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Based on document review and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.
Findings include:

1. The Hospital failed to ensure conspicuous posting of the rights of individuals in relation to emergency medical treatment and labor act (EMTALA) in the obstetrical (OB) unit. (Refer to tag A-2402)

2. The Hospital failed to ensure the the Emergency Department (ED) and OB logs were maintained with the required elements for patients presenting to the ED requesting evaluation and treatment. (Refer to tag A-2405)

3. The Hospital failed to ensure the ED provided stabilizing treatment for a patient who was determined to have an emergency medical condition. (Refer to tag A-2407)

Based on observation and interview, it was determined the Hospital failed to ensure conspicuous posting of the rights of individuals in relation to emergency medical treatment and labor act (EMTALA) in the obstetrical (OB) unit. This has the potential to affect all patients who present to the OB unit seeking a medical screening exam (MSE) to determine an emergency medical condition (EMC).

Findings include:

1. During a tour of the OB department, conducted on 10/3/14 at approximately 11:15 AM, with the Director of OB (E#5) and the Director of Quality (E#2), the surveyor did not observe any EMTALA signage, conspicuously posted, in the OB department.

2. An interview was conducted with E#2 and E#5 on 10/3/14 at approximately 10:40 AM. When asked where the EMTALA signage was located, E#5 looked at E#2 and stated "I don't know where that would be. We had the signs in the old labor and delivery rooms (these rooms are used for triaging patients), but we didn't move them when we started the construction." When asked when the construction began, E#5 stated "That started the end of July this year."

Based on document review and interview, it was determined for 2 of 21 (Pts #15, #10) patients presenting to the Emergency Department (ED) or the Obstetrical (OB) department requesting evaluation and treatment, the Hospital failed to ensure the central logs were maintained to include discharge disposition.

Findings include:

1. The ED log for April 2014 thru September 2014 was reviewed on 10/3/14 at approximately 1:00 PM with the Director of ED (E#1). Pt #15 presented to the ED on 8/7/14 requesting evaluation and treatment. The central log lacked documentation of Pt #15's discharge disposition.

2. The OB log for April 2014 thru September 2014 was reviewed on 10/3/14 at approximately 1:30 PM with the Director of OB (E#5). Pt #10 presented to the OB department on 7/3/14 requesting evaluation and treatment. The central log lacked documentation of Pt #10's discharge disposition.

3. An interview was conducted with E#5 on 10/3/14 at approximately 1:45 PM. The Director of Quality (E#2) was present. E#2 and E#5 reviewed the OB log. When asked where the patient discharge disposition would be documented on the OB log, E#5 nodded in agreement that the log lacked the discharge disposition for several patients, including Pt #10 and stated "We should do a better job of charting that."

4. An interview was conducted with E#2 on 10/7/14 with E#1 at approximately 9:30 AM. E#1 reviewed the ED log for April 2014 thru September 2014 and verbally agreed the ED lacked the discharge disposition for several patients, including Pt #15. E#1 stated "They (the staff) know they should be completing every section. There shouldn't be any blanks."

Based on document review and interview, it was determined for 1 of 3 (Pt #18) patients, who returned to the emergency department in less than 48 hours, the Hospital failed to ensure stabilizing treatment was evaluated and adjusted, in accordance with patient condition.

Findings include:

1. Pt #18, a 46 year old female, presented to the treating hospital Emergency Department (ED) on 8/20/14 at 10:23 PM with the chief complaint of abdominal pain. Pt #18's record was reviewed on 10/7/14 at approximately 10:15 AM.

A) On 8/20/14 at 10:29 PM, the initial vital signs stated a pulse oximeter (POx) of 86% on room air. At 10:39 PM, the ED Registered Nurse (RN) (E#17) documentation stated Pt #18's POx was 84-86% and placed O2 (oxygen) 3 liters per nasal cannula on at 10:41 PM. The triage note stated Pt #18 had had a similar episode of low PO2 with pneumonia in the past. "Pt states this does not feel the same." On 8/21/14 at 12:24 AM, the ED physician (MD#2) documentation lacked documentation of Pt #18's pulse oximeter reading upon admission or the presence of O2.

