HospitalInspections.org

Based on review of recorded video footage of Individual 25, interviews, documentation reviewed in 11 of 24 ED records for patients (Patients 3, 4, 11, 12, 13, 17, 18, 20, 21, 22 and 24) who presented to the hospital's ED, review of central log documentation, and review of hospital policies and procedures, it was determined the hospital failed to fully develop and enforce its EMTALA policies and procedures in the areas of MSEs, appropriate transfers, and the maintenance of a central log.

Findings include:

1. Medical Screening Examination: Refer to findings identified under Tag C2406, CFR 489.24(a) and (c), which reflects the hospital's failure to develop and enforce its EMTALA policies and procedures related to MSEs.

2. Appropriate Transfers: Refer to findings identified under Tag C2409, CFR 489.24(e)(1-2), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to appropriate transfers.

3. Central Log: Refer to findings identified under Tag C2405, CFR 489.20(r)(3), which reflects the hospital's failure to enforce its EMTALA policies and procedures related to a central ED log.

Based on review of recorded video footage for one Individual (Individual 25) who presented to the hospital's ED ambulance entrance by private vehicle and who left without coming into the hospital, interview, review of hospital policies and procedures, and review of central log documentation, it was determined the hospital failed to enforce its policies and procedures related to maintaining a central log of ED patients. The hospital failed to ensure all individuals who presented to the hospital for emergency services were recorded on the log.

Findings include:

1. A policy titled "Policy: Emergency Medical Treatment and Active Labor Act (EMTALA)/Consolidated Omnibus Budget Reconciliation Labor Act (COBRA)," effective "6-01" was reviewed and reflected "A Central log is initiated upon arrival, with the following information recorded for every ED patient:
1. Patient name, age, sex, and presenting complaint;
2. Time and date of ED arrival and departure, and mode of arrival;
3. Disposition of patient, such as:
discharged, transferred, admitted, refusal of MSE, refusal of treatment, Against Medical Advice (AMA) or Left Without Being Seen (LWBS) discharge."

2. An interview was conducted with an RN on 08/06/2014 at 1445. The RN stated he/she was on duty in the ED when Individual 25 presented to the hospital on 05/31/2014. The RN stated that Individual 25 came to the ED ambulance entrance with his/her spouse by private car. The RN stated he/she went outside and spoke with the individual and his/her spouse. The individual's spouse said the individual was not drinking enough fluids. The individual complained of a fever, not feeling well, and was fearful he/she may have spinal meningitis. The RN stated the individual did not get out of the car and the individual and his/her spouse left the hospital thereafter. During the interview the RN confirmed that the individual was never recorded on the ED central log.

3. The hospital's central log was reviewed. There was no documentation reflecting that Individual 25 presented to the hospital for emergency services on 05/31/2014.

4. During an interview on 08/06/2014 at 1100 the CNO confirmed that Individual 25 was not recorded on the hospital's central log to reflect that he/she presented to the hospital.

Based on review of recorded video footage of Individual 25, documentation reviewed in 3 of 24 ED records for patients (Patients 21, 22, and 24) who presented to the hospital's ED, interviews, review of policies and procedures and other documentation, it was determined the hospital failed to develop and enforce its policies and procedures to ensure that all individuals who presented to the hospital for emergency services were triaged and received a MSE to determine whether or not an EMC existed.

Findings include:

1. The hospital's "Bylaws and Rules and Regulations of the Medical and Allied Healthcare Staff of Blue Mountain Hospital John Day, Oregon, last amended 03/19/2008 was reviewed. Page 64 reflected "The intent of the Hospital and Medical Staff is to treat patients presenting to the Hospital's Emergency Department and Obstetrics Department in accordance with current state/federal law regarding medical screening examinations, treatment, stabilization and transfer. All active Staff Physicians, their employed Physician Assistants or Nurse Practitioners who are also credentialed by the Hospital, and the Hospital employed Registered Nurses are approved to perform the medical screening examinations in collaboration with the Emergency Department Physician to determine if a medical emergency exists. The implementation procedures for such screening examinations and record requirements are detailed in the Nursing Department's Policy and Procedure Manual."

