HospitalInspections.org

Based on record review, review of policies/procedures, and interview, the Critical Access Hospital (CAH) failed to enforce policies and procedures to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 on 2 of 2 days of on-site survey (January 11-12, 2011).

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of ?489.24. Failure of the CAH to enforce their policies and procedures relating to the Emergency Medical Treatment and Labor Act placed patients at risk of increased anxiety, suffering, distress, and pain related to their reasons for seeking assistance.

Findings include:

The CAH failed to enforce their policy/procedure regarding the need to post conspicuously in a place or places likely to be noticed by all individuals entering the emergency department, or by those individuals waiting for examination and treatment in areas other than traditional emergency departments (such as the entrance, admitting area, waiting room, and treatment area) a sign identifying the patient's right, within the capability of the hospital, to receive appropriate medical treatment to stabilize their medical condition, and if necessary an appropriate transfer to another facility; and information indicating whether or not the CAH participates in the Medicaid program (refer to C2402).

The CAH failed to enforce their policy/procedure regarding maintaining a central log on each individual who comes into the emergency department seeking assistance (refer to C2405).

The CAH failed to enforce their policy/procedure regarding providing an appropriate medical screening examination (MSE) for individuals presenting to the emergency department (refer to C2406). Failure to complete an appropriate MSE did not allow the physician and/or other qualified medical person to determine whether or not an emergency medical condition (EMC) existed (refer to C2406), if the patient's medical condition was stabilized or not prior to transfer (refer to C2407), and if the mode of transportation to the receiving hospital was appropriate and in the best interest of the individual (C2409).

The CAH failed to enforce their policy/procedure regarding not being appropriate to move a patient presenting to the emergency room to a clinic for a medical screening exam (refer to C2406).

The CAH failed to enforce their policy/procedure regarding the need of a physician and/or a qualified medical person to certify the expected benefits of the transfer outweighs the risks of the transfer (refer to C2409).

The CAH failed to enforce their policy/procedure regarding the need of a physician and/or other qualified medical person to document the receiving hospital agreed to accept transfer of the patient and agreed to provide appropriate medical treatment; and the need to document the date and time of the transfer request (refer to C2409).

The CAH failed to enforce their policy/procedure regarding the need to send the receiving hospital all of the patient's medical records (or copies thereof) related to the emergency condition that were available at the time of transfer, including available history, records related to the patient's emergency medical condition, observations of signs or symptoms, etc. (refer to C2409).

Based on observation, review of policies/procedures, and staff interview, the Critical Access Hospital (CAH) failed to post conspicuously in a place or places likely to be noticed by all individuals entering the emergency department, or by those individuals waiting for examination and treatment in areas other than traditional emergency departments (such as the entrance, admitting area, waiting room, and treatment area) a sign, on 2 of 2 days of on-site survey (January 11-12, 2011), identifying the patient's right, within the capability of the hospital, to receive appropriate medical treatment to stabilize their medical condition, and if necessary an appropriate transfer to another facility; and information indicating whether or not the CAH participates in the Medicaid program.

Findings include:

Review of the CAH's policy and procedure titled, "CATHOLIC HEALTH INITIATIVES Model Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services, " occurred on January 11-12, 2011. This policy/procedure, dated March 2006, stated,
" . . . L. Posting Signs 1. The Hospital shall conspicuously post, in the dedicated emergency departments (areas such as the Emergency Department, Labor and Delivery, Psychiatry), in off-campus departments of the Hospital that qualify as dedicated emergency departments designated with CMS provider-based status, and all areas in which patients routinely present for treatment of emergency medical conditions and wait prior to examination and treatment (such as entrance, admitting areas, waiting room or treatment room), signs in the format of the attached Exhibits D and E that specify rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions. 2. The Hospital shall conspicuously post signs stating whether or not the Hospital participates in the Medicaid program. 3. All signs must be posted in all the major languages that are common to the population of the Hospital's service area. . . ."
Exhibit D stated, "*IT'S THE LAW! * If you need emergency medical assistance or if you are pregnant and having contractions * You are entitled to receive within the capability of the hospital's staff and facility: *An appropriate medical screening exam *Appropriate medical treatment to stabilize your medical condition (including the delivery of an unborn child); and, if necessary, *An appropriate transfer to another facility, even if you are not able to pay or do not have medical insurance or were not entitled to participate in the MEDICARE or MEDICAID programs. * This hospital (does/does not) participate in the Medicaid program. . . ."

