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COZAD COMMUNITY HOSPITAL P O BOX 108, 300 EAST 12TH ST COZAD, NE 69130 June 14, 2012
VIOLATION: QA - QUALITY OF PATIENT CARE Tag No: C0336
Based on record review of the Quality Assurance (QA) audit tool used to audit Emergency Medical Treatment and Labor Act (EMTALA) compliance and staff interview, the facility failed to accurately record data demonstrating completed documentation of transfers. The audit tool identified documentation in the records as complete when it was not for 2 of 6 (Patients 4 and 5) transferred patients from the Emergency Department (ED). Failure to gather accurate data causes an inability to identify potential quality issues and/or evaluate the effectiveness of action plans. A total sample of 10 ED records were reviewed and compared with QA audit tool results and aggregate QA reports. Findings are:

A. Record review of the ED EMTALA transfer documentation dated 5/16/12 for Patient 4 revealed the section titled "Accompanied by" with lines to mark the category of personnel accompanying the patient. Choices included transfer with a Paramedic, Nurse, Perinatal transporter, Family/Friend, Physician or Other. All were all left blank. Review of the full ED record also found the information lacking notation of who accompanied the patient to the receiving hospital. Record review of the form titled "EMTALA TQM [Total Quality Management] dated 5/16/12 identified with Patient 4's medical record number noted the audit tool was completed and signed/initialed by the transferring nurse and a peer nurse. The DON (Director of Nursing) also reviewed the tool. Under the section on the form titled "Appropriate Transfer" question 4d states "Appropriate transportation mode, equipment and personnel for patient condition" both the patient's nurse and the peer documented "Y" in the yes/no box. The DON initialed review of the form on 5/24/12 with no comments made. This information was verified with the Quality Manager (QM)on 6/14/12 at 1:30 PM.

B. Record review of the ED EMTALA transfer documentation dated 5/16/12 for Patient 5 revealed the form titled EMTALA TQM dated 5/16/12 with Patient 5's medical record number lacked concurrent review of the record by the transferring nurse but did have the DON Nurse Manager review dated 6/12/12. Review of the EMTALA transfer documentation for Patient 5 found the area of the form titled "Benefits of Transfer (Not the reason for Transfer" left blank under the section titled "Physician Certification Section to be Filled Out by Physician". The DON placed a check mark indicating the record documented "Patient specific transfer risks and benefits indicated with physician cert [certification]." The form did contain documentation under "Risks" in actuality what the Benefits were in that the physician documented "for EEG [Electroencephalogram] & monitoring neurology care". There were no risks identified. Under comments on the TQM form the DON made no notes regarding this, only the checkmark that the documentation was there when it was not. Staff interview with the QM on 6/14/12 at 2:00 PM confirmed this finding.

C. Record review of the aggregate QA ER TQM report for May noted 5 of 5 records reviewed were compliant with having risks and benefits documented. 4 of 5 patient records were compliant with having appropriate transportation mode, equipment and personnel for patient condition. Interview with the QM on 6/14/12 at 3:45 PM confirmed this data is "no good, based on audits that were incorrect."

D. Staff interview with the QM on 6/14/12 at 1:30 PM revealed the audit tool was developed by the facility after the facility was cited for an EMTALA violation on 12/30/11. The tool was being used to ensure the facility was in compliance with EMTALA and was part of their Plan of Correction. The QM stated we "rely on data being correct to measure performance."