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Based on interviews, medical record reviews and policy reviews, the hospital failed to ensure that a physician provided further examination or certified in the medical record, the benefits of transfer outweighed the risks in four patients (#11, #21, #23, #26) with unstable emergency medical conditions out of 62 patients reviewed; and failed to stabilize within its capabilities one patient's (#46) emergency medical condition prior to transfer. These failures had the potential to affect all patients examined or transferred with an unstable emergency medical condition by a Nurse Practitioner (NP) in the Emergency Department (ED). Two full time Family Nurse Practitioners (FNP's) are employed by the ED. The ED treats approximately 9088 patients per year and transfers approximately 480 per year to another healthcare facility. The facility census was 52 on 08/13/13 and 59 on 10/29/13.

Findings included:

Review of the ED policy titled, "Medical Screening Examination" dated 06/13,
showed:
- Persons presenting to or being brought to the Emergency Department for unscheduled procedures or evaluation will receive a medical screening examination (MSE) by a physician utilizing ancillary services routinely available to the Emergency Department including examination, testing, treatment and the service of appropriate on-call physicians where indicated.
- The determination of whether an emergency medical condition (EMC) exists will be made by the examining physician(s) or other qualified medical personnel of the hospital as determined by hospital by-laws or rules and regulations who meet the requirement of CMS guideline ?482.55 concerning emergency services personnel and direction. Upon completion of the medical screening examination, if an emergency medical condition exists, necessary stabilizing treatment, admission and/or transfer will be provided.
- The physician in charge of the patient should make the arrangements with the receiving physician and document in the medical record.
- The patient should be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures.

Review of the facility's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA); Transfer of Emergency Room Patients to Another Facility" dated 06/11, showed the physician in charge of the patient should make the arrangements with the receiving physician and document in the medical record. The Transfer and Authorization Form should be completed by the physician.

Review of the ED's "certification For Transfer Form" (referred to in the facility's policies as the Transfer and Authorization Form) showed a place on the form for the "physician" to certify the risks and benefits of transfer in a patient with an unstable emergency medical condition. The form also provided space to document the time of transfer, the patient's condition at the time of transfer, the mode of transport and the patient's vital signs along with space for the "physician's" signature.

Review of the August 2013 ED Physicians' schedule showed that a physician was on duty in the ED 24 hours a day, seven days a week.

Review of Patient #11's medical record showed he presented to the Emergency Department on 07/22/13 at 9:45 PM with swelling of the left side of the face and left upper tooth abscess. Family nurse practitioner (FNP), Staff Q, examined patient #11 and ordered blood tests that showed an elevation of white blood cells (16.5, normal range 4-11) which is an indication of infection and a facial CT scan (computed tomography [CT] scan uses X-rays to make detailed pictures of structures inside the body) which demonstrated an abscess and swelling under the skin around the left side of the nose and jaw. Documentation in the medical record showed patient #11 required a transfer to Hospital B and had an unstable emergency medical condition at the time of transfer. Staff Q signed the "Certification For Transfer Form" in the space designated for the "physician's signature". The medical record did not contain evidence that Physician, Staff CC, available in the ED on 07/22/13 at 9:45 PM, or consulting Physicians, Staff S or V examined patient #11 to ensure he had a stable airway prior to transfer, or certified in the medical record that the benefits of transfer outweighed the risks.
Refer to tag A-2409 for details.

During concurrent interviews on 10/30/13 at 8:45 AM, Staff S, MD, Hospitalist, and Staff V, Otolaryngologist (ENT physician), confirmed that they did not examine patient #11 on 07/22/13 prior to transfer.

Review of Patient #21's medical record showed he presented to the Emergency Department on 08/12/13 at 6:31 PM accompanied by a prison guard. At 7:07 PM, Staff Q, Nurse Practitioner, (NP) examined the patient. Documentation on the application for 96 hour detention showed the patient had previously attempted suicide, and while incarcerated had tried banging his head against the wall, tried to grab a live wire and had a plan to hang himself. At 10:00 PM, NP Staff Q determined Patient # 21's condition was unchanged and required transfer to a psychiatric hospital for treatment to stabilize his emergency medical condition. Staff Q signed the "Certification For Transfer Form" in the space designated for the "physician's signature". The medical record did not contain evidence that Physician, Staff T, available in the ED on 08/12/13 at 6:31 PM provided further examination or certified in the medical record that the benefits of transfer outweighed the risks.
Refer to tag A-2409 for details.

