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Based on review of hospital documents, medical records and physician credentialing files and interviews with hospital staff, the hospital failed to enforce policies and procedures to ensure compliance with the requirements of 42 CFR 489.24. The hospital failed to enforce its policy and procedure concerning appropriate transfer of patients.

Findings:

1. Norman Regional Health System (NRHS) policies and procedures concerning EMTALA were reviewed on 03/23-03/25/15.

a. NRHS, policy and procedure, entitled, "Patient Transfer and EMTALA", effective 04/2014, documented, " ...Patients receive stabilizing treatment within the capability and capacity of NRHS to ensure: a. The EMC is removed; or b. The patient is stable for transfer...."

b. NRHS, policy and procedure, entitled, " Transfer of Patient to Another Acute Care Facility", effective 01/28/15, documented, "...To procure specialized care at Norman Regional Health System (NRHS), or because NRHS does not have the capacity to care for the patient (bed space, equipment, personnel) or to accommodate Patient request to transfer to another acute car facility (i.e. O U Medical Center)..."

2. NRHS, privilege request form, entitled, " General Surgery/General Laser Surgery", requested and approved for Staff N on 04/23/13, documented "...I hereby request core General Surgery Privileges as follows: to correct or treat various conditions, illnesses, and injuries of the : abdomen and its contents; Also included within this core of privileges: complete care of the critically ill patients with underlying surgical conditions in the emergency department and intensive are unit..."There was exclusion to age in the privileges for Staff N. This was confirmed by Staff V the credential specialist.

3. Review of the on-call emergency department (ED) schedule for the month of December 2014, documented Staff N was the on-call surgeon on 12/26/14 from 7:00 am until 11:59 pm.

4. Review of the medical record for Patient #8, documented on 12/26/14 at 11:27 am Patient #8, a 4 year old female, presented to the Porter ED, with a three-day complaint of abdominal pain and decrease in oral intake. The patient diagnosed with acute appendicitis.

5. There was no documentation of Staff N consulting or evaluating Patient #8.

Based on review of the hospital's emergency department (ED) log, policies and procedures, and interviews with hospital staff, the hospital failed to maintain a central log entry for each individual who presents seeking treatment and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. In six of six months (September 2014 through March 20,2015) the emergency services log entries for patients was not complete.

Findings:

Norman Regional Health System (NRHS), policy and procedure, entitled, "Patient Transfer and EMTALA", effective 04/2014 documented, " ...The Emergency Medical Care Log includes: (1) Includes: (a) Patient identification; (b) Date of service; (c) Medical complaint; (d) Provider name; and (e) Patient disposition;..."

Norman Regional Health System (NRHS) is an acute care hospital with two campus locations, both in Norman, Oklahoma, for inpatient care, including an ED at both facilities. The hospital also has a third ED located in Moore, Oklahoma.

1. The ED logs from all three hospitals were reviewed from 09/01/14 through 03/20/15. According to statistics submitted by the hospital, all three logs under review contained 53,321 entries for the time period. One hundred and twenty-six (126) of the entires did not contain dispositions for the patients.

Porter:
a. September 2014: seven (7) patients did not have a disposition documented.
b. October 2014: six (6) patients did not have a disposition documented.
c. November 2014: four (4) patients did not have a disposition documented.
d. December 2014: two (2) patients did not have a disposition documented.
e. January 2015: seven (7) patients did not have a disposition documented.
f. February 2015: twenty-five (25) patients did not have a disposition documented.
g. March 1 - 20, 2015: seven (7) patients did not have a disposition documented.

Moore:
a. September 2014: three (3) patients did not have a disposition documented.
b. October 2014: one (1) patient did not have a disposition documented.
c. January 2015: four (4) patients did not have a disposition documented.
d. February 2015: five (5) patients did not have a disposition documented.
e. March 1 - 20, 2015: two (2) patients did not have a disposition documented.

Healthplex:
a. September 2014: six (6) patients did not have a disposition documented.
b. October 2014: three (3) patients did not have a disposition documented.
c. November 2014: five (5) patients did not have a disposition documented.
d. December 2014: seven (7) patients did not have a disposition documented.
e. January 2015: six (6) patients did not have a disposition documented.
f. February 2015: fifteen (15) patients did not have a disposition documented.
g. March 1 - 20, 2015: eleven (11) patients did not have a disposition documented.

2. The above information was presented in the exit interview with the administrative staff.

Based on review of hospital documents, medical records and interviews with hospital staff, the hospital failed to effect appropriate transfers. In one (Record #8) of two records reviewed for the last six months, of patients who were transferred to another facility, the hospital did not execute a proper transfer. The hospital transferred a patient that they had the capability and capacity to treat.

Findings:

1. Review of the hospital policies and procedures documented:
Norman Regional Health System (NRHS), policy and procedure, entitled, "Patient Transfer and EMTALA", effective 04/2014 documented, "...Patients receive stabilizing treatment within the capability and capacity of NRHS to ensure: a. The EMC is removed; or b. The patient is stable for transfer...."

2. Review of the on-call emergency department (ED) schedule for the month of December 2014, documented Staff N was the on-call surgeon on 12/26/14 from 7:00 am until 11:59 pm.

3. During medical record review in the morning of 03/25/15, Staff E and Staff D both stated the hospital does not perform pediatric surgery at either of the inpatient locations (Porter and Healthplex).

4. NRHS, privilege request form, entitled, "General Surgery/General Laser Surgery", requested and approved for Staff N on 04/23/13, documented "...I hereby request core General Surgery Privileges as follows: to correct or treat various conditions, illnesses, and injuries of the: abdomen and its contents. Also included within this core of privileges: complete care of the critically ill patients with underlying surgical conditions in the emergency department and intensive are unit..." Staff N's credential file did not contain specifications or exclusions to the treatment that would be provided, including the specifications of the age of patients.

5. Review of the medical record for Patient #8, documented on 12/26/14 at 11:27 am Patient #8, a 4 year old female, presented to the Porter ED, with a three-day complaint of abdominal pain and decrease in oral intake. The patient received a medical screen examination (MSE) by a qualified medical person (QMP), complete blood count (CBC), basic metabolic profile (BMP),urine analysis (UA), lipase and a computerized tomography (CT scan) of the abdomen and pelvis. Based on the results of the diagnostic procedures and the examination of the QMP the patient was diagnosed with acute appendicitis.

a. The QMP documented a physician at another acute care facility was consulted and agreed to accept the patient. Patient #8 was transferred to accepting facility via ambulance.

b. The medical record did not document whether the on-call surgeon Staff N, had been consulted.

c. The medical record did not contain evidence the patient or the patient's family requested to be transferred to another acute care facility.