulations, Hospital Policy, and as required by federal and state law (e.g., EMTALA) ..."

On June 18, 2010, a review of "Emergency Medical Treatment and Active Labor Act Compliance" date reviewed October 23, 2009, revealed, "...The following individuals may conduct medical screening examinations pursuant to EMTALA REQUIREMENTS: 1. Active and Courtesy members of the LGH Medical and Dental Staff 2. Residents in the LGH Family Practice Residence program 3. Nurse practitioners 4. Physician Assistants 5. Certified Nurse Midwives. ..."

An interview conducted on June 17, 2010, at 2:00PM with EMP3 revealed, "I don't think I had any formal instruction on that Act. "

An interview on June 18, 2010, at 11:10AM with EMP2 revealed, "No EMTALA computerized based learning or formal training was given to the nurse practitioners, physician assistants, certified nurse midwives and the physicians."

Based on review of facility documents, closed medical records (MR), and interview with staff(EMP), it was determined the facility failed to follow adopted policies related to the execution of transfers in three of 10 Women and Babies triage medical records reviewed (MR12, MR17 and MR19).

Findings:

A review of the facility's policy entitled "Inter-And Intra-Facility and Inter-Departmental Transport", date of issue March 8, 2010, revealed, "...3) Consent to Transfer (LGHA3349) must be completed, with consent signatures obtained from the patient (or family) and physician."

A review on June 18, 2010, of MR12, MR17 and MR19, revealed the patients were transferred to another facility for treatment. MR12, MR17 and MR19, did not have a completed consent for transfer.

An interview conducted on June 18, 2010, at 2:00PM with EMP1 confirmed that MR12, MR17 and MR19, did not have completed consent for transfer.