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Based on clinical record reviews and interviews, the hospital failed to ensure compliance with 489.20 and 489.24. Findings include:

1. See findings cited at A 2402
2. See findings cited at A 2409

Based on observation and interview, the facility failed to post signs specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor. Findings include:

During the tour of the Emergency Department (ED) on 07/13/10 at 1400 with the ED Clinical Manager, it was confirmed that there were no signs posted at either the ambulance entrance to the ED or the waiting room area that specified the rights of individuals with emergency medical conditions and women in labor who come to the dedicated ED for health care services.

Base on record review and interview the facility failed to ensure that certifications for transfer of patients (17 of 20) to another facility contained the required information regarding "Benefit vs Risk" of transfer. The facility also failed to ensure that a transferred patient's record (16 of 20) contained documentation regarding copies of the medical record being sent to the receiving facility. Findings include

During clinical record review on 07/13/10 and 07/14/10, it was determined that the form reviewed from Hackley Hospital entitled Physician Certification For Transfer located in patient's #1, #2, #3, #4, #6, #7,
#8, #9, #10, #11, #12, #15, #16, #17, #18, #19 & #20 (Included is the focus patient named in complaint MI39052) records did not contain documentation regarding explanation of the medical benefits vs risk to the patient being transferred.

Interview with the Medical Director and Accreditation Specialist/Manager on 07/13/10 at 1600, the findings were discussed and confirmed. The Medical Director and this surveyor were in agreement that the information provided on the document was lacking the determined risk to the patient.

During clinical record review on 07/13/10 and 07/14/10, it was determined that the medical records of patient's #2, #3, #4, #5, #6, #9, #10, #11, #12, # 14, #15, #16, #17, #18, #19 & #20 lacked documentation to confirm if a copy of the medical record was sent to the receiving hospital.

These finding were reviewed and confirmed with the Accreditation Specialist/Manager on 07/14/10 at 1400.