On 8/21/14 at 12:30 AM, the ED RN (E#21) documentation stated Pt #18 was taken to the computerized tomography (CT) room and "While pt lying down pt turned purple in the face. Sat (saturation)dropped to 63%. Face mask 8 L (liters) applied. Sat up to 94% when pt sat back up." ED documentation stated Pt #18 was on 8 L via face mask from 12:30 AM until discharged at 4:13 AM with a POx of 93-95%. Pt #18 was discharged at 4:13 AM with the diagnoses cholelithiasis, biliary colic, and candida infection with prescriptions for Zofran, Hydrocodone-acetaminophen, and Diflucan. There was no documentation of physician notification of POx readings, initiation of and increase in O2 administration.

There was no documentation Pt #18's POx level was assessed on room air prior to discharge although Pt #18 was discharged home with no 02.

B) On 8/20/14, a CMP (comprehensive metabolic panel) was drawn and the potassium level was resulted as "5.5 (*)" (normal range 3.5-5.1 ) with * indicating that the result is abnormal. There was no documentation of the elevated potassium level being addressed.

2. An interview was conducted with the Clinical Coordinator of Patient Services Emergency Department (E#9) on 10/7/14 at approximately 11:35 AM. E#9 reviewed the record of Pt #18's 8/20/14 ED visit. E#9 stated there were no standing orders for O2 in the ED and nodded "yes" that the POx was not checked on room air prior to Pt #18 being discharged from the ED "and probably should have been." E#9 nodded head in agreement that there was no documentation of the elevated potassium level being addressed.

3. Pt #18 returned to the treating hospital ED on 8/23/14 at 3:35 PM with the chief complaint of abdominal pain, ear pain, and dizziness. At 3:38 PM, Pt #19's POx upon presentation to the ED was 72% on room air. O2 6 L via nc applied and the PO2 increased to 92% at 4:22 PM. Between 5:23 PM to 7:00 PM, the POx range was between 86-87% on 6 L via nc (nasal canula). There was no documentation of any change in the level of O2 administration. Pt #18's potassium level was 7.1 (*) (normal range 3.5-5.1) at 4:18 PM and 7.0 (*) when rechecked at 5:20 PM which was increased from the 8/20/14 ED visit in which the potassium level was elevated at 5.5. Pt #18's electrocardiogram at 4:25 PM showed normal sinus rhythm with lateral ST depression and the chest X-ray at 4:42 PM showed bibasilar pneumonia, per MD#5. Pt #18 was transferred to the receiving hospital via ambulance on 8/23/14 at 7:28 PM with the diagnoses hyperkalemia, acute prerenal failure, hepatitis, and non-ST elevated myocardial infarction for Nephrology, Interventional Cardiology and dialysis, services not provided by the transferring hospital.

4. An interview was conducted with E#9 on 10/7/14 at approximately 12:10 PM. E#9 reviewed the record of Pt #18's 8/23/14 ED visit. E#9 verbally agreed Pt #19's POx levels were less than 90% "and we usually want it (the oxygen level) to be greater than that (90%)" when dealing with cardiac issues. When asked about Pt #18's potassium level, E#9 stated "The doctors all review the lab results and they decide what to follow up on. I believe there is a history of kidney disease with this patient".

5. Pt #18's receiving hospital record was reviewed on 10/8/14 at approximately 2:00 PM. Pt #18 arrived at the receiving hospital at 8:35 PM in which the POx was 97% on 6 L of 02. The receiving hospital physician's documentation stated "Respiratory.... Plan: Supplemental O2 to maintain SpO2 (pulse oximetry) > (greater than) 90%."