HospitalInspections.org

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Based on interview, record review and observation of inpatient and outpatient admission information given to patients, the hospital failed to: 1) provide to patients the hospital grievance procedures for handling patient's complaints; 2) provide the State Agency (SA) contact information and/or correct SA contact information to patients; 3) provide a working phone number for the Regional Office for Civil Rights U.S. Department of Health and Human Services; and 4) post patient rights signage in the hospital per hospital policy. These failed practices denied patients/families: 1) a clearly explained procedure for submitting a complaint/grievance and 2) an opportunity to contact the SA and the Regional Office for Civil Rights for complaints/grievances. Findings:

Patients Receiving Patient Rights Information

Patient #18

During an interview on 6/28/16 at 9:20 am in the outpatient Infusion Center, Patient #18 was asked if he had received patient rights information, and if he knew he could contact the SA if he had a concern or complaint regarding his care at the hospital. He said if he had received patient rights information he didn't know he did. He also said he didn't know he could contact the SA.

Patient #19

During an interview on 6/28/16 at 11:28 am, Inpatient #19, when asked if she had received information on patient rights or how to report grievances to the SA, she replied "I don't recall any information given to me or any telephone numbers for State Agency."

Patient #20

During an interview on 6/27/16 at 3:20 pm Inpatient #20, when asked if she had received information on "Patient Rights", she stated that no one had told her anything about patient rights. When asked if she had received any information on how to report a grievance to the SA, she stated that no one told her about reporting grievances to the State Agency.

Patient #32

During an interview on 6/28/16 at 2:00 pm Inpatient #32 was asked if he had received information on patient rights, and if he knew he could contact the SA if he had a concern or complaint, the Patient stated he didn't know he could call the SA for complaints, "I didn't get that information."

Review of the hospital policy "Patient Complaints/Grievances, Handling and Resolution "effective date November 12, revealed "...Each patient and/or the patient's representative will be informed of the grievance process, including whom to contact to file a grievance or complaint. The patient will be informed that a grievance may be directly lodged with the Alaska State Department of Health [Health Facilities Licensing and Certification] regardless of whether he/she has first used the organization's grievance process. This information will be contained in the Patient's Rights and Responsibilities written handout, which will be given out to all patients and/or to their representatives..."

Review of the hospital's "PATIENT'S RIGHTS, RESPONSIBILITIES & RESOLUTION OF COMPLAINTS", given to patients on admission as an inpatient or outpatient, revealed inconsistent and missing information for the hospital's grievance process and contact information for the SA. The patient right's paperwork revealed: 1) the incorrect address and phone number for the SA; 2) it did not list the SA as an option for patients to contact for concerns, complaints, or grievances; and 3) an incorrect phone number for the Regional Office for Civil Rights U.S. Department of Health and Human Services.

Patient Rights Posted

Random observations from 6/27-30/16 throughout the hospital revealed patient rights were not posted in any patient care areas.

During an interview on 6/28/16 at 10:50 am, Charge Nurse #1 stated the "Patient Rights and Responsibilities" signage was not posted in any of their units. They took it off and never put it back after remodeling [2 years ago]."

Review of the hospital's "Patient Rights & Responsibilities (Adult & Pediatric/Neonatal)", dated June 2013, revealed "Patient Rights will be posted in the Emergency Department and Labor & Delivery...Patient Rights and Responsibilities' Statement...will be posted in public areas throughout the hospital."


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Based on interview and record review the hospital failed to ensure implementation of an effective grievance process, evidenced by failing to ensure staff reported patients grievances to the appropriate person to be investigated. This failed practice had the potential to place patients at risk for delayed investigations and responses to patient concerns. Findings:


Patient #20

During an interview on 6/27/16 at 3:20 pm when questioned about the care she'd received, Patient #20 stated, on 6/25/16 she had told two different dietary staff that she had a corn allergy. Her meal selection for dinner was for French fries but on her dinner tray there was corn substituted for the French fries. She stated she was really disappointed with that incident.

During an interview on 6/28/16 at 12:30 pm Charge Nurse (CN) #1 confirmed a grievance report had not been completed for Patient #20's complaint regarding her food allergy even though she was made aware of the incident the following day.

