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Based on interview and document review, the hospital failed to ensure compliance with requirements of 42 CFR 489.24, as evidenced by the deficient practice cited at 489.24 (a) and (c).

Based on observation and interview, the hospital failed to post signage in the Emergency Department (ED) that specified the rights of patients with emergency medical conditions and women in labor.

Findings include:

Observations during a tour of the ED on 03/13/18 at 8:45 a.m. established that no EMTALA signage was posted anywhere in the ED. EMTALA signage was absent in the main waiting area, triage station, ambulance corridor, and all 34 exam rooms. RN/C was present during the tour. RN/C showed the investigator the location where EMTALA signage was previously posted in the main waiting area near the triage station. RN/C stated that the main waiting area was recently updated with new wall paper and staff inadvertently overlooked re-posting the EMTALA signage. RN/C did not know that EMTALA signage was required in all other areas of the ED where patients were waiting for examination, such as triage and examination rooms.

The hospital's EMTALA policy, (undated), indicated the hospital "shall conspicuously post signs specifying the rights of individuals under EMTALA with respect to examination and treatment for emergency medical conditions and women in labor. The signs shall be posted in the Emergency Department as well as other areas where individuals may be waiting for examination and treatment for an emergency medical condition."

Based on interview and document review, the hospital failed to resolve a patient's emergency medical condition (EMC) prior to discharge and failed to ensure the patient was discharged to a setting that could support the patient's continued care needs, for 1 of 2 patients reviewed (P1), who presented to the emergency department (ED) for evaluation of a fall due to a change in condition. Within an hour of ED discharge, P1 had a second fall and returned to the ED with the same unresolved EMC. On return, P1 was admitted for hospitalization with a hip fracture.

Findings include:

P1's ED record indicated that P1 arrived in the ED by ambulance on 03/01/18 at 9:22 a.m. The triage assessment indicated that P1 had bruises on the bottom of the chin, right hip, and upper left buttock; P1 had abrasions on the right flank and left knee. P1 was tearful and unable to articulate what was bothering her. P1's blood pressure was 192/119. P1 was immediately roomed and examined by the physician.

MD/D's medical decision making note, dated 03/01/18, indicated that P1 had presented with injuries from an apparent fall. P1 was unable to provide any history due to advance dementia. A head C-spine CT and pelvic/right hip x-ray were negative for fractures. Chest x-ray was concerning for left-sided pneumonia. An indwelling urinary catheter was placed due to P1's bladder distention and inability to void, but there was no evidence of urinary tract infection. Blood studies were within normal parameters. MD/D discussed these findings with P1's family member who agreed P1 would not want any intravenous antibiotics or hospitalization. The plan was to discharge P1 back to the "nursing home" on oral antibiotics to cover the pneumonia. An Addendum to the medical decision making note (time not documented) indicated that P1's memory care unit had called and indicated they were uncomfortable taking P1 back. MD/D then updated P1's family member with this information, who agreed that inpatient hospitalization was the only option. MD/D noted that due a communication error between ED staff, transportation personnel arrived and picked up P1, who was taken back to the facility. While P1 was enroute, RN/E informed MD/D that she had contacted the facility; the facility was aware that P1 had an issue of urinary retention and was being discharged without a catheter; the facility was comfortable with P1's return.

The ED notes indicated that during P1's five-hour ED visit on 03/01/18, P1 required a 1:1 sitter the entire time due to P1's agitation. P1 was kept in a wheelchair or bed because P1 was not ambulating at her normal baseline. P1 was restless and constantly tried to get out of bed or stand up from the wheelchair. P1 did not respond to re-direction. P1 was uncooperative and refused oral medications.

The ambulance report sheet, dated 03/01/18 at 1:56 p.m., indicated that transportation personnel assessed P1 prior to hospital departure. P1 was confused and anxious. P1 was being transported by stretcher because P1 was unwilling to stay seated. Enroute, P1 constantly tried to remove the safety belts from the stretcher and made attempts to get off the stretcher. P1 was uncooperative enroute and would not allow ambulance personnel to obtain her vital signs. P1 left the ED at 2:17 p.m. and arrived at the assisted living facility at 2:19 p.m.

The ambulance report sheet, dated 03/01/18 at 3:37 p.m., indicated that emergency personnel responded to the assisted living facility a second time after P1 fell again and had associated leg pain. P1 was transported back to the hospital's ED.

The ED record indicated that P1 arrived in the ED a second time on 03/01/18, at 4:19 p.m. P1 was agitated, crying in pain, and screamed when the right leg was moved. Imaging identified a displaced fracture of the right femoral neck. P1 was admitted for hospitalization to orthopedic service.

