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Based on review of twenty emergency department records, a review of the hospital's bylaws, and review of the policies and procedures for patients who present to the emergency department, it was determined that in two (patients #1 and #2) of twenty records reviewed of patients who presented to the hospital requesting emergency services, the hospital failed to ensure compliance with 489.24. A physician's certification request for transfer form was not completed for patients #1 and #2, and patient #1 was not provided with an appropriate transfer to the receiving hospital on 10/31/10, and patient #2 was not provided with an appropriate transfer to the receiving hospital on 10/11/10. This resulted in deficient practice cited at 42 CFR 489.24, C2409.

Based on documentation (review of June 2010 through November 2010 ED logs) and interviews, the hospital failed to maintain complete and accurate central logs in the emergency department (ED) that accurately tracked the care and disposition of each patient presenting to the (ED) seeking medical care, in one (patient #1) of twenty patients and six months of logs reviewed. Findings include:

Review of the ED log for 10/30/10 indicated that patient #1 was discharged from the ED and sent by personal vehicle to the receiving hospital. The entry did not accurately reflect that patient #1 was actually a transfer from the ED to the receiving hospital.

Review of the June 2010 through November 2010 ED logs revealed numerous instances of crossing out information, gaps in information and missing information, including the time of arrival in the ED, address, age, sex and the disposition of all cases.

Based on the review of twenty ED records involving transfers to other hospitals and staff interviews, the hospital failed to complete appropriate transfers for two (patients #1 and #2) of twenty patients reviewed. The hospital did not complete the form which includes the physician certification of the risks and benefits of the transfers of patients #1 and #2 and failed to send patient #1's ED medical record to the receiving hospital on 10/31/10. Findings include:

The hospital's EMTALA policy and procedure was reviewed and indicated that an appropriate transfer to a medical facility is a transfer in which the transferring facility sends to the receiving facility all medical records related to the emergency condition available at the time of transfer, including but not limited to, the preliminary diagnosis, treatment provided, results of any tests, the patient's informed written consent and transfer certification. The policy further stated the certification is completed by medical staff and indicates that based upon information available at the time of transfer, that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks from the transfer. The certification must include a summary of the risks and benefits.

Patient #1's ED record was reviewed and indicated patient #1 presented to the ED on 10/30/10 at 11:40 p.m. Patient #1 complained of difficulty swallowing. The patient stated he ate dinner about four hours earlier and that a piece of chicken got stuck in his esophagus. The patient said he spit up some of the chicken but was unable to swallow his saliva or any other fluids for the past four hours. The patient stated he had mild discomfort in the middle of his chest. The patient's vital signs were normal/stable. The patient did not display any problems with his breathing, and he spoke in full sentences. The record indicated patient #1 was given nitroglycerin sublingual and Ativan 1 mg. in an effort to relax the esophagus and resolve the obstruction. However, this treatment was not effective, and physician (F) consulted with physician (C)/surgeon at the receiving hospital about the patient's condition. Physician (C) agreed to accept patient #1's case and to possibly proceed with an endoscopy in order to resolve the obstruction. The record indicated patient #1 was clinically stable to be transported via private vehicle and that his wife would transport him to the receiving hospital for further care. The record indicated patient #1 was "discharged" to the receiving hospital at approximately 1:00 a.m. and "directed" to go to the receiving hospital for an endoscopy. Patient #1 was provided a discharge instruction sheet (no medical record or risk and benefits certification form) which stated he was being "referred" to the receiving hospital and that surgeon (C) would follow up with an endoscopy related to patient #1's throat discomfort.

Patient #1's medical record from the receiving hospital was reviewed. It indicated patient #1 arrived at the hospital and was admitted to the medical-surgical floor at 2:18 a.m. on 10/31/10. Physician (C) met with the patient and observed that he was unable to swallow his saliva and that he appeared to have an obstruction of his esophagus. Patient #1 was brought to the operating room at 3:08 a.m. for the endoscopic removal of the "large piece of chicken" and the operation ended at 5:02 a.m. on 10/31/10. The patient was discharged to home at 3:41 p.m. on 10/31/10.

Patient #1 was interviewed by phone on 12/8/10, and he stated he was unable to swallow his saliva when he arrived at the ED on the evening of 10/30/10. He stated he and his wife wanted to drive their personal vehicle to the receiving hospital, but they were not offered any other choices related to the transport to the receiving hospital. He stated physician (C) and nurse (E) were waiting for them when they arrived at the receiving hospital. Patient #1 stated the risks and benefits of the transfer to the receiving hospital were not discussed with him before he left for the receiving hospital. He stated he was only given a discharge instruction sheet when he left the ED and denied that a certification form or his medical record were sent with him.

Physician (C)/surgeon was interviewed by phone on 12/8/10, and she stated physician (F) called her about patient #1's condition at approximately 11:00 p.m. on 10/30/10. She agreed to accept the case and physician (F) stated patient #1's wife would be driving him to the receiving hospital via their personal vehicle. She stated the patient was anxious and unable to swallow his saliva when he arrived. She determined that patient #1 was stable to be transported to the receiving hospital in his personal vehicle; however, there was a risk of his condition deteriorating during the transport. Patient #1 vomited after he arrived at the receiving hospital, and this was a concern because vomiting can cause the esophagus to become perforated or aspiration can occur. This was an emergent situation, and patient #1 needed to be treated immediately. She stated patient #1 was a transfer to the receiving hospital. The transferring hospital should have provided patient #1 with a signed risk and benefit certification form, and his ED medical record should have been given to him so that he could have brought it to the receiving hospital.

Physician (F) was interviewed by phone on 12/8/10, and he stated patient #1 had something stuck in his esophagus, and he needed to have an endoscope done in order to remove the object. Patient #1 was unable to swallow. Physician (F) stated he contacted physician (C)/surgeon at the receiving hospital, and she agreed to take the case and perform an endoscopic procedure. Physician (F) determined that patient #1 was stable and that he could go to the receiving hospital via his personal vehicle. Physician (F) was unsure if the ED staff spoke with nursing staff at the receiving hospital related to patient #1's condition. He stated he felt he provided appropriate care to patient #1. He stated he was unfamiliar with the need to send the EMTALA risk and benefit certification form and the patient's ED record to the receiving hospital.

Patient #2's ED medical record was reviewed. It indicated patient #2 arrived at the ED at 1:15 a.m. on 10/11/10 via ambulance and was exhibiting shortness of breath. The record indicated that patient #2 has a history of renal failure which is managed by dialysis (patient was due to have dialysis on 10/12/10), cardiac problems and chronic lung disease. After a phone consultation, patient #2 was transferred at 3:30 a.m. on 10/11/10 to a receiving hospital that provided a higher level of care related to her complex needs and her need to have dialysis on 10/12/10. Review of the record did not reveal a signed EMTALA risk and benefit certification form.