HospitalInspections.org

Based on review of the hospital's policies and procedures and staff interview it was determined that the hospital failed to adopt policies and procedures that ensured regulatory compliance with the EMTALA requirement at 489.24.

The census for the emergency department for the month of August 2011 was 2,795 patients.

Findings include:

During the entrance conference which was conducted on 09/27/11 at 10:45 AM the hospital's policies related to EMTALA (Emergency Medical Treatment and Active Labor Act) were requested. At 1:45 PM Staff C, the Director of the Emergency Department stated that he/she was unable to locate any emergency department policies and procedures. Staff C stated that the previous director's computer and floppy disks had been searched in the hope that they could be found but did not contain the requested policies.

An interview was conducted on 09/27/11 at 2:38 PM with Staff D, the hospital's general counsel. When asked to provide the hospital's EMTALA policies for review, Staff D stated that since January of 2010, the hospital has been on its own following a separation from a group of hospitals that were under University Hospital's Health Systems. Since January 2010, the hospital has not had its own EMTALA policy; therefore, it had been on the legal department's long list of things that needed to be completed.

The hospital made available a final draft of an EMTALA policy. This draft of the hospital's EMTALA policy has been approved by the legal department but has not been approved by the hospital's Medical Executive Committee.

Based on observation and interview, the facility failed to ensure a sign was posted in the emergency department waiting area that explained to the public the rights of patients related to the Emergency Medical Treatment and Active Labor Act (EMTALA).

Findings:

On 09/28/11 at 10:45 A.M. a tour was conducted of the emergency department's waiting area with the Vice President of Nursing. The surveyor did not observe signage explaining to the public the patients' rights under Emergency Medical Treatment and Active Labor Act. The surveyor did observe a sign near the patient check-in desk that stated in order to receive "basic medically necessary hospital services," individuals had to be a resident of the state of Ohio, not enrolled in the Medicaid program, and have income at or below the federal poverty line.

During an interview on 09/28/11 at 11:30 A.M., Paramedic #1, was asked where the Emergency Medical Treatment and Active Labor Act signage was. Paramedic #1's response was that he/she pointed to the sign about "basic medically necessary hospital services."

On 09/28/11 at 11:30 A.M. the Vice President of Nursing confirmed that the signage about Emergency Medical Treatment and Active Labor Act was not posted in the waiting area of the emergency department.