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Based on documentation review and interview, the Governing Board failed to ensure six contracted service providers were part of the hospital's comprehensive quality assessment and improvement (QA&I) program.

Findings included:

1. Elkhart General Hospital 2016 Quality/Performance Improvement Plan goals stated, "To develop, implement and maintain an effective planned, systematic and ongoing, system wide, data driven, interdisciplinary process to continuously assess, monitor, evaluate and improve the quality and appropriateness of carte, both direct and indirect, provided to patients. To measure, analyze and track quality indicators that processes of care, hospital service and operations."

2. The 2015 and 2016 Governing Board minutes and quality dashboards did not identify contracted services were monitored as part of the comprehensive quality assessment and improvement (QA&I) program: biohazard waste hauler, environmental service, emergency generator, air conditioning system, air handling units and humidity control system contracted service providers.

3. At 1:15 PM on 3/31/2016, staff member #1 (Director of Quality) confirmed all the above and no other documentation was provided prior to exit.

Based on documentation review and staff interview, the Governing Board failed to ensure six contracted service providers were made part of the hospital's list of contractors that included their scope of services provided.

Findings included:

1. Elkhart General Hospital 2016 Contracted Service's listing did not include the biohazard waste hauler, environmental service, emergency generator, air conditioning system, air handling units and humidity control system contracted service providers.

2. At 1:15 PM on 3/31/2016, staff member #1 (Director of Quality) confirmed all the above and no other documentation was provided prior to exit.

Based on document review and interview, the facility failed to follow its policy/procedure for monitoring all patients in restraint or seclusion for 1 of 2 behavior health medical records (MR) reviewed (patient #2).

Findings include:

1. Review of policy/procedure Restraints and Seclusion, Guidelines for Use and Documentation (revised 7-15) indicated the following: "Monitoring of patients in restraint or seclusion is accomplished through in-person observation by a trained staff member."

2. Review of patient #2's MR on 2-2-16 indicated an order for seclusion was obtained and implemented at 1225 hours and the narrative entry at 1235 hours by the behavior health unit nurse, staff A26, indicated the following: "Pt (patient) remains on 1:1 observation via [closed circuit video] monitor."

3. At 1200 hours on 3-31-16, the vice president of nursing services, staff A4, confirmed that the MR failed to indicate that in-person monitoring was performed.

Based on document review and interview, the facility failed to ensure the attending physician was consulted by the specially trained registered nurse (RN) as soon as possible after the one hour face-to-face evaluation was performed for 2 of 2 behavior health medical records (MR) reviewed (patient #2, #3).

Findings include:

1. Review of policy/procedure Restraints and Seclusion, Guidelines for Use and Documentation (revised 7-15) indicated the following: "The specially trained RN must consult with the attending physician as soon as possible after the completion of the 1 hour face to face evaluation."

2. Review of patient #2's MR on 2-2-16 indicated an order for seclusion was obtained and implemented at 1225 hours. The MR indicated a 1 hour face-to-face evaluation was performed at 1228 hours by the behavior health unit nurse, staff A26, and lacked documentation the attending psychiatrist, MD17 was consulted after the 1 hour face-to-face evaluation was completed.

3. Review of patient #3's MR on 11-27-15 indicated an order for Keyed Velcro restraints to both upper and both lower extremities was obtained at 1904 hours and implemented at 1910 hours. The MR indicated a 1 hour face-to-face evaluation was performed at 1950 hours by the behavioral health unit nurse, staff A28, and lacked documentation the attending psychiatrist, MD17 was consulted after the 1 hour face-to-face evaluation was completed.

4. On 3-31-16 at 1300 hours, the vice president of nursing services, staff A4, confirmed that the MR lacked documentation indicating the attending psychiatrist was consulted after the 1 hour face-to-face evaluation was completed for patients #2 and #3.

Based on document review and interview, the facility failed to ensure the medical record (MR) documentation of the face-to-face evaluation performed within one hour of initiating a restraint or seclusion intervention included a medical and behavioral assessment for 1 of 2 behavior health MR reviewed (patient #3).

