HospitalInspections.org

INTAKE: TN00026986

1. Based on review of the hospital's emergency department policies, the hospital's Medical Staff By-Laws, Emergency Medical Services ambulance record review, medical record review and interview, the hospital failed to provide medical screening examinations for 2 of 22 (Patients #2 and 22) sampled patients who presented to the Emergency Department seeking care. Refer to findings in deficiency A-2406.

2. Based on review of the hospital's emergency department policies, medical record review and interview, the hospital failed to ensure risks and benefits of receiving examination and treatment were provided and written refusal of examination or treatment was sought for 5 of 5 (Patients #3, 5, 6, 8 and 10) sampled patients reviewed for leaving prior to examination or treatment. Refer to findings in deficiency A-2407.

3. Based on review of the hospital's transfer policy, Medical Staff By-Laws, EMS ambulance record review and medical record review, the hospital failed to ensure an appropriate transfer to a higher level of care for 2 of 6 (Patients #2 and 22) sampled patients who were transferred. Refer to findings in deficiency A-2409.

Based on review of the hospital's emergency department (ED) Central log, the Emergency Medical Services (EMS) ambulance report, the hospital's ED policy and interview, it was determined the hospital failed to ensure that each patient who presented to the hospital's ED was documented on the hospital's ED central log for 1 of 22 (Patient #22) sampled patients who had presented to the hospital's emergency department.

The findings included:

1. Review of the hospital's ED central log dated 10/19/10 revealed no documentation that Patient #22 had presented to the hospital's ED seeking care.

2. Review of the EMS ambulance report dated 10/19/10 documented Patient #22 was transported to and arrived at the hospital's ED at 1915.

3. Review of the hospital's policy, "Priority for Patient Care: Screening and Stabilization to the ER", documented, "...A triage assessment will be performed on each patient seeking care in the emergency department...The triage/screening is to be recorded in the patient's medical record and in the ER register/log...".

4. During an interview on 10/28/10 at 10:20 AM, ED Physician #1 verified Patient #22 arrived by ambulance on 10/19/10 to the hospital's ED seeking care for a medical condition.

5. During an interview on 10/28/10 at 10:45 AM, ED LPN #1 verified Patient #22 arrived by ambulance to the hospital's ED seeking care on 10/19/10. LPN #1 stated he/she did not document the patient's name on the hospital's ED central log.

6. During a telephone interview on 11/1/10, Paramedic #1 verified he/she had taken Patient #22 by EMS ambulance to the hospital's ED on 10/19/10 seeking care for a medical condition.

Based on the hospital's emergency department (ED) policies, the hospital's Medical Staff By-Laws, Emergency Medical Services (EMS) ambulance record review, medical record review and interview, it was determined the hospital failed to ensure a medical screening examination (MSE) was performed on 1 of 22 (Patient #22) sampled patients who presented to the hospital's ED seeking medical care.

The findings included:

1. Review of the hospital's ED policy, "Emergency Department Scope of Care and Services", documented, "...All patients who present seeking attention from the Medical Staff will be seen and evaluated as follows: 1. Initial assessment by licensed personnel. 2. Medical screening by the physician. 3. Treatment as deemed appropriate by the physician. 4. Referral as indicated..."

2. Review of the hospital's policy, "Priority for Patient Care: Screening and Stabilizing in the ER", documented, "... Whenever an individual comes to the hospital emergency department requesting an examination or treatment, the individual shall be screened without delay to determine whether emergency medical condition exists ...."

3. Review of the Hospital A's Medical Staff By-Laws dated March 2010, documented, "... All patients presenting to the emergency department will be seen by a Qualified Medical Person as defined by the [name of hospital] Medical Staff By-Laws ...."

4. Review of the EMS ambulance record dated 10/19/10 documented Paramedic #1 arrived at Patient #22's residence at 1829. The ambulance record documented the patient was experiencing chest pain and ventricular tachycardia (V-tach). At 1840, Paramedic #1 administered Amiodarone 150 milligrams (mgs) intravenous push (IVP) and the patient converted to atrial fibrillation (A-fib), at which time the patient denied further chest pain. The ambulance record documented the patient was transported to Hospital A's ED.

