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Based on observation and interviews with key personnel, it was determined that the facility failed to conspicuously post a sign (in a form specified by the Secretary) specifying the rights of individuals regarding Emergency Medical Treatment and Labor Act (EMTALA) statute in places likely to be noticed by all individuals seeking treatment in the Emergency Department (ED) in 2 of 2 EDs observed (Thayer Center for Health and Alfond Center for Health).

The findings include:

1. During a tour of the ED at the Thayer Center for Health (Waterville campus), on February 21, 2017 at approximately 9:30 AM, it was observed that the notification of EMTALA rights was located in the walk in entrance area, behind a countertop containing a computer station and a filing cabinet that separated this space from the rest of the waiting room. The wording on this sign, other than the heading, was not easily visible from in front of the countertop, and a patient would have to go behind the workstation in order to read the entire posting. Additionally, any patient who approached the registration desk and went immediately to the Triage room or into a treatment room would not have passed the EMTALA signage.

This finding was confirmed, by the ED Nurse Manager, on February 21, 2017 at approximately 9:45 AM, who stated: "You're right. Most people would not look behind the workstation."

2. During a tour of the ED at the Thayer Center for Health (Waterville campus), on February 21, 2017 at approximately 9:30 AM, it was observed that the ambulance entrance failed to have any sign posted providing EMTALA notification for patients arriving by ambulance.

This finding was confirmed, by the ED Nurse Manager, on February 21, 2017 approximately 9:55 AM when she stated "I never thought about the need to place a sign here (in the ambulance entrance)."

3. During a tour of the ED at the Alfond Center for Health (Augusta campus), it was observed on February 21, 2017 at approximately 11:15 AM, that the ambulance entrance failed to have any sign posted providing EMTALA notification for patients arriving by ambulance.

This finding was confirmed, by the ED Nurse Manager, on February 21, 2017 at approximately 11:20 AM.

Based on document review, review of medical records, review of policies and procedures and interviews with key personnel, it was determined that the hospital failed to provide an appropriate medical screening examination to both patients who arrived on the same ambulance and whom were both requesting treatment at MaineGeneral Medical Center for 1 of 21 records reviewed (Record A).

The finding includes:

A telephonic interview was conducted on February 22, 2017 at approximately 7:30 AM, with the Thayer Center for Health (TCH) Emergency Department (ED) Charge Nurse who was reported to have been on duty during the early morning of February 11, 2017. The Charge Nurse stated that he/she received telephonic communication from Sebasticook Emergency Medical Services (EMS) on February 11, 2017 at approximately 2:30 AM. EMS crew reported that the ambulance was enroute to TCH with two (2) patients. The ambulance report indicated that both patients were friends who were reportedly intoxicated, both patients expressed suicidal ideation, both patients were seeking treatment for their symptoms, and both patients were described, by the paramedic, as "not safe to be home". The Charge Nurse indicated that he/she assumed that the two (2) patients had formed a "suicide pact". When asked if the Charge Nurse was advised by the paramedic that there was a suicide pact between the two patients, the Charge Nurse replied "I didn't know it as a fact, but based on what I was told I believed it could have occurred". The Charge Nurse then stated that he/she asked the paramedics if one (1) patient could go to another hospital (Hospital B) and one to TCH. He/she stated "I did not think at that time that one patient would be sitting on hospital grounds waiting to go to another facility".

A telephonic interview was conducted on February 22, 2017 at approximately 7:42 AM, with the TCH ED attending Physician who was reported to have been on duty during the early morning of February 11, 2017. The Physician stated that he/she had been advised by the Charge Nurse that Sebasticook EMS was enroute to the hospital with reportedly two (2) intoxicated patients, whom it was believed were involved in a suicide pact. The Physician stated that after receiving the initial report from the nurse the plan was to "divide these two individuals and prevent any problems by separating them". The Physician reported that the Paramedic was asked if there were any issues with the second patient going to another facility and was advised that no problems were noted. However, the Physician also stated that he/she had not spoken directly to the EMS crew. Additionally, the Physician reported that he/she did not know that the patients had specifically requested to be transported to MaineGeneral Medical Center, (TCH is a satellite of MaineGeneral Medical Center). The Physician reported that he/she believed that a hospital policy existed which would allow him/her to divert the second patient to another facility.

The medical record for Patient A indicated that the ambulance arrived at the TCH ED at 05:19 [5:19 AM] and documentation provided by Hospital B (the receiving hospital) indicated that the ambulance arrived at that facility with the second patient at 5:30 AM (a distance of 2.6 miles). This indicated that the second patient was still in the ambulance while the ambulance was at TCH dropping off the first patient. Additionally, the ambulance drop off at TCH is an enclosed garage area located physically inside the hospital building.

An interview was conducted, on February 22, 2017 at approximately 10:48 AM, with the MaineGeneral Medical Center Director of ED Nursing Services. The Nurse Director stated "the decision was in the best interest of the patients and to separate the patients." It was reported that at the time of the incident on February 11, 2017, the ED had the capacity to be able to treat both patients and the hospital was "not on diversion status".

Hospital Policy # PC-63, titled, "Ambulance Diversion" states under heading Procedure:

"1. When MaineGeneral Medical Center's resources are at capacity or it does not possess the capability to provide an appropriate medical screening examination or stabilizing treatment it may convert to diversionary status. While In diversionary status MaineGeneral Medical Center is not required to accept further transfers to the hospital from EMS. EMS telephone contact does not constitute "coming to the ED" so EMTALA does not apply. Prior to activating any level of diversion, the ED Medical, ED Nursing Director or designee will be consulted.

3. Regional hospital emergency departments to whom patients might be diverted will be notified by ED staff. Those notified will be documented on the Ambulance and Hospital Notification/Divert Log (see attached). The log will then be kept in a notebook in the ED known as the Diversion Log ..."

The facility failed to follow this policy when the second patient was diverted to the ED at Hospital B. The TCH ED's resources had not been extended beyond its capacity, there was no indication that the ED medical and Nursing Directors had been involved in the decision process, and the regional EDs had not been notified.

This finding was confirmed, by the Director of ED Nursing Services, on February 22, 2017 at approximately 11:00 AM.