Based on record review and interview the Hospital failed to have an On-call physician schedule that listed physician names. Findings include The physician On-call schedule was reviewed electronically at 11:30 A.M. on 11/9/16 with the Chief Executive Officer and President. The On-call schedule for Ear, Nose and Throat (ENT) Service for October 2016 listed an office number and not the name of the physicians. The On-call schedule for Vascular Surgery for November 2016 indicated a service telephone number and not the name of the vascular surgeons. The Surveyor interviewed the CEO at 11:30 A.M. on 11/9/16. The CEO said a staff member would call the Hospital Operator for the ENT service telephone number and the physician who was on-call would respond.

Based on records reviewed and interviews the Hospital failed for 6 transferred patients, Patient (Pt) #2, Pt #4, Pt #5, Pt #8, Pt #9 and Pt #22 in a total sample of 36 patients to ensure the Emergency Department (ED) physician certification forms (for patients with an emergency medical condition) were completed as required by the Hospital's Emergency Medical Treatment and Labor Act (EMTALA) policy and procedure. The policy titled EMTALA dated 5/6/16, indicated an Emergency Medical Condition (EMC) was defined as a medical condition manifested by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy. The policy indicated that if a patient has an EMC that has not been stabilized, the hospital may not transfer the individual unless a physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual from being transferred. The certification must contain a summary of the risks and benefits upon which it is based. The policy also indicated that all applicable fields on the Signature Page for Patient's Request/Refusal/ Consent to Transfer must be completed. Pt #2's Emergency Department (ED) medical record, dated 10/2/16, indicated Pt #2 arrived at the Hospital in cardiac arrest. The Ambulance Trip Record, dated 10/2/16, indicated that cardiopulmonary resuscitation was ongoing, Pt #2 had received 4 cardiac defibrillator shocks, had a tube placed in his/her airway to keep the airway open and was unresponsive. The Authorization for Transfer Form, dated 10/2/16, indicated Pt 2#'s EMC was stabilized (that no material deterioration of the condition is likely, within medical probably, to result from or occur during the transfer. An individual will be deemed stablized if the treating physician determined within clinical confidence that the EMC has been resolved). The Surveyor interviewed ED Attending Physician #1 at 12:00 P.M. on 11/08/16. ED Attending Physician #1 said the Hospital did not have a critical care bed for Pt #2, so the patient needed to be transferred to another hospital. ED Attending Physician #1 said after the patient received two different intravenous medications to support his/her blood pressure he/she was stable for transfer. Although Pt #2's medical record indicated the ED physician certified Pt #2's stabilization for transport to another hospital, Pt #2's medical record indicated Pt #2 was mechanically ventilated with a low blood pressure. Pt #2's medical record did not indicate the ED physician stabilized Pt #2 consistent with EMTALA definition of stabilized with an emergency medical condition. Pt #4's Authorization for Transfer Form, dated 10/8/16, indicated the ED physician did not complete the Form consistent with the Hospital's EMTALA policy. The ED physician documented Pt #4's EMC had not been stabilized. Pt #4's medical record indicated the reason for transfer was for neurosurgical treatment (not offered at the Hospital). Despite that the Authorization Transfer Form indicated Pt #4's hospital of choice, the ED physician did not ensure the risks and benefits of the transfer were documented, explained, and signed by Pt #4 or the legally responsible individual signing on the patient's behalf. The Surveyor interviewed the Chief Medical Officer at 9:00 A.M. on 11/9/16. The Chief Medical Officer said the Hospital did not provide neurosurgical services. Pt #5's Authorization for Transfer Form, dated 10/29/16 at 9:15 P.M., indicated that the ED physician did not document consistent with the Hospital's EMTALA policy. The Form did not indicate if Pt #5 was stable at the time of transfer. The ED physician did not document whether the medical benefits of the transfer outweighed the risks and the form was not signed by the patient or the legally responsible individual signing on the Patient's behalf. Pt #8's Authorization for Transfer Form, dated 10/17/16 at 7:20 P.M., indicated the ED physician did not document consistent with the Hospital's EMTALA policy. The ED physician did not indicate if Pt #8's EMC was stabilized. Patient #9's Authorization for Transfer Form, dated 10/18/16, indicated the ED physician did not document consistent with the Hospital's EMTALA policy. The ED physician did not indicate if Pt #9's EMC was stabilized or not. The ED physician did not document whether the medical benefits of the transfer outweigh the risks and the form was not signed by Pt #9 or the legally responsible individual signing on the Patient's behalf. Pt #22's Authorization for Transfer Form, dated 7/5/16 at 10:00 P.M., indicated that the ED physician did not document consistent with the Hospital's EMTALA policy. The Form did not indicate if Pt #22 was stable at the time of transfer. The ED physician did not document whether the medical benefits of the transfer outweighed the risks The Surveyor interviewed the Chief Medical Officer on 11/9/16 at 9:00 A.M. The Chief Medical Officer said the ED physicians were not using the Hospital's current Consolidated Omnibus Budget Reconciliation Act (COBRA) Forms (dated 5/6/16) as outlined in Hospital's EMTALA policies and procedures. The Chief Medical Officer said the ED physicians were using old and outdated forms (dated 9/09).

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.