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Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases] regarding appropriate transfers for 2 (P-1, P-20) of 20 patients reviewed for EMTALA requirements resulting in the lack of information and identification of resources required for appropriate transfer. Findings include:

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A-2409 Lack of information regarding EMTALA requirements for appropriate transfer

Based on observation and interview, the facility failed to provide signage pursuant to EMTALA (emergency medical treatment and labor act) in 5 of 7 waiting areas for the emergency department resulting in the potential for all emergency department patients using the waiting areas to not be informed of their rights to have a medical screening exam and stabilizing treatment. Findings include:

On 5/7/2025 at 1004 during the initial tour of the main facility, Triage Nurse Staff F stated there were two other overflow waiting areas for patients who wanted to be seen in the ED (Emergency Department).

On 5/7/2025 at 1018, Waiting Room #2 was entered and found to have 7 chairs present; however, no EMTALA signs were found in the room. This was confirmed by Staff F at the time of discovery.

On 5/7/2025 at 1020, Waiting Room #3 was entered and found to have 11 chairs present. No EMTALA signs were found in the room. This was confirmed by Staff F at the time of discovery.

On 5/7/2025 at 1021, ED Manager Staff A was informed of the findings and steps were retraced back to both waiting rooms. Staff A stated she knows that signs had been present and was surprised they were not there.

On 5/8/2025 at 0830, the lobby of child facility Free-standing ED #1 was entered. It was noted there was seating on either side of the entrance door from the outside of the building which was shared with other medical offices. No EMTALA signage was visualized in either waiting area. Additionally, during the tour of the facility on 5/8/2025 at approximately 0840, another small waiting area was present in front of the triage room which also had no EMTALA signage present. Both of these findings were confirmed by Regulatory/Compliance Staff N at their respective times of discovery.

Facility policy, Version Number 6, titled "Emergency Medical Treatment and Labor (EMTALA) approved 4/23/2024 states, "A sign will be posted in a conspicuous location, and in places likely to be noticed by individuals entering and waiting for examination, in each dedicated emergency department (including any off campus departments where medical screening examinations must be performed, such a s Labor and Delivery), specifying in clear and simple terms the rights of individuals under EMTALA with respect to examination and treatment for an emergency medical condition and of women in labor, and whether the Hospital participates in the Medicaid program."

Based on interview and record review, the facility failed to document requirements for appropriate transfer for 2 (P-1, P-20) of 6 patients reviewed for transfer resulting in the lack of information and identification of resources needed for appropriate transfer. Findings include:

Review of the medical record for P-1 revealed he was a 13-year-old male who presented to the Emergency Department (ED) on 2/24/2025 at 0131 for a headache after being seen twice (2/19/2025, 2/21/2025) at a nearby children's hospital and another time at another nearby acute care hospital (2/22/2025) for the same issue. Following evaluation in the ED and consults with pediatric providers, it was determined P-1 required transfer to the nearby children's hospital for further treatment and care. Review of the "Emergency Medical Treatment and Transfer (EMTALA [Emergency Medical Treatment and Labor Act]) Form" revealed there were no risks or benefits of transfer present. This was confirmed by Staff B 5/7/2025 at 1310.


Review of the medical record for P-20 revealed he was a 39-year-old male who presented to the ED on 12/23/2025 at 1624 for suicidal ideation (SI) with a plan to cut his neck that day. P-20 was requesting admission for medication adjustment as he felt his anti-psychotic medication was not working. Past medical history included ADHD (attention deficit hyperactivity disorder), anxiety, depression, and schizophrenia. C-SSRS (Columbia Suicide Severity Rating Scale - assessment tool used to assess suicide risk) indicated he was high risk for suicide.

Social work notes indicated P-20 was displaying current symptoms of anxiety and command hallucinations. P-20 indicated he had a plan to cut his neck and had access to kitchen knives in order to do it. His intent showed he would carry out his plan. Social work placed him at moderate risk for suicide.

Social work notes further indicated P-20 was supposed to have his injection for his anti-psychotic that day; however, he decided not to go because it was cold outside. When trying to obtain placement at the crisis center, it was discovered the injection was court-ordered, so the patient would be on a notification of non-compliance and would need in-patient hospitalization. Due to the notification of non-compliance, P-20 was made an involuntary admission. Social work indicated the facility for placement, accepting physician, admission status, transportation plan, and indicated that nurse report was completed.

P-20 was diagnosed with SI, schizophrenia, and severe episode of recurrent major depressive disorder with psychotic features. He was transferred via ambulance to a local psychiatric facility. No EMTALA paperwork was found present in the medical record indicating the risks/benefits of transfer, physician certification that the benefits outweighed the risks, resources needed for transfer or that the medical record had been sent to the receiving facility.

Facility policy, Version Number 6, titled "Emergency Medical Treatment and Labor (EMTALA) approved 4/23/2024 states, "Transfer: The movement (including the discharge of an inpatient) of an individual outside the Hospital's property at the direction of any person employed by (or affiliated or associated, directly or indirectly with) the Hospital, but does not include such a movement of an individual who (a) has been declared dead, or (b) leaves the Hospital without the permission of any such person...If after examination it is determined that an a {sic} individual has an emergency medical condition, the Hospital will provide, within the staff and facilities' capacity, capability and availability at the Hospital, for such further medical examination and treatment as may be required to stabilize the medical condition, or else provide for the transfer of the individual to another medical facility... An individual with an emergency medical condition may not be transferred until he or she is stabilized, unless: a. A physician or qualified medical personnel (as defined by the Medical Staff Bylaws) in consultation with a physician makes a determination that the medical benefits reasonably expected from treatment at another facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or her unborn child, from being transferred, and the physician or other qualified medical person signs the Physician Certification of Transfer form (Appendix A)...Transfer of an individual with an emergency medical condition to a medical facility is appropriate only where: a. The risks to the individual's health and, in the case of the woman in labor, the health of the unborn child, of the transfer are first minimized, to the extent possible within the capabilities of the staff and facilities available at the Hospital. b. The receiving facility has available space and qualified personnel for treatment of the individual and has given its consent to the transfer of the individual and to provide appropriate medical treatment. Acceptance of the transfer by receiving facility must be documented in writing. c. The transfer is effected through qualified personnel and proper transportation equipment, including the use of necessary medically appropriate life support measures during the transfer; and d. The receiving facility is provided with copies of all medical records related to the emergency medical condition available at the time of transfer, including: I. available history, records relating to the individual's emergency medical condition, observations of signs and symptoms, preliminary diagnosis, the results of diagnostic studies (or telephone reports of the same), test results, and treatment provided. ii. applicable transfer forms, including any informed written consents and the Physician Certification of Transfer form; and iii. the name and address of any on-call physician who was requested to come to the emergency department and refused or failed to appear within a reasonable amount of time to provide stabilizing treatment. Note: Other records and the results of tests not completed by the time of transfer must be sent to the receiving medical facility when available."