Review of Patient #23's medical record showed she presented to the Emergency Department on 06/11/13 at 6:16 PM with focal neurological deficit (unable to focus and cannot see). At 6:23 PM, Staff Q, NP examined patient # 23 and determined the patient had an emergency medical condition requiring transfer to another facility with a Neurologist for stabilizing treatment. The facility did not have a Neurologist on call at the time. Staff Q signed the "Certification For Transfer Form" in the space designated for the "physician's signature". The medical record did not contain evidence that Physician, Staff CC, available in the ED on 06/11/13 at 6:16 PM provided further examination, or certified in the medical record that the benefits of transfer outweighed the risks.
Refer to tag A-2409 for details.

During a telephone interview on 11/05/13 at 3:09 PM, Staff Q, FNP, stated that he was not aware that unstable patient transfers were to be countersigned by the ED Physician or that the physician is required to certify the risks/benefits of transfer when a patient had an unstable EMC. He stated that he always consulted with a physician and spent many hours documenting to show the entire picture of the patient's assessment, treatment and transfer. He stated that the ER Department did not have policies and procedures regarding the requirement for documentation and physician countersignatures but stated he knows that has recently changed.

Review of Patient #26's medical record showed he presented to the Emergency Department by ambulance on 06/18/13 at 10:09 AM with suicidal ideation and potential harm to self. A medical screening examination was initiated by Staff R, FNP at 10:28 AM and showed the patient had an emergency medical condition requiring transfer to a Psychiatric facility for stabilizing treatment. Staff R signed the "Certification For Transfer Form" in the space designated for the "physician's signature". The medical record did not contain evidence that Physician, Staff I, available in the ED on 06/18/13 at 10:09 AM provided further examination, or certified in the medical record that the benefits of transfer outweighed the risks.
Refer to tag A-2409 for details.

During an interview on 08/14/13 at 12:10 PM, Staff C, Nursing Director ER, stated that she did not know that physicians had to consult and countersign a non-physician Qualified Medical Profession (QMP) signature for transfer of an unstable patient.

During an interview on 08/14/13 at 3:30 PM, Staff I, MD, ED Medical Director, stated that he was not aware that unstable patient transfers must be countersigned by the physicians. He stated that he had collaborative agreements with the NP's but countersignatures were not addressed in the agreements.

During an interview on 11/05/13 at 2:15 PM, Staff R, FNP, stated that at the time Patient #26 was seen in the ED, the facility did not have a requirement that the Nurse Practitioners should consult with a physician or have the certificate of transfer signed by a physician.

Review of Patient #46's medical record showed he presented to the Emergency Department (ER) by ambulance on 09/26/13 at 5:15 AM with substernal (under the breastbone) heaviness (chest pain) rated seven on a scale of one to ten and diaphoresis (profuse sweating). The ambulance trip report indicated patient #46 received supplemental oxygen, an intravenous catheter (IV), two nitroglycerine (medication used to relax the arteries) tablets and one Aspirin prior to arrival in the ED. The patient's BP at the time of presentation to the ED was 61/49 (life threateningly low, normal range 90-140/60-90). Medical Screening orders were written following the facility chest pain protocol at 5:21 AM. During an interview on 11/25/13 at 5:30 PM, Staff W, MD, ED Physician, stated, "She told the nurse to hold transferring the patient until his BP was over 100 Systolic". She stated she was certain the patient's Systolic pressure was between 90 - 100 before transport.

Medical record review showed physician's orders by Staff W for 5:36 AM - Sodium Chloride 0.9% IV 1000 mL at 999mL/hour STAT for one bag - suspend (hold the order);
- Sodium Chloride 0.9% IV 1000 mL at 999 mL/hour STAT for one Bag - suspend.
The Medication Administration Record showed these medications were not administered to the patient to raise his blood pressure prior to transfer.

Review of the ED Provider Note (Staff W) showed that the Decision Time for Transfer to the nearest STEMI center was made at 5:46 AM and the reason was ACUTE MI listing the Patient's condition as Critical and deteriorated. Staff W signed the certification for transfer which showed the patient's blood pressure was 86/69.

Review of the ED Nursing Disposition Note signed by Staff W showed the patient's BP at 5:54 AM as 88/62 at the time of transfer.
Refer to tag A-2407 for details.





