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Based on a review of facility policy, facility documents, and staff interviews (EMP), it was determined that the facility failed to complete a medical screening examination for one of one patient that presented to the emergency room (PT1).

Findings include:

Review of Allegheny General Hospital Medical Staff Bylaws and Rules and Regulations Amended November 25, 2008 revealed " ... Article IX Emergency Service A. Physician Availability A licensed physician is on duty 24 hours a day..B. Emergency Department Records A medical record shall be kept for every patient receiving emergency service and shall be signed by the physician responsible for its accuracy. C. Presentation Every patient presenting to the Emergency Department will be evaluated by a physician or a CRNP/Physician Assistant under the supervision of a physician unless the patient refuses treatment."

Review of the "Emergency Medical Treatment & Active Labor Act (EMTALA) " policy, dated January 15, 2009, revealed that "Any individual who come to the Hospital Property or Premises requesting examination or treatment and appears to be suffering from an Emergency Medical Condition or expresses a complaint which could reasonably be construed as an Emergency Medical Condition, or who comes to the Dedicated Emergency Department requesting examination or treatment of a medical condition is entitled to and shall be provided an appropriate Medial Screening Examination to determine whether or not an Emergency Medical Condition exist, stabilization to the extent the facility is able to do so, and an Appropriate Transfer if necessary."

1) Review of the Shaler Area EMS (Emergency Medical Services) trip sheet, dated January 9, 2010 revealed that PT1 was brought to the facility Emergency Department (ED) at 9:39 PM.. Further review of the ambulance trip sheet revealed "While at [facility] the patient remained on stretcher...their[sic] was no transfer of care done. Crew then transferred [PT1] and [other] back to ambulance and began transfer ..."

2) Review of the Emergency Department (ED) log, January 19, 2010, at approximately 10:00 AM, revealed that from July 2009 to January 18, 2010, there was no documented evidence that PT1 was registered and/or had a medical screening at the facility ED.

3) Interview with EMP11, January 19, 2010, at approximately 11:00 PM revealed that "...the patient was never registered, therefore never appeared on the ED log and a medical record was never created for the patient. ..."

4) Interview with EMP3, January 19, 2010, at approximately 11:00 AM revealed that "EMP11 was trying to save the patient money from not registering [PT1] on the ED log, since [PT1] was only here for detox ... without doing any of the transfer forms ... there was no medical record ..."

Based on a review of facility policy, facility documents, and staff interviews (EMP), it was determined that the facility failed to complete an appropriate transfer for one of one patients (PT1).

Findings include:

Review of "Emergency Medical Treatment and Active Labor Act (EMTALA)" policy, dated June 15, 2009 revealed, "Appropriate Transfer ...(iii)the transferring hospital sends to the receiving hospital copies of all medical records related to the Emergency Medical Condition for which the individual has presented, available at the time of transfer, including records related to the individual's Emergency Medical Condition, observations or signs or symptoms, preliminary diagnosis, treatment provided ...and the informed written consent or certification required, ...3. The transferring hospital must send copies of all available medical records pertaining to the individual's condition to the hospital when the patient is being transferred. The documents include copies of the available history, records related to the individual's emergency medical condition, observation of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or written certification of the physician."

1) Review of the Shaler Area EMS (Emergency Medical Services) trip sheet, dated January 9, 2010, revealed that PT1 was brought to the facility Emergency Department (ED) at 9:39 PM.. Further review of the ambulance trip sheet revealed "While at [facility] the patient remained on stretcher...their[sic] was no transfer of care done. Crew then transferred [PT1] and [other] back to ambulance and began transfer to [FAC2] ..."

2) Review of the facility Emergency Department log on January 19, 2010, revealed no documented evidence that PT1 presented to the ED and/or that transfer arrangements were made for [PT1].

3) Interview with OTH2 on January 13, 2010, at approximately 9:00 AM revealed that "[PT1] presented to [FAC2] on January 9, 2010 ... It does not appear [PT1] was seen by a physician ... transfer does not appear to have been arranged."

4) Interview with EMP11 on January 19, 2010, at approximately 11:00 PM revealed "... the patient was never registered, therefore never appeared on the ED log and a medical record was never created for the patient."

5) Interview with EMP3 on January 19, 2010, at approximately 11:00 AM revealed "Unfortunately [PT1 was transferred] without doing any of the transfer forms ... there was no medical record ..."