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Based on record review, staff interviews, review of the facility's records/documentation, and policies and procedures, the facility failed to ensure compliance with 42 CFR Section 482.24 (Special Responsibilities of Medicare Hospitals in Emergency Cases) as:

1) the facility failed to post conspicuously in its emergency department (ED) or in a place or places likely to be noticed by all individuals entering the ED, as well as those individuals waiting for examination and treatment in areas, such as the entrance, admitting area, waiting room and treatment areas, a sign(s) specifying the rights of individuals under Section 1867 of the Act, with respect to examination and treatment for emergency medical conditions and women in labor and, to post conspicuously information indicating whether or not the hospital participates in the Medicaid program.

2) the facility failed to ensure if an individual at a hospital has an emergency medical condition that has not been stabilized, the hospital may not transfer the individual unless, 1) the transfer is an appropriate transfer, and the individual (or a legally responsible person acting on the individual's behalf) requests the transfer after being informed of the hospital's obligations and of the risk of transfer, with the request completed in writing and indicating the reasons for the request as well as indicating the individual's awareness of the risks and benefits of the transfer; 2) a physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual, with the certification containing a summary of the risks and benefits upon which it is based, and 3) the transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition with which the individual presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) and the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment.

Findings include:

Cross reference to findings at A2402 and A2409, respectively.

Based on observation and staff interview, the facility failed to post conspicuously in its emergency department (ED) or in a place or places likely to be noticed by all individuals entering the ED and in areas, such as the entrance, waiting room and treatment areas, a sign(s) specifying the rights of individuals under Section 1867 of the Act, with respect to examination and treatment for emergency medical conditions and women in labor and, to post conspicuously information indicating whether or not the hospital participates in the Medicaid program.

Finding includes:

On 10/5/11 at 11:40 A.M., during the initial ED tour with the ED Nurse Manager, the SA noted there were no signs posted conspicuously in the ED or in places such as the entrance to the ED, the waiting room, and/or in any of the treatment areas and rooms.

On 10/6/11 at approximately 4:15 P.M., the Director of Nursing confirmed there were no signs present in the ED or in places likely to be seen by all individuals entering the ED or within the ED treatment areas. On 10/7/11 the ED Nurse Manager also verified the lack of signs in the ED and printed temporary signs to be put up.

Based on record review, staff interview and review of the hospital's policies and procedures, the facility failed to ensure if an individual at a hospital has an emergency medical condition that has not been stabilized, the hospital may not transfer the individual unless, 1) the transfer is an appropriate transfer, and the individual (or a legally responsible person acting on the individual's behalf) requests the transfer after being informed of the hospital's obligations and of the risk of transfer, with the request completed in writing and indicating the reasons for the request as well as indicating the individual's awareness of the risks and benefits of the transfer; 2) a physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual, with the certification containing a summary of the risks and benefits upon which it is based, and 3) the transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition with which the individual presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) and the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment for 2 of 25 patient record reviews (Patients #5 and 10) in the case sample.

Findings include:

1. Record review on 10/6/11 revealed Patient #5 was admitted to the ED on 5/20/11 with a diagnosis of chest pain secondary to ischemia. Triage and a medical screening exam was done, medications were administered and other tests and labs were performed. The patient was then transferred to another acute facility ED via ambulance. The "Certification for Transfer" form however, was not completed by the physician who authorized the transfer. As such, there was no documentation to indicate whether Patient #5's emergency medical condition had or had not been stabilized prior to his/her transfer.

There also was no documentation to indicate whether Patient #5 or a responsible person acting on the patient's behalf requested or agreed to the transfer, and whether the patient or responsible person was informed of the risks and benefits of the transfer. In addition, there was no documentation to indicate that the receiving facility was provided with copies of appropriate medical records pertaining to the patient's emergency medical condition and treatment he/she received.

2. Record review on 10/7/11 revealed Patient #10 was admitted to the ED on 7/23/11 with a diagnosis of a TIA (transient ischemic attack). Triage and a medical screening exam was done, medications were administered and other tests and labs were performed. The patient was then transferred to another acute facility ED via ambulance. The "Certification for Transfer" form however, was not completed by the physician who authorized the transfer. Although there was documentation noted by the ED physician who stated a concern for "...possible cerebellar TIA given pt's history of cerebrovascular disease; [he/she] has essentially resolved here, not candidate for acute TPA. However [he/she] is appropriate for transfer for higher level of care for further TIA workup", the Certification form was incomplete and did not indicate whether Patient #10's emergency medical condition had or had not been stabilized prior to his/her transfer.

There also was no documentation to indicate whether Patient #10 or a responsible person acting on the patient's behalf requested or agreed to the transfer, and whether the patient or responsible person was informed of the risks and benefits of the transfer. In addition, there was no indication that the receiving facility was provided with copies of appropriate medical records pertaining to the patient's emergency medical condition and treatment received.

3. In addition, 12 of the 25 record reviews revealed that although there was a section for a "Date" entry on the "Certification of Transfer" form, there was no section for a "Time" entry to document when the physician signed, dated and timed the authorized the transfers. It was found the transfer dates and times were being documented on the Nursing Flow Sheets of the ED clinical records, but not on the Certification forms.

4. On 10/6/11 and prior to the ED Nurse Manager's interview on 10/7/11 at 8:20 A.M., she confirmed the ED physicians failed to complete the "Certification for Transfer" forms. Review of the facility's policy and procedure, "Transfer Procedure" (Policy No. NRS-ED-008, 5/08), noted for the facility's transfer procedures the "Certification for Transfer (WGH-REC-628) must be completed for all transfers (original for Medical Record, copy for receiving facility)," which was not done. The ED Nurse Manager also confirmed there was no section for a time entry on the form and stated the form would be revised.