During an interview on 6/29/16 at 1:20 pm, the Risk Manager (RM) said she reviewed and investigated all patient complaints/grievances. She said she didn't know about Patient #20's complaint until 6/28/16 when Dietary and CN #1 reported it to her, after the Surveyor spoke with them.

Patient #32

During an interview on 6/28/16 at 1:50 pm, Patient #32 was asked if he had any concerns or complaints about his hospital stay. The Patient said he had a complaint about one of the nurses taking care of him. The Patient said the nurse yelled at him several times one night because the Patient's television was so loud it prevented the RN from doing his work. The Patient said he told another nurse about the incident and someone "from higher up" spoke to him about it. The Patient said he didn't know if it was investigated or not. He never heard back from anyone.

During an interview on 6/29/16 at 1:20 pm, the RM said she didn't know about Patient #32's complaint but she should have known about it.

In a follow up interview on 6/30/16 at 1:00 pm, the RM stated the Nurse Manager (NM) #1, of Cardiovascular Unit (CVSU) had spoken to the Patient about his complaint. NM #1 confirmed the complaint was not reported to the RM.

Review of the hospital policy "Patient Complaints/Grievances, Handling and Resolution of...", dated November 2012, revealed "...Employee Receiving Grievance Documents the concern on the Patient Grievance Form...Forwards the grievance to the Director of Risk Management immediately..."



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Based on observation, interview and record review the hospital failed to provide dignity and respect for 2 patients residing on the Surgical Progressive Care Unit (SPCU) and Cardiovascular Unit (CVSU). These findings denied the patients their right to dignity and privacy. Findings:

During an observation on 6/28/16 at 11:06 am Patient #10 was observed walking in the SPCU hallway with 2 nursing staff by his side. The Patient's gown was open in the back exposing his backside.

During an observation on 6/28/16 at 1:45 pm, Patient #32 was observed walking in the CVSU hallway carrying his uncovered completely full Foley catheter bag, with urine in the catheter tubing, in one hand and holding his hospital gown closed behind his back with the other hand.

At one point the Patient stopped in front of the nurse's station and spoke to RN #2 telling her he had been waiting to get his catheter bag emptied. After the encounter the Patient left the RN and continued walking around the unit.

During an interview on 6/28/16 at 1:50 pm when asked, Patient #32 said he had been waiting close to an hour to get his catheter bag emptied. He said he had the same problem yesterday with the catheter bag being full of urine and no one to empty it.

Observation on 6/28/16 at 2:20 pm in the CVSU revealed, RN #2 going into Patient #32's room and shutting the door, 35 minutes after the Patient requested someone empty the foley bag.

Review from 6/27-30/16 of the "PATIENT'S RIGHTS, RESPONSIBILITIES & RESOLUTION OF COMPLAINTS PATIENT RIGHTS", revealed "...As a patient at this facility, you have the right to...treatment and services that respects your dignity..."

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Based on observation and policy review, the hospital failed to maintain the confidentiality of 2 patients protected health information in the critical care unit (CCU). Specifically, the hospital failed to protect the patient's personal identifiers; name; medical record number; date of birth; physician name; etc. This failed practice had the potential for unauthorized individuals to access patient's personal information. Findings:


During an observation on 6/27/16 at 3:20 pm in the CCU revealed plastic bins attached to the wall behind the nurses station, which was directly in front of the main entrance into the unit. The bins contained patient information. While standing at the nurses station this Surveyor easily observed printed labels for 2 patients (#'s 13 & 33). The labels exposed the patient's names (in capital letters); dates of birth; location; medical record numbers; and physician names.

Random observations on 6/28/16 in the CCU revealed Patient #13's printed labels could be seen in the patient's medical record bin, while standing at the nurses station.


Review of the hospital policy "HIPAA-Patient Privacy Program Requirements", effective date January 2015, revealed "Protected Health Information (PHI)...Individually-identifiable health information includes demographic information..."


Review of the hospital policy "HIPAA - Violations/Sanctions", effective date March 2016, revealed "Examples of Violations...Improper protection of sensitive information...Leaving records on counters or where otherwise accessible by unauthorized individuals."