Findings include:

1. Review of the policy/procedure Restraints and Seclusion, Guidelines for Use and Documentation (revised 7-15) indicated the following: "The physician, APN [advanced practice nurse]... or a specially trained registered nurse shall perform a face-to-face evaluation of the patient's physical and psychological status within one hour of the initiation of the restraint... The face-to-face evaluation will... evaluate the patient's clinical condition..."

2. The MR entry for patient #3 on 11-27-15 by the behavior health unit nurse, staff A27, indicated that an order for locked Velcro restraints to both upper and both lower extremities was obtained at 1904 hours from the attending psychiatrist, MD17 and the MR indicated that the restraint intervention was initiated at 1910 hours.

3. The MR entry for patient #3 on 11-27-15 at 1950 hours by the behavior health unit nurse, staff A28, describing the results of the one hour face-to-face medical and behavioral evaluation indicated the following: "Psychiatric/Mental Health Disorder". The documentation failed to indicate a review of medical systems and a behavioral assessment was performed with a description of the findings.

4. In interview on 3-31-16 at 1255 hours, the vice president of nursing services, staff A4, confirmed that the MR lacked documentation indicating a medical and behavioral evaluation was performed.

Based on documentation review and interview, the Governing Board failed to ensure six contracted service providers were part of the hospital's comprehensive quality assessment and improvement (QA&I) program.

Findings included:

1. Elkhart General Hospital 2016 Quality/Performance Improvement Plan goals stated, "To develop, implement and maintain an effective planned, systematic and ongoing, system wide, data driven, interdisciplinary process to continuously assess, monitor, evaluate and improve the quality and appropriateness of carte, both direct and indirect, provided to patients. To measure, analyze and track quality indicators that processes of care, hospital service and operations."

2. The 2015 performance improvement minutes, quality dashboards, and 2015 Annual Departments QAPI report did not evidence biohazard waste hauler, environmental service, emergency generator, air conditioning system, air handling units and humidity control system contracted service providers as part of the comprehensive quality assessment and improvement (QA&I) program:.

3. At 1:15 PM on 3/31/2016, staff member #1 (Director of Quality) confirmed all the above and no other documentation was provided prior to exit.

Based on document review and interview, nursing services failed to ensure patient nutritional care was supervised by a registered nurse for five of five open patient medical records reviewed (Patients #L15 through #L19).

Findings include:

1. Review of policies and procedures indicated the following:
A. "Nutrition Screening and Case Finding," policy number "04," last revised on "9/13," read: "The initial nutrition screening will be completed by the nursing staff on all patients within 24 hours of admission as an inpatient."
B. "Documentation Guidelines: Adult General Admission / Anesthesia Screening," policy number: "D-15," last revised on "7/2017," read: "Documentation required in EMR: A. The admission history is comprised of AdHoc (sic) admission and IView (sic) admission and includes, but is not limited to the elements below...ADL data..."

2. Review of patient medical records indicated the following:
A. Patient #L15 was admitted on 3-17-2016. There was no documentation an initial nutrition screening was completed by nursing staff within 24 hours of admission, as required by approved policy. On 3-17-16, the patient was ordered to receive a regular diet. There was no documentation in the Activities of Daily Living (ADL) data that the patient ate or refused dinner on 3-17-16, as required by approved policy. The patient was ordered to receive a puree diet from 3-27-16 to date of survey. There was no documentation in the ADL data that the patient ate or refused lunch on 3-28-16; and breakfast, lunch, and dinner on 3-29-16.
B. Patient #L16 was admitted on 3-29-2016. There was no documentation an initial nutrition screening was completed by nursing staff within 24 hours of admission, as required by approved policy.
C. Patient #L17 was admitted on 3-22-16. The patient was ordered to receive a low fat, low cholesterol, 2 gram (gm) sodium diet on 3-22-16. The diet order had not changed from 3-22-16 to date of survey. There was no documentation in the ADL data that the patient ate or refused breakfast and lunch on 3-22-16; lunch and dinner on 3-23-16; breakfast, lunch and dinner on 3-24-16; dinner on 3-26-16; breakfast and lunch on 3-28-16; and breakfast on 3-29-16 and 3-30-16.
D. Patient #L18 was admitted on 3-29-2016. There was no documentation an initial nutrition screening was completed by nursing staff within 24 hours of admission, as required by approved policy. The patient was ordered to receive a low fat, low cholesterol, 2 gm sodium diet on 3-30-16. There was no documentation in the ADL data that the patient ate or refused lunch on 3-30-16.
E. Patient #L19 was admitted on 3-28-16. The patient was ordered to receive a low fat, low cholesterol, 2 gm sodium diet on 3-28-16. The diet order had not changed from 3-28-16 to date of survey. There was no documentation in the ADL data that the patient ate or refused dinner on 3-29-16.

