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Based on observation, interviews, and review of policies and procedures, it was determined the hospital failed to develop and enforce its EMTALA policies and procedures in the following areas:
* Required posting of EMTALA signs;
* Whistleblower protections; and
* Reporting suspected incidences of individuals with an EMC transferred in violation of 489.24(e).

Findings included:

1. Posting of Signs: Refer to the findings identified under Tag C2402, CFR 489.20(q), which reflects the hospital's failure to develop and enforce EMTALA policies and procedures related to posting of the required EMTALA signs.

2. Hospital EMTALA policies and procedures were reviewed and contained no reference to the required EMTALA whistleblower protection.

3. During an interview with the ED Director on 10/25/2017 at 1550, he/she confirmed the hospital did not have an EMTALA policy and procedure that addressed EMTALA whistleblower protections. He/she stated "We don't have an EMTALA anti-retaliation policy."

4. Hospital EMTALA policies and procedures were reviewed and contained no reference to the required policy and procedure that addressed reporting of suspected incidences of individuals with an EMC transferred in violation of 489. 24(e).

5. During an interview with the Quality Director on 10/25/2017 at 1450, he/she confirmed the hospital did not have an EMTALA policy and procedure that addressed reporting of suspected incidences of individuals with an EMC transferred in violation of 489.24(e). He/she stated "We didn't find anything like that."

Based on observation, interview, and review of policies and procedures, it was determined that the hospital failed to fully develop and implement a policy and procedure for the posting of the required EMTALA signs, and failed to post the required EMTALA signs in all places likely to be noticed by all individuals entering the ED as required by this regulation.

Findings include:

1. A tour of the ED was conducted on 10/24/2017 at 1705 with the Quality Director and Facilities Operations/Safety Officer. The ED had an ambulance entrance which was separate from the main ED entrance. The ambulance entrance, adjacent hallway used by patients entering the ED, and two treatment rooms were observed. For patients arriving by ambulance, there was no EMTALA signage posted in these areas. These observations were confirmed with the Facilities Operations/Safety Officer and Quality Director at the time of the observation.

2. During an interview on 10/24/2017 at 1720, the Facilities Operations/Safety Officer acknowledged that patients entering the ED by ambulance would not have an opportunity to see any EMTALA signage during their ED visit.

3. During an interview with the CNO on 10/25/2017 at 1445, he/she stated the hospital did not have an EMTALA signage policy and procedure.

4. Hospital EMTALA policies and procedures were reviewed and contained no reference to the required posting of EMTALA signage.