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Based on observations, interview, and policy review the facility failed to ensure the kitchen was maintained and organized in an acceptable manner according to policy and the FDA (US Food and Drug Administration) standards. Specifically, the facility failed to ensure: 1) kitchen floors and equipment were kept clean; 2) sanitized dishes were stored in a clean manner; 3) food processor blades were stored in a clean manner; and 4) a refrigerator containing food items was within an acceptable temperature range. These failed practices placed all patients receiving food from the facility at risk for food borne illnesses and infestation from vermin. Findings:

1) Kitchen Floors and Equipment

Random observation throughout the survey on 6/27-30/16 revealed:

A small metal trash can under the kitchen sink had a red flaky corrosion on the top and underside of the lid. The sides, inside and out, were splattered with dried debris.

Multiple areas on the kitchen floor ,under the refrigerator, and around the floor drains contained a dried buildup of blackened dust, grease, and debris.

The outside of all the ovens in the kitchen area had a large amount of built up grease.

Observation on 6/27/16 at 2:41 pm revealed the area and equipment located behind the deep fryer was coated in an excessive amount of grease and debris build up.

During an interview on 6/27/16 at 2:41 pm the Safety Officer stated the area was covered in grease build up and should have been cleaned.

During an interview on 6/30/16 at 9:30 am, the Patient Service Manager (PSM) and the Dietary Director (DD) confirmed the kitchen had an excessive amount of debris and grease build up.

Review of the facility policy, "AREA AND EQUIPMENT CLEANING FREQUENCY/SCHEDULES", effective date January 2015, revealed there were schedules for daily cleaning of outside of ovens by designated staff.

2) Sanitized Dishes

Observation on 6/30/16 at 2:30 pm revealed multiple sanitized trays and pans stacked together. Closer examination revealed the pans and trays were wet and had water dripping off the sides.

During an interview on 6/30/16 at 2:30 pm, the PSM stated the dishwasher was supposed to allow the dishware and pans to air-dry before they were stacked together.

Review of the facility policy, "STORAGE OF POTS, DISHES, FLATWARE, UTENSILS", effective January 2015, revealed: "Air dry pots, dishes, flatware and utensils before storage, or store in a self-draining position. Do not stack or store when wet."

According to the 2013 FDA Food Code, "4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD..."

3) Food Processor Blades

An observation on 6/30/16 at 2:30 pm revealed several food processor blades were stored in a bin. There was a white powder on and around the blades.

Review of the facility policy on 6/30/16 "Facility Area and Equipment Cleaning Frequency" revealed the blade was to be cleaned after each use.

4) Patient Food Refrigerator

Review of the "Refrigerator/Freezer Temperature & Cleaning Log", dated June 2016, revealed a refrigerator, located in the Labor and Delivery Nutrition Room (LDNR), had a temperature of 44-47 Degrees F from 6/22-27/16. Further review of the log revealed "Temp Range: Food 33-40 [Degrees] F." At the bottom of the log under " Discrepancy Log", dated 6/27/16, the box for "Plant Ops Notified" was marked.

Observation in the LDNR, on 6/27/16 at 1:45 pm, revealed a patient food refrigerator contained over 20 8 oz cartons of milk. The refrigerator temperature registered 42 degrees (0) Fahrenheit (F).

During an interview on 6/28/16 at 10:35 am, when asked about the process of monitoring of the refrigerator temperatures, the Director of Women & Children's Services stated Night Shift checked the refrigerator temperatures and reported to the charge nurse in the morning if there is any temperature in unacceptable range.

During an interview on 6/28/16 at 10:50 am, Charge Nurse #1 stated when she had checked the temperature that morning it was 46 degrees F. The Nurse stated Plant Ops had not come to check the refrigerator yet.

According to the FDA food code, Annex 3 page 445, "Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature "Danger Zone" [41o F to 135o F] too long."

Review of the facility policy, "Refrigerator/Freezer: Storage of Medication & Food, Maintenance, and Proper Cleaning of", effective date August 2014, revealed in "PROCEDURE...2) Ensure all refrigerator temperatures are maintained between 38-45 degrees Fahrenheit..."
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Based on interview, record review, and policy review the facility failed to ensure 1 patient's diet was followed. Specifically, the facility failed to ensure a food allergy was listed on the patient's diet card and subsequently served the patient a food she was allergic to. This failed practice created a risk for a severe life threatening allergic reaction. Findings:

During an interview on 6/27/16 at 3:20 pm, when asked about the services at the facility, Patient #20 stated there had been a problem on 6/25/16. "I had stated that I had corn allergies before on admission. On the dinner menu I requested French fries. When my tray came I found there was a stamped message on the preprinted menu sheet we are very sorry for the substitution and they had sent corn, though I was allergic to corn and corn products."