3. In interview on 3-31-16 at 10:00 AM, Staff Member #L15 indicated patients #L15, #L16, and #L18 did not have an initial nutrition screening performed. The staff member also acknowledged there was no documentation that patients #L15, #L17, #L18 and #L19 had eaten or refused to eat during the above noted dates and meal times.

Based on document review and interview, the facility failed to ensure that all consent forms were dated, timed, and authenticated by a responsible person for 1 of 9 medical records (MR) reviewed (patient #8).

Findings include:

1. Review of the policy/procedure Consent to Treat (reviewed 12-15) indicated the following: "The hospital's role in the consent process is to verify that the patient's Consent to Treat has been obtained before the practitioner is permitted to perform the procedure or render care."

2. Review of patient #8's MR Consent to Treat for 1-28-16 visit failed to indicate the date and time when signed by the patient and failed to indicate an entry in the designated sections for a facility representative to sign, date and time the consent documentation.

3. On 3-31-16 at 1410 hours, the vice president of nursing services, staff A4, confirmed that the patient Consent for Treatment failed to indicate a date, time, or signature by a witness to establish and verify when the patient consent was obtained.

Based on Life Safety Code (LSC) survey, Elkhart General Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC).

Elkhart General Hospital is comprised of the main hospital in Elkhart, In (Building 01), and Center for Wound Healing (Building 02), and Elkhart Cardiology (Building 03), and North Central Cardiovascular Specialists (Building 04), and Sleep Disorder Center (Building 05).

Elkhart General Hospital main building, Building 01, an six story fully sprinklered building of Type II (000) construction and a fire alarm system with smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 19, Existing Health Care occupancies. Building 01 provides overnight care. Building 01 has a capacity of 252 and had a census of 177 at the time of this survey.

The Center for Wound Healing wing, Building 02, is part of an six story fully sprinklered building of Type I (332) construction with a fire alarm system with smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 18, New Health Care Occupancies.

The Elkhart Cardiology wing, Building 03, is part of an one story fully sprinklered building of Type II (000) construction with a fire alarm system with smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 18, New Health Care Occupancies.

The North Cardiovascular Specialists wing, Building 04, is part of an six story fully sprinklered building of Type I (332) construction with a fire alarm system with smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 18, New Health Care Occupancies.

The Sleep Disorder wing, Building 05, is part of an six story fully sprinklered building of Type I (332) construction with a fire alarm system with smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 18, New Health Care Occupancies.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure the building construction type for a building, four or more stories in height, to be Type II (222), Type I (332) or Type I (443) (see K 012), failed to ensure 1 of 4 of basement stair door assemblies in a vertical opening were of an approved type with appropriate fire protection rating (see K 021), failed to ensure exit access was arranged so 1 of 3 exits were readily accessible at all times (see K 038), failed to provide a written plan that addressed all components in 1 of 1 written fire plans (see K 048), failed to ensure sprinkler coverage in 1 of 1 Stairwell #1 and 1 of 1 Stair #2 was installed at the top of shaft and under the first landing above the bottom of the shaft, 1 of 5 Radiology office sprinkler heads was changed, 1 of 1 sprinklers in the 5th floor North East Men's Bathroom was unobstructed, a complete automatic sprinkler system was provided for 1 of 1 canopies and complete sprinkler coverage in 1 of 1 Stairwell #1 and 1 of 1 Mechanical Room 1723 (see K 056) and failed to conduct preventive maintenance on 3 occupational health therapy electric power drills (see A 724).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review, observation and interview, the facility failed to ensure the building construction type for a building, four or more stories in height, to be Type II (222), Type I (332) or Type I (443), failed to ensure 1 of 4 of basement stair door assemblies in a vertical opening were of an approved type with appropriate fire protection rating, failed to ensure exit access was arranged so 1 of 3 exits were readily accessible at all times, failed to provide a written plan that addressed all components in 1 of 1 written fire plans and failed to ensure sprinkler coverage in 1 of 1 Stairwell #1 and 1 of 1 Stair #2 was installed at the top of shaft and under the first landing above the bottom of the shaft, 1 of 5 Radiology office sprinkler heads was changed, 1 of 1 sprinklers in the 5th floor North East Men's Bathroom was unobstructed, a complete automatic sprinkler system was provided for 1 of 1 canopies and complete sprinkler coverage in 1 of 1 Stairwell #1 and 1 of 1 Mechanical Room 1723 (see K 056) and failed to conduct preventive maintenance on 3 occupational health therapy electric power drills (see A 724).