2. A Nursing Department policy titled "Policy: Emergency Medical Treatment and Active Labor Act (EMTALA)/Consolidated Omnibus Budget Reconciliation Labor Act (COBRA)," effective "6-01" was reviewed and contained the following language: "The primary focus of EMTALA/Cobra regulations is a uniform and consistent approach for all patients to the medical screening examinations (MSE), stabilization, and/or transfer into or out of the facility...A Medical screening examination (MSE) will be provided by either a physician, or a qualified non-physician provider, registered nurse, etc. to determine whether the individual has an Emergency medical condition...

Purpose of the MSE: to rule out an EMC through sufficient evaluation of the presenting medical condition, including results of diagnostic work and medical consults as appropriate...A physician, or qualified non-physician provider, such as a Registered Nurse, determines presence or absence of EMC by evaluating presenting complaints, clinical signs and symptoms, and medical history, as well as utilizing diagnostic tests, and consultation with specialty physicians as necessary...

Discharge of a patient is a "transfer" under EMTALA, if the MSE is to be completed elsewhere. An MD office visit (to a "lower level" of care) cannot serve to complete the MSE, only to follow up later for outpatient care...While the patient may not leave the ED to continue and finish the MSE at a physician's office, diagnostic tests obtained such as X-rays, may be examined off site. A decision can then be communicated to the provider attending the patient in the ED...

Patient Refusal of MSE, AMA, discharge, or LWBS
1. If a patient insists on leaving before MSE is initiated or completed,
a. Patient is advised that hospital will provide MSE regardless of payment source;
b. Signed Refusal of MSE is obtained, if possible, including reason for leaving;
c. Risks of leaving are addressed, and patient is advised to return to the ED if symptoms persist or get worse; the above is documented.
d. If written refusal cannot be obtained, staff will document efforts made to obtain written refusal, and reason it could not be obtained...If patient leaves without being seen (LWBS) or elopes, a follow-up call is considered for patients who are at significant risk of being untreated with an apparent high acuity."

3. An Emergency Services Department policy titled "Policy: Triage" effective "5/01" was reviewed and contained the following language: "The triage is [in] the Emergency rooms and may also be in the ICU when the E.R. is full. The area shall have privacy for an initial assessment and vital signs...The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either Emergent, Urgent, or Non-Urgent categories.

Initial evaluation shall include:
Patient's name and age
Medications and allergies
Medical history
Subjective - chief complaint
Objective - nursing observations
Tetanus status and LMP, if applicable
Weight of pediatric patient
TB screen...

Physician Response time:
Emergent: #1: Immediately enroute to the hospital if on pager, will be paged two consecutive times.
Urgent: #2 Within 30 minutes call police in all cases. A second doctor will be called based on patient [acuity]
Non-Urgent #3 A telephone disposition by the [doctor] initially. Patient to be seen within two hours if not referred to doctor's office or other arrangements made.

Triage Category Code:
Emergent #1
Urgent #2
Non Urgent #3".

4. a. An interview was conducted with an RN on 08/06/2014 at 1445. The RN stated he/she was on duty in the ED when Individual 25 presented to the hospital. The RN stated he/she received a telephone call in the ED from the individual's friend before the individual arrived at the hospital. The RN stated that the friend told him/her that the individual's spouse was bringing the individual to the ED because the individual was experiencing fevers and a headache. The RN stated sometime after the telephone call the individual arrived by private car right outside the ambulance entrance to the ED. The RN stated he/she went out to the car. Individual 25 was seated on the passenger side of the car and the spouse was standing by the passenger door. The RN stated that the individual looked "wiped out", tired, and "washed out like [he/she] didn't feel good." The RN stated the individual said he/she had a headache, felt "pretty crappy" and was fearful that he/she may have spinal meningitis. The spouse told the RN that the individual was not drinking enough fluids and he/she didn't know if the individual would get out of the car. The RN stated that he/she then started talking to the individual about supportive treatments that can be done at home for "mono" like rest, fluids, and taking Tylenol. The RN stated he/she mentioned IV fluids to the individual several times and the individual asked the RN "What can you do for me if all I need to do is drink fluids?" The RN stated he/she told the individual "I don't know." The RN said the individual then told his/her spouse that he/she wanted to go home and try to drink fluids. The RN stated "I told [his/her] [spouse] if [he/she] doesn't drink at least a gallon of water you need to bring [him/her] back." The RN stated the individual and his/her spouse then left the hospital.

