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Based on closed dedicated emergency department (DED) record reviews and administrative staff interviews, the hospital failed to comply with 42 CFR 489.24.

The Findings include:

1. ~Cross refer to Provisions of appropriate transfer, Tag A2409, Standard 489.24(e)(1)(ii)(B).

Based on policy review, closed medical record review and staff interviews the hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer for 6 of 9 sampled DED patients that were transferred with an emergency medical condition (EMC) by failing to: ensure the physician documented the medical benefits of transfer expected from the provision of appropriate medical treatment at another medical facility and the risks to the individuals's medical condition that may result from effecting the transfer. (Patient #14, #21, #16, #18, #10 and #6).

The Findings include:

Review of the hospital policy titled "EMTALA COMPLIANCE, INCLUDING PATIENT TRANSFERS (EMERGENCY MEDICAL TREATMENT AND LABOR ACT)" revealed the policy was updated and effective August, 2009. Further review of the policy revealed "Prior to any transfer of an individual who presented to the hospital with an emergency medical condition and whose condition remains unstable, the emergency physician, or when applicable, the on-call specialist physician, must examine and evaluate the person and certify in writing (see below), that, based upon reasonable risks and benefits to the patient and information available at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the individuals's medical condition that may result from effecting the transfer".

1. Medical record review of patient # 14 revealed a 24 year old presenting to the DED at 0520 on 9/5/2010 with a complaint of chest pain with pressure and shortness of breath. Record review revealed the patient awoke and his C-PAP (machine used to deliver oxygen for sleep apnea) was off. Record review revealed after the medical screening exam (MSE), the DED physician documented the patient would need possible transfer for elevated cardiac enzymes and cardiomyopathy. Further review revealed lab results CPK 843 high (normal range 22-269), CK-MB 85.1 high (normal range 0.6-6.3) and Troponin-I 12.76* critical results (normal 0.0-0.49). Record review revealed written physician certification for transfer to a higher level hospital. Record review revealed the patient was transferred by emergency medical services at 0925. Review of the record revealed no documentation of the risks associated with the transfer or benefits to be expected from appropriate care at the receiving (recipient) hospital.

Interview with administrative DED staff on 9/10/2010 at 1500 revealed the tool (form) used for documentation of the physician certification for transfer does not direct the physician to document the risks and benefits of the transfer. The interview revealed it is has not been the practice of the physicians to document the risks and benefits. The interview revealed there was no documentation available of the risks and benefits of transfer for patient #14.

2. Medical record review of patient # 21 revealed a 23 year old presenting to the Labor and Delivery department at 1039 on 6/14/2010 with a complaint of possible labor contractions. Record review revealed the patient was 32 weeks gestation. Record review revealed the patient was a gravida 2 and para 1 with one previous preterm labor at 37 weeks. Record review revealed after the MSE (medical screening exam) the patient was diagnosed with premature labor at 32 weeks gestation, 1 centimeter dilation and 50 % effacement. Record review revealed written physician certification for transfer. Record review revealed the patient was transferred by emergency medical services to a higher level of hospital care on 6-15-2010 at 1018. Record review revealed no documentation of the risks associated with the transfer or benefits to be expected from appropriate care at the receiving (recipient) hospital.

Interview with administrative Obstetrical staff on 9/9/2010 at 1400 revealed the tool (form) used for documentation of the physician certification for transfer does not direct the physician to document the risks and benefits of the transfer. The interview revealed the physicians are to document in the medical record the risks and benefits of the transfer. The interview revealed there was no documentation available of the risks and benefits of transfer for patient #21.

3. Medical record review of patient # 16 revealed a 71 year old presenting to the DED at 1312 on 5/14/2010 with a complaint of irregular heart beat. Record review revealed the patient was having an upper endoscopy in the hospital ambulatory surgery area and started having ventricular tachycardia (life threatening fast heart rate) in the the recovery room. Record review revealed after the MSE (medical screening exam) was completed the patient was diagnosed with Electrocardiograph tracings of wide complex tachycardia and inferior leads with new T wave inversion. Record review revealed written physician certification for transfer. Record review revealed the patient was transferred by emergency medical services to another hospital for a higher level of cardiology care at 1500. Record review revealed no documentation of the risks associated with the transfer or benefits to be expected from appropriate care at the receiving (recipient) hospital.