Findings include:

1. Record review with DES#1, Director of Engineering Services, on 03/29/16 between 8:34 a.m. and 11:24 a.m. indicated part of the Elkhart General Hospital main building was constructed of type II (000) construction.

2. In interview at the time of record review, the Director of Engineering Services confirmed part of the hospital was constructed at II (000) and was aware of the aforementioned condition. He/she further explained that the floor/ceiling rating was constructed of two hours, but was unable to provide documentation.

3. Observation during a tour of the facility with the Manager of Plant Operations, MPO#1, on 03/30/16 at 09:30 a.m. noted the fire rating for the basement stair door #6 protecting a vertical opening could not be determined. Upon inspection of the door, no label could be found to determine the fire rating of the door.

4. In interview at the time of observation, the Manager of Plant Operations stated there was no documentation of the door's fire rating and a contractor was scheduled on 04-01-2016 to provide documentation for the door.

5. Observation with the Director of Engineering Services on 03/30/16 at 9:37 a.m. noted Stair #9 exit discharged into grass.
6. In interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition and confirmed that path was considered an exit.
7. Record review with the Director of Engineering Services on 03/30/16 at 9:28 a.m. indicated the facility had a written fire policy that horizontal evacuation would be performed by crossing a smoke barrier. However, site plans showed there were separation doors on the third floor that were not part of a complete smoke or fire barrier which could cause staff to evacuate residents to a different part of the same smoke compartment and not to an adjacent compartment in the event of a fire.

8. In interview during record review, the Director of Engineering Services acknowledged the aforementioned condition and confirmed the site plans indicate separation doors near patient room 3111 were not part of a complete barrier.

9. Observation with the Director of Engineering Services on 03/29/16 at 11:44 a.m. and again at 11:59 a.m. noted stairwell #1 lacked sprinkler coverage at the top of the stairwell and stairwell #2 lacked sprinkler coverage at the top of the stairwell.

10. In interview at the time of each observation, the Director of Engineering Services acknowledged the aforementioned condition.

11. Observation with the Director of Engineering Services on 03/30/16 at 11:28 a.m. noted the Radiology office had a mixture of quick response sprinkler heads with the thin glass rod and standard response sprinkler heads with the thick glass rods.

12. In interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

13. Observation with the Director of Engineering Services on 03/29/16 at 12:14 p.m. noted the spray pattern for the one sprinkler head in 5th floor North East Men's Bathroom was obstructed by a ceiling light. Measurements showed the sprinkler head was 4 inches away from the ceiling light. The ceiling light was measured to be 1 inch lower than the sprinkler head deflector.

14. In interview at the time of observation, the Director of Engineering Services acknowledged the abovementioned condition and provided the measurements.

15. Observation during a tour of the facility with the Manager of Plant Operations on 03/30/16 at 11:10 a.m. noted there was an unsprinklered canvas canopy attached to the building near the OB/GYN entrance. The canvas canopy extends out 20 feet from the building.

16. In interview at the time of observation, the Manager of Plant Operations acknowledged that the canopy was attached to the building, provided the measurements of the canopy, and stated there was no documentation to confirm the canvas canopy was inherently fire resistant.

