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Based on observations, review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that facility staff failed to post conspicuously in the emergency department or in places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than the traditional emergency departments, a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital participates in the Medicaid program under a State plan approved under Title XIX.

Findings include:

Review of "UPMC Policy And Procedure ... Emergency Medical Treatment and Active Labor Act (EMTALA) Date: April 1, 2009" revealed "I. Policy It is the policy of UPMC to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C.1395dd. II. Purpose The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope This policy applies to all UPMC hospitals. Each hospital may develop its own procedures for implementing this policy, provided that such procedures are consistent with the policy. IV. Definitions 1. Dedicated Emergency Department is any department or facility of the hospital, whether on or off campus that: ... (c) based on a representative sample of patient visits during the previous calendar year, provides at least one-third (1/3) of all its outpatient visits for the treatment of emergency medical conditions without an appointment ... V. Procedure ... 9. The facility shall post conspicuous signage that identifies the rights of the individual under EMTALA with respect to examination and treatment for Emergency Conditions and indicates the hospital's participation in the Medicare and Medicaid programs."

1) During a tour of the Emergency Department, on January 12, 2010, at approximately 9:45 AM, the only observed EMTALA sign, in the waiting area, was located on a wall to the right of the ambulatory entrance of the Emergency Department. The sign was 8.5 by 11 inches in size. Further observation revealed that the sign would not likely be noticed by all individuals in the waiting area, especially for individuals who would be seated in a row of chairs which face the ambulatory entrance.

Interview with EMP3 on January 12, 2010, at approximately 2:00 PM, confirmed the above findings and revealed "Yes, you're right. You would not be able to see it from those chairs."

2) A review of the "24 Hour ERC [Evaluation and Referral Center] Log," for the months of October 2009 and December 2009, revealed that approximately 100% of patients presented unscheduled, as outpatients, to the ERC for treatment of emergency medical conditions, which were in relation to behavioral issues.

3) A review of the Emergency Department log, of patients presenting with behavioral health issues, from July 1, 2009 to December 31, 2009, was performed. A random sample of 20 records were selected from the log for review.

Review of MR1, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR52, MR53, MR56, MR59, MR60, MR61, MR63, MR64, MR65, MR67, and MR68 revealed these patients presented unscheduled, as outpatients, to the ERC for treatment of emergency medical conditions, which were in relation to behavioral issues. .

4) During a tour of the ERC area, on January 12, 2009, at approximately 10:10 AM, observation of the entire area, including the waiting area, bathroom and three exam rooms revealed no EMTALA signs.

Interview with EMP8 on January 12, 2010, at approximately 1:40 PM confirmed the above findings and revealed "There are no signs."

5) A review of the "Family Maternity Center Admission Tracking Sheet," for the months of October 2009 and December 2009, revealed that approximately 46% of patients presented unscheduled, as outpatients, to the Family Maternity Center for treatment of emergency medical conditions.

6) A review of the "Family Maternity Center Admission Tracking Sheet," for patients presenting to the Family Maternity Center, for the months of October, November and December 2009 was performed. A random sample of 21 records were selected from the log for review.

Review of MR31, MR32, MR33, MR34, MR35, MR36, MR37, MR38, MR39, MR40, MR41, MR42, MR43, MR44, MR45, MR46, MR47, MR48, MR49, MR50 and MR51 revealed these patients presented unscheduled, as outpatients, to the Family Maternity Center for treatment of emergency medical conditions.

7) During a tour of the Triage area of the Family Maternity Center on January 12, 2010, at approximately 1:00 PM, the only observed EMTALA sign was located immediately on the left wall of the hallway to the entrance of the Triage area. The sign was 8.5 by 11 inches in size. Further observation revealed that the sign would not likely be noticed by all individuals entering the Triage area. Additional observation of Triage rooms B and C revealed no other EMTALA signs.

Interview with EMP7 on January 12, 2010, at approximately 1:05 PM, confirmed the above findings and revealed "We don't have any signs in the Triage rooms ... We will put some up right now."

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that the facility failed to maintain a central log on each individual who comes to the emergency department, as defined in ?489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

Findings include:

Review of "UPMC Policy And Procedure ... Emergency Medical Treatment and Active Labor Act (EMTALA) Date: April 1, 2009" revealed "I. Policy It is the policy of UPMC to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C.1395dd. II. Purpose The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope This policy applies to all UPMC hospitals. Each hospital may develop its own procedures for implementing this policy, provided that such procedures are consistent with the policy. IV. Definitions 1. Dedicated Emergency Department is any department or facility of the hospital, whether on or off campus that: ... (c) based on a representative sample of patient visits during the previous calendar year, provides at least one-third (1/3) of all its outpatient visits for the treatment of emergency medical conditions without an appointment ... V. Procedure ... 12. Each hospital facility shall maintain a central log in the Emergency Department identifying each individual that seeks emergency medical treatment at that facility, and indicate whether they refused treatment, or whether they were transferred, admitted, or discharged."