The RN stated that the individual never got out of the car, vital signs were not collected, and a MSE was not conducted. The RN stated that he/she considered the interaction with the individual a "partial triage" because he/she visualized the individual and touched the individual's skin. The RN stated that the individual was not entered into the central log and no medical record was initiated. The RN was asked if the individual signed a refusal of treatment form. The RN stated "No, I guess because I didn't look at it as anything different than giving a phone consult except this was face to face. I should have documented my conversation and I didn't do any of that."

During the interview the RN stated he/she had not received any EMTALA training at the hospital prior to the incident involving Individual 25. He/she stated "I'm not sure what the definition of a MSE is." The RN also stated he/she was under the impression that an RN could do a MSE "because we are a CAH and there's not always a doctor on duty in the the ED." He/she stated that for "non-emergent" patients who presented to the ED, he/she would call the clinic attached to the hospital to see if they had an open slot for the patient. If they had an open slot, he/she would send the patient to the clinic to have a physician conduct a MSE there. The RN stated if they didn't have an open slot at the clinic the physician would come to the ED to conduct the MSE. The RN stated "the nurses" determine who is considered emergent and non-emergent and stated during the interview "There are no clear cut policies of what is considered emergent or non-emergent. I'm flying by the seat of my pants and going by training I received at another hospital over eight years ago."

b. Hospital video footage recording of the ambulance ED entry doors and the driveway area outside the entry doors was reviewed with the CNO on 08/07/2014 at 1300. The video recording reflected that individual 25 presented to the ED with his/her spouse by private vehicle on 05/31/2014 at 1045. The recording reflected that the spouse got out of the vehicle and pushed a button at the ED ambulance doors designated for summoning ED staff. At 1047, the RN who was interviewed on 08/06/2014 at 1445 came out the ED doors, approached the vehicle, and walked to the passenger side of the car where the individual was seated. At 1058 the RN went back inside the ED doors, and the vehicle left the hospital at 1058.

c. During an interview conducted on 08/07/2014 at 1400 the CNO verified that the video recording reviewed on 08/07/2014 in finding b. above reflected that no MSE was conducted for Individual 25 in order to determine whether or not an EMC existed.

d. During an interview conducted with the CNO on 08/06/2014 at 1100 the CNO confirmed that a medical record for Individual 25 was not initiated and there was no documentation related to that visit.

5. The ED record for Patient 21 was reviewed. Documentation on the "Emergency Department Visit Record" reflected the patient's "Admission Date/Time" was 03/04/2014 at 1220. The following "Patient Data" areas on the record were not completed and were blank:

"Chief Complaint", "Triage Time", "Triage Level", "Physician", "Registered Nurse", "Technician", "Pain Scale", "First Vital Signs", "Provider Notified Time", Provider Arrival Time", "Arrival Mode", "Bed", "Surgical History", "Assessment and Plan", "Triage Pain Assessments", "Assessments", "Vital Signs", "Orders", "Medication Order", Radiology Order", "Laboratory Order", "Department Order", and "Respiratory Order".

Nurse notes documented on 03/04/2014 at 1220 reflected "Patient triage at front for increased chest discomfort. Upon assessment patient states [he/she] has had increasing coughing with [his/her] COPD and the chest discomfort increases with movement/palpation and/or touch. Spoke with [Physician] patient given option to be seen at SWCC by [Physician] or be seen in ER patient choose to be seen in clinic".

The "Discharge Date/Time" was recorded 03/04/2014 at 1300. The "Disposition Type" was recorded "01 - Discharge to home or self care" and "patient choose to be seen at SWCC at 1320".

This record reflected that a MSE was not conducted and the patient was discharged.

6. The ED record for Patient 22 was reviewed. Documentation on the "Emergency Department Visit Record" reflected the patient's "Admission Date/Time" was 02/13/2014 at 0825. The following areas on the record were not completed and were blank:

"Chief Complaint", "Triage Time", "Triage Level", "Physician", "Registered Nurse", "Technician", "Pain Scale", "Provider Notified Time"; "Provider Arrival Time"; "Stated Complaint", "Historian", "Arrival Mode", "Bed", "Surgical History", "Assessment and Plan", "Triage Pain Assessments", "Assessments", "Orders", "Medication Order", Radiology Order", "Laboratory Order", "Department Order", and "Respiratory Order".

The "First Vital Signs" section reflected a temperature reading of "99.9" recorded at 0830. The areas for recording heart rate, blood pressure, respiratory rate, blood oxygen level, oxygen device, oxygen amount, blood sugar, pain scale, height, weight and body mass index were blank.