An administrative nurse (#2) on 01/11/11 at 10:30 a.m. identified patients seeking emergency services access the department either through the outside entrance door adjacent to the admitting room and waiting room area, or through the ambulance garage. Patients arriving by ambulance enter the emergency room directly from the ambulance bay.

Observation of the emergency room on 01/11/11 revealed a sign on the wall, 11 inches by 8 ? inches in size, which stated the following: "IT'S THE LAW If you need emergency medical assistance or if you are pregnant and having contractions, you are entitled to receive within the capability of the hospital's staff and facility: * An appropriate medical treatment to stabilize your medical condition (including the delivery of an unborn child); and, if necessary, * An appropriate transfer to another facility, even if you are not able to pay or do not have medical insurance or were not entitled to participate in the MEDICARE or MEDICAID programs. This hospital does participate in the Medicaid program."

During an interview on 01/12/11 at 7:50 a.m., an administrative staff member (#4) identified the admitting room is open Monday through Friday 6:30 a.m. - 5:30 p.m.; and is closed from 5:30 p.m. - 6:30 a.m. Monday through Friday, and on the weekends. Observation showed when the admitting room door is shut/locked, a visible sign on front of the door states, "If office staff is absent, and help is needed, . . please go to the Nurses Station. Thank you". This sign has an arrow pointing in the direction of the nurses' station.

Observation of the emergency room, and the described flow of patient traffic flow to and into the emergency room, showed the CAH failed to post the above-stated required signs/information in the admitting room, admitting room area, waiting room area located next to the emergency room, or at the nurses' station.

Based on policy/procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to maintain a central log listing each individual seeking assistance for 1 of 25 sampled records (Patient #1) reviewed and failed to maintain a central log documenting the disposition of the patient including whether the patient refused treatment, the CAH refused to treat the patient, the CAH transferred the patient, the CAH admitted and treated the patient, the CAH stabilized and transferred the patient, or the CAH discharged the patient for 4 of 25 sampled records (#13, #16, #19, and #20) reviewed. Failure to maintain a central log listing each individual seeking assistance and the patient's disposition limited the CAH's ability to track the care provided to emergency department patients.

Findings include:

Review of the CAH's policy and procedure titled, "Scope of Carrington Health Center Emergency Department," occurred on January 11-12, 2011. This policy/procedure, undated, stated, ". . . A register is maintained and contains the following information for every individual seeking care: patient name, age, and sex; date, time, and means of arrival; chief complaint; disposition of patient; date and time of discharge. . . ."

Review of the CAH's policy and procedure titled, "Emergency Dept. [Department] Admission & [and] Assessment Guidelines," occurred on January 11-12, 2011. This policy/procedure, dated January 2010, stated, ". . . POLICY: . . . All Emergency Room patients will be entered in the Emergency Department log book. . . ."

Review of the CAH's policy and procedure titled, "CATHOLIC HEALTH INITIATIVES Model Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services," occurred on January 11-12, 2011. This policy/procedure, dated March 2006, stated, ". . . [Carrington Health Center] Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services . . . III. PROCEDURES . . . H. Record-Keeping . . . 3. A central log which must list each individual seeking or in need of emergency services who comes to the Hospital, the dedicated emergency department, anywhere else on the Hospital campus, or to off-campus departments that qualify as a dedicated emergency department of the Hospital designated with CMS [Center for Medicare and Medicaid Services] provider-based status. The log must include an indication whether the individual did not consent to treatment or transfer, or was transferred, admitted and treated, stabilized and transferred, or discharged. Logs that are maintained in departments that qualify as dedicated emergency departments that perform medical screening examinations. [OPTIONAL:, such as in labor or delivery, psychiatry, outpatient] shall be deemed a part of the central log and are subject to the same requirements as the central log. 4. A central log must also include the name of each individual who comes to the Hospital, makes it clear (if it is unclear) that his or her medical condition is not an emergency nature, and a medical screening examination is performed to determine that the individual does not have an emergency medical condition. . . ."

- Reviewed on January 11-12, 2011, the medical record for Patient #1 indicated the patient sought medical assistance from the CAH on 10/24/10. Reviewed on 01/11/11, the CAH's emergency department logbook did not include an entry for Patient #1 on 10/24/10.

