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Based on observation and interview, the facility failed to conspicuously post signage specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA) in locations likely to be noticed by all individuals entering the Emergency Department (ED), as well as individuals waiting for examination and treatment. This included:

1. Near the entrance to the ED or the ambulance bay area;
2. Near the entrance to the Birth Center (Labor & Delivery [L&D]) unit.

This failure increased the potential for patients to not know their rights to receive a medical screening examination or treatment for their emergent medical condition, including active labor.

Findings:

On 3/21/2023, at 10:20 a.m., a tour was conducted of the hospital ED. No signs related to patient rights to examination, treatment, or Medicaid participation were observed near the entrance of the ED or near the ambulance bay area. One EMTALA sign, posted in English and Spanish and approximately 8 inches by 11 inches, was observed in a registration area to the right of the ED patient check-in station; the sign was not conspicuously posted.

During the tour conducted on 3/21/2022 at 10:20 a.m., the Executive Director Specialty Services (EDSS) and Assistant Director Emergency Department (ADED) confirmed the EMTALA signs were not posted outside or inside of the ED entrance, in the ambulance bay area, triage or patient treatment rooms.

Observations of the Birth Center (L&D) unit and concurrent interview with the EDSS were conducted on 3/21/2023, at 10:43 a.m. The EDSS stated laboring and emergent patients presenting to the ED were immediately brought up to L&D accompanied by a staff member. The EDSS stated the patients were brought through the double door entrance and to the L&D nurse station to check-in. No postings or signage related to patient rights to examination, treatment, or Medicaid participation were observed outside the double door of the Birth Center entrance, or immediately inside the entrance. One EMTALA sign was observed posted on the right side of the hallway from the L&D nurse station. The EDSS confirmed the EMTALA signs were not posted outside the entrance of the Birth Center, immediately inside the entrance, in the patient waiting area or at the nurse station check-in area. She agreed the patients would not go to the right side of the hallway to read the sign.

A facility EMTALA Signage Policy was requested on 3/21/23, at 3:13 p.m. to the Executive Director of Quality and Education Services (EDQES). No policy was received.

On 3/22/2023, at 9:20 a.m., the EDQES stated the facility does not have a policy on EMTALA signage and that they followed the California Hospital Association recommendation.

Review of a document from the California Hospital Association titled "California Hospital Compliance Manual 2022, indicated, "HOSPITAL SIGNAGE REQUIREMENTS ...LOCATION/LANGUAGE/SIZE AND FONT SIZE ...Signs must be posted in a place or places likely to be noticed by all individuals entering the dedicated emergency department (on or off-campus), as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (e.g., entrances, admitting area, waiting rooms, treatment areas) ..."

Based on interview and record review the hospital failed to enter one patient (Patient 1), who come to the Emergency Department (ED) seeking assistance, into an EMTALA (Emergency Medical Treatment and Labor Act) Central Log (tracking list of everyone who comes into the ED), when Patient 1 arrived via ambulance to the Hospital and was subsequently re-routed to another hospital, and was not included in the EMTALA Central Log.

Findings:

During a concurrent interview and record review of the hospital EMTALA Central Log for 10/18/20, with the Executive Director of Specialty Services (EDSS) on 3/21/23, at 1:30p.m., the EDSS stated, "Patient 1 was not entered into the Central Log, not registered and had no ED documentation."

Review of a facility document titled "Emergency Dept. [department] Patient Registration Intake Guideline," not dated, indicated the following: "All patients that enter the Emergency Department presenting for treatment or brought in for treatment must be registered into our EMR [Electronic Medical Record] ..."

A facility EMTALA Policy that was in effect in 2020 was requested on 3/21/23, at 10:30 a.m. to the Executive Director of Quality and Education Services (EDQES). No EMTALA policy was received.

During a telephone interview on 3/27/23, at 3:58 p.m., the EDQES stated there was no facility EMTALA policy in 2020.

Based on interview and record review, the facility (Hospital 1) failed to provide a medical screening exam (MSE) for 1 of 28 sampled patients (Patient 1), when Patient 1 arrived via ambulance to Hospital 1(a non-trauma center) Emergency Department (ED) after a motor vehicle accident with multiple trauma (serious injuries), the physician performed a quick physical exam and re-directed Patient 1 to flight transportation to Hospital 2 without a documented MSE.

This failure resulted in Patient 1 not receiving a medical screening exam to determine if an emergent medical condition existed, and had the potential to cause serious harm if not immediately treated or stabilized.

Findings:

Review of Patient 1's ambulance report, provided by Hospital 1, dated 10/18/20, at 10:29 p.m., indicated, "Pt [patient] had a very weak carotid pulse [blood being pushed out of the heart toward the extremities], obvious bilateral femur [thigh bone] fractures, ... and obvious injuries to the head. Due to pt extremity unstable [not within normal range] and inability to obtain a blood pressure initially, pt was transported to [Hospital 1]. [Name of ambulance vehicle] arrived at [Hospital 1] and with consultation and orders from physician that the pt was stable [within normal range] enough to be redirected to [local] airport to fly pt to [Hospital 2, a trauma center]."

Review of Patient 1's flight transport report, provided by Hospital 1, dated 10/18/20 at 11:16 p.m., indicated, "Patient was an unrestrained driver of a pickup truck that ran head-on into a tree at high speed. The truck sustained major damage with obliteration of the passenger compartment. EMS (Emergency Medical Services) reported prolonged extrication (removal of person from a vehicle) and the patient had an initial GCS (Glascow Coma Scale, used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients) of 3 (severe head injury) on their arrival but was found to have a pulse and responded to resuscitative (restoration) measures during the transport. The patient had a labile (frequent changes) GCS and had been markedly hypotensive (low blood pressure). The patient was to be transported to the closest trauma center per county trauma triage criteria."

