HospitalInspections.org

Based on observations, review of the Medical Staff By-Laws, Medical Staff Organization and Function Manual, medical record review, and interviews, the hospital failed to ensure:

a. Signs specifying the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor (EMTALA) and signs indicating whether the hospital participates in the Medicaid program were posted in places likely to be noticed by all individuals entering the emergency department.

b. Which staff members were qualified to conduct a medical screening examination for patients that presented to the Dedicated Emergency Department.

Refer to tags: A2402, A2406.

Based on observations and interviews it was determined the facility failed to ensure signs specifying the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor (EMTALA) and signs indicating whether the hospital participates in the Medicaid program were posted in places likely to be noticed by all individuals entering the emergency department.

This deficient practice had the potential to affect all patients arriving at this hospital for emergency care.

Findings include:

A tour of the Emergency Department (ED) on 9/20/22 at 10:30 AM revealed there were no signs visible by the surveyors at the ED ambulatory entrance, waiting room area, registration desk, or triage room. One sign indicating the rights of patients in respect to EMTALA and Medicaid participation was posted on the wall of the sliding doors at the ambulance entrance, which was in the hallway behind locked doors of the ED waiting area. The sign was not visible to a patient arriving via stretcher.

On 9/20/22 at 10:55 AM in an interview with Employee Identifier (EI) # 3, Registered Nurse, Emergency Department Information Systems, stated the EMTALA and Patient Rights were given to the patient at the time of registration and a copy was given to the patient.

On 9/22/22 at 10:15 AM in an interview conducted with EI # 10, Patient Registration, EI # 10 stated the patients are given copies of registration paperwork upon request of the patient at the time of registration. EI # 10 was asked if copies of EMTALA and Medicaid participation was included, EI # 10 stated "I don't think so". EI # 10 provided blank copies of the paperwork that would be given to patients. There was no documentation of EMTALA or Medicaid participation included.

On 9/22/22 at 10:35 AM an interview was conducted with the parents of an Unsampled Patient (UP) # 3 in ED room 30. The parent of UP # 3 stated they were not given any copies of anything at the time of registration. There were no signs for EMTALA or Medicaid participation in ED room 30.

On 9/22/22 at 10:45 AM an interview was conducted with the parents of UP # 4 in ED room 40. The parent of UP # 4 stated they arrived by car at approximately 8:00 AM and went through the ED registration and triage. The parent was asked if EMTALA or the rights of Medicaid patients were explained, the parent responded "no explanation of either". The parent was then asked if they had seen any signs posted in the ED about EMTALA or Medicaid participation, the parent responded "did not see any signs back there". No signs for EMTALA or Medicaid participation were posted in ED room 40.

During a tour of the ED on 9/22/22 at 10:55 AM with EI # 7, Division Director of Nursing, EI # 8, Staff Nurse ED, and EI # 9, Registration Manager, confirmed the signs for EMTALA and Medicaid participation were not posted in patient rooms or anywhere else other than the ED entrance.

In an interview conducted on 9/22/22 at 1:30 PM, EI # 1, ED Director, confirmed the EMTALA and Medicaid sings posted at the ambulance could not be seen where it was located by a patient arriving by ambulance and the signs in the ED ambulatory entrance was to the right side of the waiting room and not clearly visible when patients walk in.

Based on review of the Medical Staff By-Laws, Medical Staff Organization and Function Manual, and interview, the hospital failed to determine which staff members were qualified to conduct a medical screening examination for patients that presented to the Dedicated Emergency Department.

This had the potential to affect all patients served.

Findings include:

A review of the Medical Staff By-Laws, approved by the Medical Staff on June 10, 2019 and the Medical Staff Organization and Functions Manual, revised and approved on May 19, 2022 revealed no specific documentation to indicate which members of the medical staff were determined qualified to conduct medical screening exams for patients that presented to the Emergency Department (ED).

In an interview conducted on 9/22/22 at 1:30 PM, Employee Identifier # 1, ED Director, confirmed the Medical Staff By-Laws or Organization and Functions Manual did not indicate who could perform medical screening exams.