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Based on record review and interview, the facility failed to comply with 42 CFR 489.24.

Findings:

1) The facility failed to have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control and to provide that emergency services are available to meet the needs of individuals with emergency medical conditions (see C2404).

2) The facility failed to document all reasonable steps to secure the patient's written informed refusal (or that of a person acting on his or her behalf), description of the proposed transfer that was refused by or on behalf of the individual, and failed to document that the person was informed of the risks and benefits of the transfer and reasons for the individual's refusal, in one of one medical records reviewed (see C2408).

3) The facility failed to effect an appropriate transfer in 3 of 20 records reviewed, in the absence of certification by a physician or countersignature for qualified medical persons determined by the facility's bylaws or rules and regulations (see C2409).

Based on document review, the facility failed to have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician ' s control and to provide that emergency services are available to meet the needs of individuals with emergency medical conditions.
Findings:
1) Review of Emergency Department Policies on March 2, 2010 revealed the absence of an on-call policy.
2) A policy provided by the Performance Improvement Nurse Specialist on March 2, 2010 is missing the requirements to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control and to provide that emergency services are available to meet the needs of individuals with emergency medical conditions.
3) This finding was verified with the Performance Improvement Specialist and Acting Director of Nursing on March 2, 2010 at 3:00 p.m.

Based on document review and interview, the facility failed to maintain a complete and accurate central log, for 4 of 20 medical records reviewed (Pt. #1, Pt. #2, Pt. #3, Pt. #4).
Findings:
1) Review of the Emergency Department log on March 1, 2010 at 1:00 p.m. revealed Pt. #1's disposition was "AMA." According to Pt. #1's medical record, the patient was discharged to Pine Manor. This finding was verified with the Clinical Applications Coordinator.
2) Review of the Emergency Department log on March 1, 2010 at 1:00 p.m. revealed Pt. #2's disposition was "clinic." According to Pt. #2's medical record, the patient was transferred to North Country Regional Hospital. This finding was verified with the Clinical Applications Coordinator.
3) Review of the Emergency Department log on March 1, 2010 at 1:00 p.m. revealed Pt. #3's disposition was "Bemidji Behavioral Health " According to Pt. #3's medical record, the patient was transferred to North Country Regional Hospital. The log also documented a discharge time of 19:18, while the medical record documented the time of discharge as 18:30. This finding was verified with the Clinical Applications Coordinator.
4) Review of the Emergency Department log on March 1, 2010 at 1:00 p.m. revealed Pt. #4's disposition was " home " without any documentation regarding refused treatment. According to interview with PA #1 on March 2, 2010 at 10:00 a.m., he stated that Pt. #4 was offered a transfer to a hospital in Bemidji but wanted to go to a facility near where he lived. During interview with Pt. #4's wife on March 4, 2010 at 4:45 p.m., she stated that she was offered and refused transfer of the patient to another hospital.

Based on record review and interview, the facility failed to document all reasonable steps to secure the patient's written informed refusal (or that of a person acting on his or her behalf), description of the proposed transfer that was refused by or on behalf of the individual, and failed to document that the person was informed of the risks and benefits of the transfer and reasons for the individual's refusal, in one of one medical records reviewed (Pt. #4).
Findings:
1) Medical record review for Pt. #4 on March 1, 2010 at 1:00 p.m. revealed neither documentation that the patient refused transfer, nor any reason that the patient was incapable of making an informed choice for himself. There is no documentation that either the patient or his designee was informed of the risks and benefits of the transfer.
2) According to interview with Pt. #4 on March 4, 2010 at 4:45 p.m., he does not remember being offered transfer to another hospital for further care. Pt. #4's wife stated that she was offered and refused transfer of the patient to another hospital.
3) According to the Emergency Room Progress Notes signed by PA #1 on 02/22/10 at 21:18, "A decision was made to at the very least apply rudimentary treatment to this patient until he is stable enough to see his primary care physician or an ER physician close to his home where his insurance would be of use. The patient tolerated the procedure here at the ER well and there were no complications. The patient's daughter presented to provide transportation and he was discharged in stable condition to his daughter's care for her transportation to either primary care physician or physician of another facility."
4) During interview with Pt. #4 on March 4, 2010 at 4:45 p.m., he stated that his daughter drove him directly to a hospital near his home, where he was admitted to continue further antibiotic therapy, until his discharge to his home on February 25, 2010.

Based on record review and interview, the facility failed to effect an appropriate transfer for unstable patients in 2 of 20 records reviewed (Pt. #5, .Pt #6), due to the absence of certification by a physician or countersignature for qualified medical persons as determined by the facility's bylaws or rules and regulations.
Findings:
1) A review of the By-Laws of The Medical Staff, United States Public Health Service Indian Hospital, Cass Lake, Minnesota, on March 2, 2010 revealed the absence of a requirement for certification by a physician or countersignature for qualified medical persons upon patient transfer.
2) A review of Emergency Department Policies on March 2, 2010 revealed an absence of an established timeframe for physician's countersignature of transfer certifications.
3) A review of Policy "Out of Hospital Transfer Record (COBRA/EMTALA)", effective date: 1/2001, revision date: 5/16/05, 5/24/07, 08/03/08, and 8/14/08, review date: 2/10/08, 08/08/08, and 8/14/08, states, "The transferring medical provider (ED physician, on-call physician, attending physician, nurse practitioner or physician's assistant acting with consent and knowledge of the on-call physician) has the responsibility to make a patient transfer decision regarding transfer of the unstable patient." The policy does not specify that the certification of transfer must either be signed by a physician or countersigned for qualified medical persons.
4) Review of the "Out-Of-Hospital Transfer Record" for Pt. #5 on March 1, 2010 revealed that the patient's "condition at time of transfer" was documented as "guarded." The patient's "criteria for transfer" was documented as "unresponsive", "MVC, worsening condition", "respiratory support, ICU admission." "Preparation for transfer of patient" included "intubation." Certification for transfer included only a nurse practitioner's signature without a physician's signature or countersignature. This finding was verified with the Clinical Applications Coordinator during medical record review on March 2, 2010.
5) Review of the "Out-Of-Hospital Transfer Record" for Pt. #6 on March 1, 2010 revealed that the patient's "condition at time of transfer" was documented as "guarded." Certification for transfer included only a physicians assistant's signature without a physician's signature or countersignature. This finding was verified with the Clinical Applications Coordinator during medical record review on March 1, 2010.