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Based on observation, interviews, documentation reviewed in 1 of 7 emergency department (ED) records for patients who presented to the hospital's ED (Patient 5) with a lower extremity fracture and who were transferred to another facility, and review of hospital policies and procedures, it was determined the hospital failed to fully develop and enforce appropriate EMTALA policies and procedures related to all EMTALA requirements, including the provision of physician on-call responsibilities.

Findings included:

1. Review of the hospital's EMTALA policies and procedures revealed they did not address the following required EMTALA subject at all:

a. Posting of Signs. Refer to findings identified under Tag A2402 CFR 489.20(q) which reflects the hospital's failure to adopt and enforce policies and procedures for the required posting of EMTALA signs.

An interview was conducted with I7, the Director of Quality Resources on 09/17/2013 at 1100. He/she stated the hospital did not have a policy which addressed the required posting of EMTALA signs.

2. Review of hospital EMTALA policies and procedures revealed that the hospital failed to enforce its own policies and procedures in the following areas:

a. Availability of On-call Physicians. Refer to findings identified under Tag A2404, CFR 489.20(r)(2) which reflects the hospital's failure to enforce its policies and procedures ensuring an on-call physician was available to provide further evaluation and treatment necessary after the initial examination to stabilize a patient with an emergency medical condition.

b. Appropriate Transfer. The hospital failed to enforce its own policies and procedures ensuring that the transferring hospital sends to the receiving facility the address of any on-call physician who has failed to appear to provide necessary stabilizing treatment.

Review of a policy titled "Transfer of Patients/EMTALA," dated 01/10/2011 reflected the following internal requirements: "PROCEDURE 1. Determine the need for and initiate transfer to another acute care facility...c. Regardless of stable or unstable medical condition, nursing staff will...5) Copy and send all pertinent medical records available at the time of transfer, including...Name and address of any on-call physician who refused or failed to appear within a reasonable time to provide necessary stabilizing treatment..."

The record of the 08/19/2013 ED visit for Patient 5 was reviewed. The record failed to include the address of Physician I8, an on-call physician who failed to respond when called by Physician I3, an ED physician, to provide necessary stabilizing treatment for the patient. The patient was transferred to another hospital, Hospital 1. There was no documentation reflecting that the address of Physician I8 was submitted to Hospital 1 at any time in accordance with the hospital's policy.

An interview was conducted on 09/18/2013 at 0900 with I6, the Risk Manager. He/she identified the areas in the 08/19/2013 ED record for Patient 5 that were submitted to Hospital 1 when the patient was transferred. None of the documentation included the address of Physician I8.

Based on observation, interview, and review of policies and procedures, it was determined that the hospital failed to adopt a policy and procedure for the posting of the required EMTALA signs and failed to post the required EMTALA signs conspicuously in a place or places likely to be noticed by all individuals entering the ED as required by this regulation.

Findings include:

1. A tour of the ED was conducted on 09/16/2013 at 1515. The ED had an ambulance entrance which was separate from the main ED entrance. Patient treatment rooms were located in a bay immediately inside the ambulance entrance. For any patients arriving via ambulance, there was no EMTALA signage visible in the ambulance entrance or the bay inside the ambulance entrance.

2. An interview was conducted with I2, the ED Manager on 09/16/2013 at 1540. He/she stated that none of the ED treatment rooms or the bay at the ambulance entrance, had the required EMTALA signage. When queried if patients coming through the ambulance entrance would see EMTALA signage, he/she stated "If they come in through the ambulance doors, they're not going to see one."

3. EMTALA policies and procedures were reviewed. It was determined the hospital failed to include the required posting of EMTALA signage in its policies and procedures.

Based on interview and documentation reviewed in 1 of 7 emergency department (ED) records for patients (Patient 5) who presented to the hospital's ED with a lower extremity fracture and who were transferred to another facility, and review of hospital policies and procedures, it was determined that the hospital failed to ensure that a specialist physician who was on-call for duty was available after the initial examination of the patient, to provide further evaluation and/or treatment necessary to stabilize the patient's emergency medical condition.

