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Based on the failure of the Hospital to maintain compliance with the requirements in CFR 489.24 (a), 1 i, Medical Screening Examination, CFR 489.24(d)(1-3), Stabilizing Treatment, 489.24 (d)(4-5), Delay in Examination or Treatment, and 489.24 (e) (1)-(2), Appropriate Transfer, the hospital has failed to maintain its agreement with 489.24.

Based on record review, policy and procedure review, Emergency Department Staff Meeting minutes review, and interview, it was determined that the Hospital failed to require a physician to conduct an ongoing Medical Screening Examination (MSE), when treatments and ancillary services ordered were not conducted, and the patient was instructed to present to another Emergency Department (ED) for further treatment (Patient #1).

Findings include:

The "Northwest Medical Center Emergency Medical Treatment and Labor Act (EMTALA)" policy and procedure, effective 05-14-09, revealed: "...1. To provide a Medical Screening Examination by a Physician or other Qualified Medical Person for any individual who 'Comes to the Dedicated Emergency Department' and requests (or has a request made on his or her behalf for) an examination or medical treatment for the purpose of determining if the individual has an emergency medical condition...6. It is further the policy of the Hospital to not: a. delay the provision of a Medical Screening Examination, stabilizing treatment, or appropriate transfer in order to inquire about the individual's method of payment or insurance status...."

The Northwest Medical Center Emergency Department Staff Meeting, conducted on 10-20-09, revealed: "...EMTALA-Attached presentation was distributed and reviewed. In addition, there will be a posted presentation in the Hallway behind the Physician area and your Assistant Manager will have a hand out for those who did not attend the October staff meeting to review and sign receiving the policy. We potentially have an EMTALA complaint and will be receiving a visit. For any patient that comes here and will be transferring to another facility we are to...Receive, Stabilize, and Redirect to the next facility...."

Patient #1, a prisoner at a private prison approximately fifty (50) miles from the Hospital, accompanied by two (2) security guards, presented to the Emergency Department on 10-03-09, at 10:45 A.M. The patient's triage vital signs revealed a temperature of "96.5" degrees, a blood pressure of 187/85, a pulse of 73, and respirations of 16. The triage assessment of pain revealed a pain level of 7-8 (Wong-Baker Scale in which "0" represents no pain, and "10" represents the worst pain imaginable).

The triage "Pre-Hospital Treatments" revealed: "Hand Cuffs accompanied c (with) 2 guards." The "Subjective" field revealed: "'My shoulder popped out lifting wts (weights) today. This happened just a month ago'." The "Objective" field revealed: "Pt c sling on arrival. + (positive) distal pulses."

The "Northwest Medical Center ED (Emergency Department) Nursing Assessment," conducted at 10:45 A.M. by a different nurse, revealed that the pain Patient #1 was experiencing was in the L (left) shoulder. The "Pain Intensity Scale" had an "x" over the line extending downward from the numeral "8." Underneath the numeral "8" was a pre-printed verbal description on the amount of pain "8" represented. The verbal descriptor was "Horrible." The "ED Nursing Assessment" revealed that Patient #1 had "Severe Weakness" in the left arm.

The "ED Nursing Assessment," conducted at 10:45 A.M., revealed in the field labeled "Wound/Injury," that Patient #1 had an injury to the left upper lip. The documentation does not clarify the type of injury to the lip.

The physician's orders for Patient #1 revealed: "NS (normal saline) lock IV (intravenous). X-R (x-ray) L (left) shoulder. 4 mg. (milligrams) Zofran (antiemetic) and 4 mg. Morphine (narcotic analgesic)."

The "Northwest Medical Center ED Nursing Notes," in the field labeled "Pain Medications and Assessment," revealed no documentation that pain medication or antiemetic medication had been administered to the patient during the time he was in the Northwest Medical Center Emergency Department. The "ED Nursing Notes," in the field for "IV (intravenous) Management" revealed no Normal Saline IV lock was inserted as ordered.

The Northwest Medical Center policy titled "Discharge of Patient from the Emergency Department" revealed: "...1. At the conclusion of treatment, the Emergency Department Physician/Attending Physician completes the discharge instructions...."

The Northwest Medical Center "Discharge Instructions" for Patient #1 revealed: "...Please GO to the St. Mary's Emergency Department FOR FURTHER TREATMENT...."