- Reviewed on January 11, 2011, the CAH's emergency department logbook failed to include the disposition of the patient including whether the patient refused treatment, the CAH refused to treat the patient, the CAH transferred the patient, the CAH admitted and treated the patient, the CAH stabilized and transferred the patient, or the CAH discharged the patient for the following entries:
*Patient #16 on 07/03/10
*Patient #20 on 08/24/10
*Patient #19 on 08/31/10
*Patient #13 on 10/01/10

During interview on 01/12/11 at 1:45 p.m., an administrative nursing staff member (#2) confirmed the CAH did not enter Patient #1 in the emergency department logbook and did not include in the emergency department logbook entries for Patients #16, #20, #19, and #13 whether the patient refused treatment, the CAH refused to treat the patient, the CAH transferred the patient, the CAH admitted and treated the patient, the CAH stabilized and transferred the patient, or the CAH discharged the patient.

Based on policy/procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to provide a medical screening examination to determine whether an emergency medical condition existed for 2 of 25 sampled records (Patients #1 and #2) reviewed of individuals presenting to the CAH's emergency department (ED).

Findings include:

Review of the CAH's policy and procedure titled, "Emergency Dept. [Department] Admission & [and] Assessment Guidelines," occurred on January 11-12, 2011. This policy/procedure, dated January 2010, stated, ". . . POLICY: A medical screening exam will be rendered to any ill or injured person who presents himself to the Emergency Department. None, regardless of race, diagnosis, financial status, national origin, color, or handicap, will be turned away without a medical screening. An Emergency Department Record will be completed on all patients cared for in the Emergency Department. . . . The PA [physician assistant] and/or physician will evaluate and treat all E.R. [emergency room] patients. . . ."

Review of the CAH's policy and procedure titled, "CATHOLIC HEALTH INITIATIVES Model Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services," occurred on January 11-12, 2011. This policy/procedure, dated March 2006, stated, ". . . [Carrington Health Center] Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services I. Policies
A. It is the policy of Carrington Health Center (the 'Hospital') that if an individual comes to the Emergency Department (as defined below): 1. The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists. . . .
B. This policy applies to: 1. All individuals seeking or needing an examination or treatment for emergency medical services who come to the Hospital's dedicated emergency department or on Hospital property, even if they present at a location other than the dedicated emergency department or to an off-campus department of the Hospital that meets requirements of a dedicated emergency department . . .
II. DEFINITIONS . . . B. An individual 'comes to the emergency department' or 'comes to the Hospital' when such individual, who is not a patient: 1. Presents at a Hospital's dedicated emergency department, as defined in this Section, and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition, or 2. Presents on the Hospital property, as defined below, other than the dedicated emergency department(s), and request examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs emergency examination or treatment . . .
J. 'Medical screening examination' means the screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist. Triage is not considered a medical screening examination. . . .
III. PROCEDURES B. Medical Screening Examination
1. The Hospital shall provide a medical screening examination for an individual who a. Comes to the on-campus dedicated emergency department, requesting examination or treatment for a medical condition or has such a request made on his or her behalf, or if based on the individual's appearance or behavior, the individual needs an examination or treatment for a medical condition. (The Hospital shall also provide such an examination for an individual who comes to another area (non-emergency department) of the Hospital campus.) . . .
4. . . . The physician or Qualified Medical Person [QMP] shall determine within reasonable clinical confidence whether the individual has an emergency medical condition, utilizing the services within the capability of the emergency department, using ancillary services and resources routinely available in the emergency department for individuals with similar symptoms. . . . The medical screening examination must be documented in the medical record. . . .
9. If it is unclear whether the individual is requesting an emergency medical examination, then the Hospital shall provide a medical screening examination. . . .
5.0 Responsibilities of the On-Call Physician: . . .
5.2. . . . The patient will not be sent to the physician's office for examination and treatment except in the following circumstances: (a) a patient has received a medical screening exam and the ED physician or QMP has determined that the patient does not have an emergency medical condition; (b) the ED physician or QMP determines that the patient is stable for discharge; or (c) in rare circumstances when the physician's office has equipment or capabilities unavailable at the Hospital (e.g. ophthalmology exam equipment). In circumstance (c), the transfer to the physician's office shall comply with all requirements for an appropriate transfer, including completion of the Transfer Summary."