17. Observation with the Director of Engineering Services on 03/30/15 at 12:33 p.m. noted there was no sprinkler coverage in the Mechanical Room 1723.
18. Record review indicated the site plans failed to indicate a construction rating.
19. In interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.
20. Clinical Engineering policy #CE-04 stated, "The Clinical Engineering Department will complete and document safety and performance inspections. All electrical medical equipment shall receive an initial electrical safety inspection." The policy was last reviewed March 2013.

21. The clinical engineering preventive maintenance documentation did not evidenced any preventive maintenance inspections on the three electric drills used in Occupational Health for therapy of their patients.

22 At 2:20 PM on 3/30/2016, staff member #29 (Clinical Engineering Director) confirmed all the above and no other documentation was provided prior to exit.

Based on documentation review and interview, the hospital failed to conduct preventive maintenance on 3 occupational health therapy electric power drills.

Findings include:

1. Clinical Engineering policy #CE-04 stated, "The Clinical Engineering Department will complete and document safety and performance inspections. All electrical medical equipment shall receive an initial electrical safety inspection." The policy was last reviewed March 2013.

2. The clinical engineering preventive maintenance documentation did not evidenced any preventive maintenance inspections on the three electric drills used in Occupational Health for therapy of their patients.

3. At 2:20 PM on 3/30/2016, staff member #29 (Clinical Engineering Director) confirmed all the above and no other documentation was provided prior to exit.

Based on documentation review, observation and interview, the hospital failed to ensure annual infection control training were provided to 5 of 25 hospital employees (#15, 33, 34, 35 and 36) and failed to ensure that a sanitary environment was maintained and ensure that personal protective equipment (PPE) was available in all areas to prevent and control the transmission of infections and communicable diseases for patients and personnel at the facility.

Findings included:

1. Review of the 2015 Infection Control Program stated, "Education training will be provided via policy, educational material, and quizzes on-line for initial and annual education."

2. Review of personnel files for 25 hospital employees. Five hospital employees (#15, 33, 34, 35 and 36) lack documentation of infection control training for 2015. Hospital employees #15, hired in November 2014, and #35, hired in October 1997, lacked documentation of infection control training since hired.

3. At 10:30 AM on 3/31/2016, staff member #31 (Human Resource Manager) confirmed all the above and no other documentation was provided prior to exit.


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4. Review of the policy/procedure Routine Cleaning of Work Stations and Sterile Processing Areas (revised 1-16) indicated the following: "To provide clean work and storage areas, the routine cleaning procedures should be completed by all three shifts... All surfaces shall be cleaned using hospital approved cleanser or wipes... These items to be cleaned once per week... Shelves, items stored on the shelves should be removed before cleaning...The supervisor in each area is responsible for assigning personnel to this cleaning job."

5. During a tour of the central sterile reprocessing areas on 3-30-16 at 1135 hours, in the company of the infection control (IC) nurse, staff A27, and the central sterile services manager, staff A25, the presence of dust was observed on a desktop computer located on a shelf over a workstation for wrapping surgical instruments.

6. During a tour of the central sterile reprocessing areas on 3-30-16 at 1138 hours, in the company of staff A27, A25, and A21, the presence of dust was observed on a shelf containing wrapping material located over a second workstation for wrapping surgical instruments.

7. On 3-30-16 at 1138 hours, the infection control (IC) nurse, staff A27, and the central sterile services manager, staff A25, confirmed the presence of dust in the area for preparing instruments for sterilization was unsanitary.

8. Review of the facility policy/procedure Sanitation in the Perioperative Area (revised 11-15) indicated the following: "All areas and equipment in the surgical practice setting will be cleaned according to an established basis. Areas and equipment are cleaned on a weekly or monthly basis should include... heating and air-conditioning equipment (which will be performed by facilities management)... Other areas requiring cleaning and disinfection include, but are not limited to, all horizontal surfaces..." It could not be determined what areas were designated to be cleaned on a periodic basis.

9. Review of a cleaning schedule obtained from the director of surgical services, staff A14 failed to ensure that all areas in the restricted surgical environment outside of the ORs were being cleaned on a daily or periodic basis.