Review of the medical record on 6/27/16 revealed Patient #20 was on a regular diet and was allergic to "Corn Containing Products."

Review of the "Hospitality Suite NCM Select " used by dietary to prepare the trays, revealed the corn allergy was not listed.

During an interview on 6/28/16 at 9:15 am, when asked about Patient #20 receiving the wrong diet, the Dietary Director stated although the dietary department had a different computer system than the nursing units, the systems should link the patient diets and any food allergies, to the dietary system. The Dietary Director confirmed Patient #20 had received the wrong food because the allergy was not listed in the diet information.

During an interview on 6/28/16 at 9:20 am, Dietary Staff (DS) #1 stated "In 200 patients one may happen like this [referring to the Patient receiving the food she was allergic to]. DS #1 confirmed the allergy and order had been entered correctly into the system and stated the computer system had not picked up the allergy when the menu was printed.

Facility Policy Title,"CPCS Diet System & Downtime Procedures Policy," ...effective 2014, revealed "The Diet Aide, Supervisor, Dietician will:...Diet Aides check menus with list of current diets prior to each meal. LIST MEAL LABELS is used to identify menu. Stickers are placed on menus for more attention such as FOOD ALLERGY, FLUID RESTRICTION."

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Based on observation, interview and record review the facility failed to maintain their hemodialysis (removing waste products from the blood) machines in a manner to reduce the risk of infections and potential life threatening reactions for patients receiving hemodialysis in the facility. This failed practice placed all patients receiving hemodialysis at the facility in immediate jeopardy for harm and/or death from chlorine, chloramines and other harmful organic substances potentially entering the blood stream during the dialysis process. The risk of immediate harm to the patients receiving dialysis was reported to the facility's administrative team on 6/30/16 at 9:10 am. The facility removed the immediacy at 6/30/16 at 11:20 am. Findings:

Refer to CFR 482.41(c)(2) / A-0724.


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Based on observation, interview and record review the facility failed to maintain their hemodialysis (removing waste products from the blood) machines in a manner to reduce the risk of infections and potential life threatening reactions for patients receiving hemodialysis in the facility. Specifically, the facility failed to ensure their hemodialysis machines operated with two carbon filters (used to remove impurities from the dialyzing water) in a safe manner and per manufacturer's recommendations. This failed practice placed all patients receiving hemodialysis at the facility in immediate jeopardy for harm and/or death from chlorine, chloramines and other harmful organic substances potentially entering the blood stream during the dialysis process. This failed practice and the risk of immediate harm to the patients receiving dialysis was reported to the facility's administrative team on 6/30/16 at 9:10 am. The facility removed the immediacy at 6/30/16 at 11:20 am. Findings:

Observations on 6/27/16 at 2:55 pm revealed 1 patient in the facility's dialysis room receiving hemodialysis. The dialysis room had 6 operating dialysis machines. All the machines had a single carbon tank used to remove chlorine and chloramines from the water. There were no dates on the tanks that indicated the last time they were changed.

During an interview on 6/28/16 at 2:00 pm, when asked about the carbon tanks, Biomed Technician #s 1 and 2 stated the carbon tanks were replaced when they were needed. When asked if the carbon tanks were backwashed regularly (flushed to prevent bacterial growth and reticulate carbon) or what the empty bed contact time was, the Biomed Technicians responded they did not know.

Review of the preventative maintenance records for the 6 reverse osmosis machines on 6/28/16 revealed only 2 carbon tanks had been replaced between 5/2014 - 3/2016.

Review of the manufacturer's instructions provided by the facility revealed "Warning: carbon is not regenerated...[Mar Cor Purification-the manufacturer of the water system] strongly recommends the use of two carbon tanks, used in a series configuration."

During an interview on 6/30/16 at 11:35 am, the Nephrologist stated he was not aware the facility had only one carbon filtration system for the RO (reverse osmosis-a process of purification using a semipermeable membrane) water.

Review of the ANSI/AAMI RD52:2004, 5.2.5 Carbon absorption revealed "...For free chlorine and chloramine removal, carbon absorption systems and carbon media should be selected and configured as described in ANSI/AAMI RD62:2001...That is, two carbon beds [filters] shall be installed in series with a sample port following the first bed..."

