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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 and interview, the facility failed to provide documentation of a medical screening examination (MSE) competed for 1 of 10 (#3) patients that presented to the facilities emergency department (ED). Findings include:

During review of the electronic medical record for patient #3 on 10/10/2011 at 1000, the Chief Nursing Officer (CNO) was unable to locate documentation of a MSE being completed by a physician on patient #3 who presented to the ED on 09/28/2011. The CNO also stated that "medical records could not locate any documentation of a MSE for the patient." The patient was transferred to another hospital.

Based on record review and interview the facility failed to ensure that the authorization for transfer was adequately completed for 1 of 10 patient records reviewed (#2). 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 10/10/2011, it revealed that patient #2 presented to the emergency department (ED) on 09/29/2011. After completion of a medical screening examination (MSE) by the physician it was determined that the patient had an emergency medical condition (EMC) and required transfer to another hospital with "specialist available." Review of the documentation provided by the hospital titled Authorization for Transfer which the physician certifies discussing with the patient and documenting the medical benefits of transfer versus the medical risk that may result from the transfer lacked documentation of the medical risk being discuss with the patient.

This was confirmed by the Chief Nursing Officer during record review at 0950.