The "Emergency Room Report," dictated by Physician #1 on 10-03-09 at 1:07 P.M., revealed: "This is a...-year-old male incarcerated patient who has a chief complaint of left shoulder pain. The patient states he was lifting weights, and his left shoulder 'popped out.' He states it happened a month ago, and he was treated for same. He has no other complaints."

The "Emergency Room Course" revealed: "The patient had a clinical anterior left shoulder dislocation. He had a strong radial pulse. I ordered IV narcotics, IV antiemetics, and an x-ray. ____ by the _______here that because he is a prisoner he apparently has a contract at another facility and is being transported out by the officers that brought him in." The entry was electronically signed by Physician #1.

An Addendum was written to the record, and dictated on 10-07-09 at 8:11 P.M., by Physician #1. The addendum revealed: "The patient had a clinical anterior left shoulder dislocation. He had stable vital signs with a resting pulse of 73. He appeared to be in no distress. Neurovascular exam is intact including a strong radial pulse. I ordered IV narcotics, IV anti-emetics, and x-ray of the left shoulder. I was subsequently notified by the charge nurse in the emergency department that I was unable to continue care of the outpatient, as he was a prisoner and has a contract at another facility and the guards present with him had requested transfer. Apparently he was transported out by the officers who brought him into the facility.

I was informed initially by the charge nurse that the guards were calling to see if I would be allowed to treat the patient and I subsequently notified after the patient had left the department that he had been transferred out. In addition, I subsequently was notified that the patient did not receive morphine that has been ordered, and in fact, there is a hand written note canceled across the medication order and that it should be noted it is not my handwriting nor did I cancel that order. Unfortunately, the patient was transported out prior to receiving that medication."

Medical record review, conducted on 01-04-10 at 4:15 P.M., revealed no x-ray report for the x-ray of the left shoulder that was ordered by Physician #1 for Patient #1.

The CNO acknowledged, during interview conducted on 01-04-10 at 4:45 P.M., that Patient #1 did not receive a left shoulder x-ray as ordered by the physician, prior to being "transported out" to Carondelet St. Mary's Hospital Emergency Department.

Physician #1 stated, during telephone interview conducted on 01-06-10 at 3:10 P.M., that
Patient #1 presented to the ED accompanied by two security guards. Physician #1 stated
that the "CNO" (clarified by surveyor as Clinical Nurse Leader) told him that there may be some "contract problems" with the prison, and the physician stated he was told the patient had been transferred to Carondelet St. Mary's Hospital. Physician #1 stated that transferring the patient without adhering to the appropriate process and paperwork were "My mistake." Physician #1 stated he that mistakenly believed at the time of the occurrence, that maybe something was "different" with the prison system patients.

Based on record review, policy and procedure review, Emergency Department Staff Meeting minutes, and interview, it was determined that the Hospital failed to stabilize a patient with a dislocated shoulder and a lip laceration, prior to directing the patient to go to another Hospital Emergency Department for "further treatment" (Patient #1).

Findings include:

The "Northwest Medical Center Emergency Medical Treatment and Labor Act (EMTALA)" policy and procedure, effective 05-14-09, revealed: "...6. It is further the policy of the Hospital to not: a. delay the provision of a Medical Screening Examination, stabilizing treatment, or appropriate transfer in order to inquire about the individual's method of payment or insurance status...PROCEDURE: 5. Individuals who have an Emergency Medical Condition c. To be considered stable, the Emergency Medical Condition which caused the individual to seek care in the Dedicated Emergency Department must be resolved...d. Once the Emergency Medical Condition has been resolved, the hospital's EMTALA obligation ends and the physician may discharge, admit, or transfer the individual...."

The Northwest Medical Center Emergency Department Staff Meeting, conducted on 10-20-09, revealed: "...EMTALA-Attached presentation was distributed and reviewed. In addition, there will be a posted presentation in the Hallway behind the Physician area and your Assistant Manager will have a hand out for those who did not attend the October staff meeting to review and sign receiving the policy. We potentially have an EMTALA complaint and will be receiving a visit. For any patient that comes here and will be transferring to another facility we are to...Receive, Stabilize, and Redirect to the next facility...."

Patient #1, a prisoner at a private prison approximately fifty (50) miles from the Hospital, accompanied by two (2) security guards, presented to the Emergency Department on 10-03-09, at 10:45 A.M. The patient's triage vital signs revealed a temperature of "96.5" degrees, a blood pressure of 187/85, a pulse of 73, and respirations of 16. The triage assessment of pain revealed a pain level of 7-8 (Wong-Baker Scale in which "0" represents no pain, and "10" represents the worst pain imaginable).

