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Based on tour of the Labor and Delivery entrance and waiting room, the facility failed to post EMTALA signage in places likely to be noticed by all individuals entering the area.

Tour of the unit was conducted on 09/12/18 at approximately 11:00 AM. The tour revealed there was no visible EMTALA signage in the front part of the waiting room or the entrance way. The waiting room was an inverted letter L-shape. At the very back of the waiting room a small sign was posted across the back wall. The failure to conspicuously post EMTALA signage did not ensure patients were fully informed of their rights.

Based on a review of 30 emergency department medical records, it was determined the facility failed to provide timely and appropriate Medical Screening Exams to 3 of 30 patients.

Patient #4 was a 50+ year old who presented to the hospital's emergency department (ED) as a walk-in around 20:20 in early August 2018. Per triage RN documentation at 20:31, "Pt [patient] reports cold s/s [signs and symptoms] x 3 wks. +productive cough. Today began having vomiting, frontal HA, and disorientation. Pt reports increased feeling of pressure in head. Family states pt was babbling at home."

Pain was present at triage per documentation however there was no pain score documented. Patient's blood pressure (BP) at triage was 161/101 mmHg. ESI was classified as 2 by the triage RN. (The ESI is the Emergency Severity Index, a common 5-level scoring tool used to determine the priority of examination and treatment based on symptoms and the likelihood of deterioration without care. ESI 2 is the second most severe presentation.) Four hours later, at 00:21, patient #4 had vitals retaken by the ED technician. BP at this time was 160/100 mmHg and HR was 104 bpm. No pain score was documented. No other interventions were documented prior to this time.

At around 01: 33, orders for labs, CT of head without contrast, chest X-ray and EKG were placed by the ED provider. Patient #4 was documented as having been seen by the ED provider at 01:36, approximately 5 hours later from the time the patient presented to the ED. Per ED provider note, "Patient only complained of a headache at this time. Patient states (he/she) normally does not get a headache like this and this feels like the worst headache of (his/her) life." The CT scan showed a hemorrhage in the brain. The on-call neurosurgeon was consulted who recommended transfer. Patient #4 was transferred by helicopter around 05:00 to another facility for further treatment.

Patient #12 was a 45+ year old who presented to the hospital's ED around 22:32 as a walk-in with a chief complaint of chest pain. Vital signs where within normal limits except for BP of 148/96 mmHg. ESI was classified as 2. Patient's pain was documented as a 4/10 on the pain scale. An EKG and chest X-ray where completed around 23:13 and were normal. Patient #12 refused to have blood drawn for labs. At around 05:00 the next morning, patient was brought back from the waiting room to the main ED. Vital signs were retaken at 05:20. Patient #4's BP was 199/104 mmHg at this time. Patient's pain was documented as 0. Vitals were retaken at 06:00 and 06:59. Patient's BP at those time were 178/106 mmHg and 157/95 mmHg respectively. A physician assistant (PA-C) saw the patient at 07:02, approximately 8.5 hours since presenting to the ED. Per PA note, patient #4 continued to refuse a blood draw. The PA stated, "I discussed with (patient) that if (he/she) is unwilling to undergo blood work, then (he/she) would have to leave AMA as I am unable to ensure that (he/she) did not have a cardiac event or does not have another emergent or life-threatening cause for his chest pain." Patient was also seen by attending ED physician who also documented a discussion with the patient of the risks of missed pathology and that the patient refused any kind of workup. Patient verbalized understanding of the risks leaving AMA.

Patient #15 was a 40+ y/o who presented to the hospital's ED at 21:46 as a walk-in with a chief complaint of stomach fullness and chest pain. ESI was classified as 2 by rapid triage nurse and then changed to a 3 by triage nurse at 21:52. Vital signs were within normal limits. Pain in abdomen was 4/10. An EKG was completed at 22:03 and was normal. Vitals were retaken at 01:17 and 06:47 and were unremarkable.

The next morning at 07:51, a chest X-ray and set of labs were ordered. Labs were negative and the chest X-ray showed a mildly enlarged heart. Patient #15 was seen by ED provider around 07:54, approximately 10 hours after presenting to the ED. Patient #4 reported that the chest pressure had been intermittent for the last 2 days. The stomach pain had been going on for months with symptoms getting worse over time. Patient denied nausea, shortness of breath or diaphoresis. A CT of the abdomen was ordered at 10:57 and was unremarkable. Patient was transferred in stable condition to another facility. Per transfer form at 10:54, the reason for transfer was private physician requested transfer and patient agreed.

The MSEs received by these three patients were inadequate to assess and diagnose the presence of an emergency medical condition as evidenced by the late administration of stabilizing treatment. In addition, the hospital lacked a written process or policies that provided guidelines related to ED patient assessment, reassessment, and reporting of critical values found during assessments. Multiple request were made for a copy of the reassessment policy. Interviews with both ED floor staff and with ED leadership both stated that there was a policy that indicated Q4 hour reassessments of vital signs, but the hospital was not able to provide a policy. Quality department leadership later confirmed that a policy does not exist.

Based on a review of 30 emergency department medical records, it was determined the facility failed to provide timely and appropriate stabilizing treatment to one of 30 patients.

Patient #4 was a 50+ year old who presented to the hospital's emergency department (ED) as a walk-in around 20:20 in early August 2018. Per triage RN documentation at 20:31, "Pt [patient] reports cold s/s [signs and symptoms] x 3 wks. +productive cough. Today began having vomiting, frontal HA, and disorientation. Pt reports increased feeling of pressure in head. Family states pt was babbling at home."

Headache pain and pressure was present at triage per documentation however there was no pain score documented nor was there any documentation of quality or duration of the pain. Patient's blood pressure (BP) at triage was 161/101 mmHg. Four hours later, at 00:21, patient #4 had vitals retaken by the ED technician. BP at this time was 160/100 mmHg and HR was 104 bpm. No pain score was documented. No other interventions were documented prior to this time.

Patient #4 was documented as having been seen by the ED provider at 01:36, approximately 5 hours from the time the patient presented to the ED and orders for labs, CT of head without contrast, chest X-ray and EKG were placed by the ED provider. Per ED provider note, "Patient only complained of a headache at this time. Patient states (he/she) normally does not get a headache like this and this feels like the worst headache of (his/her) life." The CT scan showed a hemorrhage in the brain. The on-call neurosurgeon was consulted at 0220, and recommended transfer. Patient #4 was transferred by helicopter around 05:00 to another facility for further treatment.

Because the MSE was delayed for over five hours, stabilizing treatment was also delayed. Even though neurosurgical services are available at the hospital, patient #4 was transferred to a regional referral center for definitive treatment. It is not known if the delays in MSE and stabilizing treatment contributed to the need to transfer the patient.