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Based on review of hospital documents and emergency room (ER) policies and procedures, and interviews with hospital staff, the hospital failed to develop and enforce policies and procedures to ensure compliance with the requirements of 42 CFR 489.24. The hospital failed to:

1. Develop a policy concerning recipient hospital responsibilities.

2. Enforce its policy and procedure concerning transfer of unstable patients to another acute care facility. This occurred for one of four patients (Patient #11 of Patients #8, 11, 16 and 18) who were transferred to another acute care facility and whose medical record was reviewed.

Findings:

1. Upon arrival at the hospital on the morning of 01/13/2010, the surveyors requested to review the hospital's policies concerning EMTALA (Emergency Medical Treatment and Active Labor Act) requirements. The Director of nurses supplied four policies and procedures. Policies entitled "Emergency Room Policy", "Assessment of Patients Seeking Medical and Psychiatric Care" and "Emergency Room Admission/Referrals/Discharge"contained medical screening requirements. The fourth policy, "Transfer of Patients" recorded the procedure for transfer of patient to other facilities.

2. Transfer:
The hospital did not follow its "Transfer of Patients" policy, revision date of 06/2000, which complied with EMTALA requirements and required the physician to document the risk and benefits for patients that were transferred in an unstable condition. The ER physician documented Patient #11 needed to be transferred to another acute care hospital. She documented in the patient's Physician Certification that the patient was in unstable condition, but did not document the risks and benefits for this particular patient. The record contained a second form that listed possible risks and benefits for transfer, but the form only contained the physician's signature.

3. Recipient hospital responsibilities:
The policies provided to the surveyors did not contain a policy concerning recipient hospital responsibilities. The Chief Nursing Officer told the surveyors the hospital did not have a policy concerning this requirement.

Based on a review of the Emergency Department's (ED) log, ED policies and procedures, Medical Staff Meeting Minutes dated 10/21/09, and staff interviews, the hospital failed to ensure the ED log was complete and contained all the required information. From May 2009 through to January 2010, the log did not contain 60 dispositions/discharges and 1 non-entry of a patient who was provided ED care.

Findings:

1. The hospital's policy, Emergency Room Admission/Referral/Discharge, with a revision date of 07/14/2008, stipulated that the emergency room (ER) log should contain the "patient's name, age, time and date of admission to ER, diagnosis, doctor called, nurse caring for the patient and disposition of the case."

2. Review of the grievance documents recorded Patient #A presented to the ER on the night of 11/13/2009. This was confirmed on 01/14/2010, by staff interviews with the individuals involved with Patient #A presentation on the night of 11/13/2009.

3. The ER log did not contain an entry for Patient #A's 11/13/2009 visit. On 01/14/2010 at 0945, the ER nurse who saw Patient #A stated that Patient #A was not listed in the ER log and no ER record of Patient #A's 11/13/2009 visit was created.

4. The surveyors reviewed the ER log for completeness for the time period of July 1, 2009 through December 31, 2009. The log contained 5408 entries for this time period. The ER log did not contain the disposition for:
a. May 1 to July 6, 2009 - 9 patients.
b. July 7 to September 9, 2009 - 6 patients.
c. September 9, to September 30, 2009 - 6
d. October 2009 - 7 patients.
e. November 2009 - 11 patients plus 1 non entry.
f. December 2009 - 14 patients.

5. The surveyors reviewed and verified findings #4 with the Chief Nursing Officer on the afternoon of 01/14/2010. All findings were reviewed during the exit conference on the afternoon of 01/14/2010.