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Based on interview, record review and policy review the facility failed to stabilize within its capabilities prior to transfer, one patient (#46) of 62 patients reviewed. This had the potential to affect all patients transferred from the Emergency Department (ED). The ED treats approximately 9088 patients per year and transfers approximately 480 per year to another healthcare facility. The facility census was 52 on 08/13/13 and 59 on 10/29/13.

Findings included:

Review of Patient #46's medical record showed he presented to the Emergency Department (ED) by ambulance on 09/26/13 at 5:15 AM. Documentation in the ambulance trip sheet showed the patient received Oxygen, Aspirin, and two Nitroglycerin tablets (medication that relieves chest pain) per protocol on the way to the ED:

Record review of the ED Physician, Staff W's notes dated 09/26/13 showed the patient was distressed, pale and diaphoretic (sweating):
The patient's vital signs were documented at 5:19 AM:
- Pulse: 63;
- Respirations 20;
- BP: 61/49 (normal range 90/140/60-90):
- Pain intensity: 7 (on a scale of 1-10).

Record review of Patient #46's physician orders and Medication Administration Record showed the following timeline of medical interventions:
5:16 AM - Patient #46 arrived in the ED.
The following interventions were ordered by ED physician Staff W:
5:21 AM - Obtain EKG (electrical tracing of the heart's activity);
- Continuous Cardiac (heart) Monitoring;
- Establish an IV (intravenous catheter);
- Obtain Vital Signs Per protocol;
- Obtain Laboratory blood tests;
5:34 AM - a chest X-RAY was obtained;
5:36 AM Staff W ordered the following medications that were administered to the patient:
- 4,000 Units of Heparin (medication that stops blood from clotting) by IV catheter;
- Two mg Morphine (pain medication ) by IV catheter;
- Four mg Zofran (anti-nausea medication) by IV catheter;
5:42 AM - Two mg Morphine by IV catheter.

Review of the medications administration record (MAR) showed the following medications were ordered by Staff W but suspended and never administered to the patient:
5:36 AM - Two Liters of Normal Saline (IV fluid);
5:38 AM - Heparin continuous infusion by IV catheter.

Review of the EKG results showed the patient was having an Acute MI/STEMI (type of deadly heart attack).

Review of the ED Nursing Disposition Note showed the patient's vital signs at transfer to Hospital C at 5:54 AM were:
- Pulse: 68;
- Respirations: 20;
- BP: 88/62;

Review of the ED Provider Note (Staff W) showed that the Decision Time for Transfer to Hospital C was made at 5:46 AM and the reason was ACUTE MI listing the Patient's condition as Critical and deteriorated. Staff W made note that the case was discussed with another physician.

During an interview on 11/25/13 at 5:30 PM, Emergency Department Physician, Staff W, stated that:
- When the patient arrived in the ED he was sitting upright in obvious distress, rocking back and forth, clutching his chest and begging to have something done for his pain.
- Patient #46's initial blood pressure (BP) was noted to be 61/49 on arrival to the ED; patient was alert and rocking in the bed.
- She ordered IV fluids (Normal Saline) to infuse at a rapid rate to bring the patient's BP back up and for the nurse to re-administer Morphine one mg when the patient's systolic (top number of the BP) BP was over 100.
- Labs, EKG and medications were ordered according to the facility chest pain protocol.
- Because of Patient #46's discomfort and inability to hold still multiple attempts were made to obtain an EKG. Once the tracing was complete the patient was noted to have ST elevations in three leads (meaning he was having a STEMI, deadly type of heart attack).
- She left the room to contact the STEMI referral center to obtain permission to transfer the patient.
- The patient was alert, actively writhing in pain, and vocally crying out during his stay in the ED but they were unable to manage his pain because the Morphine lowered his BP.
- She considered administering Dopamine (medication used to support the BP when a patient is in shock) when she saw the patient's low BP, but clinically the patient looked as if his blood pressure was higher and he had improved with the fluid challenge. She was hesitant to administer pressors (medication capable of raising the blood pressure) because they would strain the heart even more.
- She told the nurse to hold transferring the patient until his BP was over 100 (Systolic). She was certain the patient's pressure was 90 - 100 before transport (Staff W signed the "Certification For Transfer Form" which showed the patient's BP was 86/69).

Review of the ambulance trip sheet showed patient #46 received 2.5 Liters of Normal Saline by IV catheter, that he continued to thrash around during the trip to Hospital C and that his BP remained low. The ambulance crew documented they arrived at Hospital C at 7:32 AM, approximately two hours and 15 minutes after patient #46 initially presented to the ED.