Findings include:

1. The record of the ED visit for Patient 5 was reviewed. The record reflected that Patient 5 arrived by ambulance to the hospital ED on 08/19/2013 at 2223. The physician ED provider notes dated 08/20/2013 at 0622 reflected the patient's chief complaint was ankle pain, right ankle deformity, and pain after missing the last step out of a motorhome and falling. The physician physical examination reflected "Right ankle: [He/she] exhibits decreased range of motion, swelling, ecchymosis [bruising], and deformity. [He/she] exhibits normal pulse. Tenderness. Lateral malleolus and medial malleolus tenderness found." Physician ED course notes reflected "2311 - 2335 Call placed to [Physician I8, the on call orthopedic physician] on [his/her] cell phone. Went to Voicemail. Attempted x3, msg left with pager number (which forwards to clinic), attempted to text [Physician I8] as well on [his/her] cell phone...8/20/2013 0002 I talked to [Physician I14], [Hospital 1] orthopedist. [He/she] did accept care of this patient. [He/she] did ask that I try to contact [Physician I8] one more time, which I did from another phone line while on the phone with [Physician I14]. Once again, the phone went to voicemail. I did inform the patient that I was going to send the patient via ambulance to [Hospital 1]." The record reflected the patient was transferred via ambulance to Hospital 1 on 08/20/2013 at 0132.

2. Review of a policy titled "Transfer of Patients/EMTALA," dated 01/10/2011 reflected the following internal requirements: "4. On-call physicians...A list of on-call physicians is maintained in the Emergency Department, including specialists and sub-specialists who are available to provide treatment necessary to stabilize individuals with emergency medical conditions...SHS is responsible for ensuring that on-call physicians respond within a reasonable period of time..."

3. Review of "Rules and Regulations of the Medical Staff of Samaritan North Lincoln Hospital," approved 12/13/2012 reflected "C. On Call Physicians
Specialty physicians including First Call physicians/practitioners shall be available by phone or pager and respond within 15 minutes and available to come to the Hospital within the time interval requested by the E.D. physician."

4. Review of the physician on-call schedule titled "Samaritan North Lincoln Hospital Call Schedule," for 08/19/2013 and 08/20/2013 reflected that Physician I8, a orthopedic (specialist) physician, was on-call for the ED for 08/19/2013 and 08/20/2013.

5. An interview was conducted on 09/18/2013 at 0700 with Physician I3, an ED physician . He/she confirmed that he/she was the physician on duty in the ED on 08/19/2013 when Patient 5 presented to the hospital. The ED physician stated the patient came to the hospital's ED by ambulance with "an obviously broken ankle." The ED physician stated that X-rays showed multiple fractures and that's when he/she placed a call to Physician I8, the on-call orthopedic physician. The ED physician stated he/she tried to reach Physician I8 by cell phone three times and by pager, but was unable to reach him/her. The ED physician stated the reason he/she attempted to call Physician I8 was "I needed [him/her] to fix [his/her] ankle. We stabilized [him/her] here in the ER but we couldn't definitively treat [him/her]." The ED physician was asked if the patient had an emergency medical condition and he/she stated "Yea, absolutely an emergency medical condition, a trimalleolar fracture" and "[He/she] needed the care of a specialist that I could not provide here." Physician I3 stated "After all that I still felt the patient needed something done for [his/her] ankle." Physician I3 stated he/she then called and spoke with an orthopedic physician from another hospital (Hospital 2). After speaking with that physician, he/she then made arrangements to transfer the patient to Hospital 1.

6. An interview was conducted on 09/18/2013 at 1045 with Physician I8. Physician I8 confirmed that he/she was the on-call orthopedic physician for the ED on 08/19/2013 when Patient 5 presented to the ED. The orthopedic physician stated that he/she was called by the ED, but slept through the phone call. He/she stated the next morning (08/20/2013), he/she checked his/her phone and noticed that there were three phone calls and a text message from the hospital that he/she had missed. Physician I8 stated he/she came to the ED the next day and learned that Patient 5 had been transferred to another hospital. He/she stated "It was an ankle fracture. I don't know why they transferred it." Physician I8 stated that he/she slept through another call from the ED while he/she was the on-call physician prior to the 08/19/2013 incident. He/she stated "I know what my responsibilities are. I slept through it. There's no excuses."

7. An interview was conducted with I4, the Chief Executive Officer on 09/18/2013 at 0900. He/she stated that the hospital was aware of a potential EMTALA violation involving Physician I8. When asked when he/she first learned about the potential EMTALA violation, he/she stated he/she heard about it the day after the incident took place. I4 stated that [Physician I8] didn't hear his/her phone go off while he/she was on call for the ED. He/she further indicated that Physician I8 also failed to respond to a page while on call for the ED the previous week. I4 stated that the hospital would be looking into both occurrences involving Physician I8, but had not yet because they were so close together. He/she indicated that both incidents had been turned over to the Chief of Surgery and the medical staff committee for review and final determination.