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Based on review of medical records, review of policies and procedures, review of information provided and interviews with key staff on August 18, and 24-26, 2010, it was determined that the hospital failed to complete an appropriate transfer.

Findings include:

1. On August 18, 2010, an unrelated Federal complaint investigation was conducted at Down East Community Hospital (DECH). During a review of randomly selected medical records, surveyors identified a possible EMTALA [Emergency Medical Treatment and Labor Act] violation. In Patient Q ' s medical record, there was no documentation that the transferring hospital sent the patient's medical records to the receiving facility.

2. On August 18, 2010, documentation of all April 2010 transfers from Down East Community Hospital was reviewed. The review revealed that Patient Q ' s medical record was not included in the document provided. The patient presented to DECH on April 18, 2010. The treating physician evaluated the patient and ordered the patient to be transferred to Maine Coast Memorial Hospital in Ellsworth, Maine.

3. 42 CFR 489.24 defines transfer to mean " ....the movement (including the discharge) of an individual outside a hospital ' s facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who (i) has been declared dead or (ii) leaves the facility without the permission of any such person. "

4. Patient Q's discharge instructions stated, " Go directly to Ellsworth Hospital for ultrasound. You need to have an ultrasound of your left ovary to rule out torsion and possibly of your gallbladder as well. You have refused ambulance transfer. "

5. The Down East Community Hospital policy titled ' Transfer of Patients ' stated, " 1. Transfer is initiated by order of the physician. Transfer complies with EMTALA guidelines in place at time of transfer ...3. Appropriate x-rays and medical information shall accompany patient at the discretion of the physician .....4. A copy of DECH ' s EMTALA form shall accompany each patient, including vital information, reason for transfer, name of receiving physician, and physical/mental status of patient. Transfer form is to be completed jointly by physician and charge nurse or team leader .....11. Discharge nurse shall call receiving nurse and give a complete patient status report. "

6. A review of medical Record Q on August 24, 2010, revealed no documentation that an EMTALA form had been completed. In fact, there was no EMTALA form found in the record.

7. A telephone interview was conducted with the Emergency Department Nurse Manager on August 25, 2010. He/she stated, " I believe we fell down on the record in question by not filling out the EMTALA form. " When asked to describe the transfer process for patients who transfer by private car, he/she stated that the EMTALA form was still required to be completed, including the patient ' s signature when they refuse ambulance transfer. He/she further stated that the medical record was to be copied and either faxed to the receiving facility or sent with the patient.

8. The continued review of medical Record Q on August 24, 2010, revealed that the Emergency Department Physician Assessment and Orders form stated, " Discharge Condition: Stable; and Disposition: Transfer; and Time: 0950. " The physician ' s signature was present. Additional documentation stated, " Discharge Diagnosis: Abd [abdominal] pain r/o [rule out] torsion. " A note at the bottom stated " Dr. Kenneth Christian ...accepting [?] Ellsworth. "

9. On August 25, 2010, a telephone interview was conducted with an Emergency Department Staff Nurse who provided care to Patient Q on April 18, 2010. He/she stated that the form titled ' Emergency Department Physician Assessment and Orders ' is where the physician writes all the orders.

10. On August 24, 2010, an interview was conducted with the Clinical Director of Nursing Services. He/she confirmed that the physician ' s orders for transfer would be found on the ' Emergency Department Physician Assessment and Orders ' form.

11. On August 18, 2010, a telephone interview was conducted with the accepting physician at Maine Coast Memorial Hospital (MCMH). He/she stated, " He/she came here by car from DECH and it was a transfer on 4/18/2010. " He/she noted no records accompanied the patient and confirmed this with his/her Physician ' s Assistant, who had examined the patient.

12. On August 24, 2010, a review of Record Q revealed no documentation that the discharging nurse had called the receiving nurse to give a complete patient status report.

13. On August 25, 2010, a review Patient Q ' s medical record for his/her April 18, 2010 visit to Maine Coast Memorial Hospital was completed. The medical record failed to contain any documentation from DECH.

14. On August 24, 2010, a review of medical Record Q from DECH revealed that there was no documentation that any medical records were sent with the patient at the time of transfer.

15. During a telephone interview on August 24, 2010, a, PA-C, at Ellsworth Hospital [Maine Coast Memorial Hospital] stated, " I received no paperwork from DECH, though there was a CD [computerized disc] of the CT [computerized tomography] but our system could not read it. "

16. On August 26, 2010, a telephone interview was conducted with Patient Q. The patient stated that he/she was given none of his/her medical records to take with him/her to Maine Coast Memorial Hospital.

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Based on review of policies and procedures on August 24, 2010, it was determined that the facility policy titled, 'Transfer of Patients' No: 6020010, failed to comply with the requirement that( iii) the transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer.

Findings include:

Down East Community Hospital policy No: 6020010 titled, "Transfer of Patients' stated, " Appropriate x-rays and medical information shall accompany patient at the discretion of the physician."