HospitalInspections.org

Based on policy review, observations and staff interview hospital staff failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signage was posted conspicuously and visible to all patients who entered the Dedicated Emergency Department (DED) for evaluation of an emergency medical condition at 1 of 2 DED entrances (ambulatory [walk-in] entrance used for patients presenting to the Emergency Department).

Findings include:

Review of the EMTALA policy, effective 07/2022, revealed "... I. Additional Requirements ....3. (Name) Hospitals will conspicuously post in its dedicated emergency department and in other places likely to be noticed by all individuals entering the Emergency Department for examination and treatment, signage specifying the rights of individuals under EMTALA with respect to examination and treatment for emergency medical conditions and women in labor. ... "

Observation during initial tour of the Campus A DED on 10/24/2023 at 1640 revealed two entrances to the department (ambulatory/walk-in and ambulance). A posting of an English and a Spanish version of EMTALA signage was noted at the ambulance entrance and in the waiting room area. The observation revealed no posted EMTALA signage located at the patient ambulatory/walk-in entrance or where the patients registered.

On 10/25/2023, the hospital administrative staff provided this surveyor with a picture of EMTALA signage that had been placed at the patient ambulatory/walk-in entrance after the initial DED tour.

Observation during a second tour of the Campus A DED on 10/26/2023 around 1745 revealed that the EMTALA signage that had been put in place on 10/25/2023, based on picture provided by the facility, was no longer in place on the wall at the patient ambulatory/walk-in entrance to the Campus A DED. Observation revealed that there was no EMTALA signage in the registration area where the patients present their reason for visit. There was signage in the DED waiting room area and at the ambulance entrance doors.

Interview with the ED Director during tour on 10/26/2023 around 1800, revealed that the EMTALA signage that had been placed at the patient ambulatory/walk-in entrance on 10/25/2023 had been removed. Interview revealed the Director had not been notified that the EMTALA signage had been removed. Interview confirmed that there was no EMTALA signage notices available for patients presenting to the DED with an emergency medical condition to review.