Chlorine/Chloramine Testing

Observations on 6/28/16 at 7:30 am after a dialysis machine heat disinfection, revealed Dialysis Registered Nurse (RN) #2 taking water from the dialysis machine without allowing the RO to run to the drain for any time before completing a chlorine/chloramine test.

Record review of the "Millenium Reverse Osmosis Unit" maintenance manual provided by Biomed staff, revealed "Product Water Analysis Procedure: Operate the RO unit with product water and waste flows to drain for at least 15 minutes...before drawing sample."

Record review of the policy "Hemodialysis WaterCulture" dated 6/2015, revealed "At each point of collection, open the valve and allow the water to flow for a minimum of 2 minutes before the sample is collected."

Acid Concentrate

Observation on 6/28/16 at 9:30 am revealed multiple Renasol acid concentrate jugs labeled Ca0.0 / K0.0. The acid concentrate jugs were stored adjacent to the standard K2 Ca2.5 jugs of acid concentrate.

Leadership was notified on 6/28/16 at 4:00 pm of the acid storage concern because both the lethal acid concentrate and the standard acid concentrate looked identical with red and white labels. On 6/29/16 at 8:00 am the acid concentrate had not been removed from the storage area.

New Dialysate Meter

Observation on 6/28/16 at 7:30 am revealed a minion dialysate meter without a preventative maintenance label. During an interview at the same time, Dialysis RN #4 stated it was recently new to the department.

During an interview on 6/29/16 at 9:30 am Biomed Technician #1 stated the biomed department had no record of the new minion dialysate meter and therefore could not ensure the reliability of the equipment.

Hemodialysis Competency

During an interview on 6/28/16 at 2:10 pm Biomed Technician #s 1 and 2 stated they had not had any education or certification for hemodialysis water maintenance. In addition, they stated the one dialysis nurse that did have knowledge was no longer employed at the facility.

Record review of the dialysis competencies provided for the staff currently working on the dialysis unit, revealed all competencies were "self" competencies for hemodialysis. One staff member had completed multiple ongoing educations in other states. In addition, no staff were certified hemodialysis technicians, to include biomed staff.


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Based on observation, record review and interview the facility failed to ensure: 1) rubber tops on unopened medication vials were disinfected prior to use; 2) an accurate system for identifying endoscopes was documented in 2 patient records; 3) central line dressings were changed when soiled; 4) handwashing was performed between patients having their blood drawn; 5) patient equipment was cleaned between patients, and 6) staff performed hand hygiene between patients. These failed practices placed patients at risk for illness from infectious diseases. Findings:

Medication Vials

An observation on 6/27/16 at 11:35 am revealed RN #1 preparing to give medications to Patient #1 prior to her scheduled procedure. During the observation the RN popped the lid off a vial of Versed (medication used to cause sleepiness) and a vial of Fentanyl (opiate pain medication), and without disinfecting the rubber stopper with alcohol, used 2 syringes to withdraw the medication and administered them to the Patient. RN #1 then popped the cap off a vial of Zofran (medication for nausea) and, without disinfecting the rubber stopper, withdrew the medication in a syringe and administered it to the Patient.

During an observation on 6/28/16 at 10:29 am, the Certified Registered Nurse Anesthetist (CRNA) prepared to administer medication to Patient #27 prior to her surgery. The CRNA popped the lid off a vial of medication and without disinfecting the rubber stopper, withdrew the contents into a syringe for administration to the Patient. The CRNA then popped the top off of a vial of Propofol (sedative), and without disinfecting the rubber stopper, withdrew the medication into a syringe for use during Patient #27's surgery.

During an observation on 6/29/16 at 10:50 am, Scrub Technician #s 1 and 2 popped the plastic top off a vial of lidocaine (a numbing medication), and without disinfecting the rubber stopper, withdrew the medication into a syringe to use during Patient #28's surgery.

According to the Centers for Disease Control Prevention, accessed at www.CDC.gov on 7/11/16, "Injection Safety Checklist...The rubber septum [stopper] on a medication vial is disinfected with alcohol prior to piercing."