The medical record did not contain evidence that patient #46's emergency medical condition was stabilized within the hospital's capabilities. The patient was transferred without further interventions to stabilize his persistently low BP or to improve his safety for transport, and delayed his treatment for cardiogenic shock (MI with symptoms including pale skin color, sweating, low BP, restlessness) until he arrived at Hospital C.

Based on interview, record review and policy review the facility failed to ensure a physician provided further examination and certified in the medical record the benefits of transfer outweighed the risks in four patients (#11,#21,#23,#26,) with unstable emergency medical conditions out of 62 patients reviewed. This failure had the potential to place all patients transferred with an unstable emergency medical condition at risk. The ED treats approximately 9088 patients per year and transfers approximately 480 per year to another healthcare facility. The facility census was 52 on 08/13/13 and 59 on 10/29/13.

Findings included:

Review of the facility's policy titled, "Medical Screening Examination" dated 06/13, showed the determination of whether an emergency medical condition (EMC) exists will be made by the examining physician(s) or other qualified medical personnel of the hospital as determined by hospital by-laws or rules and regulations who meet the requirement of CMS [Centers for Medicare and Medicaid Services] guideline ?482.55 concerning emergency services personnel and direction. Upon completion of the medical screening examination (MSE), if an emergency medical condition exists, necessary stabilizing treatment, admission and/or transfer will be provided.

Review of the facility's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA); Transfer of Emergency Room Patients to Another Facility" dated 06/11, showed the physician in charge of the patient should make the arrangements with the receiving physician and document in the medical record. The Transfer and Authorization Form should be completed by the physician.

Further record review showed there was no requirement for a physical examination or consultation with an available physician prior to the Family Nurse Practitioner (FNP) initiating the transfer of an unstable patient to another facility when stabilizing treatment is not available.

Review of Patient #21's ED medical record showed he presented to the Emergency Department on 08/12/13 at 6:31 PM accompanied by a prison guard. The patient had developed suicidal ideation's while incarcerated. A medical screening examination was initiated by Staff Q, FNP, at 7:07 PM and showed the patient had an emergency medical condition requiring transfer to a Psychiatric facility for stabilization. The Certification for Transfer to a Psychiatric Center was signed at 10:40 PM by Staff Q, FNP.

Further review of Patient #21's ED medical record showed, "Order for 96 Hour Detention, Evaluation (Mental Health) and Treatment and Warrant" dated 08/12/13 and signed by a New Madrid County Circuit Court Judge. The Certification for Transfer to a Psychiatric Center was signed at 10:40 PM by Staff Q, FNP.

There was no evidence in the medical record that Physician T, available in the ED on 8/12/13 at 6:31 PM provided further examination or certified in the medical record the benefits of transfer outweighed the risks.

During a telephone interview on 11/05/13 at 3:09 PM, Staff Q, FNP, stated that Patient #21 was 47 years old and didn't meet the criteria for admission to the Geriatric Psychiatric (Geri Psych) Unit. He stated, "No question the patient had to be transferred, especially since he was suicidal and had a plan." He stated he had documented all of this and couldn't understand why it didn't show up in the patient's medical chart. Staff Q stated that the patient was transported to hospital #3 by law enforcement staff and that he was assured the patient would be taken directly to that hospital without delay and had no concerns for the patients safe transport.

Record review of Patient #23's ED medical record showed she presented to the Emergency Department on 06/11/13 at 6:16 PM with focal neurological (neuro) deficit (unable to focus and cannot see). A medical screening examination was initiated by a Staff Q, FNP, at 6:23 PM and showed the patient had an emergency medical condition requiring transfer to another facility with a Neurologist for stabilizing treatment. The CT exam of the head was inconclusive for diagnosis. A Neurologist at another facility was consulted by telephone and recommended the patient be transferred that night for an MRA (magnetic resonance angiogram (MRA) is a type of magnetic resonance imaging (MRI) scan that uses a magnetic field and pulses of radio wave energy to provide pictures of blood vessels inside the body. In many cases MRA can provide information that can't be obtained from an X-ray , ultrasound, or computed tomography (CT) scan). The Certification for Transfer to another hospital was completed by Staff Q, for services and equipment not available in the ED. There was no documentation in the patient's medical record to show that ED physician CC, available in the ED on 6/11/13 at 6:16 PM provided further examination, or certified in the medical record the benefits of transfer outweighed the risks.

