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Based on review of hospital policies/procedures, hospital documents, medical record review, and staff interviews it was determined the hospital failed to enforce policies/procedures that comply with the requirements of 42 CFR 489.24, as evidenced by failure to:

A-2406 489.24(a)
provide a Medical Screening Exam for Patient #1 (target patient), after the patients arrival to the emergency department (ED).

A-2408 489.24(d)(4)(iv)
provide a Medical Screening Examination (MSE) to 7 of 38 patients, prior to requesting signature of the Conditions of Admissions (COA).

Based on policies and procedures, observation during tours of the dedicated emergency departments (DED), and staff interviews, it was determined the hospital failed to conspicuously post signage specifying the rights of individuals under section 1867 of the Act regarding examination and treatment of emergency medical conditions and women in labor.

Findings include:

Hospital policy titled "EMTALA Policy #QMD.0003" requires: "...The Hospital will post a sign in the emergency department and other waiting areas...of the rights to obtain a medical screening examination...."

Tours of the main hospital ED, Obstetrical (OB) ED and the Single Group Licensed Emergency Center were conducted on 09/20/13 between 0945 and 1045 hours.

The main ED had one EMTALA sign inside the ED at the registration desk, and another sign located at the ambulance entrance, however, there was no signage in the hospital waiting room or triage area.

The Director of Nursing confirmed during an interview conducted on 09/20/13 at 1000 hours, that the hospital was undergoing some remodeling; and the EMTALA signage was not posted in the ED waiting or triage area.

The free standing Single Group Licensed Emergency Center had no EMTALA signage located at the ambulance entrance.

The Risk Manager confirmed during an interview conducted on 09/20/13 at 0945, that there was no signage at the ambulance entrance and stated "it's not a patient entrance."

Based on Hospital policies/procedures, review of emergency/obstetrical logs and staff interviews it was determined the hospital failed to complete the Hospital's ED central log for each individual presenting to the hospital for emergency treatment.

Findings include:

Hospital policy titled "EMTALA Policy #QMD.0003" requires: "...The Hospital will keep...central log of each person...seeking emergency medical treatment and whether he or she refused treatment...voluntarily left...refused treatment...transferred...admitted...discharged shall be maintained...."

Random review of the Hospital's main ED log revealed the following:

05/03/13 one (1) patient presented to the ED at 2137 hours; there was no documentation of the patient's diagnosis,disposition time or disposition.

06/14/13 three (3) patients presented to the ED between 1823 and 1926 hours; there was no documentation of the patients diagnosis or disposition.

06/23/13 four (4) patients presented to the ED between 1527 and 1730 hours; there was no documentation of the patients diagnosis or disposition.

06/28/13 two (2) patients presented to the ED between 1406 and 1416 hours; there was no documentation of the patients diagnosis, disposition time or disposition.

06/29/13 three (3) patients presented to the ED between 0626 and 0637 hours; there was no documentation of the patients diagnosis, disposition time or disposition.

07/03/13 five (5) patients presented to the ED between 1345 and 1540 hours; there was no documentation of the patients diagnosis, disposition time or disposition.

08/26/13 one (1) patient presented to the ED at 2202 hours; there was no documentation of the ED physician, the patients diagnosis, disposition time or disposition.

09/12/13 one (1) patient presented to the ED at 2343 hours; there was no documentation of a chart number, how the patient arrived, the ED physician, the patients diagnosis, disposition time or disposition.

09/13/13 eight (8) patients presented to the ED between 0957 and 1838 hours with no documentation of one or more of the following : a chart number, how the patient arrived, the ED physician, patient's diagnosis, disposition time or disposition.

09/14/13 six (6) patients presented to the ED between 0839 and 1334 hours; there was no documentation of a disposition time.

The Interim ED Director confirmed during an interview conducted on 09/23/13 at 1600 hours that the ED log was incomplete.

Based on review of Patient #1's (target patient) medical record, hospital policies/procedures, hospital documents and staff interviews, it was determined that the hospital failed to provide a Medical Screening Exam for Patient #1 (target patient), after the patients arrival to the emergency department (ED).

Findings include:

Hospital policy titled "EMTALA Policy #QMD.0003" requires: "...The Hospital will provide a medical screening examination to all persons who come to the Hospital's premises requesting emergency services (or when such a request is made on their behalf), regardless of their ability to pay...."

