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Based on clinical record reviews and interviews, the hospital failed to ensure compliance with 489.20 and 489.24. Findings include:

See findings cited at A 2409

Based on transfer forms, record review and interview the facility failed to certify the risks and benefits of transfer that are specific to the individual patient's medical condition in 9 of 21 (#1, #2, #6, #8, #9, #10, #12, #15, #16) patients. Findings include:

Review of the transfer forms for patients (#1, #2, #6, #8, #9, #10, #12, #15, #16) that were transferred to an acute care hospital revealed that the risk or benefit of transfer related to the patient's specific medical condition was not provided.

Patient #1 came to ED with a complaint of abdominal pain/pregnancy 26 1/2 weeks. The risk of transfer documented as being provided to the patient was "Deterioration of condition and motor vehicle accident."

Patient #2 came to ED with complaint of abdominal pressure/ pregnancy 31 weeks. The risk of transfer documented as being provided to the patient was "death/disability."

Patient #6 came to the ED with a complaint of attempted suicide drug overdose. The risk of transfer documented as being provided to the patient was "motor vehicle accident."

Patient #8 came to ED with a complaint of attempted suicide. The risk of transfer documented as being provided to the patient was "accident."

Patient #9 came to ED with a complaint of attempted suicide. The risk of transfer documented as being provided to the patient was "motor vehicle collision."

Patient #10 came to ED with a complaint of acute psychosis. The risk of transfer documented as being provided to the patient was "traffic accident."

Patient #12 came to ED with a complaint of severe depression. The risk of transfer documented as being provided to the patient was "accident."

Patient #15 came to ED with a complaint of suicide attempt. The risk of transfer documented as being provided to the patient was "motor vehicle accident."

Patient #16 came to ED with a complaint of foreign body in urethra. The risk of transfer documented as being provided to the patient was "traffic accident."

These findings were reviewed and confirmed with the director of Quality & Risk Management during review of the medical records on 3/29/11.

During investigation on 03/29/2011, it was determined that the patient (#5) presented to the ED on 03/13/2011 at 0350 with complaints of vomiting, cramping and abdominal pain. The patient reported that she was 18 weeks pregnant. The emergency department triage form completed by the RN documents vital signs taken and a pain assessment that was completed. Vital signs were within normal range and the patient reported her pain at 9 of 10. The patient was placed on a fetal monitor with fetal heart tones recorded at 147. At 0400 the patient received a medical screening exam by ED physician #2. No additional information was documented on the emergency physician record and ED physician #2 signed off on the report at 0410 and documented the patient's condition as stable. Review of form #3750583 emergency department record reads that the patient was discharged to home, yet additional instructions given to the patient were to "go directly to [nearby] Hospital." The patient left the ED at 0450 without further follow up instructions for pain assessment and care. There is no evidence indicating that the ED notified the receiving hospital of the patient visit, medical condition or that the patient had been directed to go directly to the receiving hospital.

Interview with the Director of Quality & Risk at the transferring facility, confirmed that the patient was discharged as stated above.

Interview with the Quality & Risk Manager at the receiving hospital on 03/30/2011 at 0830, he confirmed that there had been no contact between the two facilities in regards to the patient and there were no emergency department records sent with the patient.