RN/F was interviewed on 03/13/18 at 2:25 p.m. RN/F stated she assisted with P1's care during the morning of 03/01/18. A 1:1 sitter was assigned to remain at P1's bedside the entire time. P1 was confused and kept trying to climb out of bed. The ED got busy around 1:00 p.m. and P1's bed was needed for another patient. MD/D had already written P1's discharge order to return to the assisted living facility. P1's foley catheter was removed and RN/F took P1 by wheelchair to the Charge nurse's desk where RN/F monitored P1 until transportation staff arrived. P1 was still very agitated and tried to hit RN/F several times. RN/E offered to help with P1's care during the time P1 was at the Charge nurse's desk. RN/E called the assisted living facility with updates and provided the verbal discharge report to the facility nurse. Transportation staff arrived and P1 left the ED on a stretcher. Shortly thereafter, MD/D approached RN/F and said not to discharge P1, but P1 was already gone.

RN/E was interviewed on 03/13/18 at 2:05 p.m. RN/E stated she observed P1's behavior around 1:15 p.m. when P1 was sitting in a wheelchair at the Charge nurse's desk. P1 was agitated and restless. RN/E changed the discharge transportation mode from wheelchair to stretcher, due to P1's agitation which intensified during the time P1 sat at the Charge nurse's desk. RN/E called the assisted living facility nurse around 1:15 p.m. and learned that it was abnormal for P1 to be agitated and restless; RN/E updated the facility nurse about P1's behavior, urinary retention, and pneumonia. The facility nurse stated that the assisted living environment could not support P1's potential need for intermittent catheterization or 1:1 staffing for unsafe behavior. RN/E reported this information to MD/D, who said he would call the facility nurse. RN/E called the facility a second time and provided P1's discharge report. RN/E did not know that MD/D had changed P1's plan of care from ED discharge to inpatient admission. Shortly after P1 was discharged, RN/E got a voice-mail from the assisted living facility nurse that hospital staff had prematurely discharged P1 to an inappropriate environment, without resolving P1's emergent condition; P1 had fallen again and was on her way back to the hospital.

MD/D was interviewed on 03/13/18 at 1:10 p.m. MD/D stated P1 underwent an extensive work-up due to her dementia and inability to provide any history about her symptoms. P1 was found to have a lung infiltrate but all other imaging studies and labs were negative. MD/D's initial plan was to discharge P1 back to her residence on oral antibiotics for the pneumonia. P1's family member was in agreement with this plan so MD/D initiated the discharge paperwork to transfer P1 to the residence by wheelchair. RN/E then told MD/D that the facility was uncomfortable accepting P1 back, due to P1's change in condition and increased needs. MD/D had a follow-up conversation with P1's family member about the facility's concerns. P1's family member agreed that the best option was inpatient admission. When MD/D went to change P1's discharge plan to inpatient admission status, MD/D learned that P1 had left the ED and was already enroute to the facility. MD/D told RN/E to call the ambulance back to the hospital, but RN/E said the facility had accepted the patient back for facility readmission.

RN/I was interviewed on 03/12/18 at 9:23 a.m. RN/I stated that P1 lived in a secure memory care unit, due to dementia. P1 normally ambulated without difficulty, completed most activities of daily living independently, and expressed her needs. P1 was usually calm and cooperative. On the morning of 03/01/18, RN/I assessed P1 at 8:30 a.m. after unlicensed staff reported that P1 seemed weak and didn't want to get out of bed. RN/I observed that P1 had a small laceration on the top of the right scalp and a bruise under the chin, suspicious for a fall. P1 had no fall history and was unable to articulate if she had fallen. P1's personality was different. P1 barely talked and looked distressed. RN/I sent P1 to the hospital for further evaluation of the change in condition. A few hours later, a hospital nurse contacted RN/I and reported that P1's examination showed no abnormalities except urinary retention, which had required catheterization for a large amount of residual urine; the plan was to discharge P1 back to the facility. RN/I explained that the facility was not equipped with resources to catheterize patients. RN/I requested to speak with the hospital physician, who contacted RN/I about an hour later. The physician reported that P1 was currently agitated, restless, and upset. After speaking with RN/I, the physician agreed that P1's behavior did not represent P1's normal baseline status. RN/I discussed the limitations of care that could be provided in an assisted living facility; RN/I suggested that P1 needed continued care at a transitional care unit and the physician seemed to be in agreement with that plan. Shortly thereafter, a hospital nurse contacted RN/I to provide a verbal report regarding P1's course of treatment in ED because P1 was being discharged back to the facility; RN/I again expressed that the facility could not accept the patient back due to insufficient resources to meet P1's needs. During the phone call from the hospital nurse, the ambulance crew arrived with P1 and took her to her room. RN/I finished the phone call report from the hospital nurse, reviewed the discharge orders, and then went to check on P1. P1 was already on the floor of her room. P1 was holding her right leg, crying in pain. RN/I called an ambulance and then notified the hospital that P1 was returning with another fall due to the same unresolved symptoms. P1 never returned to the facility after the second ED visit.

The hospital's EMTALA policy (undated) indicated "the MSE is an ongoing process and the medical record must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or appropriately transferred...an individual is stable for discharge when a Qualified Medical Provider treating the individual determines, within reasonable clinical confidence, that an individual has reached the point where his/her continued care, including diagnostic workup and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions."