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Based on review of Medical Staff Bylaws, facility policy, medical record (MR) and interviews with staff (EMP) it was determined that Saint Catherine Medical Center Fountain Springs failed to follow their adopted policies in relation to the Emergency Medical Treatment And Labor Act (EMTALA).

Findings include:

A review conducted on October 6, 2010, of Saint Catherine Medical Center Fountain Springs Medical Staff Rules and Regulations, last revised January 2010 revealed, "... Article VI. Emergency Medical Screening, Treatment, Transfer & On-call Policy 6.1 Screening Treatment & Transfer 6.1(a) (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition...6.1 (b) Stabilization (1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge...6.1 (c) Transfer (1) The Emergency Department physician shall obtain the consent of the receiving hospital facility before the transfer of an individual...(2) The condition of each transferred individual shall be documented in the medical records by the physician responsible for providing the medical screening examination and stabilizing treatment...(3) Upon transfer the Emergency Department shall provide appropriate medical records regarding its treatment of the individual...(4) All reasonable steps shall be taken to secure the written consent or refusal of the patient (or the patient's representative) with respect to the transfer..."

A review conducted on October 6, 2010, of Saint Catherine Medical Center Fountain Springs Nursing Administration EMTALA Guidelines, last reviewed March 2010 revealed, " ...1. Documentation on all Emergency Care records must include: a. Patient has received explanation for transfer and potential risks involved as well as benefits of transfer. b. patient or responsible party has signed the consent to transfer. c. Receiving physician has been contacted by the Emergency Care Center physician and agrees to accept transfer, receiving physician's name must be documented on Emergency care record... (d) Patient is stabilized for transport. (e) Transform [sic] form is attached."

1) A review conducted on October 6, 2010, of the Pennsylvania EMS report on October 6, 2010, revealed, "...Narrative 38-02 Was dispatched by Schuylkill 911 Center for a 1 year old female with an unknown problem. Upon arrival on scene found mother holding a one year old female who was shaking and unresponsive. Mother walked out to the ambulance with the child and climbed in the back of the ambulance and sat on the stretcher...Writer made the decision to Stop [sic] at St Catherine Medical Center to stabilize the patient. Doctor at St catherine's [sic] decided to send the patient to Schuylkill Medical center [sic] South..." Further review revealed the ambulance was dispatched on October 1, 2010, and arrived on scene at 5:08 AM.

2) An offsite review conducted on October 7, 2010, of MR25, obtained from Schuylkill Medical Center South Jackson, revealed the patient was admitted on October 1, 2010, at 5:50 AM. Further review of Schuylkill Medical Center South Jackson Emergency Department Report revealed, "...HISTORY OF PRESENT ILLNESS: ...via ALS to the Emergency Department after being seen at St. Catherine's..." Further review revealed the patient had a diagnosis of Status Epilepticus, received treatment and was transferred to Geisinger Medical Center.

3) An interview conducted on October 6, 2010, at 8:30 AM with EMP1 confirmed that the one year old female brought to the emergency department by ambulance on October 1, 2010, was not entered on the emergency room log and no medical record containing a medical screening examination and, no patient transfer was created.

Based on review of the Emergency Department central log and interview with staff (EMP), it was determined the facility failed to ensure that a central log entry was generated on each individual who came to the Emergency Department, seeking assistance, whether or not the individual was refused treatment, transferred or stabilized and transferred for one of one patent reviewed (PT1).

Findings include:

1) A review on conducted October 6, 2010 of the "Emergency Department Patient Log" for October 1, 2010, revealed that PT1 was not listed on the log.

2) An interview conducted with EMP1 on October 6, 2010, at 8:30 AM, confirmed that PT1 had not been entered onto the log.

Based on a review of facility policies, documents and interview with staff (EMP), it was determined that Saint Catherine Medical Center Fountain Springs failed to document an appropriate medical screening examination by qualified medical personnel to an individual seeking examination and failed to effect an appropriate transfer for one patient that presented to the Emergency Department of St Catherine Medical Center Fountain Springs (PT1).

Findings include:

A review conducted on October 6, 2010, of Saint Catherine Medical Center Fountain Springs Medical Rules and Regulations, last revised January 2010 revealed, "Article VI Emergency Medical Screening, Treatment, Transfer & On-call Policy 6.1 Screening Treatment & Transfer 6.1(a) (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition..."

A review conducted on October 6, 2010, of Saint Catherine Medical Center Fountain Springs Medical Staff Bylaws, last reviewed January 25, 2010, revealed, "...3.3 (f) Adequately prepare and complete in a timely fashion the medical and other required records for all patients....in any way provides care to..."

1) A review conducted on October 6, 2010, of the Pennsylvania EMS report on October 6, 2010, revealed, "...Writer made the decision to Stop [sic] at St Catherine Medical Center to stabilize the patient. Doctor at St catherine's [sic] decided to send the patient to Schuylkill Medical center [sic] South..."

2) An offsite review conducted on October 7, 2010, of MR25 (PT1's MR) obtained from Schuylkill Medical Center South Jackson revealed that PT1 was admitted on October 1, 2010, at 5:50 AM. Further review revealed, " Schuylkill Medical Center South Jackson Street Emergency Department Report...HISTORY OF PRESENT ILLNESS: ...via ALS to the Emergency Department after being seen at St. Catherine's..."

3) An interview conducted on October 6, 2010, at 1:30 PM with EMP2, confirmed that no medical record was created for PT1. EMP2 stated, " I checked the child over. If the child had a medical record initiated, I would have been obligated to perform additional testing. After the child left the ED, I returned to the call room and documented my thoughts and interpretations onto a progress note."

Based on review of Saint Catherine Medical Center Fountain Springs Medical Staff Rules and Regulations, documents and interview with staff (EMP) and others (OTH), it was determined that the facility failed to provide a medical screening examination and treatment and stabilization of an emergency medical condition within its capability and capacity for one patient presenting to their Emergency Department (PT1).

Findings include:

A review conducted on October 6, 2010, of Saint Catherine Medical Center Fountain Springs Medical Staff Rules and Regulations, revised January 2010 revealed, "Article VI Emergency Medical Screening, Treatment, Transfer & On-call Policy 6.1 Screening Treatment & Transfer...6.1 (b) Stabilization (1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge..."

1) A review conducted on October 6, 2010, of the Pennsylvania EMS report dated October 6, 2010, revealed, "...Narrative 38-02. Was dispatched by Schuykill 911 Center for a 1 year old female with an unknown problem. Upon arrival on scene found mother holding a one year old female who was shaking and unresponsive. Mother walked out to the ambulance with the child and climbed in the back of the ambulance and sat on the stretcher...Writer made the decision to Stop [sic] at St Catherine Medical Center to stabilize the patient. Doctor at St catherine's [sic] decided to send the patient to Schuylkill Medical center [sic] South..."

2) A telephone interview conducted on October 6, 2010, at 10:05 AM with OTH1. OTH1 stated that Basic Life Support (BLS) unit had been dispatched to a residence for a one year old with possible seizure activity. OTH1 was to transport PT1 to Schuylkill Medical Center South Jackson (SMCSJ). OTH1 stated that PT1 started to shake and began to aspirate. OTH1 felt PT1 was not stable enough to complete the trip to SMCSJ and made the decision to stop at the Emergency Department (ED) at St. Catherine Medical Center Fountain Springs. OTH1 stated that after a few minutes, St. Catherine's staff made the decision that PT1 was stable and transport to SMCSJ could continue so the child was placed in the ALS ambulance and transported to SMCSJ.

3) An interview conducted on October 6, 2010, at 1:30 PM with EMP2, confirmed that no medical record was created for PT1. EMP2 stated, " I checked the child over. If the child had a medical record initiated, I would have been obligated to perform additional testing. After the child left the ED, I returned to the call room and documented my thoughts and interpretations onto a progress note."

Based on review of facility documents, ambulance records, and interview with staff (EMP), it was determined that Saint Catherine Medical Center Fountain Springs failed to provide a proper transfer to another facility for three of seven patients transferred from their Emergency Department (PT1, MR1, and MR14).

A review conducted on October 6, 2010, of Saint Catherine Medical Center Fountain Springs Medical Staff Rules and Regulations, last revised January 2010 revealed, "Article VI Emergency Medical Screening, Treatment, Transfer & On-call Policy ...6.1 (c) Transfer (1) The Emergency Department physician shall obtain the consent of the receiving hospital facility before the transfer of an individual...(2) The condition of each transferred individual shall be documented in the medical records by the physician responsible for providing the medical screening examination and stabilizing treatment...(3) Upon transfer the Emergency Department shall provide appropriate medical records regarding its treatment of the individual..."

1) A review conducted on October 6, 2010, of the facility Emergency Department log on October 6, 2010, revealed no documented evidence that PT1 presented to the ED and/or that transfer arrangements were made for PT1.

An interview conducted on October 6, 2010, at 8:30 AM with EMP1 confirmed that PT1 was brought by ambulance to the emergency department on October 1, 2010. Further interview confirmed the transfer was not documented.

2) A review conducted on October 6, 2010, of MR1 and MR14 revealed no documented evidence that medical records related to the emergency condition were sent to the receiving facility.

An interview conducted on October 6, 2010, at 1:15 PM with EMP1 confirmed that MR1 and MR14 had no documented evidence that medical records related to the emergency condition were sent to the receiving facility.