The triage "Pre-Hospital Treatments" revealed: "Hand Cuffs accompanied c (with) 2 guards." The "Subjective" field revealed: "'My shoulder popped out lifting wts (weights) today. This happened just a month ago.'" The "Objective" field revealed: "Pt c sling on arrival. + (positive) distal pulses."

The "Northwest Medical Center ED (Emergency Department) Nursing Assessment," conducted at 10:45 A.M. by a different nurse, revealed that the pain Patient #1 was experiencing was in the L (left) shoulder. The "Pain Intensity Scale" had an "x" over the line extending downward from the numeral "8." Underneath the numeral "8" was a pre-printed verbal description on the amount of pain "8" represented. The verbal descriptor was "Horrible." The "ED Nursing Assessment" revealed that Patient #1 had "Severe Weakness" in the left arm.

The "ED Nursing Assessment," conducted at 10:45 A.M., revealed in the field labeled "Wound/Injury," that Patient #1 had an injury to the left upper lip. The documentation does not clarify the type of injury to the lip.

The physician's orders for Patient #1 revealed: "NS (normal saline) lock IV (intravenous). X-R (x-ray) L (left) shoulder. 4 mg. (milligrams) Zofran (antiemetic) and 4 mg. Morphine (narcotic analgesic)."

The "Northwest Medical Center ED Nursing Notes," in the field labeled "Pain Medications and Assessment," revealed no documentation that pain medication had been administered to the patient during the time he was in the Northwest Medical Center Emergency Department.

The Northwest Medical Center policy titled "Discharge of Patient from the Emergency Department" revealed: "...1. At the conclusion of treatment, the Emergency Department Physician/Attending Physician completes the discharge instructions...."

The Northwest Medical Center "Discharge Instructions" for Patient #1 revealed: "...Please GO to the St. Mary's Emergency Department FOR FURTHER TREATMENT...."

The "Emergency Room Report," dictated by Physician #1 on 10-03-09 at 1:07 P.M., revealed: "This is a...-year-old male incarcerated patient who has a chief complaint of left shoulder pain. The patient states he was lifting weights, and his left shoulder 'popped out.' He states it happened a month ago, and he was treated for same. He has no other complaints."

The "Emergency Room Course" revealed: "The patient had a clinical anterior left shoulder dislocation. He had a strong radial pulse. I ordered IV narcotics, IV antiemetics, and an x-ray. ____ by the _______here that because he is a prisoner he apparently has a contract at another facility and is being transported out by the officers that brought him in." The entry was electronically signed by Physician #1.

An Addendum was written to the record, and dictated on 10-07-09 at 8:11 P.M., by Physician #1. The addendum revealed: "The patient had a clinical anterior left shoulder dislocation. He had stable vital signs with a resting pulse of 73. He appeared to be in no distress. Neurovascular exam is intact including a strong radial pulse. I ordered IV narcotics, IV anti-emetics, and x-ray of the left shoulder. I was subsequently notified by the charge nurse in the emergency department that I was unable to continue care of the outpatient, as he was a prisoner and has a contract at another facility and the guards present with him had requested transfer. Apparently he was transported out by the officers who brought him into the facility.

I was informed initially by the charge nurse that the guards were calling to see if I would be allowed to treat the patient and I subsequently notified after the patient had left the department that he had been transferred out. In addition, I subsequently was notified that the patient did not receive morphine that has been ordered, and in fact, there is a hand written note canceled across the medication order and that it should be noted it is not my handwriting nor did I cancel that order. Unfortunately, the patient was transported out prior to receiving that medication."

Medical record review, conducted on 01-04-10 at 4:15 P.M., revealed no x-ray report for the x-ray of the left shoulder that was ordered by Physician #1 for Patient #1.

The CNO acknowledged, during interview conducted on 01-04-10 at 4:45 P.M., that Patient #1 did not receive a left shoulder x-ray as ordered by the physician, prior to being "transported out" to Carondelet St. Mary's Hospital Emergency Department.

Physician #1 stated, during telephone interview conducted on 01-06-10 at 3:10 P.M., that
Patient #1 presented to the ED accompanied by two security guards. Physician #1 stated
that the "CNO" (clarified by surveyor as Clinical Nurse Leader) told him that there may be some "contract problems" with the prison, and the physician stated he was told the patient had been transferred to Carondelet St. Mary's Hospital. Physician #1 stated that transferring the patient without adhering to the appropriate process and paperwork were "My mistake." Physician #1 stated he that mistakenly believed at the time of the occurrence, that maybe something was "different" with the prison system patients.

