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Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure signage pertaining to the Emergency Medical Treatment and Active Labor Act (EMTALA) and corresponding patient rights' was posted in areas likely to be notice by patients entering the Emergency Department (ED) or waiting for treatment. This had potential to affect all patients presenting to the ED seeking care and treatment.

Findings include:

On 6/24/19, at 12:35 p.m. a tour of the ED and corresponding hospital corridors was conducted with ED nurse manager, registered nurse (RN)-A who explained the process patients follow when coming to the ED for care and treatment. The main entrance to the hospital served as the ED entrance for non-emergency transported (i.e. via ambulance) patients, which entered into a large, open foyer area which had a volunteer / information desk and some chairs for sitting. However, there were no visible EMTALA signage displayed in the foyer area.

Immediately to the side of the foyer, two registration rooms were used to get the patient' name and complaint before the patient was placed in a ED bay for treatment. The registration areas were separated by a partial wall which extended up to the ceiling. On the back wall of this shared space was a EMTALA sign which outlined a patient' rights when presenting to the hospital for emergency care. The single sign was hung on the wall on "Registration 1" side of the shared space; however, there was no signage in place in the "Registration 2" room. The sign was visible from the "Registration 2" side; however, the font was not readable due to the distance from where it was hung to where the patient's sat to be registered.

When interviewed on 6/24/19, at 12:53 p.m. admitting assistant (AA)-A explained the process a patient follows when present via non-emergent transport to the ED which included stopping at the registration desk(s) to register their name and chief complaint. AA-A observed the EMTALA signage displayed in "Registration 1" and verified the lack of signage in the second registration space used. AA-A stated the displayed EMTALA signage was not readable from the desk in "Registration 2" and added the sun created a "bad glare" on the glass of the displayed picture frame which housed the EMTALA signage. Further, AA-A stated the admitting personnel provided no information to patients on EMTALA when they present to the ED.

RN-A explained after a patient stopped to file their name and medical complaint at the registration desk(s), they were directed to a single waiting room outside of the foyer. Inside the waiting room, a red colored "Emergency Department" sign was suspended from the ceiling. There were several chairs present; however, no patients waiting at this time. Further, the waiting area lacked any hung or displayed EMTALA signage to inform waiting patients and family of a patient' rights as it pertained to EMTALA.

In the ED, several bay(s) were toured with RN-A. These spaces were used to provide care and treatment to patients in the ED. However, none of the reviewed bay(s) had any information or signage pertaining to EMTALA.

Immediately following the tour of the ED, RN-A was interviewed and acknowledged the lack of EMTALA signage as outlined on the tour.

A hospital policy on EMTALA signage was not provided.

Based on interview and document review, the critical access hospital (CAH) failed to ensure physician certification(s) of transfer to higher levels of care included a documented summary of risks vs benefits for 5 of 20 patients (P2, P7, P10, P11, and P14) whose closed records were reviewed.

Findings include:

P2's Emergency Room Record dated 5/21/19, identified P2 presented to the Emergency Department (ED) with symptoms of a stroke, and was transported to another hospital via ambulance.

P2's Physician Assessment and Certification dated 5/21/19, identified several components which included the name of physician accepting P2's care at the receiving hospital and if any personnel were accompanying P2. The form identified P2's condition had not stabilized; however, P2 would benefit from a higher level of care with their condition listed as, "Critical." A section was provided which read, "I have explained to the individual/legally responsible person the following risks and benefits of being transferred/refusing transfer," with several blank lines underneath to hand-write the risks and benefits discussed; however, these lines were left blank and not completed. The form was signed by P2's physician at the bottom.

P7's Emergency Room Record dated 6/5/19, identified P7 presented to the Emergency Department (ED) with symptoms of being intoxicated and suicidal.

P7's Physician Assessment and Certification dated 6/5/19, identified several components which included the name of physician accepting P7's care at the receiving hospital and if any personnel were accompanying P7. The form identified P7's condition had stabilized and no deterioration of her condition was likely due to her being transferred. A diagnosis was listed of, "Suicidal ideation," and her condition was recorded as, "Stable." A section was provided which read, "I have explained to the individual/legally responsible person the following risks and benefits of being transferred/refusing transfer," with several blank lines underneath to hand-write the risks and benefits discussed; however, these lines were left blank and not completed. The form was signed by P7's physician at the bottom.

P10's Emergency Room Record dated 6/10/19, identified P10 presented to the Emergency Department (ED) with symptoms of weakness and was transferred to a different hospital for care.

P10's Physician Assessment and Certification dated 6/10/19, identified several components which included the name of physician accepting P10's care at the receiving hospital and if any personnel were accompanying P10. The form identified P10's condition had not stabilized; however, P10 would benefit from a higher level of care. A section was provided which read, "I have explained to the individual/legally responsible person the following risks and benefits of being transferred/refusing transfer," with several blank lines underneath to hand-write the risks and benefits discussed; however, these lines were left blank and not completed. The form was signed by P10's physician at the bottom.

P11's Emergency Room Record dated 6/12/19, identified P11 presented to the Emergency Department (ED) with symptoms of low back pain.

P11's Physician Assessment and Certification dated 6/12/19, identified several components which included the name of physician accepting P11's care at the receiving hospital and if any personnel were accompanying P11. The form identified P11's condition had stabilized and no deterioration of their condition was likely due to her being transferred. A diagnosis was listed of, "Chronic lumbar pain with exacerbation, [left lower quadrant] abdominal pain [and] UTI," however, the spacing to record their condition at the time of transfer was left blank and not completed. A section was provided which read, "I have explained to the individual/legally responsible person the following risks and benefits of being transferred/refusing transfer," with several blank lines underneath to hand-write the risks and benefits discussed; however, these lines were left blank and not completed. The form was signed by P11's physician at the bottom.

P14's Emergency Room Record dated 6/22/19, identified P14 presented to the Emergency Department (ED) with a police escort and reports of being delusional. P14 was to be transferred to another hospital and a 72-hour hold was to be implemented at the receiving hospital.

P14's Physician Assessment and Certification dated 6/22/19, identified several components which included the name of physician accepting P14's care at the receiving hospital and if any personnel were accompanying P14. The form identified P14's condition had stabilized and no deterioration of their condition was likely due to her being transferred. A diagnosis was listed of, "Paranoid Delusions," was listed. A section was provided which read, "I have explained to the individual/legally responsible person the following risks and benefits of being transferred/refusing transfer," with several blank lines underneath to hand-write the risks and benefits discussed; however, these lines were left blank and not completed. The form was signed by P14's physician at the bottom.

On 6/25/19, at 8:55 a.m. the ED nurse manager (RN)-A reviewed the medical records with the surveyor and verified the missing documented summaries on the patient records.

A hospital provided Transfer or Discharge of Unstable/Stable Individuals to Another Institution policy dated 8/2013, identified when a patient is determined to have a emergency medical condition, the hospital would provide necessary examination and treatment to stabilize the patient and follow established guidelines for transfer of the patient to another facility. A procedure was listed which included completing the Physician Certification form. Further, the policy directed when completing the Physician Certification, " ... The risks and benefits are to be documented."