The EMS ambulance record documented upon arrival at Hospital A's ED at 1915, ED Physician #1 met the ambulance in the parking lot and "convinced " Patient #22 to go to a critical care unit at Hospital B. The ambulance record documented Patient #22 was immediately transported to Hospital B .

5. During an interview on 10/28/10 at 10:20 AM, ED Physician #1 stated Patient #22 arrived by EMS ambulance on 10/19/10 to Hospital A's ED. ED Physician #1 stated he/she met the ambulance in Hospital A's ED parking lot and "convinced" the patient to go to a critical care unit at Hospital B. ED Physician #1 stated he/she instructed the EMS personnel to take Patient #22 to Hospital B. ED Physician #1 stated he/she did not perform a medical screening examination on the Patient #22.

6. During an interview on 10/28/10 at 10:45 AM, ED LPN #1 stated he/she had received a call from the EMS ambulance on 10/19/10 that the EMS ambulance was in route to Hospital A's ED with Patient #22, with a diagnosis of V-tach which had converted to A-fib after receiving Amiodarone 150 mgs IVP. ED LPN #1 stated he/she informed ED Physician #1 of Patient #22's pending ambulance arrival and diagnosis.

ED LPN #1 stated when the ambulance arrived at Hospital A's ED, ED Physician #1 went outside and met the ambulance in Hospital A's ED parking lot. ED LPN #1 stated when ED Physician #1 came back into the ED he stated he instructed the ambulance to take Patient #22 to Hospital B.

7. During a telephone interview on 11/1/10 at 2:32 PM, Paramedic #1 verified he/she arrived at Patient #22's residence on 10/19/10. Paramedic #1 verified the Patient was complaining of chest pain and was in V-tach. Paramedic #1 verified Amiodarone 150 mg was administered IVP and the patient converted to A-Fib and denied further chest pain. Paramedic #1 verified the patient was then transported to Hospital A's ED.

Paramedic #1 verified upon arrival at Hospital A's ED, ED Physician #1 met the ambulance in Hospital A's ED parking lot. Paramedic #1 verified Ed Physician #1 instructed the EMS ambulance personnel to take the patient to Hospital B. Paramedic #1 verified ED Physician #1 did not come inside the ambulance and perform a medical screening examination on Patient #22. Paramedic #1 verified Patient #22 was transported to Hospital B.

8. Review of Hospital B's ED record dated 10/19/10 documented Patient #22 arrived by EMS ambulance at 2012. ED Physician #3, at Hospital B, performed a MSE at 2035 and stabilized the patient. ED Physician #3 documented, "...We are going to finish the load of Amiodarone, and undergo further workup and treatment..." The patient was admitted to the facility.

9. Review of the medical records for Patients #9, 16 and 21 documented the patients presented to Hospital A's ED with complaints similar to Patient #22 and were provided a MSE:

Patient #9 arrived at the hospital's ED on 7/23/10 at 1627 with complaints of chest pain, unrelieved by nitroglycerin 3 tablets sublingual (SL) and aspirin 81 mg by mouth (PO), shortness of breath (SOB) and diaphoresis. The patient rated the chest pain an 8 on a scale of 1 - 10, with 10 being the most intense. ED Physician #2 documented he/she performed a medical screening examination (MSE) at 1640, stabilized the patient and transferred the patient to a higher level of care.

Patient #16 arrived at the hospital's ED on 10/14/10 at 1435 with complaints of chest pain radiating to the left arm. The patient rated the chest pain a 10 on a scale of 1 - 10, with 10 being the most intense. ED Physician #3 documented he/she performed a MSE, stabilized the patient and admitted the patient to the hospital for observation.

Patient #21 arrived to the hospital's ED on 5/27/10 at 1334 with complaints of chest pain, rating the chest pain an 8 on a scale of 1 - 10, with 10 being the most intense. ED Physician #2 documented he/she performed a MSE at 1410, stabilized the patient and transferred the patient to a higher level of care.