The report indicated the primary impression was traumatic injury (serious injuries which require immediate medical attention) with the secondary impression of alcohol intoxication; altered level of consciousness (inability to arouse); hypotension (blood pressure below normal); and pain.

The report included a mental status assessment, which indicated Patient 1 was intermittently unresponsive to painful stimulus, flailing arms, screaming, and did not follow commands.

The report included documentation, which indicated Patient 1 was intubated (placement of a tube down the windpipe to maintain an open airway) on 10/18/2020 at 11:29 p.m. during the flight to the Hospital 2. The report indicated Patient 1 arrived at Hospital 2 on 10/18/2020 at 11:33 p.m.

During a concurrent interview and record review of Hospital 1's "Central Log" (tracking list of everyone that comes into the ED), with the Executive Director of Specialty Services (EDSS) on 3/21/23, at 1:30 p.m., the EDSS indicated Patient 1 was not entered into the Central Log, not registered, and ED documentation was not done.

During a telephone interview on 3/22/23 at 11:15 a.m. with the Emergency Department Medical Doctor (EDMD), the EDMD stated he did not recall the event of 10/18/20. Once details were given, the EDMD stated, "[it] sounds vaguely familiar," The EDMD stated Patient 1 was "Not in the log or registered." The EDMD stated, "now [I] recall." The EDMD confirmed that he was the ED medical provider working on 10/18/20. The EDMD explained the MSE process of a patient brought in by an ambulance to the ED, and stated, "The patient is evaluated, stabilized to the best of our ability, then transferred out."

During the same telephone interview on 3/22/23 at 11:15 a.m., the EDMD stated he went into the ambulance and evaluated Patient 1. At the time he felt Patient 1 was stable to transfer. The EDMD stated, "I did not want to lose that opportunity [air ambulance availability]. The Chart had not been created." The EDMD stated because Patient 1 had not been registered he "could not document an MSE." The EDMD stated he did an MSE, which consisted of "classic ABCs, airway, breathing and circulation. A quick physical exam, vital signs (pulse, respirations, blood pressure) from EMS. [Patient 1] Mentation was appropriate. That was my assessment at that time." [Patient 1] was stable to transfer to the helicopter (air ambulance) and taken to the receiving facility. The EDMD stated he did not do any documentation, and stated the "failure was of no documentation."

A telephone interview was conducted with the ED Medical Director (EDMC) on 3/22/23, at 11:26 a.m. The EDMC stated, "Patients that come to us are our responsibility. The patient needs to be MSE'd and stabilized. Stabilized means, clinically, no impending decompensation (deterioration). The expectation is for the MSE to be documented." The EDMC also stated that annual EMTALA training was provided to all ED medical providers.

A telephone interview was conducted with the ED Charge Nurse (EDCN) on 3/22/23, at 11:40 a.m. The EDCN confirmed she was the EDCN on 10/18/20 and was MICN (Mobile Intensive Care Nurse) certified. The EDCN stated her role included answering the radio calls from the paramedics. These calls included Trauma (life threatening) calls. For trauma patients, protocols (instructions) were followed to guide the paramedics to the appropriate Trauma Level (I or II) Hospital.

During the same telephone interview with the EDCN on 3/22/23, at 11:40 a.m., the details of Patient 1's case from 10/18/20 was provided. The EDCN stated she did not recalled Patient 1's case. The EDCN also stated, based on the information provided, Patient 1 would have met "Full Trauma Activation and taken to a Level I trauma center". The EDCN stated, "If the ambulance arrives at our facility the patient would be treated and transferred".

The facility policy titled, "Emergency Services Trauma Transfer Protocol," revised 11/2018, indicated the following:

"To ensure early identification, appropriate and timely transfer of trauma patients that require intervention and treatment at a level of intensity or type of service not available at [Hospital 1]. These patients shall be transferred to an appropriate Level 1 or Level II Trauma Center...2. Initiate Trauma Surgeon Evaluation prior to transfer for the following indications: ...pelvic fractures ...3. Initiate resuscitation and stabilization...5. Attending physician will initiate transfer arrangements, in accordance with EMTALA regulations, by direct contact and discussion with the receiving physician/surgeon ...Transfer arrangements to appropriate trauma facility and bed confirmation will be obtained prior to patient departure. Nursing report is given to the receiving nurse by phone prior to patient departure and documented on the transfer summary..."

The facility document titled, "Emergency Dept. Patient Registration Intake Guideline," not dated, indicated the following: "All patients that enter the Emergency Department presenting for treatment or brought in for treatment must be registered into our EMR [Electronic Medical Record] ..."

Review of the facility Medical Staff Bylaws, not dated, indicated the following: "MEDICAL SCREENING EXAMS...The following personnel may perform medical screening exam under standardized procedures approved by the Medical Staff, in designated locations: Nurse Practitioners/Physician Assistants, Registered Nurses specially trained to perform Medical Screening Exam, Emergency Department, Obstetrical Services." No other EMTALA related requirements provided.

During an interview on 3/23/23, at 10:55 a.m., the Chief Medical Officer (CMO) stated the "Medical Staff Bylaws do not specifically address EMTALA."

During a telephone interview on 3/27/23, at 3:58 p.m., the Executive Director of Quality and Education Services (EDQES) stated there was no facility EMTALA policy in 2020.