1) A review of the "Family Maternity Center Admission Tracking Sheet," for the months of October 2009 and December 2009, revealed that approximately 46% of patients presented unscheduled, as outpatients, to the Family Maternity Center for treatment of emergency medical conditions.

2) Further review of the "Family Maternity Center Admission Tracking Sheet," for the months of October 2009 and December 2009 revealed that 285 of 588 entries on the logs did not indicate whether the patients were transferred, admitted and treated, stabilized and transferred, or discharged.

Interview with EMP9 on January 14, 2010, at approximately 2:05 PM, confirmed the above findings and revealed "We need to do a better job at writing down the disposition."

Based on a review of facility policy, medical records (MR), and staff interview (EMP), it was determined that the facility failed to provide an appropriate medical screening for one of one patient (MR30), as defined in ?489.24(a), a request is made by the individual or on the individual's behalf for examination or treatment of a medical condition.

Findings include:

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA) Date: April 1, 2009 1. POLICY It is the policy of UPMC to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act ... V. PROCEDURE 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a Medical Screening Exam to such person. If an individual seeking emergency medical care comes to any other portion of the hospital campus, including on-campus clinics, sidewalks, driveways, and parking lots, and makes a request for emergency medical care, physicians or another QMP shall offer a Medical Screening Exam to that person. ... "

Review of facility policy "Transfers from the Emergency Department to Another Medical Facility, Reviewed 6/08" revealed " ... 1. In cases where it is deemed that the patient requires treatment beyond the scope that Mercy Hospital can provide, or there is no specialty physician on call, the DEM attending/private physician must sign a certification that the medical benefits reasonably expected from treatment at another facility outweigh the increased risks to the individual and in the case of labor, to the unborn child. a. The hospital must inform the individual (or legally responsible person acting on the patient's behalf) of the risks and benefits of transfer. b. A written request for transfer, or a written informed consent to refuse transfer, will be obtained by the physician. ... "

Review of "UPMC Mercy Medical Staff Bylaws" dated January 13, 2009, revealed " ... 2.3 Responsibilities Medical Staff members shall fulfill all responsibilities outlined in these Bylaws, ... the Medical Staff Rules and Regulations, applicable departmental Rules and Regulations ... Patient Transfer Accepting Transfers: All requests for transfer to Mercy will be accepted by the DEM physician (or DEM physician designee) except as noted below ... "

Review of Elizabeth Township Area EMS trip sheet dated January 5, 2010, revealed " ... 19:18 Arrived at UPMC Mercy. A2 and A3 escorted 77 year old female into ED, At this point, patient's father entered the patient compartment of the ambulance, ... Emergency Department RN came to the back of the ambulance and spoke with me stating that the trauma physician on duty is refusing the patient based on age. I requested to speak with the trauma physician and was not given a chance to state my physical findings to him/her. At no point was an assessment performed on this patient by any staff member of UPMC Mercy and we were continually denied requests for our patient to be brought into their Emergency Department. ..."

1) Interview with EMP1 on January 12, 2010, at approximately 11:00 AM, revealed "Yes, I saw the 13 year old patient. After the first patient was brought in after [EMP10] stated [they] will not see the patient. I walked out and went in [ambulance] and did a brief assessment on the child. [The patient] stated [they] only had a headache. Patient was on seat, the paramedic and an older gentleman was with [them]. ... I talked with [EMP2], and [they] said [they] don't take kids under fourteen. At the time, I was talking with [EMP2] and then [EMP10] showed up. [EMP10] told them that [they] were not going to see the thirteen year old, said to send to Children's hospital."

2) Telephone interview with EMP2 on January 13, 2010, at approximately 2:35 PM, revealed " ... I talked with [EMP1], and asked why are we getting the thirteen year old, [they] should be going to Children's. [EMP1] said it was because [they] are on the same ambulance. We need to send the child to Childrens. ... I made the decision to send the child to Childrens because of the policy and in retrospect, I should [have]seen the kid. I made the decision on my own. I talked to EMS at bedside, I did ask the EMS if patient was stable and they said yes."

3) Telephone interview with OTH1 on January 14, 2010, at approximately 10:33 AM, revealed "They advised me that I cannot bring the thirteen year old as requested. I stayed with the thirteen year old the whole time. The charge nurse came out and said that. Requested to talk to trauma physician at Mercy and was told they refused."