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Based on documentation and interviews, the hospital failed to ensure compliance with requirements of 42 CFR 489.24, when the hospital failed to provide an appropriate transfer for a patient who presented to the ED resulting in deficient practice cited at 42 CFR 489.24 (e)(1-2) C2409.

Based on observations during a tour of the emergency department on October 12, 2010, the hospital failed to post conspicuously in the emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination, signs specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment in the emergency room. The findings include:

A tour of the ED was conducted with employee (A) at 3:16 p.m. on October 12, 2010. The hospital has three entrances one of which is the ambulance entrance, which is utilized more frequently by individuals in the winter. There were no signs referencing EMTALA rights in the ambulance entrance.

The hospital has two bays and a waiting room. Patients are brought directly to the bays. Once the bays are full, the patients wait in the one waiting room to be seen. There were no signs referencing EMTALA rights in the waiting room.

This was confirmed with employee (A) during the tour.

Based on documentation review and interviews the hospital does not have a list of physicians who are on call after the initial examination to provide further evaluation and or treatment. In addition, the hospital does not have written policies and procedures in place to respond to a situation in which a specific specialty is not available. Findings include:

The hospital does not have a physician onsite twenty-four hours a day seven days a week. However, the hospital has a physician schedule indicating which physician is on-call each day of the week to complete the initial examination to patients who present to the ED. This list was provided to the investigator as the on-call list.

The hospital did not maintain a list of specialty physicians who are on-call after the initial examination to provide further evaluation and/or treatment necessary to stabilize a patient.

Employee (A)/administrative staff provided the investigator with a list of consulting physicians. However, the list did not contain contact information for the physicians. Employee (A) provided the investigator with a "Phone List for ER Transfers" this document has a list of specialties and the hospital to call related to these specialties.

Employee (A)/administrative staff was interviewed on October 12, 2010 at 2:45 p.m. and further stated that the hospital also uses a telecommunication device linked to another hospital that all staff have access to and can use to consult with physicians in the ED and other specialties as needed.

Employee(B)/nurse was interviewed on October 13, 2010 at 9:38 a.m., and stated that the physician's determine which physician to call for consulting.

Employee (D)/nurse was interviewed on October 13, 2010 at 8:21 a.m. and stated that all of the staff at the hospital can use the telecommunication device to consult with another physician. Otherwise she contacts another hospital to see who is available for consults.

Physician (G) was interviewed on October 13, 2010 at 11:22 a.m. and stated that he has worked at the hospital for over thirty years and was able to identify specific hospitals or clinics he would call for each specialist he would call for consult.

Based on documentation review and interviews the facility failed to complete an appropriate transfer for one of twenty (#1) patient records reviewed when the hospital failed to call and receive acceptance from the receiving hospital and failed to complete the transfer form which includes the physician certification of the risks and benefits of the transfer. Findings include:

The hospital's EMTALA policy and procedure was reviewed and indicated that an appropriate transfer is one which includes a written certification by a physician that the risks of transferring the patient are outweighed by the medical benefits of transferring the patient; the receiving hospital has been contacted and accepts the transfer, and the patient is accompanied by copies of the medical record. In addition, the policy and procedure states that a patient may request transfer to another facility, but an appropriate transfer must still be completed.

Patient #1's ED record was reviewed and indicated the patient presented to the hospital on September 18, 2010 at 7:16 p.m. The patient was four weeks old and had a fever for two days. The patient's pulse was 126, axillary temperature was 102.3 degrees Fahrenheit, and the last wet diaper was at 5:00 p.m. The staff at the hospital initiated a sepsis work up and obtained a chest x-ray and a complete blood count. The plan was to obtain a urine specimen to run a urinalysis and culture, in addition, a lumbar puncture was discussed. While the staff was attempting an intravenous catheterization to be used for antibiotic administration, the parents requested the patient be transferred to another hospital. The patient's lab results and x-ray (scanned to a disc) were sent with the patient. The patient was driven to the receiving hospital by her parents.

Employee (B) called the receiving hospital after the patient had left to inform the receiving hospital the patient was on the way to the hospital. There is no documentation to confirm the receiving hospitals acceptance of the patient. The transfer form was not completed which included the physicians certification that the risks and benefits of the transfer were explained to the patient in accordance with their policy.

The documentation from the receiving hospital revealed that the sending hospital sent the lab results, a CD of the x-ray, and the face sheet, which included the patient's demographics. However, the face sheet did not include any documentation from the physician related to the patient ' s emergency medical condition, preliminary diagnosis, or treatments provided.

Employee (B)/nurse was interviewed on October 13, 2010 at 9:38 a.m. and stated that she was working in the ED when patient #1 was transferred out of the ED. She stated that the physician told her this was not a transfer and not to fill out any transfer paper work.

Physician (E) was interviewed on October 12, 2010 at 3:07 p.m. and stated that he was working the ED when patient #1 presented. He conducted the medical screening exam and during the process, the patient's father stated that they wanted to transfer to another hospital. Physician (E) stated that he did not consider this a transfer, did not receive acceptance from the receiving hospital and did not explain the risks and benefits of the transfer.

Physician (G)/Chief of Staff was interviewed on October 13, 2010 at 11:22 a.m. and stated after reviewing patient #1 ED record, the procedure for transferring patients to another hospital/facility was not followed.