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Based on observation, it was evident that the facility posted a sign in the triage area in full view of arriving patients that contained information that advised prospective patients that they could not access emergency services if they did not have sufficient funds. The language in the sign could deter patients who had limited financial ability from securing emergency treatment.

During the tour of the ED on 10/25/11, the surveyor found a sign conspicuously posted in the triage area that read "Please be advised that payments of all co-pays, deductibles, and/or coinsurance are due at time of service." It further states that "it is your responsibility to know your health coverage." It also referred to the types of credit cards that are acceptable.

The administrative ED staff removed that sign during the survey and reported that they would place it in the financial area only, not in the triage area.

Based on record review and hospital staff interview, it was determined that the facility failed to provide a high risk pregnant patient with a medical screening examination when she presented to the ED with a complaint that included contractions.

Findings include:

Review of the ED log did not find any record of the patient's encounter with the ED staff on 10/18/11. The Surveyor interviewed the on-call obstetrician on 10/26/11 by telephone in the presence of Risk Management staff. The on-call obstetrician stated that he spoke to ED staff on 10/18/11 who called him to advise that the patient (MR#1) was in the triage area of the ED and that she had contractions, but intended to sign out against medical advice (AMA) after an assessment.
The on-call obstetrician said he offered to speak with the patient at that time via the telephone, but the patient refused to speak to him. Based on interviews with the hospital's ED staff, the patient refused treatment, stated that she was going to the other hospital where her primary obstetrician practiced, and left the hospital AMA.
ED staff failed to enter the patient in the ED log, complete a pre-triage form, take vital signs, and perform a medical screening exam for this patient. There was no documented evidence that the risks and benefits of leaving AMA were explained to this patient at that time.
The on-call obstetrician did not document the discussion with the ED staff nor did he communicate with any ED physician regarding this case.
ED staff did not advise any ED physician or management staff that this patient had presented to the ED.
The on-call obstetrician was informed that the patient would be going to another hospital's ED 70 minutes (60 miles) away via her personal car. ED staff did not communicate with the recipient facility to ensure that its staff would be aware of the patient's arrival.

Based on record review, it was determined that the facility failed to ensure that a high risk obstetrical patient was transferred in a safe manner to another higher level facility.

Findings include:

Review of MR#1 on 10/25/11 found that the patient presented to the facility on 8/30/11 at fourteen weeks gestation after she was reportedly punched and kicked in the stomach by her brother. This morbidly obese patient complained of back pain and cramping. Previous Medical History (PMH) included a Deep Vein Thrombosis at 6 weeks with "apparent PE (pulmonary emboli)". A Medical Screening Exam was done and initially a fetal heart rate could not be detected, but one was later obtained by ultrasound. The facility offered to transport the patient to another facility but she did not want to do so. The patient stated she will transport herself via auto (a 70 minute drive).

The facility wrote the patient's disposition as a "discharge home" and an order that states "going to Vassar - refused transport." There was no evidence of an AMA form completed or a transfer summary found.

The facility did not ensure that the patient actually went to the higher level facility on August 30, 2011 and did not take into consideration that such a disposition of an unstable patient represented potential harm to both the patient and the fetus.