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Based on policy and procedure reviews, medical records reviews, hospital documentation reviews, staff and physician interviews, the hospital failed to comply with §489.24 as evidenced by the Dedicated Emergency Department (DED) physician failing to complete a written physician certification for transfer by documenting the increased risks associated to the transfer and by transfering a patient in a personal vehicle that did not provide immobilization required for a back injury.

Cross refer to 489.24(e)(1)(2) Risks and Benefits, Tag A2409.

Based on policy and procedure reviews, closed medical record reviews, staff and physician interviews, the hospital's Dedicated Emergency Department (DED) failed to ensure an appropriate transfer by failing to complete a written physician certification for transfer by documenting the increased risks associated to the transfer specific to the condition of the patient in 1 of 7 (1 of 6 ED and 0 of 1 Obstetrical) DED patients having an Emergency Medical Condition (EMC) that were transferred to another hospital ( DED Patients #1).

Findings include:

Review on 12/09/2014 of the hospital's policy "Medical Screening Examination, Stabilization, and Transfer (EMTALA)" (revised 05/2011) revealed "POLICY: To comply with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA). PROCEDURE: 1. Dedicated Emergency Department...F. An unstable patient may not be discharged or transferred to another facility unless: 3. The physician certifies that the reasonable expected benefits of transfer outweigh the increased risks. IV. Transfer of Hospital Patients to Another Hospital.. C. Prior to transfer, a provider must complete following sections of the Certification of Transfer form (Attachment II)..2. The Risk and Benefits section, describing to the patient (and to her unborn child if the patient is pregnant) the risks and the benefits of transfer. D. Nursing Staff will complete the rest of the Certification of Transfer form and have the patient or a family member sign the form."

Review on 12/09/2014 of the hospital's form, "Certification of Transfer", revised 04/2011, revealed, "Based on reasonable risk and benefits to the patient and/or unborn child(ren), and based upon the information available at the time of the patient's examination, I certify that the medical benefits reasonably expected from the provision of diagnostic testing and/or appropriate medical treatment at another medical facility outweigh the increased risk, if any, to the individual. A summary of the risk and benefits upon which this Certification is based is as follows (attach additional sheet if necessary): Risks:________________ Benefits:____________" Further form review revealed a space for "Receiving Physician, Date, Time and Hospital Physician Signature."

1. Medical record review on 12/10/2014 for Patient #1 revealed the patient presented to the hospital A's (transferring hospital) DED on 11/01/2014 at 1952 with a complaint of "Back Pain." Record review of the DED Physician's (#6) medical screening examination (MSE) revealed the patient had concerns for "Cauda Equina Syndrome" and needed Magnetic Resonance Imagining (MRI) to be performed. The documentation further revealed the patient had imaging in the past at Hospital B so a transfer to the hospital's DED for repeat MRI was needed. The documentation revealed that a DED physician at Hospital B agreed to accept the patient in transfer with the patient's wife driving the patient to the DED. Documentation revealed the importance of going to Hospital B's DED for the MRI was discussed due to potential spinal cord problems that are new would need emergent surgery. Record review revealed a form for "Certification of Transfer"was completed for the patient on 11/01/2014 at 2235 with the section for "Risks" documented as "MVC" (Motor Vehicle Collision) only. No other information was found in the patient's medical record to indicate that specific increased risks of transfer were explained to the patient particularly because he was going in his personal vehicle that did not provide the ability to immobilize the patient. Record review revealed the patient left the DED via private vehicle at 2235 for transfer to Hospital B.

Medical record from Hospital B revealed the patient arrived at the hospital's DED on 11/01/2014 at 2318 through 11/02/2014 at 0427.

Interview on 12/10/2014 at 1250 with the hospital's DED physician (#6) revealed that she did examine patient #1 at the hospital's DED on 11/01/2014 for what she described as "chronic impingement of spinal cord." The interview revealed that during the patient's DED visit, he needed a MRI and the service was not available at the hospital when the patient presented. The interview also revealed that the physician determined that a transfer was needed to Hospital B since they had MRI available and the patient had received care there before. The physician indicated in interview that the patient was able to go by private vehicle since his wife was able to drive him and she felt that was an appropriate transport. The interview did reveal an EMC (emergency medical condition) did exist for the patient as if he did have "Cauda Equina Syndrome", he would need emergency surgery to prevent debilitation.

NC00102119