Nurse notes documented on 02/13/2014 at 0829 reflected "[patient with] non emergent c/o 'I have the creeping crud' sore neck, chills and low grade temp. appt obtained for pt at clinic with [Physician] at 1000."

The "Discharge Date/Time" was recorded 02/13/2014 at 1134. The "Disposition Type" was recorded as "01 - Discharge to home or self care".

This record reflected the patient did not receive a MSE and was sent to a clinic.

7. The ED record for Patient 24 was reviewed. Documentation on the "Emergency Department Visit Record" reflected the patient's "Admission Date/Time" was 04/15/2014 at 0905. The chief complaint was recorded as "Abdominal pain", the triage level was recorded "5 - Non-Urgent", and the "Pain Scale" was recorded "-1".

The following areas on the record were not completed and were blank: "Physician", "Registered Nurse", "Technician", "Stages of Care", "Assessment and Plan", "Assessments", "Notes", "Orders", "Medication Order", Radiology Order", "Laboratory Order", "Department Order", and "Respiratory Order".

The "Chief Complaint" section reflected "pain to abd just right of umbilicus, states onset approximately 3 days ago while getting out of bed to void. since [sic] the abdominal discomfort has continued mainly with movement. The discomfort can be eased with palpation. Spoke with [Physician] patient to follow up in clinic as soon as possible. patient advised to return to ED if abdominal discomfort increases or patient starts having fevers."

The "Surgical History" section reflected "Hernia Repair" followed by a date of "01/01/0001".

The "Provider Notified Time" and "Provider Arrival Time" were recorded as 04/15/2014 at 0905.

The "Discharge Date/Time" was recorded 04/15/2014 at 0910. The "Disposition Type" was recorded "01 - Discharge to home or self care".

This record reflected the patient did not receive a MSE and was sent to a clinic.

8. Based on review of HCRQI Medicare certification records, the clinic adjacent to the hospital (Strawberry Wilderness Community Clinic, 180 Ford Road, John Day, Oregon 97845) is a separately Medicare certified Rural Health Clinic (RHC) and is not a department of the licensed hospital.

9. During an interview conducted on 08/08/2014 at 0915 the CNO stated that nurses were not qualified to conduct a MSE. He/she stated that the nursing staff had no training to conduct a MSE and that only physicians were qualified to conduct MSEs.

However, the CNO further stated during the interview that for "non-urgent" patients, nurses conducted MSE's "in collaboration with a physician". He/she stated that "in collaboration with a physician" means the nurse does a portion of the examination along with the physician to determine if an EMC exists. The CNO stated that when a physician was not present in the ED, the nurse would call a physician at the clinic adjacent to the hospital, and the physician would conduct a MSE of the patient over the telephone based on information provided by the nurse. If the physician determined the patient did not have an EMC based on the information received from the nurse, then the patient would be discharged from the hospital and the ED staff would make arrangements for the patient to be seen at the clinic.

Based on documentation reviewed in 7 of 7 ED records of patients (Patients 3, 4, 12, 13, 17, 18 and 20) who presented to the hospital's ED with an EMC and who were transferred to other facilities for stabilizing treatment, and review of hospital policies and procedures, it was determined that the hospital failed to effect appropriate transfers of those individuals as required by the hospital's policies and procedures. The hospital failed to ensure the required physician certification that the benefits of the transfer outweighed the risks of transfer; and the hospital failed to ensure documentation that all medical records available at the time of transfer related to the individual's EMC were sent to the receiving hospital.

Findings include:

1. A policy titled "Policy: Emergency Medical Treatment and Active Labor Act (EMTALA)/Consolidated Omnibus Budget Reconciliation Labor Act (COBRA)," effective "6-01" was reviewed and reflected "Consent (or refusal) of transfer is obtained from patient in writing, after being fully informed of risks involved, any alternatives, and the hospital's obligation to stabilize patient within capacity, or initiate transfer...If patient is not "stabilized for transfer," physician certifies that medical benefits reasonably expected outweigh increased risks of transfer to patient, or in the case of a woman in labor, to the woman or unborn child, and those risks and benefits of transfer were explained to patient. Documented risks include possible worsening of specified condition, and hazards of travel...Specific clinical condition at time of transfer is well documented."

2. A policy titled "Policy: Transfer of Patient From the Emergency Room to Another Facility" effective "07/01" was reviewed and reflected "Purpose: To Provide communication and documentation which will allow informed transfer of care. To provide safe, expedient transportation allowing for the appropriate continuity of care...The following should be complete and sent with the patient:

a. A copy of the E.R. record (face sheet); Nurses flow record And/or Trauma Flow record.
b. A copy of the completed pre-hospital care record.
c. Copies of the lab reports and EKG
d. X-rays, copies of
e. A Medical Release Form must be signed by the patient if possible or the nearest relative if possible
f. A copy of the progress report by the transferring physician."

3. The ED record for Patient 3 was reviewed. Documentation on the "Emergency Department Visit Record" reflected the patient's "Admission Date/Time" was 05/31/2014 at 1638. The "Patient Data" section reflected the patient's chief complaint was cardiopulmonary arrest.

Nurse notes documented on 05/31/2014 at 1647 reflected that the patient arrived to the ED by ambulance, was being "bagged" with an endotracheal tube in place, and was unresponsive.

The 05/31/2014 physician "Emergency Room Report" reflected a MSE was conducted. The "Overall Assessment and Plan" section of the report reflected the patient had a cardiac arrest and was being life-flighted to another hospital for critical care.

Nurse notes documented on 05/31/2014 at 1809 reflected "1800 - [Patient] care turned over to Airlink crew."

There was no documentation in the record to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks; and there was no documentation to reflect that available medical records were sent to the receiving facility at the time of the patient's transfer.

4. The ED record for Patient 20 was reviewed. Documentation on the "Emergency Department Visit Record" reflected the patient's "Admission Date/Time" was 03/23/2014 at 1258.

Nurse notes documented on 03/23/2014 at 1300 reflected that the patient presented to the ED by ambulance and was unresponsive.

The 03/23/2014 physician "ER Transfer Note From Blue Mountain Hospital" reflected a MSE was conducted. The "Assessment and Plan" section of the note reflected the patient was "...found down in [his/her] home likely secondary to pneumonia, sepsis, dehydration and renal failure." The notes reflected that arrangements were made to transfer the patient to another hospital.

Nurse notes documented on 03/23/2014 at 1447 reflected "[patient] packaged for air transport, discharged via air link..."

A form titled "Certificate of Patient Transfer" was signed and dated/timed by a physician on "3/23/14 1340." The following sections of the form were not completed and were blank:

"Based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or in the case of a woman in labor, to the health of the individual or the unborn child. Findings (risks) pertinent to the transfer of the patient are:" This was followed by a blank space.

"Medical benefits reasonably expected from provision of medical care at another facility are:" This was followed by a blank space.

There was no documentation in the record to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks; and there was no documentation to reflect that available medical records were sent to the receiving facility at the time of the patient's transfer.

5. The ED record for Patient 18 was reviewed. Documentation on the "Emergency Department Visit Record" section of the record reflected the patient's "Admission Date/Time" was 03/07/2014 at 1449. The record reflected that the patient's chief complaint was abdominal pain and the arrival mode was "Carried."

The 03/07/2014 physician "Emergency Room Report" reflected a MSE was conducted. The "Emergency Room Course/Medical Decision Making:" section of the report reflected "Concern for obstruction versus malrotation of the gut was evident upon history and physical and then confirmed with x-ray." The report reflected that arrangements were made to transfer the patient via PANDA to another hospital.

A form titled "Certificate of Patient Transfer" was signed and dated but not timed by a physician on 03/07/2014. The following sections of the form were not completed and were blank:

"Based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or in the case of a woman in labor, to the health of the individual or the unborn child. Findings (risks) pertinent to the transfer of the patient are:" This was followed by a blank space.

"Medical benefits reasonably expected from provision of medical care at another facility are:" This was followed by a blank space.

There was no documentation in the record to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks; and there was no documentation to reflect that available medical records were sent to the receiving facility at the time of the patient's transfer.

6. The ED record for Patient 17 was reviewed. Documentation on the "Emergency Department Visit Record" section of the record reflected the patient's "Admission Date/Time" was 02/23/2014 at 1850. The record reflected that the patient's chief complaint was "Numbness/Weakness/Paralysis" and the "Arrival Mode" was "Wheelchair."

The 02/23/2014 physician "Emergency Room Report" reflected a MSE was conducted. The "A & P:" section of the report reflected "...slurred speech and left-sided weakness...Slurred speech concerning for stroke."

Nurse notes documented on 02/23/2014 at 2320 reflected "EMS ground crew here; [patient] loaded onto [gurney]...off to airport then to [another hospital] via fixed wing..."

A form titled "Certificate of Patient Transfer" was signed and dated/timed by a physician on "2/23/14 2300." The following sections of the form were not completed and were blank:

"Based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or in the case of a woman in labor, to the health of the individual or the unborn child. Findings (risks) pertinent to the transfer of the patient are:" This was followed by a blank space.

"Medical benefits reasonably expected from provision of medical care at another facility are:" This was followed by a blank space

There was no documentation in the record to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks; and there was no documentation to reflect that available medical records were sent to the receiving facility at the time of the patient's transfer.

7. The ED record for Patient 4 was reviewed. Documentation on the "Emergency Department Visit Record" reflected the patient's "Admission Date/Time" was 06/22/2014 at 0958. The record reflected that the patient's chief complaint was abdominal pain and the arrival mode was "Wheelchair."

The 06/22/2014 physician "Blue Mountain Hospital Transfer ER Note" reflected a MSE was conducted. The "Assessment and Plan" section of the note reflected "Left lower quadrant pain, likely secondary to an acute splenic infarct secondary to emboli. The patient transferred to [another hospital] for further workup...Left breast abnormalities concerning for an inflammatory breast cancer versus cellulitis. Further work up will be pursued at [another hospital]."

Nurse notes documented on 06/22/2014 at 2210 reflected "...transferred to stretcher per 4 person lift, and [patient] to Airport via ambulance 901 to meet with Air Link fixed wing."

A form titled "Certificate of Patient Transfer" was signed and dated but not timed by a physician on "6/22/14". The following sections of the form were not completed and were blank:

"Based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or in the case of a woman in labor, to the health of the individual or the unborn child. Findings (risks) pertinent to the transfer of the patient are:" This was followed by a blank space.

"Medical benefits reasonably expected from provision of medical care at another facility are:" This was followed by a blank space.

There was no documentation in the record to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks; and there was no documentation to reflect that available medical records were sent to the receiving facility at the time of the patient's transfer.

8. The ED record for Patient 12 was reviewed. Documentation on the "Emergency Department Visit Record" reflected the patient's "Admission Date/Time" was 05/03/2014 at 1615. The record reflected that the patient arrived by ambulance and the chief complaint was "Extremity Pain/Trauma-Lower" and "bucked off horse and c/o [severe] right hip and thigh pain."

The 05/03/2014 physician "Blue Mountain Hospital Transfer" form reflected a MSE was conducted. The "Assessment and Plan" section of the report reflected the patient had a right hip fracture.

Nurse notes documented on 05/03/2014 at 1755 reflected "Xray shows [fracture] hip and [patient] transported by ground EMS to airport for Air Link transfer to [another hospital]."

A form titled "Certificate of Patient Transfer" was signed and dated/timed by a physician on "5/3/14 1720." The following sections of the form were not completed and were blank:

"Based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or in the case of a woman in labor, to the health of the individual or the unborn child. Findings (risks) pertinent to the transfer of the patient are:" This was followed by a blank space.

"Medical benefits reasonably expected from provision of medical care at another facility are:" This was followed by a blank space.

There was no documentation in the record to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks; and there was no documentation to reflect that available medical records were sent to the receiving facility at the time of the patient's transfer.

9. The ED record for Patient 13 was reviewed. Documentation on the "Emergency Department Visit Record" reflected the patient's "Admission Date/Time" was 02/25/2014 at 1328. The record reflected that the patient arrived by ambulance, the chief complaint was chest pain, and the arrival mode was "Wheelchair."

The 02/25/2014 physician "Emergency Room Report" form reflected a MSE was conducted. The "Impression" section of the report reflected the patient experienced a myocardial infarction. The "Emergency Department Course:" section of the report reflected "The patient was transported up to the airport by our advanced ambulance crew and was then flown to [another hospital]..."

A form titled "Certificate of Patient Transfer" was signed and dated/timed by a physician on "2/25/14 1435".

Documentation on the transfer form reflected "Based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or in the case of a woman in labor, to the health of the individual or the unborn child. Findings (risks) pertinent to the transfer of the patient are:" This was followed by "air accident".

There was no documentation in the record to reflect that the physician had identified patient specific risks and certified that the benefits of the transfer outweighed those risks; and there was no documentation to reflect that available medical records were sent to the receiving facility at the time of the patient's transfer.