HospitalInspections.org

Based on review of a sample of a 20 patient medical records, review of a medical record from a receiving hospital, and interview with staff, it was determined that the hospital did not comply with the provider agreement as defined in 42 Code of Federal Regulations (CFR). 489.24.

Findings include:

1. The hospital failed to comply with 42 CFR 489.24 (r) and 489.24(C) by not providing an appropriate medical screening exam for one (patient 6) out of 20 sampled patients. (Refer to tag A2406)

2. The hospital failed to comply with 42 CFR 489.24(d) by not providing appropriate stabilizing treatment for one (patient 6) out of 20 sampled patients. (Refer to tag A2407)

3. The hospital failed to comply with 42 CFR 489.24 (e) by not providing an appropriate transfer for one (patient 6) out of 20 sampled pateints. (Refer to tag A2409)

Based on record review and interview, it was determined that emergency department 1(ED1), did not perform a medical screening exam for 1 of 20 patients whose records were randomly selected and reviewed on 7/7/10. Specifically, patient 6 did not receive a medical screening exam prior to being sent to ED 2.

Findings include:

1. Patient 6 was taken to ED1 by a skilled nursing facility transport van on 6/11/10 at 11:23 AM. The ED1 staff assisted the transport driver to transfer patient 6 from the transport be onto an ED bed.

At 11:35 AM, the transporter from the nursing facility informed the ED nurse that he had brought patient 6 to the wrong hospital ED. The ED staff assisted the transporter to transfer patient 6 back onto the transport bed and patient 6 was taken to the hospital ED2.

Review of the " Emergency Department Charge Sheet " from ED1 dated 6/11/10 at 11:23 AM, revealed that an ED1 staff member had documented, " LPMSE (left prior to medical screening exam). "

Patient 6 did not receive a medical screening exam in ED1 prior to being sent to ED2.

An interview was held with the ED1 ' s hospital risk manager on 7/7/10 at 2:00 PM. She stated that she learned of the incident from the ED2 ' s hospital risk manager. She stated that she conducted a full investigation and it was determined that ED1 ' s staff did not perform a screening exam.

The risk manager stated that all the ED1 ' s staff has been re-educated on EMTALA. She also stated that the hospitals EMTALA policies have been re-written and adopted by the medical staff. She stated that the hospital conducts QAPI (Quality Assurance Performance Improvement) meetings quarterly, and the incident that occurred on 6/11/10, is on the agenda for review at the next meeting.

Based on record review and interview, it was determined that emergency department 1(ED1), did not ensure that treatment was provided for 1 of 20 patients whose records were randomly selected and reviewed on 7/7/10. Specifically, patient 6 did not receive any medical treatment prior to being sent to ED 2.


Patient 6 was taken to ED1 by a skilled nursing facility transport van on 6/11/10 at 11:23 AM. The ED1 staff assisted the transport driver to transfer patient 6 from the transport be onto an ED bed.

At 11:35 AM, the transporter from the nursing facility informed the ED nurse that he had brought patient 6 to the wrong hospital ED. The ED staff assisted the transporter to transfer patient 6 back onto the transport bed and patient 6 was taken to the hospital ED2.

Patient 6 did not receive any medical treatment in ED1 prior to being sent to ED2

Review of the " Emergency Physicians Orders " dated 6/11/10 at 11:23 AM, from ED1 revealed that an ED1 staff member had documented, " LWBS (left without being seen), wrong hospital-not seen by EDP (emergency department physician). "

An interview was held with the ED1 ' s hospital risk manager on 7/7/10 at 2:00 PM. She stated that she learned of the incident from the ED2 ' s hospital risk manager. She stated that she conducted a full investigation and it was determined that ED1 ' s staff did not provide any treatment for patient 6 prior to sending patient 6 to ED2.

Based on record review and interview, it was determined that emergency department 1(ED1), did not ensure that a proper transfer was provided for 1 of 20 patients, whose records were randomly selected and reviewed on 7/7/10. Specifically, patient 6 did not receive a proper transfer to ED 2.


Patient 6 was taken to ED1 by a skilled nursing facility transport van on 6/11/10 at 11:23 AM. The ED1 staff assisted the transport driver to transfer patient 6 from the transport be onto an ED bed.

At 11:35 AM, the transporter from the nursing facility informed the ED nurse that he had brought patient 6 to the wrong hospital ED. The ED staff assisted the transporter to transfer patient 6 back onto the transport bed and patient 6 was taken to the hospital ED2.

A review of the " Clinical Report - Nurses " dated 6/11/10 at 11:29 AM, from ED1 revealed that a registered nurse had documented, " Pt (patient) is a resident at (skilled nursing facility), brought in ED for eval of hip pain. Pt was transferred off transport bed and placed on ED bed. At that time the (skill facility) transporter informed us that Pt needs to be seen at (ED2). Transfer paperwork from (skilled nursing facility) also stated to take to the (ED2) Pt taken from ED at 1135. "

An interview was held with the ED1 ' s hospital risk manager on 7/7/10 at 2:00 PM. She stated that she learned of the incident from the ED2 ' s hospital risk manager. She stated that she conducted a full investigation and it was determined that ED1 ' s staff did not initiate and properly transfer patient 6 to ED2.