- Reviewed on January 11-12, 2011, the medical record for Patient #1 indicated the patient sought medical assistance from the CAH on 10/24/10 for shortness of breath and history of atrial fibrillation. The medical record lacked evidence the physician (#7) performed a medical screening examination to determine whether an emergency medical condition existed. The physician's note, dated 10/24/10, stated, ". . . I did not think it was necessary to do a formal emergency room consult as the daughter basically brought her mother in with the question of how she could get her seen sooner rather than wait until she was seen as things were going. The daughter said that she was worried that she would run out of time and that her mother would die. . . ." An addendum to the physician's note, dated 10/24/10 at 5:36 [not specified as a.m. or p.m.], stated, ". . . I had nothing to offer this patient here so I did not do EKGs [electrocardiograms], lab, chest x-rays, and the like but rather I called [name of facility] and talked to the emergency room doctor, [name of physician] explained the situation to him and asked him if he could arrange for her to see cardiology on call to see whether or not she was a candidate for something further being done. . . ." The record indicated the CAH transferred Patient #1 by private vehicle to another facility 142 miles away.

During interview on 01/11/11 at 2:05 p.m., an administrative staff member (#1) confirmed the physician (#7) had not performed a medical screening examination on Patient #1 on 10/24/10 to determine whether an emergency medical condition existed.

- Reviewed on January 11-12, 2011, the medical record for Patient #2 indicated the patient sought medical assistance from the CAH on 01/05/11 at 12:50 p.m. for feeling faint, nausea, and left sided neck pain. The emergency department orders, dated 01/05/11 at 1300 (1:00 p.m.), stated, "Triage to clinic to see [initials of physician]. The medical record did not include evidence the physician's assistant (#6) performed a medical screening examination to determine whether an emergency medical condition existed before staff escorted Patient #2 to the adjoining rural health clinic for treatment by a physician.

During interview on 01/12/11 at 1:25 p.m., a physician's assistant (#6) confirmed he had not documented in Patient #2's emergency department medical record that he performed a medical screening examination on 01/05/11 before transferring the patient to the adjoining rural health clinic for treatment by a physician.

Based on policy/procedure review, record review, and interview, the Critical Access Hospital (CAH) failed to ensure hospital staff stabilized the patient's condition before transfer for 1 of 16 sampled patients (Patients #1) transferred to another facility from the CAH's emergency department. Failure to ensure hospital staff stabilized the patient's condition before transfer placed the patients at risk of developing complications during transfer.

Findings include:

Review of the CAH's policy and procedure titled, "CATHOLIC HEALTH INITIATIVES Model Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services," occurred on January 11-12, 2011. This policy/procedure, dated March 2006, stated, ". . . [Carrington Health Center] Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services . . . II. Definitions . . . N. 'To stabilize' or 'stabilize' or 'stabilized' means: 1. With respect to an emergency medical condition, that the patient is provided such medical treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient . . ."

- Reviewed on January 11-12, 2011, the medical record for Patient #1 indicated the patient sought medical assistance from the facility for shortness of breath and weakness with a history of atrial fibrillation on 10/24/10. The record lacked evidence the physician performed a medical screening examination. Failure to complete an appropriate medical screening examination did not allow the physician to determine whether or not an emergency medical condition existed or if the patient's medical condition was stabilized before transfer by private vehicle to another facility 142 miles away. The Emergency Room Note, dated 10/24/10, stated, ". . . Apparently the patient has had atrial fibrillation since April of this past year. She has been tolerating things relatively well until the last 2 days when she has become progressively short of breath, weaker, and unable to get around much at all. She was scheduled to see [name of physician] for electrical conversion . . . she [patient's daughter] was especially worried about what to do since her mother appeared to be getting worse and wondered about how she could see a cardiologist. . . . [name of patient's daughter] will drive her mother to the emergency room at [name of receiving facility]. The patient was stable when she left, I see no problem with them driving via automobile. I did not think it was necessary to do a formal emergency room consult as the daughter basically brought her mother in with the question of how she could get her seen sooner rather than wait until she was seen as things were going. The daughter said that she was worried that she would run out of time and that her mother would die. . . ." An addendum to the Emergency Room Note, dated 10/24/10 at 5:36 [unspecified as a.m or p.m.], stated, ". . . I had nothing to offer this patient here so I did not do EKG's [electrocardiogram], lab, chest x-rays, and the like . . ."

