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Based on clinical record review and interview, it was determined the Facility failed to maintain the transfer documents of two (#4 and #5) of five (#1, #2, #5, #13 and #16) patients who were transferred to other facilities for care. Failure to maintain the transfer documents did not allow for documentation of who accepted the patient, how the patient was transferred, who made the decision to transfer and that the risks and benefits were explained to the patients. The failed practice affected two of five patients. Findings follow:

A. Review of the clinical records of two (#4 and #5) of five (#1, #2, #5, #13 and #16) patients transferred revealed the clinical records did not contain any transfer documents containing information of who accepted the patient, how the patient was transferred, who made the decision to transfer and that the risks and benefits were explained to the patients.

B. The above findings were verified by the Director of Nursing at 1445 on 10/08/12.

Based on review of clinical records and interview, it was determined the Facility failed to document a medical screening in three (#2, #21 and #23) of four (#2, #21, #22 and #23) patients. Patients #2, #21, #22 and #23 were selected from the Emergency Room Log because they were dispositioned to a physician's office; review of those records revealed no evidence of a medical screening exam. Failure to document a medical screening exam did not allow the Facility to maintain a complete and accurate accounting of the assessment, care and disposition of the patients. The failed practice affected three (#2, #21 and #23) of four (#2, #21, #22 and #23) patients.

Findings:

A. Patient #2

A 24-year old, female patient presented to the ER at approximately 1:15 AM on 10/04/2012 with complaints of passing blood clots and heavy bleeding during menstrual period. Patient stated that on the day of presentation, she had used 3 pads in 30 minutes. No physician examination or diagnostic evaluation was conducted to exclude the presence of an emergency medical condition. The patient was discharged home.

B. Patient #23

A 70-year old, male patient presented to the ED at approximately 12:34 PM on 07/09/2012, with 24-hour of weakness of his left side, weakness to left hand with numbness to forearm. The symptoms were strongly suggetive of an acute ischemic CNS event. A Registered Nurse (RN) obtained the patient's history but no neurological assessment was done. The patient was sent to the physician's office. There was no appropriate medical screening examination conducted to exclude the presence of an emergency medical condition.

C. Patient #21

A 37-year old patient presented to the ED at approximately 2:00 PM on 09/04/2012 with complaints of eye pain for three days but worse on the day pof presentation. No medical screening examination was conducted and the patient was sent to the physician's clinic.

D. During an interview with Physician #2 at 1455 on 10/08/12 in the Emergency Room (ER) he was asked about ER nurses assessing patients and sending them to the office. Physician #2 stated the ER nurses conduct a patient assessment, call him and give him a report. Physician #2 stated at that point he makes a decision as to if the patient is emergent or can be treated at the office. Physician #2 stated that if the patient is emergent he will come to the ER, but if he felt the patient could be treated in his office, he would tell the ER nurses to send the patient to his office.

E. During an interview with RN #2 at 1505 on 10/08/12 she was shown the clinical records for Patients # 2, #21, #22 and #23. RN #2 was then asked if these patients were ER patients or medical screening patients. RN #2 stated they were all medical screening patients.

F. Review of the Emergency Room clinical records for Patient #2, #21, #22 and #23 revealed that three (#2, #21 and #23) of four (#2, #21, #22 and #23) did not contain medical screening forms. Patient #2's clinical record did not contain values for vital signs.

G. Review of the Emergency Room clinical records for Patients #2, #21, #22 and #23 revealed no physician's orders for disposition of the patients.

H. The findings for C and D were verified by the Director of Nursing at 1445 on 10/08/12.