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Based on observations, interviews, review of policies and procedures, and documentation the hospital failed to post the required signage and failed to include "Whistleblower Protection."

Findings include:

1. Refer to the findings identified under Tag A 2402, CFR 489.20(q), Posting of Signs, which reflects the hospital's failure to post the required EMTALA signs in accordance with its policies and procedures.

2. It was determined that the hospital failed to include "Whistleblower Protection" information in the EMTALA policy. The policy must include information that a participating hospital may not penalize or take adverse action against a physician or qualified medical person because they refuse to authorize the transfer of an individual with an EMC who has has not been stabilized or against any hospital employee because the employee reports a violation of this requirement per CFR 489.24(e)(3).

3. An interview with the Quality and Risk Director on 05/03/2012 at 1600 confirmed he/she acknowledged there was no "Whistleblower Protection'" specific to EMTALA in current hospital policies.

Based on observation, interviews, and review of policies and procedures, it was determined that the hospital failed to post the required EMTALA signs in accordance with its own policies and procedures.

Findings include:

1. A tour of the ED was conducted on 05/02/2012 at 1005 with the Quality and Risk Director and the ED Manager. The tour began at the patient walk-in entrance to the department where ambulatory patients and visitors were met by registration staff. From this viewpoint, signage specifying the EMTALA rights of individuals was visible behind the ED registration clerk. The tour continued through the ambulance entrance of the ED past the central nursing station and into various patient rooms. For any patients arriving via ambulance, there was no signage in the ambulance entrance, main ED or patient treatment rooms.

2. The Silverton Hospital Network PATIENT CARE MANUAL policy titled "EMTALA COMPLIANCE POLICY," #PC-POC-764," last approved 5/20/11 was reviewed. Documentation on page 2 reflected the following internal requirement: "[Silverton Hospital] will post signs in conspicuous locations for patients entering the ED, [Family Birth Center], and other areas where patients are screened. Signs will specify the rights of individuals with emergency conditions and women in labor who come to the Emergency Department or to other areas of the Hospital for health care services..."

3. An interview with the Quality and Risk Director and the ED Manager on 05/02/2012 at 1020 confirmed that the hospital failed to post the mandated signage in the ambulance entrance or in ED patient rooms for any patients entering the hospital through the ambulance entrance.

4. During the Exit Conference on 05/03/2012 at approximately 1600, the Quality and Risk Director informed the surveyors that the required signage had been posted in the ambulance entrance to the ED. Pictures of the signage were sent via e-mail to the surveyors following the exit conference.