Endoscope Documentation

During an interview on 6/27/16 at 11:55 am, Endo Technician (ET) #1 explained the process of sterilizing the endoscopes. The ET stated surgical staff provided patient stickers with the last four numbers of the scope on it. Staff taped the sticker to whichever side of the duel sided endoscope washing machine the scope was being washed in. ET #1 showed the Surveyor how the numbers of the scope were manually entered into the endoscope washer's computer. After the process was completed, the scope was dried and a tag was attached to the scope. The slip with the patient's name and the serial numbers of the scope was entered into a log book.

Review of the Endoscope log book on 6/27/16, revealed Patient #2 used an endoscope with serial #2898541 and with the ID #8540 written on the slip. Patient #3 used an endoscope with serial #2069464 with the ID #8119 written on the slip.

Review of Patient #2's medical record on 6/28/16 revealed the Patient had an EGD (scope of the upper GI) on 6/27/16 at 10:10 am. The serial number of the instrument used was Colon S/N (serial number) 2808540.

Review of Patient #3's medical record on 6/28/16 revealed the Patient had a scheduled colonoscopy (scope of the lower GI) and polypectomy (removal of polyps) on 6/27/16. The serial number of the instrument used was the Colon S/N 2898119.

When asked about the discrepancy in the numbers, ET #1 stated they were supposed to match but they didn't.

Central Line Dressings

Observation on 6/27/16 at 2:10 pm revealed large amount of dried blood under the a central line dressing on the right upper arm of Patient #10

Further observation on 6/28/16 at 7:15 am, revealed the same dried bloody dressing present on Patient # 10's right upper arm.

Observation on 6/28/16 at 9:45 am revealed a large amount of blood under the central line dressing on the right upper arm of Patient #12

IV Tubing

Observation on 6/27/16 at 2:10 pm revealed #10's IV tubing attached to an empty bag of IV fluids was not labeled with a date.

Observation on 6/27/16 at 2:45 pm revealed the IV tubing for Patient #34 was not labeled with a date.

Review of facility policy "Central Line Management" dated, 11/22/12, revealed "...Bio-occlusive dressing will be changed...,if the integrity becomes compromised e.g. loose, damp, visibly soiled, bloody...Date and time all dressings and IV tubing."

Hand Hygiene

Observation on 6/28/16 between 7:10 am and 7:18 am revealed Phlebotomist #1 and a student Phlebotomist drawing blood from the Patients in rooms 331, 332, 333 and 335. The phlebotomist removed gloves after each patient blood draw but did not perform hand hygiene before or after each blood draw on the 4 patients.

Patient Equipment and Hand Hygiene

An observation in Cardiac Rehabilitation on 6/30/16 at 8:50 am revealed, RN #3 checking patient blood pressures using a stethoscope and blood pressure cuff. The RN moved from patient to patient, in the group of patients attending the class, checking blood pressure readings without cleaning the stethoscope or blood pressure cuff between the patients. RN #3 then handed the blood pressure cuff and stethoscope to the Physical Therapist (PT) without cleaning the equipment. The PT continued to check blood pressure readings on the remaining patients, again with no cleaning between the patients. Neither the RN nor the PT washed hands between patients.

Further observation on 6/30/16 at 9:30 am revealed class participants using and moving between various pieces of exercise equipment including; treadmills, hand bikes, floor mats and various weights without any cleaning of the equipment between patients.

During an interview on 6/30/16 at 9:00 am RN #3 stated she only cleaned the equipment in the morning before the patients come for exercise, not between each patient using the equipment.

During an interview on 6/30/16 at 10:00 am the Director of Rehab stated equipment cleaning should be done between patients.




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Based on observation the facility failed to ensure signage informing patients of the Emergency Medical Treatment and Labor Act (EMTALA) was posted at all entrances to the Emergency Department (ED) and in the ED treatment areas. These failed practices denied patients access to information about their right to a Medical Screening Exam. Findings:

Random observations from 6/27-30/16 of the Emergency Department revealed no EMTALA signage when entering the ED from the ambulance bay. Observations also revealed no EMTALA signage in the exam and treatment areas of the ED.

During an interview on 6/30/16 the Charge Nurse #2 confirmed there was no EMTALA signage in the ambulance bay entrance and in the exam and treatment areas of the ED.

Review of the hospital policy "EMTALA - Signage", dated March 2014, revealed "...Signage must be conspicuously posted in any place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment..."

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