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Based on observation, interview, and facility policy review, the facility failed to conspicuously post signage specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA) in locations likely to be noticed by all individuals entering the Emergency Department (ED), as well as individuals waiting for examination and treatment including the entrance and waiting areas of the ED, and the entrance of the Labor and Delivery unit.

This failure resulted in the potential for patients to not know their rights to receive a medical screening examination or treatment for their emergent medical condition, including active labor.

Findings:

On 5/24/2022 at 9:29 a.m., a tour was conducted of the hospital ED. No postings or signage related to patient rights to examination, treatment, or Medicaid participation were observed in the outside ED entrance, in the ED entrance interior, the patient check-in area, or the triage and patient waiting area. One EMTALA sign posted in English was observed in a registration area to the right of the ED patient check-in station.

During the tour conducted on 5/24/2022 at 9:29 a.m., the Interim Director of the ED (IDED) indicated the EMTALA sign posted in the patient registration area to the right of the patient check-in station was the only EMTALA sign posted in the ED entrance.

An additional tour was conducted of the Labor and Delivery (L&D) unit on 5/24/2022 at 9:51 a.m. with the Director of L&D (DLD). The DLD indicated laboring and emergent patients presenting to the ED were immediately brought up to L&D accompanied by a staff member in either a wheelchair or ambulatory. DLD indicated the patients were brought through the double door entrance, down the hallway and to the L&D nurse station to check-in. No postings or signage related to patient rights to examination, treatment, or Medicaid participation were observed outside the double door L&D entrance, immediately inside the entrance, or along the L&D hallway to the check-in area. One EMTALA sign, approximately 8 inches by 11 inches was observed to be posted at the L&D nurse station.

On 5/25/2022 at 2:42 p.m., an additional interview and observation was conducted with the IDED. The IDED indicated ED patients did not typically go to the patient registration area to the right of the patient check-in station, and it was sometimes used for patient overflow.

Review of a hospital Administrative policy, "Appendix A - [Facility Name] Signage Requirements per Regulation 2020", revised 10/2020, was conducted. The policy indicated, "EMTALA Signage 'It's the Law,' The sign(s) must be posted in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment (e.g., entrance, admitting area, waiting room, treatment area). Specify the rights of individuals with EMCs [Emergent Medical Conditions] and women in labor who come to the emergency department for health care services; Indicate whether the facility participates in the Medicaid program; The wording of the sign(s) must be clear and in simple terms and language(s) that are understandable by the population served by the hospital."

Based on interview and record review, Hospital 1 failed to provide a Medical Screening Examination (MSE) for 1 of 30 sampled patients (Patient 1), when Patient 1 presented to the Emergency Department (ED) by ambulance and was subsequently sent to Hospital 2 without an MSE. This failure resulted in Patient 1 not being screened to determine if an emergent medical condition existed and had the potential to cause serious harm if not treated or stabilized.

Findings:

According to the Ambulance Run Report, provided by the County Metropolitan Fire District (CMFD), [M61; Medical Unit 61] arrived on scene on 1/11/22 at 2:25 a.m. to find a 44 year old female with a chief complaint of contractions. The narrative report indicated the, "patient stated she was 7 months pregnant, was experiencing contractions, and her water had broken." An addendum stated, "M61 notified [Hospital 1] of patient status and the belief that she was pregnant. [Hospital 1] acknowledged report. Upon arrival to hospital grounds a nurse (name unknown) greeted crew at back of ambulance ... The nurse then told crew that the nursery/maternity floor was impacted and told us to divert to [Hospital 2]."

A 1/11/22 "Report of Occurrence" document written by M61 indicated, "No physician examined the patient prior to us being told to divert to [Hospital 2]."

A review of the "Incoming EMS Log" for Hospital 1 indicated that M61 had a 44 year old female who was pregnant with a chief complaint of abdominal pain, 28 weeks pregnant, and contractions. In the section labeled "Patient Sticker," it states "To [Hospital 2]."

During an interview on 5/25/22, at 1:16 p.m., with Registered Nurse 1 (RN 1), RN 1 confirmed he was the charge nurse on shift on 1/11/22. RN 1 stated the Labor and Delivery (L&D) unit was notified of the pending arrival of Patient 1, but RN 1 stated he was told they could not admit her to the L&D unit because they would not be able to provide appropriate services for a baby who was approximately 28 weeks old. L&D informed RN 1 they were encumbered with other patients and could not assist the ED with an assessment upon Patient 1's arrival. RN 1 stated he conducted a brief assessment of Patient 1 inside of the ambulance parked in the ED bay to ensure Patient 1 was not in active labor. RN 1 stated he instructed M61 to take Patient 1 to [Hospital 2]. RN 1 stated a physician was not consulted or notified of Patient 1 prior to sending Patient 1 to [Hospital 2].

During an interview on 5/25/22, at 11:20 a.m., with the Quality and Patient Safety Director, (QPSD), the QPSD confirmed that an MSE was not performed for Patient 1. The QPSD agreed an MSE should have been completed for Patient 1.

The facility policy, "Emergency Medical Treatment and Active Labor Act (EMTALA) Corporate Policy," with a board approval date of 8/26/21, directed the following:

The policy defined Comes to the Emergency Department as an individual who, "Is in a non-hospital owned ground or air ambulance that is on hospital property for the purpose of presenting an individual at the hospital DED [Dedicated Emergency Department] for examination or treatment for a medical condition."

The policy defined a Medical Screening Exam as, "the process of examination and evaluation of the individual required to determine, within the capabilities (services and staff) if an individual who comes to the Dedicated Emergency Department has an Emergency Medical Condition or is in Labor."

The policy stated, "All individuals who come to a DED of the hospital (whether on campus or off-campus) for examination or treatment, and all individuals who present on hospital property requesting examination or treatment of an Emergency Medical Condition shall receive an appropriate Medical Screening Examination."

A review of the hospital Medical Staff Rules and Regulations, approved January 28, 2021, stated, "This screening examination may be performed by the following persons: 1. In the Emergency Department (ED): by a Physician or by either a Physician Assistant (PA) or Nurse Practitioner (NP) who has been determined by the Medical Staff to be qualified and experienced in screening for emergency conditions and who is required to follow standardized procedures approved by the Medical Staff."