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Based upon review of hospital policies/procedures, Emergency Department Log, and interviews, the hospital failed to meet the EMTALA requirements as defined in CFR 489.24 for failing to provide an adequate medical screening examination on patient #18 (Tag A2406), and complete the Memorandum of Transfer Form to include the stability of the patient at the time of transfer and the risks and/or benefits of the transfer (Tag A2409).

Based upon review of 1 of 31 emergency department records (#18), policy and procedure, and staff interviews, the hospital failed to provide an appropriate medical screening examination which included laboratory services. This was evidenced by failure of Emergency Department Physician S7 to identify the CBC (Complete Blood Count) for patient #18 was not obtained as ordered; however, was documented as "normal". Patient #18 returned to the ED again approximately 4 1/2 hours later with the chief complaint of fever and low oxygen saturations. Even though the ED Physician S7 re-examined patient #18, it was still not identified the CBC was not obtained to order to identify if there was an infectious process occurring. Findings:

Review of Emergency Department Record for patient #18 revealed on 12/26/11 at 1:40 AM, the patient presented to the ED by ambulance, accompanied by nursing home staff, for the chief complaint of Altered Mental Status, Right Sided Weakness, and seizure activity. The patient's past medical history was significant for Type II Diabetes, renal disease, and dialysis. For laboratory tests, ED Physician S7 ordered a Complete Blood Count with Differential (CBC), Comprehensive Metabolic Profile, Dilantin Level, Troponin T, and a Prothrombin Time. Review of these laboratory results revealed there failed to be evidence the Complete Blood Count with differential was in the patient's emergency department record.

Interview with Medical Records Personnel S12 on 02/15/12 at 9:00 AM, revealed when asked about the CBC, S12 responded she would check and returned with two forms related to the laboratory inquiry. The first form, titled "Lab Specimen Internal Inquiry" revealed on 12/26/11 at 1:49 AM, the laboratory specimen was "cancelled" due to being "unable to collect". Review of patient #18's emergency department record revealed ED Physician S7 identified the CBC was "normal", even though the CBC laboratory test was cancelled and not completed.

On 02/15/12 at 10:30 AM, a telephone interview was conducted with ED Physician S7 related to patient #18's ED visit on 12/26/11. When asked why he documented the CBC was normal when the CBC was actually not done, physician S7 replied he was not aware the laboratory test had been cancelled and "normal" was written in by mistake.

On 12/26/11 at 8:51 AM, patient #18 returned to the ED, approximately 4 1/2 hours after the first ED visit, by ambulance. The patient was accompanied by nursing home staff who related to the ED nursing staff the patient experienced low oxygen saturations (55%) and a fever with an axillary temperature of 100.5 degrees.

Review of RN S8's admission assessment revealed patient #18 was on 2 liters of oxygen by nasal cannula, oxygen saturations were at 97%, and the patient's oral temperature was 98.7 degrees. Review of ED Physician S7's evaluation of patient #18 revealed according to the progress portion of the ED record, Physician S7 documented while in the ED the patient maintained oxygen saturations of greater than 95% since the ER presentation and was afebrile. For the "Clinical Impression", ED Physician S7 documented "(1) O2 (oxygen) sats (saturations) - resolved (2) fever - resolved". The patient was discharged in stable condition back to the nursing home 10:38 AM.

On 12/26/11 at 12:28 AM, patient #18 was emergently transported to the ED at Hospital A. Upon arrival, patient #18's vital signs were: Blood Pressure 93/62, Pulse 77, Respirations 16, Temperature 99.9 degrees, and Pulse Oxygenation at 95% on room air. Laboratory tests were obtained and it was identified the CBC with differential (test that was omitted at Christus Coushatta Health Care) showed a white count of 16.8 (normal 4500 to 10,000). Patient #18 was admitted to Hospital A with the diagnoses of 1) Sepsis with impending respiratory failure; 2) Right lower lobe pneumonia with bilateral infiltrates; 3) Stool impaction with chronic constipation; 4) End stage renal disease on hemodialysis in need of emergent dialysis secondary to electrolytes; 5) Seizure disorder with recurrent seizures; 6) Multiple cerebrovascular accidents with aphasia; 7) Right-sided paresis and functional quadriplegia; 9) Encephalopathy, metabolic type; 10) Suspected anemia.

Review of the hospital policy titled "Admissions Screening For ED" revealed "2. Medical Screening Exam is a process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Depending on the patient's presenting symptoms the medical screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex (process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans, and/or diagnostic test procedures."

Based upon review of 5 of 8 Emergency Department Transfers out of a sample size of Emergency Department Records, policy and procedure, and staff interviews, the hospital failed to ensure the Physician Assessment and Certification on the Memorandum Of Transfer for patients #8, #14, #22, #25, and #27, was completed and identified the patient's condition and the Risks and/or Benefits of transfer. Findings:

Review of the form titled "Memorandum of Transfer" revealed for the "Physician Assessment And Certification: Patient Condition", the physician was to identify one of the following:
1.___The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer.
2.___The individual's condition has not stabilized and may be at risk for deterioration from or during transport, however the individual will benefit from a higher level of care.
3.___The individual is having labor contractions or (describe)_______.

For the "Risks and/or Benefits" the physician was to identify in writing the Risks and/or Benefits of the transfer for the following:

1. I have explained the following risks and benefits of TRANSFER/REFUSING TRANSFER to the individual:
Risks:_____________
(X) All transfers have inherent risks of delays or accidents in transit, pain, or discomfort upon movement, and limited medical capacity of transport units that may limit available care in the event of a crisis.

2. Benefits:_____________________________
(X) Equipment and/or services not available at this facility: (list)______________.

At the bottom of the Physician Assessment and Certification was the statement:

Based upon my examination, the information available to me at the time of transfer and these reasonable risks/benefits to the individual and/or unborn child(ren), the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from effecting the transfer.

Physician Signature Date and Time:____________________________________.

Review of the Memorandum of Transfer for emergency department patients #8, #14, #22, #25, and #27 revealed the physician failed to 1) identify #1, #2 or #3 related to the Patient Condition, 2) identify the risks and/or benefits of the transfer, and 3) document the time on the form. For patients #8, #22, #25, and #27, the physician failed to document the date.

Review of Emergency Department policy and procedure titled "Transferring A Patient To Another Facilities" revealed "5. B. A physician signs a certification which includes a summary of the risks and benefits to the patient, and based upon the information at the time, a statement that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical center outweigh the increased risk."

Interview with the emergency department director RN S3 on 02/17/12 at 10:50 AM, revealed after reviewing the Memorandum of Transfer forms for emergency department patients #8, #14, #22, #25, and #27, RN S3 confirmed the transfer forms were not completed in accordance with hospital policy.

The hospital failed to follow policy and procedure related to the emergency department physician's documentation of the risks and/or benefits of transfer and if the patient's medical condition had been stabilized or not prior to the transfer.