During a telephone interview on 01/14/11 at 10:40 a.m., the receiving emergency department physician (#9), stated he could not believe the condition the patient was in when she walked into the ER. This physician (#9) stated the patient did not have much time left, maybe an hour, and the outcome would have been much different. This physician (#9) said he would expect rudimentary work-up, breathing treatment, O2 (oxygen), dose of steroid, and transfer via ambulance (not a private car) in case a problem arose on the way.

1. Based on policy/procedure review, record review, and interview, the Critical Access Hospital (CAH) failed to ensure the use of an appropriate mode of transportation for 1 of 16 sampled records (Patients #1) reviewed of patients transferred to another facility from the CAH's emergency department. Failure to use an appropriate mode of transportation put the patients at risk of not receiving appropriate care during transfer.

Findings include:

Review of the CAH's policy and procedure titled, "CATHOLIC HEALTH INITIATIVES Model Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services," occurred on January 11-12, 2011. This policy/procedure, dated March 2006, stated, ". . . [Carrington Health Center] Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services I. Policies . . . B. With Certification. The individual may be transferred if a physician . . . has documented on the 'Physician Certification' section of Exhibit A that the medical benefits expected from transfer outweigh the risks. . . . e. The transfer shall be effected through appropriately trained professionals and transportation, equipment, including the use of necessary and medically appropriate life support measures during the transfer. The physician is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer. . . ."

- Reviewed on January 11-12, 2011, the medical record for Patient #1 indicated the patient sought medical assistance from the facility for shortness of breath and weakness on 10/24/10. The record lacked evidence the physician completed a medical screening examination. Failure to complete an appropriate medical screening examination did not allow the physician to determine whether or not an emergency medical condition existed, whether the patient's medical condition was stabilized before transfer, and the appropriate mode of transporatation. The Emergency Room Note, dated 10/24/10, stated, ". . . Apparently the patient has had atrial fibrillation since April of this past year. She has been tolerating things relatively well until the last 2 days when she has become progressively short of breath, weaker, and unable to get around much at all. She was scheduled to see [name of physician] for electrical conversion . . . she [patient's daughter] was especially worried about what to do since her mother appeared to be getting worse and wondered about how she could see a cardiologist. . . . [name of patient's daughter] will drive her mother to the emergency room at [name of receiving facility]. The patient was stable when she left, I see no problem with them driving via automobile. I did not think it was necessary to do a formal emergency room consult as the daughter basically brought her mother in with the question of how she could get her seen sooner rather than wait until she was seen as things were going. The daughter said that she was worried that she would run out of time and that her mother would die. . . ." An addendum to the Emergency Room Note, dated 10/24/10 at 5:36 [unspecified as a.m. or p.m.], stated, ". . . I had nothing to offer this patient here so I did not do EKG's [electrocardiogram], lab, chest x-rays, and the like . . ."

During a telephone interview on 01/14/11 at 10:40 a.m., the receiving emergency department physician (#9), stated he could not believe the condition the patient was in when she walked into the ER. This physician (#9) stated the patient did not have much time left, maybe an hour and the outcome would have been much different. This physician (#9) said he would expect rudimentary work-up, breathing treatment, O2 (oxygen), dose of steroid, and transfer via ambulance (not a private car) in case a problem arose on the way. The patient arrived at the receiving facility with no physician note or documentation showing that anything was done at the transferring facility.


2. Based on policy/procedure review, record review, and interview, the Critical Access Hospital (CAH) failed to ensure the physician certified the medical benefits outweighed the risks at the time of transfer for 3 of 16 sampled records (Patients #3, #4, and #8) reviewed of patients transferred to another facility from the CAH's emergency department. Failure to ensure the physician certified the medical benefits outweighed the risks for transfer placed the patients at risk of receiving an inappropriate transfer.