During an interview on 10/30/13 at 8:30 AM, Staff S, MD, Hospitalist, stated that he was not actually consulted on Patient #23. He stated that he was passing through the Emergency Department on 09/26/13 and overheard a discussion regarding Patient #23 and the need to contact a Neurologist. He stated that since there was not a Neurologist on call for the ED he elected to assist in contacting one and facilitated the call to a Neurologist at another facility. The consulting Neurologist recommended the patient be transferred to a higher level of care where they could obtain an MRA that evening because the patients presenting symptoms were consistent with a basilar artery aneurysm (the basilar artery is the most important artery in the back of the brain. The basilar artery can develop a bulge [aneurysm] that pushes outward, putting stress on the artery wall and causing it to burst) and can result in death. Staff S stated that the facility was unable to do an MRA for this patient because it was after regular office hours and there was not a Radiologist on call. A Radiologist familiar with the exam was required to be present during the exam.

During an interview on 10/30/13 at 10:20 AM, Staff A, Chief Executive Officer (CEO), stated that the facility had Radiologists scheduled on site from 8:00 AM until the exams scheduled for 5:00 PM were completed. They had no Radiologists on call. Radiological exams after hours were sent directly to a contracted Virtual Radiology Group (VRG) for interpretation. Staff A, stated that the Neurologists from a neighboring community had privileges at the hospital and held clinic near the facility during the week. They were available to the Emergency Department during office hours only. He stated that the On-Call Physician Information that was posted in the ED for 06/11/13 showed a Neurologist on call but it was only during office hours. Staff A, stated that an MRA exam was not available after 5:00 PM on 09/26/13 for Patient #23. MRI/MRA and Neurologists are not available after 5:00 PM.
Further review of Patient #23's medical record showed physician orders including:
- EKG, Urgent vision changes
- CT Head (Stroke Protocol) without contrast, Urgent
- Intravenous (IV) fluids STAT
- Assess Vital Signs, Urgent. Vital signs (including temp one time) at time of arrival, then every 15 minutes.
- Assess Neuro-checks (neuro assessment is a comprehensive exam covering several critical areas: level of consciousness and mentation (mental activity, especially thinking), cranial nerves, movement, sensation, cerebella function (part of the brain serving to control and coordinate muscular activity and maintain balance), and reflexes. This initial exam establishes baseline data with which to compare subsequent assessment findings. Urgent. Neuro checks at time of arrival then every 15 minutes. Further review of the medical record showed vital signs and Neuro checks were not documented.

During an interview on 10/30/13 at 2:00 PM, Staff C, RN, Nursing Director of Emergency Services, stated that the new (installed 04/13) electronic medical record (EMR) for the facility does not capture vital signs in the Emergency Department. She stated she believed the staff was doing vital signs and neuro checks but she could not provide the documentation from the EMR.

Review of Patient #26's medical record showed he presented to the Emergency Department by ambulance per request of the sheriff's department on 06/18/13 at 10:09 AM with suicidal ideation and potential harm to self. A medical screening examination was initiated by Staff R, FNP, at 10:28 AM and showed the patient had an emergency medical condition requiring transfer to a Psychiatric facility for stabilizing treatment. The Certification for Transfer for Inpatient Psychiatric care was completed by Staff R. The medical record did not contain evidence that Physician I, available in the ED on 6/18/13 at 10:09 AM provided further examination or certified that the benefits of transfer outweighed the risks.


During an interview on 10/30/13 at 3:55 PM, Staff X, Master of Social Work (MSW), Program Director for Geri-Psych Unit, stated that the unit admits patients that are 55 years old and older. She stated that Geri-Psych does not receive a call from the Emergency Department unless the patient is at least 55 years old. Staff X stated that the Geri-Psych Medical Director consults on the patients on the medical units and the Emergency Department if the patient meets the 55 years and older criteria. The Geri-Psych Medical Director was only on call for Geriatric patients.

During an interview on 10/30/13 at 4:20 PM, Staff Y, Licensed Master of Social Work (LMSW), stated that the facility admitted psychiatric patients 55 years of age and older, all others were kept only for medical stabilization then transferred. Staff Y, stated that she remembered performing the Mental Health Assessment for Patient #26 on 06/18/13. Her evaluation indicated the patient needed inpatient treatment because he had thoughts of harming his wife and had tried to hurt her earlier that day and he had suicidal thoughts.

