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Based on clinical record reviews and interviews, the hospital failed to ensure compliance with 489.20 and 489.24. See findings cited at A 2406 and A 2409.

Based on record review, interview and review of the Governing Body Bylaws, the facility failed to perform a medical screening examination (MSE) on an individual that came to the facility (and subsequently was sent elsewhere) and on 5 of 20 patients (#11, #14, #16, #19, #20) that were not directed elsewhere for care. Findings include:

On 02/22/2011 a female entered the ED's ambulance bay, told ED Nurse #1 that she was pregnant and having abdominal pains. ED Nurse #1 told the woman that the hospital did not have an obstetric department (OB) and instructed the woman to go to a hospital approximately 32 miles away for treatment. The hospital Chief Nursing Officer confirmed this during on 03/21/2011 at 1600. The CNO also stated that that she did not know the patient's name and had no record for her since the woman was not registered.

The Governing Body Laws for Mercy Health Partners Lakeshore Campus states that a MSE must be performed by QMP [QMP is defined as a physician MD/DO].

During review of the records for patients #11, #14, #16, #19, #20 on 03/21/2011, there is no documentation of a MSE being completed. The findings were confirmed by the CNO at the time of the record review.

Based on record review and interview the facility failed to ensure that the authorization for transfer was adequately completed for 19 of 20 patient records reviewed (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20). The authorization for transfer was the form used by the facility to document the risk versus benefits of transfer. Findings include:

During review of the medical records on 03/21/2011, it was determined that the authorization for transfer for patients #1, #2, #3, #7, #8, #9, #10, #15, #16 lacked documentation of the date and time of notification to the receiving facility.

During further review of the authorization for transfer it was also determined that in the medical records for patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #18, #19 contained incomplete documentation regarding explanation of the medical benefits versus risk to the patient being transferred. The forms all contained the same photo copied information and were not specific to the emergency medical condition of the patient.

Review of the records for patient ' s #11, #14, #20, the Chief Nursing Officer was unable to produce the authorization for transfer for these patients which resulted in no documentation of Risk versus Benefits of transfer for these patients.

Also during clinical record review on 03/21/2011, it was determined that the medical records for patient's #1, #4, #5, #6, #7, #14 lacked documentation to confirm if a copy of the medical record was sent to the receiving hospital.

These finding were confirmed with the Chief Nursing Officer on 03/21/2011 during the record reviews.