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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 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."