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Based on tours/observations, staff interviews and review of medical records, policies/procedures and other facility documents, the facility failed to comply with the Medicare provider agreement as defined in ?489.20 and ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

1. The facility failed to meet the following requirement under the EMTALA regulations:

Tag A 2402 - Posting of Signs
The facility failed to ensure EMTALA signage was posted throughout the facility. This failure did not ensure patients were fully informed of their rights with respect to examination and treatment of emergency medical conditions, as well as whether the facility participates in the Medicaid program under a State approved plan.

Tag A 2409 - Appropriate Transfer
The facility failed to ensure eight of ten patients transferred from the facility's labor and delivery department were transferred with appropriate paperwork and documentation of EMTALA specific requirements.

Based on observation tour of the facility and staff interviews, the facility failed to ensure EMTALA signage was posted throughout the facility.

This failure did not ensure patients were fully informed of their rights and created the potential for a negative outcome.

Findings:

1. The facility failed to post EMTALA signage at the ambulance bay entrance of the main emergency department as well as the offsite emergency department.

a) The facility's policy titled EMTALA and Transfer Policy, last effective 10/09/13, stated the following: "EMTALA Signage: Each department that provides Emergency care shall post a sign (English and Spanish) in a place or places likely to be noticed by all individuals entering the department."

b) On 11/05/13 at 3:35 p.m., a tour of the emergency department located at the main campus was conducted with the facility's VP Clinical Operations and the Director of the Emergency Department. Observations revealed there was signage in the waiting room of the emergency department. There was no signage posted in the ambulance bay or inside the ambulance bay door, to be viewed by individuals who did not enter the emergency department through the waiting room. These findings were confirmed with the facility staff present on the tour.

c) On 11/06/13 at 8:35 a.m., a tour of the facility's free standing emergency department was conducted with the facility's VP Clinical Operations and the Director of the Emergency Department. Observations revealed there was signage in the waiting room of the emergency department. There was no signage posted in the ambulance bay or inside the the ambulance bay door, to be viewed by individuals who did not enter the emergency department through the waiting room. These findings were confirmed with the facility staff present on the tour.

Based on interview, review of medical records, and facility policy/procedure review, the facility failed to ensure 8 of 10 Obstetric (OB) patients transferred from the facility's obstetric department were transferred with appropriate paperwork and documentation of EMTALA specific requirements (patients #11, #12, #13, #15, #16, #17, #19 and #20) .

This failure created the potential for negative outcome.

Findings:

POLICY

According to the facility's policy, titled "EMTALA and Transfer Policy", effective 10/19/13, which stated "Patient Transfer: To Another Facility: When transferring, the treating physician must document the name of the accepting individual and facility. The receiving facility must agree to accept the patient prior to arranging transfer. The treating physician must also send pertinent documents, imaging studies, and test results relating to the emergency condition to the receiving facility. The physicians must make contact for report and the nurses must make contact for report. When transferring a patient it is our responsibility to arrange the appropriate medical transport that is staffed with qualified personnel and appropriate medical equipment. All of this information is documented on the EMTALA transfer paperwork."

1. The facility utilized a one page EMTALA Transfer Form for OB patients and, in review of 10 medical records of patients transferred from the OB department to a higher level of care, 8 of the forms were not completed in entirety and inclusive of critical information.

a) Review of the medical record for Patient #11 revealed the patient was an OB patient that was transferred emergently to a hospital with a higher level of obstetric/neonatal care. The EMTALA Transfer Form was without documentation in the following areas: medical condition, name of destination hospital, name of individual who received report at the destination hospital (as well as date/time report called), entire portion of accompanying documentation section, and entire portion of transportation section (including transport agency, who accompanied the patient, and what life support measures were required). The nurses's final note stated the name of the transport team that transported the patient and the name of the nurse that report was given to.

b) Review of the medical record for Patient #12 revealed the patient was an OB patient that was transferred emergently to a hospital with a higher level of obstetric/neonatal care. The EMTALA Transfer Form was without documentation in the following areas: name of individual who received report at the destination hospital (as well as date/time report called), the entire portion of accompanying documentation section, and entire portion of transportation section (including transport agency, who accompanied patient, and what life support measures required). The nurse's final note stated the name of the transport team that transported the patient.

c) Review of the medical record for Patient #13 revealed the patient was an OB patient that was transferred emergently to a hospital with a higher level of obstetric/neonatal care. The EMTALA Transfer Form was without documentation in the following areas: Name of individual who received report at the destination hospital (as well as date/time report called), signature of patient's consent to transfer, name of destination hospital, entire portion of accompanying documentation section, and entire portion of transportation section (including transport agency, who accompanied patient, and what life support measures required). The nurse's final note stated the name of the transport team and name of receiving hospital.

d) Review of Patient #15's medical record revealed the patient was an OB patient that was transferred emergently to a hospital with a higher level of obstetric/neonatal care. The EMTALA Transfer Form was without documentation in the following areas: Name of individual who received report at the destination hospital (as well as date/time report called), time of transfer, vital signs just prior to transfer, and entire portion of transportation section (including transport agency, who accompanied patient, and what life support measures required). The nurse's final note stated the name of the transport team that transported the patient.

e) Review of the medical record for Patient #16 revealed the patient was an OB patient that was transferred emergently to a hospital with a higher level of obstetric/neonatal care. The EMTALA Transfer form was without documentation in the following areas: Reason for transfer, name of destination hospital, name of individual who received report at the destination hospital (as well as title and date/time report called), signature of staff who gave report at transferring hospital, entire portion of accompanying documentation section, and entire portion of transportation section (including transport agency, who accompanied patient, and what life support measures required).

f) Review of the medical records for Patient's #17, #19 and #20 revealed similar findings of the OB patients being transferred emergently to a hospital with a higher level of obstetric/neonatal care with an incomplete EMTALA Transfer Form

g) In an interview with the facility's Director of the OB department, on 11/04/13 at 1:00 p.m., s/he confirmed the EMTALA Transfer form for the eight medical records reviewed was not complete.