Based on policy review, medical record review and interview, it was determined the hospital failed to ensure all patients who refused examination and treatment were informed of the risks and benefits of examination and and failed to seek written informed refusal of the examination and treatment for 5 of 5 (Patients #3, 5, 6, 8 and 10) sampled patients who left the Emergency Department (ED) Against Medical Advice (AMA).

The findings included:

1. Review of the facility's policy, "Priority for Patient Care: Screening and Stabilizing in the ER [emergency department]" documented, "...If the patient or their representative refuses the treatment, after being informed of the risks and benefits to the patient, ER personnel shall obtain the informed refusal in writing on the Refusal of Emergency Treatment or Transfer form. If refusal can not be obtained, ER personnel shall document steps taken to secure written refusal and the reason it could not be obtained ..."

2. Medical record review for Patient #3 revealed the patient arrived to the ED on 5/7/10 at 2325 with complaints of foot pain. The patient was triaged at 2325 and received a Medical Screening Examination (MSE) at 2340. At 2345 the patient refused further treatment and left against medical advice (AMA). There was no documentation the patient had been informed of risks and benefits of leaving the ED without medical treatment or that written refusal of treatment was sought.

3. Medical record review for Patient #5 documented the patient was transported by the Emergency Medical Services (EMS) to the ED on 5/8/10 at 2045 with complaints of self mutilation. The patient was triaged at 2100. The Registered Nurse (RN) documented at 2115, "Pt [patient] stated she was leaving and left the facility. No attempt was made to stop the pt... sheriff dept [department] called...sheriff dept came to the ER and reported that pt was found back at her residence..." There was no documentation the patient had been informed of the risks and benefits of leaving the ED without medical examination and treatment or that written refusal of examination and treatment was sought.

4. Medical record review for Patient #6 documented the patient arrived to the ED on 5/27/10 at 1349 with complaints of chest pain that radiated to the left arm/jaw/neck area and increased in the chest when neck pain starts. The patient was triaged at 1349 with oxygen, telemetry and serial vital signs initiated and an electrocardiogram was performed. The RN documented at 1446, "Pt leaves AMA. Pt removes BP [blood pressure] cuff and telemetry. Pt instructed on implications of leaving AMA. Talked with pt about need to stay. Nurses had been attending to more critical pt. Pt states 'I can not lay here anymore, I don't care what you are doing.' Pt walked out of ER." The statement, "Left prior to Medical Screening" was handwritten on the Emergency Department Record form. There was no documentation the patient had been informed of the risks and benefits of leaving the ED without medical examination and treatment or that written refusal of examination and treatment was sought.

During an interview on 10/28/10 at 11:09 AM, the Director of Nursing (DON) verified the patient had not been presented with an AMA form for a signature.

During an interview on 10/28/10 at 11:09 AM, the ED Nurse Manager verified there was no documentation anywhere the patient had refused to sign the AMA form.

5. Medical record review for Patient #8 documented the patient arrived to the ED on 7/23/10 at 0815 with complaints of congestion and facial swelling. The Registered Nurse (RN) documented, "At 0825 Pt left stating, 'I know you don't have any patients and I'm leaving cause I've not been seen yet,'" A handwritten note on the Emergency Department Record documented, "Pt left before being triaged." There was no documentation the patient had been informed of the risks and benefits of leaving the ED without medical examination and treatment or that written refusal of examination and treatment was sought.

6. Medical record review for Patient #10 documented the patient was transported by EMS to the ED on 8/1/10 at 1630 with complaints of chest pain. The RN triaged the patient at 1630 and documented, "Upon arrival patient reports anxiety and that she is ready to go home..." The Emergency Department Record documented the patient left AMA at 1720 "before being seen... I am fine, I don't have any problems" was handwritten on the form. There was no documentation the patient had been informed of the risks and benefits of leaving the ED without medical examination and treatment or that written refusal of examination and treatment was sought.

Based on review of the hospital's transfer policy, Medical Staff By-Laws, EMS ambulance record review and medical record review, it was determined the hospital failed to ensure that patient's who required transfer to a higher level of care were informed of the risks and benefits of the transfer, certified by physicians the appropriateness of the transfer, and to ensure the receiving hospital was notified and had agreed to the transfer for 2 of 6 (Patients #2 and 22) sampled patients who were transferred.