Findings include:

Review of the CAH's policy and procedure titled, "CATHOLIC HEALTH INITIATIVES Model Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services," occurred on January 11-12, 2011. This policy/procedure, dated March 2006, stated, ". . . [Carrington Health Center] Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services . . . III. PROCEDURES . . . E. An Individual Who Has An Emergency Medical Condition . . . b. Provide for an appropriate transfer of the unstabilized individual to another medical facility in accordance with these procedures. Transfers of unstabilized individuals are permitted only pursuant to individual request . . . or when a physician, or a Qualified Medical Person in consultation with a physician, certifies that the expected benefits to the transfer outweigh the risks of transfer . . .
2. If an individual has an emergency medical condition that has not been stabilized, the individual may be transferred only if the transfer is carried out in accordance with the procedures set forth below. The individual may be transferred: . . . b. With Certification. The individual may be transferred if a physician or, should a physician not physically be present at the time of the transfer, a Qualified Medical Person in consultation with a physician has documented on the 'Physician Certification' section of Exhibit A that the medical benefits expected from transfer outweigh the risks. The date and time of the certification should be close in time to the actual transfer. . . ."

- Reviewed on January 11-12, 2011, the following medical records lacked evidence the physician certified the medical benefits outweighed the risks at the time of transfer:
*Patient #3 - treated in the ER on 09/13/10 for early stage of active labor
*Patient #4 - treated in the ER on 10/23/10 for back pain
*Patient #8 - treated in the ER on 07/12/10 for unstable angina

During interview on 01/12/11 at 1:45 p.m., an administrative nursing staff member (#2) confirmed the medical records for Patients #3, #4, and #8 lacked evidence the physician certified the medical benefits outweighed the risks at the time of transfer.

3. Based on policy/procedure review, record review, and interview, the Critical Access Hospital (CAH) failed to ensure the receiving facility agreed to accept the transfer and provide treatment for 2 of 16 sampled records (Patients #5 and #8) reviewed of patients transferred to another facility from the CAH's emergency department and failed to document the date and time the CAH made the transfer request to the receiving facility for 16 of 16 sampled records (Patients #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #17, #18, and #21) reviewed of patients transferred to another facility from the CAH's emergency department. Failure to ensure the receiving facility agreed to accept the transfer and provide treatment, placed the patient at risk of not receiving treatment upon transfer.

Findings include:

Review of the CAH's policy and procedure titled, "Transfer Policy" occurred on January 11-12, 2011. This policy/procedure, undated, stated, ". . . 3. Telephone contact must be made by the attending or Emergency Room physician/midlevel to the institution's receiving physician where the patient is transferred. The receiving physician's name and time of phone call should be placed on the Transfer Record. . . ."

Review of the CAH's policy and procedure titled, "CATHOLIC HEALTH INITIATIVES Model Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services," occurred on January 11-12, 2011. This policy/procedure, dated March 2006, stated, ". . . [Carrington Health Center] Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services . . . III. PROCEDURES . . . E. An Individual Who Has An Emergency Medical Condition . . . 3. When the Hospital transfers an individual with an unstabilized emergency medical condition to another facility the transfer shall be carried out in accordance with the following procedures. . . . b. A representative of the receiving facility must confirm that: . . . (2) The receiving facility agrees to accept transfer of the individual and to provide appropriate medical treatment. . . ."

- Reviewed on January 11-12, 2011, the following medical records lacked evidence the receiving facility agreed to accept the transfer and provide treatment:
*Patient #5 - treated in the ER on 10/24/10 for acute and chronic subdural hematoma
*Patient #8 - treated in the ER on 07/12/10 for unstable angina

- Reviewed on January 11-12, 2011, the following medical records lacked evidence of the date and time the CAH contacted the receiving facility to request acceptance of transfer and provision of treatment:
*Patient #1 - treated in the ER on 10/24/10 for shortness of breath, weakness, and history of atrial fibrillation
*Patient #3 - treated in the ER on 09/13/10 for early stage of active labor
*Patient #4 - treated in the ER on 10/23/10 for back pain
*Patient #5 - treated in the ER on 10/24/10 for acute and chronic subdural hematoma
*Patient #6 - treated in the ER on 09/10/10 for unstable cervical fracture
*Patient #7 - treated in the ER on 09/18/10 for probable cerebrovascular disease, labile hypertension
*Patient #8 - treated in the ER on 07/12/10 for unstable angina
*Patient #9 - treated in the ER on 12/25/10 for ankle injury
*Patient #10 - treated in the ER on 09/15/10 for vaginal tear
*Patient #11 - treated in the ER on 08/02/10 for spontaneous pneumothorax
*Patient #12 - treated in the ER on 07/28/10 for trauma secondary to auger injury
*Patient #14 - treated in the ER on 10/16/10 for lower abdominal pain
*Patient #15 - treated in the ER on 11/10/10 for possible sepsis
*Patient #17 - treated in the ER on 09/23/10 for open fracture to fourth left metacarpal
*Patient #18 - treated in the ER on 09/27/10 for fractured radius and ulna following a motor vehicle collision
*Patient #21 - treated in the ER on 10/22/10 for intractable head and facial pain

