HospitalInspections.org

Based on observation and interview the hospital failed to post Emergency Medical Treatment & Active Labor Act (EMTALA) signage in prominent areas throughout the Emergency Department (ED) to notify patients of their right to examination and treatment of emergency medical conditions. The findings include:

Tour of the ED on 4/4/2022 at 2:30 PM with Director #1 and ED Director #2 identified one EMTALA sign located on the wall in the ED walk-in entrance vestibule. Further tour of the ED failed to identify any additional signage or that any EMTALA signs that were in the Spanish language.

Interview with Director #1 on 4/4/2022 at 2:30 PM identified that there used to be an EMTALA sign next to the registration desk but it appeared that it was removed and replaced with another sign by someone without knowledge of EMTALA regulations.

The hospital's Emergency Medical Treatment & Active Labor Act (EMTALA) policy identified the hospital shall post signs in the emergency department stating that if you have an emergency condition or are in labor you have the right to receive within the capabilities of the hospital's staff and facilities an appropriate medical screening exam, necessary stabilizing treatment, an appropriate transfer to another facility if necessary, even if you cannot pay or do not have medical ensure or Medicare or Medicaid, this hospital does participate in the Medicaid program. Signs shall be printed in English and Spanish and shall be posted in a place or places likely to be noticed by all individuals entering the emergency department.

Based on clinical record reviews, hospital policy review and interviews for 1 of 20 patients reviewed for medical screening evaluations in the Emergency Department (ED) (Patient #6), the hospital failed to ensure that a patient who was waiting for a medical screening evaluation was provided a timely medical screening evaluation or was advised of the risk of leaving without treatment prior to the patient leaving. The findings include:

a. Patient #6 presented to the ED on 1/7/22 at 8:54 PM with a chief complaint of depression, was triaged at 9:28 PM, denied suicidal ideations, was homeless and recently kicked out of a shelter. The patient was sent back to the waiting room after triage to await an open bed. On 1/8/22 at 9:03 AM the patient was removed from the hospital's bed board (12 hours after entering the ED) and identified as left without being seen after triage. Interview with the RN ED Educator on 4/4/22 at 1:00 PM and review of Patient #6's clinical record identified that it was unable to be determined how long Patient #6 was in the waiting room pending the medical screening evaluation before leaving. The RN ED Educator identified that the expectation is for staff to conduct rounding in the waiting room to have an awareness of what is happening with the waiting patients.

The hospital policy for Emergency Medical Treatment & Active Labor Act (EMTALA) effective date July 2021 identified that if an individual requests a medical examination or treatment, an appropriate medical screening shall be provided.

Based on clinical record reviews, hospital policy review and interviews for 5 of 20 patients reviewed for stabilizing treatment in the Emergency Department (ED) (Patients #2, #9, #17, #18 & #19), the hospital failed to ensure that documentation reflected that those patients who wished to leave Against Medical Advice (AMA) were offered to sign AMA documents or that the patients' refusals to sign were documented per policy. The findings include:


a. Patient #2 presented to the ED on 10/17/21 at 12:30 PM with a chief complaint of chest pain, was triaged at 12:50 PM, and placed in the inner waiting room. When approached by a phlebotomist, Patient #2 stated "I'm leaving" and left. Review of the clinical record failed to identify that AMA documents were signed or that staff documented that the patient refused to sign the AMA document. Interview with RN ED Educator on 4/4/22 at 1:00 PM identified that Patient #2 should have been offered AMA paperwork.


b. Patient #9 presented to the ED on 2/10/22 at 9:47 PM with a chief complaint of being assaulted, was triaged at 9:52 PM, stated being struck in the face with a bat, an assessment showed no evidence of trauma, the patient was brought to a room at 9:58 PM, and was seen by the MD at 10:22 PM and again at 11:43 PM. The MD identified that the patient wanted to leave AMA and was discharged. Review of the clinical record failed to identify that AMA documents were signed or that staff documented that the patient refused to sign the AMA document. Interview with RN ED Educator on 4/3/22 at 1:45 PM identified that Patient #9 should have been offered AMA paperwork.


c. Patient #16 presented to the ED on 3/29/22 at 9:42 PM with a chief complaint of fall, triaged at 9:45 PM, stated was intoxicated and fell face first, now ambulatory and gait OK, and brought to a room at 9:53 PM. At 10:18 PM the patient refused to stay, and the patient eloped. Although the MD was made aware of the patient elopement, the MD failed to document Patient #16's disposition and review of the clinical record failed to identify that AMA documents were signed or that staff documented that the patient refused to sign the AMA document.


d. Patient #17 presented to the ED on 3/30/22 at 12:23 PM with a chief complaint of fall and back pain, was triaged at 1:32 PM and a CT scan was ordered. At 3:15 PM the patient was leaving. A Physician Assistant (PA) at the front desk asked the patient to stay, risks of leaving were explained, but the patient left AMA. Review of the clinical record failed to identify that AMA documents were signed or that staff documented that the patient refused to sign the AMA document.


e. Patient #18 presented to the ED on 3/31/22 at 11:08 PM with a chief complaint of headache and post-surgical pain, was triaged at 11:14 PM, patient stated fell from bed, and was brought to a room at 12:11 AM (4/1/22). An assessment and physical exam were conducted by the APRN, and the patient was seen by an MD at 4:00 AM with a plan to obtain an MRI. At 9:11 AM Patient #18 did not want to wait for the MRI and left AMA. Review of the clinical record failed to identify that AMA documents were signed or that staff documented that the patient refused to sign the AMA document.

Interview with the RN ED Educator on 4/5/22 at 9:30 AM and with the Director of Safety and Quality on 4/5/22 at 2:30 PM identified that the patients who left the ED AMA should have been offered AMA paperwork to sign.

The hospital policy for Emergency Medical Treatment & Active Labor Act (EMTALA) effective date July 2021 identified that if an individual requests a medical examination or treatment, an appropriate medical screening shall be provided. If a patient left AMA, one of the following must be noted in the medical record: a complete, signed, and witnessed "Leaving Against Medical Advice" form or documentation of the patient's refusal to sign the "Leaving Against Medical Advice" form.