Interview with administrative DED staff on 9/10/2010 at 1500 revealed the tool (form) used for documentation of the physician certification for transfer does not direct the physician to document the risks and benefits of the transfer. The interview revealed it is has not been the practice of the physicians to document the risks and benefits. The interview revealed a copy of the physician certification for transfer was retrieved from the receiving hospital. The interview revealed the staff could not locate the physician certification for transfer. The interview revealed there was no documentation available of the risks and benefits of transfer for patient #16.

4. Medical record review of patient # 18 revealed a 29 year old presenting to the DED at 2042 on 4/15/2010 with a complaint of left shoulder pain and "droop" in left shoulder. Record review revealed the patient had a history of multiple dislocations of the left shoulder with four (4) previous surgeries. Record review revealed radiology impression of antero-inferior dislocation of the left humeral head. Record review revealed the DED physician attempted three unsuccessful (3) times under conscious sedation to reduce the shoulder. Record review revealed the patient was "very" drowsy and placed on 2 liters of oxygen after dropping oxygen saturation levels to 91 % on room air. Record review revealed orthopedic specialty services were not available at the hospital. Record review revealed written physician certification for transfer. Record review revealed the patient was transferred by emergency medical services to another hospital for orthopedic specialty care at 0830. Record review revealed no documentation of the risks associated with the transfer or benefits to be expected from appropriate care at the receiving (recipient) hospital.

Interview with administrative DED staff on 9/10/2010 at 1500 revealed the tool (form) used for documentation of the physician certification for transfer does not direct the physician to document the risks and benefits of the transfer. The interview revealed it is has not been the practice of the physicians to document the risks and benefits. The interview revealed there was no documentation available of the risks and benefits of transfer for patient #18.

5. Medical record review of patient # 10 revealed a 73 year old presenting to the DED at 1434 on 3/20/2010 with a complaint of chest pain. Record review revealed the patient complained of pain at a 7 out of 10. Record review revealed after the MSE (medical screening exam) the patient was diagnosed with an acute myocardial infarction. Record review revealed written physician certification for transfer. Record review revealed the patient was transferred by emergency medical services to another hospital for a higher level of cardiology care at 1702. Record review revealed no documentation of the risks associated with the transfer or benefits to be expected from appropriate care at the receiving (recipient) hospital.

Interview with administrative DED staff on 9/10/2010 at 1500 revealed the tool (form) used for documentation of the physician certification for transfer does not direct the physician to document the risks and benefits of the transfer. The interview revealed it is has not been the practice of the physicians to document the risks and benefits. The interview revealed there was no documentation available of the risks and benefits of transfer for patient #10.

6. Medical record review of patient # 6 revealed a 20 year old presenting to the DED at 1908 on 3/16/2010 with a complaint motor vehicle crash with multiple injuries including trauma. Review of the record revealed after the MSE (medical screening exam) was completed the patient was diagnosed with a grade 2 femur fracture, laceration over the right eye socket and a closed head injury. Record review revealed documentation by the DED physician, the patient would be transferred to another hospital "secondary to the lack of a neurosurgeon". Record review revealed written physician certification for transfer to a higher level of care at another hospital. Record review revealed the patient was transferred by emergency medical services at 2141. Record review revealed no documentation of the risks associated with the transfer or benefits to be expected from appropriate care at the receiving (recipient) hospital.

Interview with administrative DED staff on 9/10/2010 at 1500 revealed the tool (form) used for documentation of the physician certification for transfer does not direct the physician to document the risks and benefits of the transfer. The interview revealed it is has not been the practice of the physicians to document the risks and benefits. The interview revealed there was no documentation available of the risks and benefits of transfer for patient #6.