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NORWOOD HOSPITAL 800 WASHINGTON STREET NORWOOD, MA 02062 Nov. 9, 2016
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on records reviewed for 9 (Patients #2, #4, #5, #8, #9, #18, #22, #26, and #27) of 33 transferred patient medical records in a total sample of 36 Emergency Department (ED) medical records and policy review the Hospital failed to ensure that ED physicians' documentation in patient medical records was consistent with Hospital policy.

Findings included:

Hospital policy titled Emergency Medical Treatment and Active Labor Act, EMTALA, dated 5/6/16, indicated the Authorization for Transfer Form must be completed by a Physician who authorized the patient transfer to another acute care facility in accordance with EMTALA. The Authorization for Transfer policy indicated the Hospital revised the Authorization for Transfer Form in July 2012.

Authorization for Transfer Forms for Patient's #2, #4, #5, #8, #9, #18, #22, #26, and #27 medical records did not indicate patient transfer information was consistent with the Hospital policy.

1.) Authorization for Transfer Forms for Patient #4, dated 10/8/16; Patient #5, dated 10/29/16; Patient #8, dated 6/1/16; Patient #9 dated 10/18/16: and Patient #22 dated 7/5/16, did not indicate that the ED Physician documented if Patients #4, #5, #8, #9 and #22's Emergency Medical Condition (EMC) were stabilized.

2.) Authorization for Transfer Forms for Patient #4, dated 10/8/16; Patient #5, dated 10/29/16; Patient #8, dated 6/1/16; and Patient #9, dated 10/18/16, did not indicate that the ED Physician documented if the medical benefits outweighed the risk of transfer.

3.) Authorization for Transfer Forms for Patient #4, dated 10/8/16; Patient #5, dated 10/29/16; Patient #9, dated 10/18/16; Patient #18, undated; Patient #26, undated, and Patient #28, dated 6/1/16, did not indicate that the ED Physician ensured that the Patient or the legally responsible individual signed the Authorization for Transfer Form on the Patient's behalf.

4.) Authorization for Transfer Forms for Patient #18 and Patient #26 did not indicate that the ED Physician dated and signed the Form.

5.) Patients #2, #4, #5, #8, #9, #18, #22, #26, and #27 medical records indicated Authorization for Transfer Forms with a revision date of September 2009. Patients #2, #4, #5, #8, #9, #18, #22, #26, and #27 medical records did not indicate ED physicians documented patient transfer information on an updated Authorization for Transfer Form, revision date of July 2012, consistent with Hospital policy.