The findings included:

1. Review of the hospital's transfer policy documented in order for patients to be transferred to another hospital emergency department (ED) the following rules must be followed, "...1. Upon completion of a physician's assessment and diagnosis, the patient and/or family member should be made aware of circumstances that necessitate the transfer. 2. The physician must contact a receiving physician as to the patient status and to determine acceptance and bed availability. The receiving physician and receiving facility must agree to accept the transfer. 3. Upon acceptance, the nurse must obtain the patient's, or responsible person if patient is unable to give, permission in writing to be transferred to the receiving facility/physician...".

2. Review of the Medical Staff By-Laws dated March 2010 documented, "...Patients with conditions whose definitive care is beyond the capabilities of this Hospital shall be referred to the appropriate facility, when in the judgment of the attending practitioner; the patient's condition permits such a transfer. The Hospital's procedures for patient transfers to other facilities shall be followed and in accordance with EMTALA regulations ..."

3. Medical record review for Patient #2 documented the patient arrived at the hospital's ED on 5/3/10 at 1135 and was stabilized and discharged home. At 1450 the patient returned to the hospital's ED, was treated with medication and transferred by Air Ambulance to a higher level of care. There was no documentation the patient/family member or responsible party signed a consent form for the transfer or the risks and benefits of the transfer were explained to the patient.

4. Review of the EMS ambulance record dated 10/19/10 documented Patient #22 was transported to Hospital A's ED at 1915 with complaints of chest pain and ventricular tachycardia (V-tach).

The ambulance record documented upon arrival to the Hospital A's ED at 1915, ED physician #1 met the ambulance in the parking lot and "convinced" Patient #22 to go to a critical care unit at Hospital B. The ambulance record documented Patient #22 was transported to Hospital B.

There was no documentation Patient #22, or the patient's family/responsible party, had signed a consent form for the transfer and the risk and benefits of the transfer were explained to the patient. There was no documentation of a physician certification for the appropriateness of the transfer or the receiving hospital's or physician's acceptance of the transfer.

INTAKE: TN00026986

1. Based on review of the hospital's emergency department policies, the hospital's Medical Staff By-Laws, Emergency Medical Services ambulance record review, medical record review and interview, the hospital failed to provide medical screening examinations for 2 of 22 (Patients #2 and 22) sampled patients who presented to the Emergency Department seeking care. Refer to findings in deficiency A-2406.

2. Based on review of the hospital's emergency department policies, medical record review and interview, the hospital failed to ensure risks and benefits of receiving examination and treatment were provided and written refusal of examination or treatment was sought for 5 of 5 (Patients #3, 5, 6, 8 and 10) sampled patients reviewed for leaving prior to examination or treatment. Refer to findings in deficiency A-2407.

3. Based on review of the hospital's transfer policy, Medical Staff By-Laws, EMS ambulance record review and medical record review, the hospital failed to ensure an appropriate transfer to a higher level of care for 2 of 6 (Patients #2 and 22) sampled patients who were transferred. Refer to findings in deficiency A-2409.

Based on review of the hospital's emergency department (ED) Central log, the Emergency Medical Services (EMS) ambulance report, the hospital's ED policy and interview, it was determined the hospital failed to ensure that each patient who presented to the hospital's ED was documented on the hospital's ED central log for 1 of 22 (Patient #22) sampled patients who had presented to the hospital's emergency department.

The findings included:

1. Review of the hospital's ED central log dated 10/19/10 revealed no documentation that Patient #22 had presented to the hospital's ED seeking care.

2. Review of the EMS ambulance report dated 10/19/10 documented Patient #22 was transported to and arrived at the hospital's ED at 1915.

3. Review of the hospital's policy, "Priority for Patient Care: Screening and Stabilization to the ER", documented, "...A triage assessment will be performed on each patient seeking care in the emergency department...The triage/screening is to be recorded in the patient's medical record and in the ER register/log...".

4. During an interview on 10/28/10 at 10:20 AM, ED Physician #1 verified Patient #22 arrived by ambulance on 10/19/10 to the hospital's ED seeking care for a medical condition.