During interview on 01/12/11 at 1:45 p.m., an administrative nursing staff member (#2) confirmed the medical records for Patients #5 and #8 lacked evidence the receiving facility agreed to accept the transfer and provide treatment; and the medical records for Patients #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #17, #18, and #21 lacked evidence of the date and time the CAH contacted the receiving facility to request acceptance of transfer and provision of treatment.

4. Based on policy/procedure review, record review, and interview, the Critical Access Hospital (CAH) failed to ensure staff sent the medical records related to the emergency condition to the receiving facility for 10 of 16 sampled records (Patients #1, #3, #4, #7, #8, #10, #12, #15, #17, and #18) reviewed of patients transferred to another facility from the CAH's emergency department. Failure to ensure staff sent pertinent medical records to the receiving facility, placed the patient at risk of not receiving appropriate treatment at the receiving facility.

Findings include:

Review of the CAH's policy and procedure titled, "CATHOLIC HEALTH INITIATIVES Model Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services," occurred on January 11-12, 2011. This policy/procedure, dated March 2006, stated, ". . . [Carrington Health Center] Policies and Procedures for the Treatment and Transfer of Individuals in Need of Emergency Medical Services . . . III. PROCEDURES . . . E. . . . 3. . . . c. The Hospital shall send the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (2) records related to the individual's emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; and (8) a copy of the completed applicable sections of the Transfer Summary . . . The Hospital shall forward to the receiving facility relevant records, pending lab work and test results that were not available at the time of transfer. . . ."

Review of the CAH's policy and procedure titled, "Transfer Policy" occurred on January 11-12, 2011. This policy/procedure, undated, stated, ". . . 5. A complete Transfer Record is sent with the patient. Copies to include: - Transfer form (signed by MD [medical doctor]) - Emergency Room Nurse's Notes (transfers from E.R. [emergency room]) - Face Sheet (if available) - Lab reports - X-rays - EKG's [electrocardiogram] - H & P [history and physical] (if available) - Discharge Summary (if available) - Trauma transfer form (pertains only to trauma patients) - EMS [emergency medical services] run ticket (must be enclosed with all trauma transfers) - If time does not allow for all the above paperwork to be completed before the patient is transferred it is allowable to fax the information to the receiving facility when completed. This should be done in a timely manner with the facility to receive the paperwork via fax before the patient's arrival. . . ."

- Reviewed on January 11-12, 2011, the following medical records lacked evidence of the CAH sent the medical records related to the emergency condition to the receiving facility:
*Patient #1 - transferred on 10/24/10 with no evidence of sending records to the receiving facility
*Patient #3 - transferred on 09/13/10 with no evidence of sending records including the transfer form to the receiving facility
*Patient #4 - transferred on 10/23/10 with no evidence of sending records to the receiving facility
*Patient #7 - transferred on 09/18/10 with no evidence of sending records to the receiving facility
*Patient #8 - transferred on 07/12/10 with no evidence of sending clinical notes to the receiving facility
*Patient #10 - transferred on 09/15/10 with no evidence of sending records to the receiving facility (except lab results)
*Patient #12 - transferred on 07/28/10 with no evidence of sending records to the receiving facility (except the EKG's)
*Patient #15 - transferred on 11/10/10 with no evidence of sending records to the receiving facility (except lab results)
*Patient #17 - transferred on 09/23/10 with no evidence of sending records to the receiving facility
*Patient #18 - transferred on 09/27/10 with no evidence of sending records to the receiving facility

During interview on 01/11/11 at 5:20 p.m., an administrative staff member (#2) stated CAH staff sent only the Transfer Form for Patient #1 to the receiving facility on 10/24/10.
During interview on 01/12/11 at 1:45 p.m., an administrative nursing staff member (#2) confirmed the medical records for Patients #1, #3, #4, #7, #8, #10, #12, #15, #17, and #18 lacked evidence the CAH sent copies of the pertinent medical records to the receiving facility.