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Based on medical record review, policy and procedure review, and staff interview, it was determined the hospital failed to comply with the requirements at 489.20 and 489.24. Specifically, the hospital failed to ensure 1 of 20 closed sample patients (#4) was transferred to another acute care hospital with the appropriate paperwork (C-2409). The hospital also failed to obtain acceptance from the receiving hospital. Finally, the hospital failed to ensure the emergency department log was complete and accurate (C-2405).

Based on emergency department central log review, policy and procedure review, and staff interview, the facility failed to maintain an accurate and complete log. The findings were:

1. Review of the facility emergency department log titled, "ER Log" for the last twelve months showed each page had an area for three patients with areas for detailed information. The individual pages were not numbered or identified in any special way. The patient's name, date of birth, and date of admission were placed on the log with a sticker. Then, additional information written in by the emergency room nurse showed the time the provider was called and saw the patient, laboratory and x-ray times, mode of arrival, disposition, and treatments that could be circled. The following concerns were noted:
a. On 12/30/11 a patient was registered at the top of a page in the ER log, but areas for the next two patients were left blank and crossed out. On another page, two patients were registered for 1/3/12 and 1/5/12, but the area for the third patient was left blank and crossed out. On a third page, two patients were registered for 1/23/12 and 1/24/12, but the area for the third patient was left blank and crossed out. The facility failed to document why these areas were crossed out.
b. Two patients were registered on 1/16/12 in the ER log, but on the middle area information without a date or patient name was registered and then crossed out. Two patients were registered on 1/19/12 in the log, but on the bottom area information without a date or patient name was registered and crossed out. Two patients were registered on 4/6/12 in the log, but on the bottom area information without a date or patient name was registered and crossed out. The facility failed to document why these areas were crossed out.
c. One patient was registered into the ER log on 2/20/12 with partial information, and then crossed out. The facility failed to document why these areas were crossed out.

2. During an interview with the director of nursing on 4/13/12 at 10 AM, she stated the emergency department log should have a documented explanation when anything is crossed out or if there were gaps in information.

3. Review of the facility policy and procedure titled, "Emergency Room Log" last revised 4/2011 showed the following under the subtitle "Emergency Room Log Protocol": "1. Entries are made in sequence, first patient seen is the first patient entered. 2. Place a sticker from the patient's admission chart if available (if not, write it in) on the established form to accurately record the appropriate information concerning the admission. 3. Entries should include the date, time in and out, initials of nurse attending, circle appropriate care and procedures done, a brief diagnoses, disposition of the patient, and the charge code on the established form. The time the Provider was notified and the time the Provider was in and out."

Based on the emergency department (ED) log and medical record review, review of facility policy and procedure, and staff interview, the facility failed to obtain acceptance from the receiving facility for 1 of 20 closed sample patients (#4) who were transferred. In addition, the facility failed to send documentation to the receiving facility during that transfer. The findings were:

1. Review of the facility ED log showed patient #4 was admitted to the ED on 3/25/12 at 11:30 AM. The patient disposition area had "home" circled. However, handwritten in the patient disposition area was a note that stated the patient was sent to another ED. Review of the corresponding emergency room record showed the patient was assessed at 11:31 AM by registered nurse (RN) #1. The assessment showed the patient's left foot was reddened and warm from the second toe to the mid-arch. RN #1 also documented in "additional notes" the family was told to take the patient to another ED where the patient had been seen previously for the same foot condition. The RN also stated the physician who had seen the patient at the other facility had told the family to bring the patient back for issues related to the foot that included redness, swelling, or drainage. Another note stated the facility physician called the receiving ED to let them know the patient was transferring to that facility. The physician notes showed the clinical impression was "left foot with gangrenous second toe." The physician further documented the patient needed to be seen by the physician who was already treating the patient for issues related to his/her foot. The following concerns were identified:
a. The record review showed the facility failed to complete the required COBRA Transfer Form for the patient.
b. Interview with RN #1 on 4/12/12 at 10 AM confirmed the facility failed to complete a COBRA Transfer Form for patient #4 on 3/25/12. She further revealed the facility failed to obtain acceptance from the receiving facility or send the receiving facility any documentation.
c. Interview with the physician on 4/12/12 at 1 PM showed the facility failed to obtain acceptance of the receiving facility for the transfer of the patient. Instead, the physician notified the receiving facility the patient was on the way to their facility via private vehicle. The physician stated the transferring facility failed to send documentation to the receiving facility because he had not considered patient #4 as an actual ED patient of their ED.
d. Interview with the DON on 4/13/12 at 10 AM showed the facility expectation was for ED staff to complete a COBRA Transfer Form for all transfers. She further stated all steps should be followed which included gaining acceptance from the receiving facility physician, and forwarding a copy of all the transferring ED documentation.

2. Review of the facility policy and procedure titled, "EMTALA and COBRA Transfers" last revised 9/2011, showed the following under the sub-title "EMTALA/Patient Transfer Procedure 9/2011": "5. Patients who present to NHLC emergency department requesting care will not be directed to any other location to receive treatment, including....." Under the sub-title "In regard to Stabilization and Transfer" the following was noted: "2. For a transfer to be completed appropriately the following requirements must be met and documented on the COBRA Transfer Form: a. Section 1-The physician certifies (with their signature) the patient has been stabilized to the extent possible and/or the benefits of transfer outweigh the risks. b. Section 2-The reason for transfer is documented. c. Section 3-The receiving hospital has agreed to accept the patient (established via hospital-to-hospital staff communication) with the name of the individual who accepts the patient recorded along with the date and time. d. Section 4-The mode of transport is documented and the personnel and equipment match the level of patient need. e. Section 5-The Risks and Benefits of transfer are documented. f. Section 6-Necessary medical records are documented and accompany the patient or are faxed to the receiving facility. g. Section 7-Patient consent to transfer (or inability to give consent) is documented. h. Final section-Discharge vital signs are documented. 3. A COBRA Transfer Form will be completed for all transfer patients."