5. During an interview on 10/28/10 at 10:45 AM, ED LPN #1 verified Patient #22 arrived by ambulance to the hospital's ED seeking care on 10/19/10. LPN #1 stated he/she did not document the patient's name on the hospital's ED central log.

6. During a telephone interview on 11/1/10, Paramedic #1 verified he/she had taken Patient #22 by EMS ambulance to the hospital's ED on 10/19/10 seeking care for a medical condition.

Based on the hospital's emergency department (ED) policies, the hospital's Medical Staff By-Laws, Emergency Medical Services (EMS) ambulance record review, medical record review and interview, it was determined the hospital failed to ensure a medical screening examination (MSE) was performed on 1 of 22 (Patient #22) sampled patients who presented to the hospital's ED seeking medical care.

The findings included:

1. Review of the hospital's ED policy, "Emergency Department Scope of Care and Services", documented, "...All patients who present seeking attention from the Medical Staff will be seen and evaluated as follows: 1. Initial assessment by licensed personnel. 2. Medical screening by the physician. 3. Treatment as deemed appropriate by the physician. 4. Referral as indicated..."

2. Review of the hospital's policy, "Priority for Patient Care: Screening and Stabilizing in the ER", documented, "... Whenever an individual comes to the hospital emergency department requesting an examination or treatment, the individual shall be screened without delay to determine whether emergency medical condition exists ...."

3. Review of the Hospital A's Medical Staff By-Laws dated March 2010, documented, "... All patients presenting to the emergency department will be seen by a Qualified Medical Person as defined by the [name of hospital] Medical Staff By-Laws ...."

4. Review of the EMS ambulance record dated 10/19/10 documented Paramedic #1 arrived at Patient #22's residence at 1829. The ambulance record documented the patient was experiencing chest pain and ventricular tachycardia (V-tach). At 1840, Paramedic #1 administered Amiodarone 150 milligrams (mgs) intravenous push (IVP) and the patient converted to atrial fibrillation (A-fib), at which time the patient denied further chest pain. The ambulance record documented the patient was transported to Hospital A's ED.

The EMS ambulance record documented upon arrival at Hospital A's ED at 1915, ED Physician #1 met the ambulance in the parking lot and "convinced " Patient #22 to go to a critical care unit at Hospital B. The ambulance record documented Patient #22 was immediately transported to Hospital B .

5. During an interview on 10/28/10 at 10:20 AM, ED Physician #1 stated Patient #22 arrived by EMS ambulance on 10/19/10 to Hospital A's ED. ED Physician #1 stated he/she met the ambulance in Hospital A's ED parking lot and "convinced" the patient to go to a critical care unit at Hospital B. ED Physician #1 stated he/she instructed the EMS personnel to take Patient #22 to Hospital B. ED Physician #1 stated he/she did not perform a medical screening examination on the Patient #22.

6. During an interview on 10/28/10 at 10:45 AM, ED LPN #1 stated he/she had received a call from the EMS ambulance on 10/19/10 that the EMS ambulance was in route to Hospital A's ED with Patient #22, with a diagnosis of V-tach which had converted to A-fib after receiving Amiodarone 150 mgs IVP. ED LPN #1 stated he/she informed ED Physician #1 of Patient #22's pending ambulance arrival and diagnosis.

ED LPN #1 stated when the ambulance arrived at Hospital A's ED, ED Physician #1 went outside and met the ambulance in Hospital A's ED parking lot. ED LPN #1 stated when ED Physician #1 came back into the ED he stated he instructed the ambulance to take Patient #22 to Hospital B.

7. During a telephone interview on 11/1/10 at 2:32 PM, Paramedic #1 verified he/she arrived at Patient #22's residence on 10/19/10. Paramedic #1 verified the Patient was complaining of chest pain and was in V-tach. Paramedic #1 verified Amiodarone 150 mg was administered IVP and the patient converted to A-Fib and denied further chest pain. Paramedic #1 verified the patient was then transported to Hospital A's ED.