Review was conducted of Patient #1's prison medical record for 10-03-09, for care he received prior to transport to Northwest Medical Center Emergency Department. The prison medical record, dated 10-03-09 at 8:20 A.M., revealed: "...Assessment Anterior dislocation of left shoulder, recurrent. NO neurovascular compromise. Attempt at reduction was unsuccessful. (+) muscle spasm present. lip laceration-requiring suturing. superficial lac (laceration) on bridge of nose-could be closed with steri-strips. Plan 1) will transport to ER for treatment, via van, as on-site reduction was not successful." The entry was signed by Physician #3, a prison physician.

Record review was conducted of Patient #1's medical record at Carondelet St. Mary's Hospital, the Hospital to which the patient was transferred from Northwest Medical Center. Patient #1 arrived and was triaged, at 11:55 A.M., on 10-03-09. Upon triage, Patient #1 had a pulse of 83, respirations of 16, and a blood pressure of 152/88.

An x-ray of the left shoulder revealed the following "Impression: Anterior dislocation without clear fracture."

The Carondelet St. Mary's Hospital "Emergency Department Note" revealed: "...A fit-appearing man is in obvious pain. There is an obvious dislocation to the left glenohumeral joint...He does have a small cut on the left side of his nose...He has a 1 cm (centimeter) laceration to the left upper lip in his mustache. There is no bleeding. It is a through and through laceration, but the mucosal wound in minimal. His teeth are firm...IV was initiated. The patient was given morphine for pain while preparation was made for the reduction...Initially placed 10 ml (milliliters) of 0.5% bupivacaine (local anesthetic) into the glenohumeral joint, then gave the patient a total of 15 mg. of etomidate (anesthetic agent used for moderate sedation). This did decrease his mental status, but he continued to have significant (muscle) tone, so I was unable to successfully reduce the shoulder with that medication...Procedure #2: Left lip laceration repair. Under 0.5% left infraorbital nerve block with bupivacaine the mustache hair was trimmed. The wound was cleansed with saline Q-tips. It was explored. No foreign body was found. It was closed with two 5-0 Novafil sutures...Procedure #3: Repeat attempted reduction of the left shoulder. After the patient had recovered I repeated the procedural sedation, this time with propofol (anesthetic agent used for moderate sedation). The patient received a total of 175 mg in aliquots. This did provide adequate relaxation for a successful reduction using a slow Kocher maneuver...Post procedure x-ray shows successful reduction...I recommend that he followup with an orthopedic surgeon...."

Patient #1 was discharged from Carondelet St. Mary's Emergency Department on 10-03-09 at 4:00 P.M., with prescriptions, discharge instructions, and copies of the "chart."

Based on record review, policy and procedure review, and interview, it was determined that the Hospital failed to avoid delay of an appropriate medical screening examination for a patient (Patient #1), when the Emergency Department physician initiated the Medical Screening Examination, then failed to conduct an ongoing examination when contractural issues with the prison from which the patient presented arose.

Findings include:

The "Northwest Medical Center Emergency Medical Treatment and Labor Act (EMTALA)" policy and procedure, effective 05-14-09, revealed: "... 6. It is further the policy of the Hospital to not: a. delay the provision of a Medical Screening Examination, stabilizing treatment, or appropriate transfer in order to inquire about the individual's method of payment or insurance status...

Patient #1 presented to the Northwest Medical Center Emergency Department on 10-03-09 at 10:45 A.M., with a complaint of shoulder pain. The "ED Nursing Assessment" completed on 10-03-09 at 10:45 A.M., revealed that the pain was "8" on a scale of 0-10, with 10 being high.

The physician's orders for Patient #1 revealed: "NS (normal saline) lock IV (intravenous). X-R (x-ray) L (left) shoulder. 4 mg. (milligrams) Zofran (antiemetic) and 4 mg. Morphine (narcotic analgesic)."

The "Emergency Room Course" revealed: "The patient had a clinical anterior left shoulder dislocation. He had a strong radial pulse. I ordered IV narcotics, IV antiemetics, and an x-ray. ____ by the _______here that because he is a prisoner he apparently has a contract at another facility and is being transported out by the officers that brought him in." The entry was electronically signed by Physician #1.

