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Based on medical record review, interview and document review, it was determined that Emergency Department staff at St. James Hospital in Hornell did not provide an appropriate transfer for Patient #1 to ensure compliance with 42 CFR 489.24 and related provisions at 42 CFR 489.20.

Findings Include:

Review of Patient #1's medical record, staff interviews and hospital documentation revealed the Emergency Department staff did not comply with all of the provisions of ensuring the receiving hospital had available space, qualified personnel and agreed to accept the transfer of Patient #1. Please reference findings under Tag A-2409.

Based on medical record review, interview and document review, the Emergency Department (ED) staff did not ensure the receiving hospital had available space, qualified personnel and agreed to accept the transfer of Patient #1.

Findings Include:

Review of the ED record and staff interviews revealed that Staff #5 and Staff #10 made transfer arrangements with Strong Memorial Hospital but sent Patient #1 to Rochester General.

Review on 9/24/12 of a certified copy of the ED record for the index case/Patient #1 provided by the facility revealed the following:

- Outcome evaluation information page 4 of 4, noted Patient #1 was transferred to Rochester General Hospital ED via ambulance on 9/11/12 at 12:15. Report was given to the Rochester General Communication nurse.

- Review of the Emergency Room Report dated 9/11/2 at 10:22 by Staff #5 noted he spoke with a GI doctor at Rochester General Hospital who accepts Patient #1 on transfer.

- The Inter-Institutional Transfer form revealed a transfer order by Staff #5 dated 9/11/12 at 10:12 revealed the receiving hospital as Rochester General Hospital ED. The area listing the name of the accepting physician is blank.

Interview on 9/25/12 at 0900 with Staff #10 stated Staff #5 gave her the telephone number of the receiving hospital and said there was an available bed . She spoke to the communication nurse who she thought was from Rochester General Hospital but in retrospect she had called Strong Memorial Hospital.

Interview on 9/26/12 at 0750 with Staff #5 stated he received a verbal report from Staff #4 when he came in at 0800. Staff #5 spoke with a physician who accepted Patient #1, he thought he was speaking to a physician at Rochester General but in fact he was speaking to a physician at Strong Memorial Hospital. Additionally staff #5 acknowledged that the name of the accepting physician was blank on the Inter-Institutional Transfer form.

Review of policy " Emergency Medical Treatment and Labor Act (EMTALA) " last revised 1/12 revealed if a patient is to be transferred, the receiving hospital must have available space and qualified staff for the treatment of the patient. The receiving hospital must give acceptance in advance which is documented in the medical record.
However, both medical and nursing staff failed to follow this policy.