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.

NORWEGIAN-AMERICAN HOSPITAL 1044 N FRANCISCO AVE CHICAGO, IL 60622 Dec. 2, 2016
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 2 of 4 clinical records reviewed for transfers to another hospital, (Pt. #6 and Pt. 7) the Hospital failed to ensure an appropriate transfer.

Findings include:

1. The policy entitled "Emergency Medical Treatment and Active Labor ACT (EMTALA)" (revised 4/2014) was reviewed. This policy indicated "6. b...The receiving medical facility's agreement to accept the transfer shall be documented, including the date and time of the agreement to accept shall be documented and the name of the person accepting the transfer...d. (The Hospital) must send a copy of all the medical records available at the time of transfer related to the emergency condition...and a copy of the patient's (or legally responsible person's) written request for transfer for the physician certification."

2. On 12/2/2016 at approximately 10:00 AM, the clinical record of Pt. #6 was reviewed.
Pt. #6 was a [AGE] year old male who presented to the Emergency Department (ED) on 11/6/2016 with a chief complaint of stab wound lower left quadrant of the abdomen. The clinical record indicated Pt. #6 was transferred to another hospital on [DATE] at 7:07 AM via ambulance.

The Nurse Notes dated 11/6/2016 at at 7:07 AM indicated "Consents (to transfer) were obtained." However Pt #6's clinical record did not contain a consent to transfer to another hospital. Pt. #6's clinical record also lacked a transfer form, to include the accepting physician at the receiving hospital, the physician's certification for transfer and the patient's or legally responsible person's written consent for transfer.

3. On 12/2/2016 at approximately 10:20 AM, the clinical record of Pt. #7 was reviewed. Pt. #7 was a [AGE] year old male who (MDS) dated [DATE] with chief complaints of overdose, suicide attempt and psychiatric evaluation. The clinical record indicated Pt. #7 was transferred to a Psychiatric hospital on [DATE] at 5:26 PM. Pt. #7's clinical record did not contain a transfer form, that would include, the accepting physician at the receiving hospital, the physician's certification for transfer and consent from the patient or legally responsible person's written consent for transfer.

4. On 12/2/2016 at 10:30 AM, the findings were discussed with the Nurse Manager of the Emergency Department (E #1). E #1 stated the clinical records should have contained an "Informed Consent to transfer" and a completed transfer form.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on document review and interview, it was determined for 2 of 4 clinical records reviewed for transfers to another hospital, (Pt. #6 and #7) the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure an appropriate transfer. Refer to A 2409.