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Based on document review and interview, the facility failed to ensure EMTALA (Emergency Medical Treatment and Labor Act) signs were conspicuously posted in places where they were likely to be seen by all persons entering the ED (Emergency Department)(see tag A2402), failed to maintain a central log of ED patients (see tag A2405), failed to ensure documentation indicating an MSE (Medical Screening Exam) was performed (see tag A2406), and failed to ensure copies of all medical records related to the presenting EMC (Emergency Medical Condition) were sent with the patient at or around the time of transfer (see tag A2409) for 1 facility.

Findings include:

1. See findings cited at 489.20(q) Posting of Signs A2402, 489.20(r)(3) Emergency Room Log A2405, 489.24(1) Medical Screening Exam A2406 and 489.24(e)(2)(iii) Appropriate Transfer A2409.

Based on observation and interview, the facility failed to ensure EMTALA (Emergency Medical Treatment and Labor Act) signage (specifying the rights of individuals under section 1867 of the Act) was conspicuously posted in areas likely to be seen by all patients entering the Emergency Department (ED) for 1 of 2 primary patient access portals observed in the ED (ambulance entrance).

Findings include:

1. During a tour of the ED on 6-12-18 at 1715 hours, in the company of the Director of Outpatient Services, staff A3, a lack of EMTALA signage was identified in the ambulance garage area and access corridor leading into the ED.

2. On 6-12-18 at 1715 hours, staff A3 confirmed the ambulance garage area and access corridor lacked a conspicuously posted sign indicating the EMTALA rights of patients with respect to examination and treatment of emergency medical conditions and women in labor.

Based on document review and interview, the facility failed to maintain a central log of each individual that comes to the ED (Emergency Department) seeking assistance and medical care including information whether the patient refused treatment, or was refused treatment, or was transferred, or treated and discharged, or admitted and treated, or stabilized and transferred for 1 of 24 medical records (MR) reviewed (Patient #1).

Findings include:

1. Review of the policy/procedure Patient Access/Emergency Department Registration Procedure (approved 12-15) indicated the following: "...Use the Emergency Arrival function to register all Emergency Department (ED) patients. Upon arrival, the patient will present at [the] Emergency front desk, Quick ED admit is completed, and Triage called."

2. Review of facility administrative documentation for Facility A titled ED Patient Log lacked documentation indicating Patient #1 was registered upon arrival to the ED on 5-31-18 at approximately 0100 hours.

3. Review of the MR for Patient #1 obtained from Facility B indicated the patient arrived on 5-31-18 at 0153 hours to the ED and the MR entry on 5-31-18 at 0508 hours by the SANE (Sexual Assault Nurse Examiner) Nurse, staff N13 indicated Patient #1 visited the ED of Facility A and was redirected to the ED of Facility B.

4. On 6-14-18 at 1630 hours, the Director of Quality, staff A2 and the Director of Outpatient Services, staff A3 confirmed no ED log documentation indicated Patient #1 went to the ED at Facility A around the time of the allegations.

Based on document review and interview, the facility failed to document an assessment of the patient's condition on arrival to the ED (emergency department) to ensure the patient was appropriately prioritized until a MSE (medical screening exam) by a Physician or other QMP (qualified medical provider) was completed for 4 of 24 medical records (MR) reviewed (Patients #1, 17, 18 and 20).

Findings include:

1. Review of the policy/procedure Patient Care Services Plan Policy (approved 5-17) indicated the following: "The Emergency Department provides prompt recognition of physiological and emotional needs of patients by monitoring and evaluating the patient's status upon arrival and on a continuous basis until discharged."

2. Review of the policy/procedure Triage of Emergency Department Patients Procedure (approved 10-15) indicated the following: "Triage personnel will be notified upon patient arrival and will escort the patient to a bed in the ED if available; and if not, to the triage area for assessment... Triage Nurse will determine severity of illness/injury of patients after the triage assessment. If the patient is stable, the patient will be escorted to registration..."

3. Review of the policy/procedure Medical Screening Exam Policy (approved 1-16) indicated the following: "The Emergency Department will provide a medical screening exam to every patient presenting to the ED as required by EMTALA."

4. Review of the MR for Patient #1 obtained from Facility B indicated the patient arrived on 5-31-18 at 0153 hours to the ED and the MR entry on 5-31-18 at 0508 hours by the SANE (Sexual Assault Nurse Examiner) Nurse, staff N13 indicated Patient #1 visited the ED of Facility A and was redirected to the ED of Facility B for a rape kit (forensic sexual assault examination).

5. On 6-14-18 at 1630 hours, the Director of Quality, staff A2 and the Director of Outpatient Services, staff A3 confirmed Patient #1 went to the ED at Facility A on 5-31-18 at approximately 0100 hours and confirmed no MR documentation indicated the patient received a triage assessment and/or an MSE by a Physician or QMP.