Paramedic #1 verified upon arrival at Hospital A's ED, ED Physician #1 met the ambulance in Hospital A's ED parking lot. Paramedic #1 verified Ed Physician #1 instructed the EMS ambulance personnel to take the patient to Hospital B. Paramedic #1 verified ED Physician #1 did not come inside the ambulance and perform a medical screening examination on Patient #22. Paramedic #1 verified Patient #22 was transported to Hospital B.

8. Review of Hospital B's ED record dated 10/19/10 documented Patient #22 arrived by EMS ambulance at 2012. ED Physician #3, at Hospital B, performed a MSE at 2035 and stabilized the patient. ED Physician #3 documented, "...We are going to finish the load of Amiodarone, and undergo further workup and treatment..." The patient was admitted to the facility.

9. Review of the medical records for Patients #9, 16 and 21 documented the patients presented to Hospital A's ED with complaints similar to Patient #22 and were provided a MSE:

Patient #9 arrived at the hospital's ED on 7/23/10 at 1627 with complaints of chest pain, unrelieved by nitroglycerin 3 tablets sublingual (SL) and aspirin 81 mg by mouth (PO), shortness of breath (SOB) and diaphoresis. The patient rated the chest pain an 8 on a scale of 1 - 10, with 10 being the most intense. ED Physician #2 documented he/she performed a medical screening examination (MSE) at 1640, stabilized the patient and transferred the patient to a higher level of care.

Patient #16 arrived at the hospital's ED on 10/14/10 at 1435 with complaints of chest pain radiating to the left arm. The patient rated the chest pain a 10 on a scale of 1 - 10, with 10 being the most intense. ED Physician #3 documented he/she performed a MSE, stabilized the patient and admitted the patient to the hospital for observation.

Patient #21 arrived to the hospital's ED on 5/27/10 at 1334 with complaints of chest pain, rating the chest pain an 8 on a scale of 1 - 10, with 10 being the most intense. ED Physician #2 documented he/she performed a MSE at 1410, stabilized the patient and transferred the patient to a higher level of care.

Based on policy review, medical record review and interview, it was determined the hospital failed to ensure all patients who refused examination and treatment were informed of the risks and benefits of examination and and failed to seek written informed refusal of the examination and treatment for 5 of 5 (Patients #3, 5, 6, 8 and 10) sampled patients who left the Emergency Department (ED) Against Medical Advice (AMA).

The findings included:

1. Review of the facility's policy, "Priority for Patient Care: Screening and Stabilizing in the ER [emergency department]" documented, "...If the patient or their representative refuses the treatment, after being informed of the risks and benefits to the patient, ER personnel shall obtain the informed refusal in writing on the Refusal of Emergency Treatment or Transfer form. If refusal can not be obtained, ER personnel shall document steps taken to secure written refusal and the reason it could not be obtained ..."

2. Medical record review for Patient #3 revealed the patient arrived to the ED on 5/7/10 at 2325 with complaints of foot pain. The patient was triaged at 2325 and received a Medical Screening Examination (MSE) at 2340. At 2345 the patient refused further treatment and left against medical advice (AMA). There was no documentation the patient had been informed of risks and benefits of leaving the ED without medical treatment or that written refusal of treatment was sought.

3. Medical record review for Patient #5 documented the patient was transported by the Emergency Medical Services (EMS) to the ED on 5/8/10 at 2045 with complaints of self mutilation. The patient was triaged at 2100. The Registered Nurse (RN) documented at 2115, "Pt [patient] stated she was leaving and left the facility. No attempt was made to stop the pt... sheriff dept [department] called...sheriff dept came to the ER and reported that pt was found back at her residence..." There was no documentation the patient had been informed of the risks and benefits of leaving the ED without medical examination and treatment or that written refusal of examination and treatment was sought.

4. Medical record review for Patient #6 documented the patient arrived to the ED on 5/27/10 at 1349 with complaints of chest pain that radiated to the left arm/jaw/neck area and increased in the chest when neck pain starts. The patient was triaged at 1349 with oxygen, telemetry and serial vital signs initiated and an electrocardiogram was performed. The RN documented at 1446, "Pt leaves AMA. Pt removes BP [blood pressure] cuff and telemetry. Pt instructed on implications of leaving AMA. Talked with pt about need to stay. Nurses had been attending to more critical pt. Pt states 'I can not lay here anymore, I don't care what you are doing.' Pt walked out of ER." The statement, "Left prior to Medical Screening" was handwritten on the Emergency Department Record form. There was no documentation the patient had been informed of the risks and benefits of leaving the ED without medical examination and treatment or that written refusal of examination and treatment was sought.

