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Based on observation and staff interviews, it was determined that the facility failed to post EMTALA (Emergency Medical Treatment and Labor Act) signage. Specifically, EMTALA signs were not posted in the Emergency Department (ED) and the Labor and Delivery Department.

Findings include:

During a tour of the Emergency Department on 11/07/13 at 11:30 AM it was observed that EMTALA signage in English and Spanish was posted in the main waiting room.

There was no EMTALA signage in the two main entrances (Ambulatory and Ambulance entrances) as well as the registration and ED treatment areas. There was no signage in a smaller waiting room located near the registration booth.

At interview with the ED Nurse Manager on 11/07/13 at 11:45 AM, she stated ambulance patients are taken directly to one of the ED treatment areas and some ambulatory patient depending on their acuity are also triaged in the ED treatment area.

Therefore not all patients could visualize the posted signage in the main waiting room.

In addition, the tour of the Labor and Delivery (L&D) triage unit on 11/07/13 at 12:25 AM noted there was no EMTALA signage posted.

At interview with the L&D Nurse Manager on 11/07/13 at 12:30 PM, she stated there is signage in the ED and she is not aware of the requirement to post the EMTALA signage in L&D triage unit. She acknowledged that some of their patients come directly to L&D bypassing the Emergency Department.

Based on interview and review of the Emergency Department (ED) Log, it was determined that the facility failed to maintain a complete log.

Specifically, the Labor and Delivery (L&D) Department failed to indicate the disposition of each patient presenting for evaluation and treatment. This finding was noted in 5 of 5 applicable medical records reviewed. (MR #27, 28, 29, 30 and 31).

Findings include:

Review of MR # 31 documented a 31 year-old, Gravida (pregnancies regardless of pregnancy outcome) 3, Para ( pregnancies that have reached viability) 1 at 38 weeks who presented to the L&D triage on 10/31/13 at 12:00 AM for complaints of flu-like symptoms, cramping and achiness. The patient was discharged home on 10/31/13 at 1:55 AM after labor was ruled out. There was no disposition noted in the L&D log for this patient.

Review of MR #28 documented a 30 year-old, Gravida 1, Para 0, at 27 weeks gestation who presented on 6/10/13 at 11:50 AM with complaints of lower abdominal pain. The June 2013 log did not indicate the disposition of the patient; however, the review of the patient ' s record revealed she was discharged home following a medical screening examination and the rule out of labor.

During interview with the L&D Nurse Manager on 11/08/13 at 9:35 AM, she stated nurses are responsible for logging in the disposition of patients assigned to them but the Nurse Manager is ultimately responsible for log completion. She added that the disposition of each patient can be found in the " Delivery Room Short Stay Form " if is not indicated in the log.

Review of MR #27 documented a patient who presented to L&D triage on 4/8/13 at 8:19 PM to rule out labor. The patient was a 27 year-old, Gravida 3, Para 1 at 36 weeks gestation with complaints of contraction. The disposition of the patient was not noted in the L&D log and the Delivery Room Short Stay form did not indicate the disposition of the patient.

During a follow up interview with the L&D Nurse Manager on 11/08/13 at 2:15 PM, she stated upon review of patient ' s (MR #29) record that the patient received intravenous fluid and although the patient ' s disposition was not indicated in the Delivery Room Short Stay form, labor was ruled out and the patient was discharged home.

Based on interview, the review of medical records and other documents, it was determined the facility failed to secure written informed refusal of treatment for patients opting to leave the Emergency Department prior to the completion of stabilization treatment of an emergency medical condition. This was evident in 3 of 5 patients who left the Emergency Department against medical advice. (MR # 36, #38, and # 42).

Findings include:

Review of MR #36 documented a 53-year-old female who presented to the ED on 10/31/13 at 2:02 PM with complaints of chest pain, and shortness of breath. The patient's medical history was significant for ovarian cancer, antiphospholipid antibody syndrome and lupus.

The physician assessment at 2:34 PM noted the patient's complaint as a sharp pulling pain at left sternal border and left chest that intermittently moves to right chest and back to left.

A 12 lead electrocardiogram completed at triage was normal and laboratory tests were unremarkable.

The physician noted at 4:05 PM that the patient wants to leave because of a family engagement. The physician noted that CT scan was not done and the patient understands the risks including but not limited to worsening symptoms and death and agrees to sign out Against Medical Advice (AMA).

The patient's record did not include a signed informed refusal of treatment.

Review of MR #38 documented a 55-year-old male who was triaged on 9/13/13 at 1:03 PM. The patient stated his left leg " went dead " for 30 minutes shortly after he developed mid sternal chest pain that resolved.

At 4:25 PM, following diagnostic tests that were unremarkable, the physician noted that the patient was advised he would be admitted for further work up. The physician further noted that the patient refused admission and will sign AMA. However, there was no signed informed consent in the medical record or documentation of the reason for the refusal to sign the AMA form.

Review of MR #42 documented a 63 year-old male who presented to the ED on 7/1/13 and triaged at 7:46 PM with complaint of substernal chest pain associated with nausea upon awaking this morning.

The physician at 7:51 AM noted chest heaviness rated 7 (seven) on a pain scale of 1-10. The patient stated he took four baby Aspirin and pain is now down to 2/10. The patient's medical history included hypertension and melanoma. Electrocardiogram, chest X-ray, and laboratory tests were normal.

At 10:46 AM, physician noted the patient wants to leave against medical advice to take care of his autistic son and is refusing a second set of cardiac enzymes. The physician noted that the patient understands the risks including but not limited to worsening symptoms, heart attack and death, and that the patient agrees to sign out AMA.

A written informed refusal of treatment was not obtained prior to the discharge of the patient on 7/1/13 at 11:09 AM.

The review of policy (OF-ADM-182) titled " Discharge Against Medical Advice " indicates that " every competent adult patient who is leaving against medical advice ... should be asked to sign the Patient Leaving Against Medical Advice form. If the patient or health care agent or relative or close friend refuses to sign the form or leaves without speaking with a health care professional, a progress note must be written in the patient ' s medical record describing the departure situation by a health care professional caring for the patient " .

During interview with the Director of Nursing for the Emergency Department on 11/08/13 at 11:30 AM, she stated upon review of MR # 38 that the physician informed the patient of risks of leaving before the completion of treatment but did not secure a signed informed consent. She confirmed there was no written documentation that indicates the reason for the patient refusal to sign the AMA form.