During an interview 11/05/13 at 2:15 PM, Staff R, FNP, stated that Patient #26 told her he took an overdose of Klonopin (a drug used to treat seizures, panic disorder, and anxiety) the previous night and that he had plans of "doing it again and not getting up". She stated that given the suicidal ideation's he was considered to have an emergency medical condition. Staff R, stated that at the time Patient #26 was seen in the ED, the facility did not have a policy that the Nurse Practitioners should consult with a physician or have the Certificate of Transfer signed by a physician.

Review of Patient #11's medical record showed he presented to the Emergency Department on 07/22/13 at 9:45 PM with swelling of the left side of the face and left upper tooth abscess. Family nurse practitioner (FNP), Staff Q, examined patient #11 and ordered blood tests that showed an elevation of white blood cells (16.5, normal range 4-11 x10e3/uL) which is an indication of infection and a facial CT scan (computed tomography [CT] scan uses X-rays to make detailed pictures of structures inside the body) which demonstrated an abscess and swelling under the skin around the left side of the nose and jaw. At 1:20 AM Staff Q documented he contacted Physician S, the on duty hospitalist (physician who specializes in the care of hospitalized patients) to discuss possible admission. At 1:25 AM, Staff Q documented that that he paged Physician V, an ear, nose and throat specialist. At 1:42 AM patient #11 received one dose of an intravenous (IV) antibiotic (Clindamycin), an IV anti-inflammatory and pain medication (Toradol) and a pain pill (Norco). At 1:50 AM Staff V was paged a second time and at 2:00 AM called the ED back and "stated to transfer the patient" to a hospital with an available oral surgeon. The ED nurse documented at 3:07 AM that patient #11 had deteriorated" and arrangements were made to transport him to Hospital B in an ambulance equipped with advanced cardiac life support. The medical record did not contain evidence that patient #11's emergency medical condition was stabilized, or that Staff S, ED Physician available in the ED on 07/22/13 at 9:45 PM, or Physicians S or V examined patient #11 to ensure he had a stable airway prior to transfer, or certified in the medical record that the benefits of transfer outweighed the risks.

Review of Hospital B's medical record showed patient #11 arrived at 4:52 AM on 07/23/13 and was admitted for treatment to stabilize his emergency medical condition.

During concurrent interviews on 10/30/13 at 8:45 AM, Staff S, MD, Hospitalist and Staff V, Otolaryngologist (ENT physician), confirmed that they did not examine patient #11 on 07/22/13 prior to transfer. Staff S stated that he told Staff Q, FNP, to contact an ear, nose and throat) specialist or an Oral surgeon to arrange a transfer. Staff S stated that the hospital did not have an oral surgeon on staff. Staff Q contacted Staff V, MD, ENT Surgeon, and it was recommended the patient be transferred to Hospital B for the services of an oral surgeon.

During an interview on 10/30/13 at 9:00 AM, Staff V, MD, ENT Surgeon, stated that he received a call in the middle of the night regarding Patient #11 and was told that the CT scan showed an abscess with subcutaneous (beneath the skin) swelling and inflammation. He stated that when the swelling from an abscess extends down the neck, he becomes concerned about a possible compromise (obstruction) of the airway which is why he recommended the patient be transferred to a hospital with an oral surgeon. Staff V stated that a patient with an abscess and continued facial swelling can rapidly deteriorate and obstruct their airway, making intubation (insertion of a tube into the wind pipe) difficult to impossible.

During a telephone interview on 11/05/13 at 3:09 PM, Staff Q, FNP, stated that he remembered Patient #11 due to the seriousness of his presentation to the ED. Staff Q stated (referring to patient #11), "That guy needed care other than what we could give him, he absolutely needed to be transferred for care". Staff Q stated that he was not aware that patient transfers were to be countersigned by the ED Physician. He stated that he always consulted with a physician and spent many hours documenting to show the entire picture of the patient's assessment, treatment and transfer. He stated that the ED did not have policies and procedures regarding the requirement for documentation and physician countersignatures but stated he knows that practice has recently changed.

During an interview on 08/14/13 at 12:10 PM, Staff C, Nursing Director ED, stated that she did not know that physicians had to consult and countersign a non-physician FNP signature for a patient MSE or transfer.

During an interview on 08/14/13 at 3:30 PM, Staff I, MD, ED Medical Director, stated that he was not aware that Nurse Practitioner's must consult with a physician and document the consults after patient MSE's and before patient transfers. He stated that this had not been the practice in the ED and he was not aware that physician countersignatures were required for those processes.





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