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Based on the findings at A2401 the facility failed to ensure compliance with CFR 489.24.

Based on document and interview, the facility failed to ensure CMS (Center for Medicare and Medicaid Services) or the State Agency were notified of a possible inappropriate transfer/referral of a patient from another facility for 1 of 33 sampled patients (Patient #15).

Findings include:

Patient # 15

Patient #15 presented to the Emergency Department (ED) on 9/8/12 at 3:20 PM with complaints of worsening flank pain and dribbling of urine.

The initial nurse triage note documented Patient #15's pain level was 10/10, and the patient appeared to be in pain.

Documentation in the Physician's Notes indicated Patient #15 had been seen in the ER of Hospital #2 on the same day. The notes also documented Hospital #2 diagnosed the patient with possible kidney stone and left sided hydronephrosis.

Patient #15 received additional workup including laboratoy testing and an ultrasound of the abdomen. The patient received pain medication with relief documented.

Patient #15's medical record at Hospital #1 included a discharge instruction sheet from Hospital #2 dated 9/8/12 13:55 (1:55 PM), which documented: "Follow up with: Go to Sunrise hospital as soon as you are able, as you need urgent urology evaluation for stenting of your left ureter. When: Within 1 to 3 days"

Review of the On Call Specialist log documented there was no urology on-call on 9/8/13. The ED physician indicated Patient #15 did need a urology consult. The patient was then transferred to Hospital #3.

On 5/6/13 at the Director of Emergency Serviceas and Trauma (DEST) and the Director of Regulatory Compliance (DRC) were interviewed. The Director of Emergency Services was asked if a patient was discharged from this ED and required services that this ED could not provide, would the patient be told to go to another hospital to receive the service. The employee responded - No, that may be considered an EMTALA (Emergency Medical Treatment and Labor Act) violation. The employee was then asked to review the file of Patient #15 and to determine if she thought this was an appropriate referral from another facility. She responded, No.

The Director of Regulatory Compliance verbalized - at the time of Patient #15's admission, it had been identified as problem by QI (Quality Improvement). The employee added the COO (Chief Operating Officer) of this hospital had tried to contact the COO of Hospital #2 by telephone to obtain additional information regarding this transfer. The COO of this hospital was never able to connect with the COO of Hospital #2. The issue was then dropped.

The DEST and DRC were asked if they were familiar with the EMTALA reporting requirements. Both staff indicated they were aware of the requirements. The DEST indicated this incident had not been reported to CMS or the state as a possible EMTALA violation.

The hospital's policy titled EMTALA Transfer last reviewed 4/20/12, documented "7. a. Receiving Hospitals. Receiving hospitals have a duty to report any inappropriate transfer received from a transferring institution. A hospital that suspects it may have received an improperly transferred individual (transfer of an unstable individual with an EMC (Emergency Medical Condition) who has not provided an appropriate transfer according to Section 489.24(e)(2)), is required to promptly repoort the incident to the Centers for Medicare and Medicaid Services or the state agency within 72 hours of the occurrence."