The Northwest Medical Center "Discharge Instructions" for Patient #1 revealed: "...Please GO to the St. Mary's Emergency Department FOR FURTHER TREATMENT...."

Patient #1's Northwest Medical Center Emergency Department medical record revealed that no pain medication or antiemetic medication were administered as ordered, and no shoulder x-ray was taken as ordered. The "ED Nursing Assessment" revealed a "Wound/injury" to the left upper lip for which no treatment was provided.

The CNO acknowledged, during interview conducted on 01-04-10 at 4:45 P.M., that Patient #1 did not receive a left shoulder x-ray as ordered by the physician, prior to being "transported out" to Carondelet St. Mary's Hospital Emergency Department.

Physician #1 stated, during telephone interview conducted on 01-06-10 at 3:10 P.M., that
Patient #1 presented to the ED accompanied by two security guards. Physician #1 stated
that the "CNO" (clarified by surveyor as Clinical Nurse Leader) told him that there may be some "contract problems" with the prison, and the physician stated he was told the patient had been transferred to Carondelet St. Mary's Hospital. Physician #1 stated that transferring the patient without adhering to the appropriate process and paperwork were "My mistake." Physician #1 stated he that mistakenly believed at the time of the occurrence, that maybe something was "different" with the prison system patients.

Record review was conducted of Patient #1's medical record at Carondelet St. Mary's Hospital, the Hospital to which the patient was transferred from Northwest Medical Center. Patient #1 arrived and was triaged, at 11:55 A.M., on 10-03-09, over an hour after he had first presented to the Emergency Department at Northwest Medical Center. Upon triage, Patient #1 had a pulse of 83, respirations of 16, and a blood pressure of 152/88.

The Carondelet St. Mary's Hospital "Emergency Department Note" revealed: "...A fit-appearing man is in obvious pain. There is an obvious dislocation to the left glenohumeral joint...He does have a small cut on the left side of his nose...He has a 1 cm (centimeter) laceration to the left upper lip in his mustache. There is no bleeding. It is a through and through laceration, but the mucosal wound in minimal. His teeth are firm...IV was initiated. The patient was given morphine for pain while preparation was made for the reduction...Initially placed 10 ml (milliliters) of 0.5% bupivacaine (local anesthetic) into the glenohumeral joint, then gave the patient a total of 15 mg. of etomidate (anesthetic agent used for moderate sedation). This did decreases his mental status, but he continued to have significant (muscle) tone, so I was unable to successfully reduce the shoulder with that medication...Procedure #2: Left lip laceration repair. Under 0.5% left infraorbital nerve block with bupivacaine the mustache hair was trimmed. The wound was cleansed with saline Q-tips. It was explored. No foreign body was found. It was closed with two 5-0 Novafil sutures...Procedure #3: Repeat attempted reduction of the left shoulder. After the patient had recovered I repeated the procedural sedation, this time with propofol (anesthetic agent often used for moderate sedation). The patient received a total of 175 mg in aliquots. This did provide adequate relaxation for a successful reduction using a slow Kocher maneuver...Post procedure x-ray shows successful reduction..I recommend that he follow up with an orthopedic surgeon...."

Patient #1 was discharged on 10-03-09 at 4:00 P.M..

Based on record review, policy and procedure review, the "Northwest Medical Center Transfer Record" form review, and interview, it was determined that the Hospital failed to require an appropriate transfer for a patient (Patient #1) with a dislocated shoulder and a lip laceration requiring suturing as evidenced by:

1. failing to provide medical treatment within its capacity;

2. failing to require the Emergency Department physician complete a certification of transfer;

3. failing to require the Emergency Department physician make the patient aware of the risks and benefits of transfer;

4. failing to require the Emergency Department physician ensured the receiving facility agreed to the transfer and had the space and qualified personnel to care for the patient; and

5. failing to send all medical records to the receiving hospital.

Findings include:

1. Patient #1, a prisoner at a private prison, presented to the Emergency Department on 10-03-09, at 10:45 A.M. The patient's triage vital signs revealed a temperature of "96.5" degrees, a blood pressure of 187/85, a pulse of 73, and respirations of 16. The triage assessment of pain revealed a pain level of 7-8 (Wong-Baker Scale in which "0" represents no pain, and "10" represents the worst pain imaginable).

The triage "Pre-Hospital Treatments" revealed: "Hand Cuffs...." The "Subjective" field revealed: "'My shoulder popped out lifting wts (weights) today. This happened just a month ago.'" The "Objective" field revealed: "Pt c sling on arrival. + (positive) distal pulses."

