The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HSHS ST ELIZABETH'S HOSPITAL ONE ST ELIZABETH BOULEVARD O FALLON, IL 62269 Nov. 17, 2011
VIOLATION: RECEIVING AN INAPPROPRIATE TRANSFER Tag No: A2401
A. Based on a review of Hospital letter, a review of internal documentation, and staff interview, it was determined the Hospital failed to ensure notification to The Center for Medicare and Medicaid Services (CMS) or the State survey agency within 72 hours of receiving an individual who has been transferred in an unstable emergency medical emergency (EMC) from another hospital in violation of the Emergency Medical Treatment and Labor Act (EMTALA).

Findings include:

1. A hospital letter dated 11/3/11 from the hospital to CMS was reviewed on 11/16/11. It indicated that on October 23, 2011 an improper transfer from a transferring hospital to the hospital had occurred. It further indicated that " prior to making this report, the hospital has been working with transferring hospital to identify the EMTALA violation and prepare a corrective action plan for the facilities affected by the violation ... "

2. During a staff interview, conducted with the CEO on 11/16/11 at 11:00 AM, it was verbalized that the hospital was advised per legal counsel to await notification of CMS and/or the State agency pending an investigation to ensure that an EMTALA violation had occurred. It was further verbalized that communication had occurred between the hospital and the transferring hospital (which legal asserted privilege over) and a determination was made that an EMTALA had occurred and the facilities jointly reported the event on 11/3/11.

3. During a staff interview, conducted with the Division Vice President Legal Affairs on 11/17/11 at 8:45 AM, it was confirmed that legal counsel had instructed the hospital not to report the possibility of an EMTALA violation pending further investigation of the event in question. It was further confirmed that transferring hospital and the hospital had met to investigate the event and upon determining that an EMTALA had occurred had jointly reported it on 11/3/11.

4. During a staff interview, conducted with the CEO on 11/17/11 at 10:00 AM, the above findings were confirmed.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
A. Based on a review of Hospital Bylaws Rules and Regulations, a review of Emergency Department (ED) and Obstetrical logs, a review of Hospital policy, medical record review, and staff interview, it was determined the Hospital failed to ensure notification to The Center for Medicare and Medicaid Services (CMS) or the State survey agency within 72 hours of receiving an individual who has been transferred in an unstable emergency medical emergency (EMC) from another hospital in violation of the Emergency Medical Treatment and Labor Act (EMTALA). Please see deficiency cited at A-2401; the Hospital failed to ensure the patient and/or patient's representative were informed of the risks and benefits of the transfer and that all pertinent information were sent to the receiving Hospital. Please see deficiency cited at A-2409.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 2 of 7 (Pts #10, #17) medical records reviewed, in which the patient was transferred to an outlying hospital, the hospital failed to ensure the patient's representative was informed of the risks and benefits of the transfer and the hospital failed to complete a detailed physicians certification that indicated risks or benefits of the transfer.

Findings include:

1. The Hospital policy titled " EMTALA- Provision of Services and Patient Procedures " effective 8/3/09 was reviewed on 11/16/11. It indicated " C. Restricting Transfer Until Patient Stabilization: 1. If a patient has an Emergency Medical Condition (EMC) that has not been stabilized, the hospital may not transfer the individual unless: a) The individual requests a transfer in writing (after being informed of risks of transfer) (Form #149, Request/ Permission for Transfer)." " ... E. Information which is to accompany the transfer of an individual with an EMC: 1. All records related to the person ' s EMC (including those that may have been generated during prior hospital admission) 2. Observation of signs or symptoms 3. Preliminary diagnosis. 4. Treatment provided 5. Results of any tests 6. Transfer form. "

2. The medical record of Pt #10 was reviewed on 11/16/11 thru 11/17/11. Pt #10, a 3 year old presented to the Emergency Department (ED) on 10/29/11 at 9:38 PM with the Chief Complaint (CC) Abdominal Pain, Nausea, and No Bowel Movement and was triaged, received a Medical Screening Exam (MSE), had laboratory testing (Complete Blood Count and Complete Metabolic Panel), and was transferred to another hospital to Rule Out appendicitis. There was no documentation to indicate that Pt. #10's representative requested transfer and or was instructed on the risks and/or benefits of the transfer, prior to the transfer. The physician certification was incomplete regarding a summary of the risks and benefits upon which the transfer was based on.

3. The medical record of Pt #17 a 4 year old was reviewed on 11/16/11 thru 11/17/11. Pt #17 (MDS) dated [DATE] with the CC Dyspnea and Asthma was triaged, received a MSE, received intravenous therapy, nebulizers, oxygen,and laboratory testing and then was transferred to another hospital for further evaluation. There was no documentation to indicate that Pt #17's representative requested the transfer and/or was instructed on the risks and/or benefits of the transfer, prior to the transfer. The physician certification was incomplete regarding a summary of the risks and benefits upon which the transfer was based on.

4. During a staff interview, conducted with the CEO on 11/17/11 at 10:00 AM, the above findings were confirmed.