6. Review of the MR for Patient #17 indicated the patient was registered at Facility A on 5-29-18 at 1651 hours and no documentation indicated a triage assessment was performed upon arrival and severity of illness/injury determined by a Triage Nurse and/or indicated a MSE was performed by a Physician or QMP prior to the entry at 1954 hours by the ED Tech, staff N14 indicating the patient was no longer present in the waiting area.

7. Review of the MR for Patient #18 indicated the patient was registered at Facility A on 5-29-18 at 1659 hours and no documentation indicated a triage assessment was performed upon arrival and severity of illness/injury determined by a Triage Nurse and/or indicated a MSE was performed by a Physician or QMP prior to the entry at 1955 hours by the ED Tech, staff N14 indicating the patient was no longer present in the waiting area.

8. Review of the MR for Patient #20 indicated the patient was registered at Facility A on 5-29-18 at 2301 hours and no documentation indicated a triage assessment was performed upon arrival and severity of illness/injury determined by a Triage Nurse and/or indicated a MSE was performed by a Physician or QMP prior to the entry at 2354 hours by the ED Tech, staff N14 indicating the patient was no longer present in the waiting area.

9. On 6-14-18 at 1601, 1605, and 1610 hours, the Director of Quality, staff A2 and the Director of Outpatient Services, staff A3 confirmed the MR's for Patients #17, 18 and 20 lacked documentation indicating a triage assessment was performed upon arrival to the ED and each patient was appropriately prioritized until a MSE by a Physician or other QMP could be performed.

Based on document review and interview, the facility failed to ensure copies of all ED (Emergency Department) documentation were sent with the patient upon transfer to an accepting facility for 5 of 23 medical records (MR) reviewed (Patients #2, 7, 10, 11 and 14).

Findings include:

1. Review of the policy/procedure Transfer for Emergency Department and/or Inpatients Procedure (approved 2-16) indicated the following: Transfer for Emergency Department and/or Inpatients Procedure (approved 2-16) indicated the following: "Copies of records to be sent with patient include all lab results, X-Rays, EKG, progress notes, EKG monitor strips, ED record, and any other pertinent information... [and]...Copies of all transfer forms will accompany patient to receiving facility."

2. Review of the MR for Patient #2 indicated the patient presented to the ED on 12-7-17 at 1744 hours by ambulance after being seen by a mental health therapist for evaluation of anxiety, depression, and suicidal ideation with a plan. The MR indicated a Psychiatrist MD30 accepted the patient in transfer and lacked documentation indicating a copy of the ED Physician MD12's provider notes was sent with the patient to the accepting facility.

3. On 6-13-18 at 1515 hours, the Director of Quality, staff A2 and the Director of Outpatient Services, staff A3 confirmed the MR for Patient #2 lacked the indicated transfer documentation.

4. Review of the MR for Patient #7 indicated the patient presented to the ED on 2-13-17 at 1304 hours for evaluation of right lower quadrant abdominal pain and nausea with vomiting. The MR indicated a General Surgeon MD31 accepted the patient in transfer and lacked documentation indicating a copy of any portion of the ED record was sent with the patient to the accepting facility.

5. On 6-13-18 at 1650 hours, staff A2 and staff A3 confirmed the MR for Patient #7 lacked the indicated transfer documentation.

6. Review of the MR for Patient #10 indicated the patient presented to the ED on 5-28-18 at 1740 hours for evaluation of cough and wheezing and a history of asthma. The MR indicated a Pediatric Hospitalist MD32 accepted the patient in transfer and lacked documentation indicating a copy of the ED nurse's notes was sent with the patient to the accepting facility.

7. On 6-14-18 at 1240 hours, staff A2 and staff A3 confirmed the MR for Patient #10 lacked the indicated transfer documentation.

8. Review of the MR for Patient #11 indicated the patient presented to the ED on 5-30-18 at 2209 hours by ambulance for evaluation of unresponsiveness with a recent history of weakness and dizziness for 4 days. The MR indicated an Intensivist Physician MD33 accepted the patient in transfer and lacked documentation indicating a copy of the ED Physician MD14's provider notes was sent with the patient to the accepting facility.

9. On 6-14-18 at 1345 hours, staff A2 and staff A3 confirmed the MR for Patient #11 lacked the indicated transfer documentation.

10. Review of the MR for Patient #14 indicated the patient presented to the ED on 4-15-18 at 0911 hours for evaluation of an allergic reaction that began 24 hours earlier. The MR indicated a Pediatric Hospitalist MD34 accepted the patient in transfer and lacked documentation indicating a copy of the ED Physician MD19's provider notes and a copy of the ED nurse's notes were sent with the patient to the accepting facility.

11. On 6-14-18 at 1515 hours, staff A2 and staff A3 confirmed the MR for Patient #14 lacked the indicated transfer documentation.