10. Review of the contracted services policy/procedure Surgical Area Cleaning (approved by the IC committee 3-16) indicated the following: "A multidisciplinary team should establish a cleaning schedule for perioperative areas and equipment that should be cleaned on a regular (weekly/monthly/quarterly) basis." It could not be determined what areas were designated to be cleaned on a periodic basis by the environmental services (EVS) staff.

11. On 3-31-16 at 1015 hours, the interim EVS manager, staff A12, confirmed that a cycle cleaning schedule (indicating the areas and equipment to be cleaned on a periodic basis) was not available.

12. During a tour of the surgery services on 3-30-16 at 1245 hours, in the company of the infection control (IC) nurse, staff A27, the director of surgical services, staff A14, and the surgery services educator, staff A21, the presence of dust was observed on the upper surfaces of the door opener units located over the doors to OR 8.

13. On 3-30-16 at 1245 hours, the staff A27, A14 and A21 confirmed the presence of dust in the restricted surgical area was unsanitary and the area had not been properly maintained.

14. During a tour of the surgery services on 3-30-16 at 1250 hours, in the company of the infection control (IC) nurse, staff A27, the director of surgical services, staff A14, and the surgery services educator, staff A21, the presence of dust was observed on the upper surfaces of the infrared door sensors located on the doors to OR 9.

15. On 3-30-16 at 1250 hours, the staff A27, A14 and A21 confirmed the presence of dust in the restricted surgical area was unsanitary and the area had not been properly maintained.

16. During a tour of the cardiac catheterization labs on 3-30-16 at 1700 hours, in the company of the vice president of nursing, staff A4, and the director of cardiovascular services, staff A28, the presence of a significant amount of accumulated dust was observed on a 12" x 24" wall-mounted ventilation grille in catheterization lab 2.

17. On 3-30-16 at 1700 hours, the staff A4 and A28 confirmed the presence of dust in the procedural area was unsanitary and confirmed the equipment had not been properly maintained.

18. During a tour of the basement support services on 3-29-16 at 1550 hours, in the company of the executive director of nursing services, staff A18, a lack of available PPE (disposable nonsterile gloves) was identified inside and outside the soiled laundry room #956 where soiled laundry is discharged from a laundry chute before loading in a cart for transport to commercial laundry facility and the observation was confirmed by staff A18.

19. On 3-29-16 at 1555 hours, the EVS personnel, staff A29 confirmed that no PPE was available for use in the immediate area including the soiled laundry room if needed and confirmed that compromised plastic laundry bags and loose laundry was periodically discharged from the laundry chute.

20. On 3-31-16 at 1040 hours, the interim EVS manager, staff A12, confirmed that the policy/procedure titled Soiled Linen Handling (approved 3-16) failed to indicate a process for managing soiled laundry beginning with the point of discharge from the laundry chute in room #956 until loading onto a truck for transport to an offsite laundry facility.

Based on document review and interview, the facility failed to follow established policy/procedure for transferring emergency department (ED) patients for 1 of 9 MR reviewed (patient #9).

Findings:

1. Review of policy/procedure Transferring a Patient To Another Facility (reviewed 12-13) indicated the following:
"2. Complete the following forms:
B. MR-113 Transfer Form which include (sic) Physician certification
7. Secure test results, treatment information, and a copy of the patient record for transfer with the patient".

2. The MR for patient #9 indicated the patient arrived to the ED on 11-19-15 at 0855 hours in the company of law enforcement and indicated a physician with admitting privileges at a regional psychiatric facility accepted the patient in transfer. The MR lacked documentation indicating a physician certification was completed on the Form MR-113 and lacked documentation confirming a copy of the patient's MR was sent with the patient around the time of transfer at 1215 hours.

3. In interview on 3-31-16 at 1410 hours, the chief nursing officer, staff A4 confirmed that the MR for patient #9 lacked documentation of MR-113 Emergency Department Transfer Form including the provider certification of transfer risks and benefits and documentation indicating the MR copies that were sent with the patient.

4. In interview on 3-31-16 at 1420 hours, the vice president of medical affairs, physician A5 confirmed that the MR for patient #9 failed to indicate the Emergency Department Transfer Form M-113 was present and no other documentation was available.