HospitalInspections.org

Based on a review of facility policy, observations, and staff interview (EMP), it was determined the facility failed to ensure conspicuous signage was posted in all required areas specifying the rights of individuals under section 1876 of the Act with respect to examination and treatment for emergency medical conditions and women in labor, as well as information indicating whether or not the hospital participates in the Medicaid program.

Findings include:

On January 4, 2022, a review of the facility policy, EMTALA (Emergency Medical Treatment and Labor Act)...Revision date...May, 2016, revealed, "Signs--Signs will be posted in conspicuous locations likely to be noticed by all individuals entering the Emergency Department, as well as those individuals waiting for examination and treatment. Signs must state the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor. Signs will indicate whether the faciliy participates in the Medicaid Program."


On January 4, 2022, at 10:20 AM, a tour of the Emergency Department (ED) was conducted. The ED has 3 exam rooms and 6 exam bays. The entrance to the ED, the ED registration area, and the ED waiting area all lacked EMTALA signage. The 6 exam bays also lacked EMTALA signage During an interview at the time of the tour, EMP 1 confirmed the ED had no EMTALA signage in the above areas.

Based on a review of facility policy and medical records (MR) and staff interview (EMP), it was determined that the facility failed to take all reasonable steps to secure the patient's written informed refusal of transfer, failed to inform the patient of the risks and benefits of the transfer, and failed to document the reason for the patient's refusal for one of 24 medical records reviewed (MR1).


Finding include:

On January 5, 2022, a review of the facility policy, EMTALA (Emergency Medical Treatment and Labor Act) with revision date of May 2016, revealed ". ... PROCEDURE: Hospitals that have an Emergency Department that participate in Medicare are required to do the following: Obtain or attempt to obtain written and informed refusal of examination, treatment or an appropriate transfer in the case of an individual who refuses examination, treatment or transfer...."

On January 5, 2022, at 1:15PM, a review of MR1 indicated that the patient was admitted to the facility's Emergency Department (ED) on December 10, 2021, at 23:11, with the Chief Complaint of left testicular drainage. The review of MR1 revealed that attending physician EMP1 wanted the patient to be seen by a urologist as it "could turn into something worse if it progresses the abscess could be larger and this could develop into Fournier's" and that the patient did not want to be transferred. Further review determined that MR1 did not include documentation of written informed refusal of transfer, did not include documentation of risks and benefits of transfer, and did not include documentation of the patient's reason for refusal.

On January 5, 2022, at 1:10PM, during an interview EMP1 stated that the patient was offered a transfer. Additionally, EMP1 confirmed that there was no attempt to obtain written informed refusal of a transfer, as required per facility policy.