During an interview on 10/28/10 at 11:09 AM, the Director of Nursing (DON) verified the patient had not been presented with an AMA form for a signature.

During an interview on 10/28/10 at 11:09 AM, the ED Nurse Manager verified there was no documentation anywhere the patient had refused to sign the AMA form.

5. Medical record review for Patient #8 documented the patient arrived to the ED on 7/23/10 at 0815 with complaints of congestion and facial swelling. The Registered Nurse (RN) documented, "At 0825 Pt left stating, 'I know you don't have any patients and I'm leaving cause I've not been seen yet,'" A handwritten note on the Emergency Department Record documented, "Pt left before being triaged." There was no documentation the patient had been informed of the risks and benefits of leaving the ED without medical examination and treatment or that written refusal of examination and treatment was sought.

6. Medical record review for Patient #10 documented the patient was transported by EMS to the ED on 8/1/10 at 1630 with complaints of chest pain. The RN triaged the patient at 1630 and documented, "Upon arrival patient reports anxiety and that she is ready to go home..." The Emergency Department Record documented the patient left AMA at 1720 "before being seen... I am fine, I don't have any problems" was handwritten on the form. There was no documentation the patient had been informed of the risks and benefits of leaving the ED without medical examination and treatment or that written refusal of examination and treatment was sought.

Based on review of the hospital's transfer policy, Medical Staff By-Laws, EMS ambulance record review and medical record review, it was determined the hospital failed to ensure that patient's who required transfer to a higher level of care were informed of the risks and benefits of the transfer, certified by physicians the appropriateness of the transfer, and to ensure the receiving hospital was notified and had agreed to the transfer for 2 of 6 (Patients #2 and 22) sampled patients who were transferred.

The findings included:

1. Review of the hospital's transfer policy documented in order for patients to be transferred to another hospital emergency department (ED) the following rules must be followed, "...1. Upon completion of a physician's assessment and diagnosis, the patient and/or family member should be made aware of circumstances that necessitate the transfer. 2. The physician must contact a receiving physician as to the patient status and to determine acceptance and bed availability. The receiving physician and receiving facility must agree to accept the transfer. 3. Upon acceptance, the nurse must obtain the patient's, or responsible person if patient is unable to give, permission in writing to be transferred to the receiving facility/physician...".

2. Review of the Medical Staff By-Laws dated March 2010 documented, "...Patients with conditions whose definitive care is beyond the capabilities of this Hospital shall be referred to the appropriate facility, when in the judgment of the attending practitioner; the patient's condition permits such a transfer. The Hospital's procedures for patient transfers to other facilities shall be followed and in accordance with EMTALA regulations ..."

3. Medical record review for Patient #2 documented the patient arrived at the hospital's ED on 5/3/10 at 1135 and was stabilized and discharged home. At 1450 the patient returned to the hospital's ED, was treated with medication and transferred by Air Ambulance to a higher level of care. There was no documentation the patient/family member or responsible party signed a consent form for the transfer or the risks and benefits of the transfer were explained to the patient.

4. Review of the EMS ambulance record dated 10/19/10 documented Patient #22 was transported to Hospital A's ED at 1915 with complaints of chest pain and ventricular tachycardia (V-tach).

The ambulance record documented upon arrival to the Hospital A's ED at 1915, ED physician #1 met the ambulance in the parking lot and "convinced" Patient #22 to go to a critical care unit at Hospital B. The ambulance record documented Patient #22 was transported to Hospital B.

There was no documentation Patient #22, or the patient's family/responsible party, had signed a consent form for the transfer and the risk and benefits of the transfer were explained to the patient. There was no documentation of a physician certification for the appropriateness of the transfer or the receiving hospital's or physician's acceptance of the transfer.