The "Northwest Medical Center ED (Emergency Department) Nursing Assessment," conducted at 10:45 A.M. by a different nurse, revealed that the pain Patient #1 was experiencing was in the L (left) shoulder. The "Pain Intensity Scale" had an "x" in over the line extending downward from the numeral "8." Underneath the numeral "8" was a verbal description on the amount of pain "8" represented. The verbal descriptor was "Horrible." The "ED Nursing Assessment" revealed that Patient #1 had "Severe Weakness" in the left arm.

The "ED Nursing Assessment," conducted at 10:45 A.M., revealed in the field labeled "Wound/Injury," that Patient #1 had an injury to the left upper lip. The documentation does not clarify the type of injury to the lip.

The physician's orders for Patient #1 revealed: "NS (normal saline) lock IV (intravenous). X-R (x-ray) L (left) shoulder. 4 mg. (milligrams) Zofran (antiemetic) and 4 mg. Morphine (narcotic analgesic)."

The "Northwest Medical Center ED Nursing Notes," in the field labeled "Pain Medications and Assessment," revealed no documentation that pain medication had been administered during the patient's time in the Northwest Medical Center Emergency Department. There was no documentation in the field labeled "IV (intravenous) Management" that the "NS lock IV" (normal saline lock IV) had been inserted. There was no documentation that Patient #1 was sent for an x-ray of the shoulder, and no x-ray report in the medical record. There was no documentation that the lip injury noted by the Registered Nurse was treated prior to the patient being transferred to Carondelet St. Mary's Emergency Department.

An Addendum was written to the record, and dictated on 10-07-09 at 8:11 P.M., by Physician #1. The addendum revealed: "The patient had a clinical anterior left shoulder dislocation...I ordered IV narcotics, IV anti-emetics, and x-ray of the left shoulder. I was subsequently notified by the charge nurse in the emergency department that I was unable to continue care of the outpatient, as he was a prisoner and has a contract at another facility and the guards present with him had requested transfer. Apparently he was transported out by the officers who brought him into the facility.

I was informed initially by the charge nurse that the guards were calling to see if I would be allowed to treat the patient and I subsequently notified after the patient had left the department that he had been transferred out. In addition, I subsequently was notified that the patient did not receive morphine that has been ordered, and in fact, there is a hand written note canceled across the medication order and that it should be noted it is not my handwriting nor did I cancel that order. Unfortunately, the patient was transported out prior to receiving that medication."

The CNO acknowledged, during interview conducted on 01-04-10 at 4:45 P.M., that Patient #1 did not receive a left shoulder x-ray as ordered by the physician, prior to being "transported out."

2. Review was conducted of the medical record of Patient #1. The review revealed there was no "Northwest Medical Center Transfer Record" in the medical record for the 10-03-09 Emergency Department visit.

3. A "Northwest Medical Center Transfer Record" form revealed: "My signature to the left confirms that I have reviewed the information above and request/consent to be transferred to another facility. I have been informed of the risks, benefits and reason for transfer. If my medical condition is marked 'unstable' above I understand that Northwest Medical Center is required to stabilize my emergency medical condition, unless I request to be discharged/transferred to the other facility or unless the physician certifies that the medical benefits reasonably expected at the other facility outweigh the risks of transfer."

Record review revealed there was no "Northwest Medical Center Transfer Record" in the medical record for the 10-03-09 Emergency Department visit of Patient #1. There was no other documentation in the medical record that indicated that Patient #1 had been apprised of the risks and benefits of transfer.

4. Record review was conducted of the 10-03-09 Emergency Department visit of Patient #1. Review revealed there was no completed "Northwest Medical Center Transfer Record" in the medical record of Patient #1. A "Northwest Medical Center Transfer Record" revealed: "...Name of accepting physician at the receiving facility who accepts the patient in transfer...." There was no documentation in the medical record from Carondelet St. Mary's Hospital that they had been contacted by a physician at Northwest Medical Center regarding the transfer of the patient.

5. Review was conducted of the medical record of the 10-03-09 Emergency Department visit of Patient #1. Review revealed no documentation that medical records were sent to Carondelet St. Mary's Hospital with the patient. Record review was conducted of the 10-03-09 Emergency Department visit of Patient #1 to Carondelet St. Mary's Emergency Department. The record contained no medical records from the patient's visit earlier in the day to the Northwest Medical Center Emergency Department.