The Hospital ED Log revealed Patient #1 arrived on 08/28/13 at 0017 hours via private vehicle. The primary discharge diagnosis was documented as LWBS (left without being seen).

Patient #1's medical record dated 08/28/13, "Triage Sign-In Form" contained the patient's name, date of birth, social security number, mailing address, telephone number and the patient's problem was listed as odd behavior/mental illness.

The Emergency Department Chart dated 08/28/13, revealed: under "disposition" the following: "...NOT SEEN BY ER ATTENDING...Disposition status is patient left without Triage. pt previously assaulted staff members at WVEC, per triage RN pt not allowed to be seen at this facility. Patient physically left department...."

The Director of Risk Management confirmed during an interview conducted on 09/19/13 at 1445 hours, that the facility completed an internal investigation regarding the incident; the investigation revealed the ED nursing staff turned the patient away, the patient did not receive a medical screening exam (MSE).

Based on review of hospital policies/procedures, hospital documents, medical records, and staff interview, it was determined that the hospital failed to provide a Medical Screening Exam for 7 of 38 patients prior to the patients signing the Conditions of Admission form (Patients #2, 4, 8, 16, 25, 34, and 35).

Findings include:

Hospital policy titled "Registration Forms" requires: "...All patients registering for services are required to sign the Conditions of Admission (COA)...basic agreement giving general consent for treatment...authorizes the hospital to release pertinent information to the insurance company...if patient is unable to sign...document the medical reason the form is not signed...Emergency treatment is given as an Implied Consent, and before further treatment is given, the patient should sign the COA to document the patient's consent to routine care...."

The conditions of Admission Agreement requires: "Payment for Medical and Related Care: I agree to pay the charges for the care I receive as ordered by my doctor(s) at this hospital. I guarantee full payment of all charges unless restricted by Medicare or Medicaid. These charges may include screening tests and treatment for emergencies. I will make reasonable financial arrangements satisfactory to the hospital and if the account is sent to an attorney for collection, I agree to pay reasonable attorney's fees, collection expenses, and interest which may be applied and is not to exceed 18% per year. This contract contains the entire agreement of the parties. It can be modified only in a writing signed by both parties."

Patient #2 arrived at the ED on 04/17/13 at 2319 hours, with complaints of self inflicted cutting. The patient has a history of depression. The COA was signed by parent at 1923 hours; the MSE was conducted at 1925 hours.

Patient #4 arrived at the ED on 04/05/13 at 0802 hours, with suicidal thoughts. The patient has a history of Paranoid Schizophrenia. The COA was signed at 0854 hours; the MSE exam was conducted at 1306 hours.

Patient #8 arrived at the ED on 04/24/13 at 2005 hours, with suicidal thoughts. The patient has a history of kidney cancer. The COA was signed at 2204 hours; the MSE was conducted at 2316 hours.

Patient #16 arrived at the ED on 06/28/13 at 0531 hours, with complaint of Syncopy due to tailbone pain. The COA was signed at 0542 hours; the MSC was conducted at 0609 hours. The patient signed out AMA at 0837 hours.

Patient #25 arrived at the ED on 04/05/13 at 1122, hours with complaint of laceration to forehead. The COA was signed at 1125 hours; the MSE was conducted at 1140 hours.

Patient #34 arrived at the ED on 08/01/13 at 1458 hours with complaint of abdominal pain. The COA was signed at 1458 hours; the MSE was conducted at 1508 hours.

Patient # 35 arrived at the ED on 09/16/13 at 2103 hours, with complaints of abdominal cramping and possible rupture of membranes. The patient was 24.3 weeks pregnant. The COA was signed at 2104 hours; the MSE was conducted at 2220 hours.

The Director of OB and the OB Unit Clerk confirmed during an interview conducted on 09/20/13 at approximately 1030 hours, that the OB Unit has the patient sign the COA prior to the MSE.

The CNO and the Interim ED Director confirmed during an interview conducted on 09/20/13 at 1030 hours, that the ED asks the patient for a picture ID and insurance card at the time of arrival. If the patient appears to need immediate attention they are taken back to the ED immediately. Treatment is not delayed.

The CNO confirmed during an interview conducted on 09/23/13, that the Hospital's percentage of patient's "left without being seen" is below the national average. The CNO and the Interim ED Director do not believe the registration process at the Hospital discourages individuals from remaining for further evaluation.