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Based on observation, interview and record review, the facility failed to conspicuously post the required signage notifying patients of their rights in the Emergency Department (ED) entrance, waiting room and the triage area, ambulance entrance, and the triage area of the Labor and Delivery (L&D) unit.

This failure resulted in the potential for patients to not know their rights to receive a medical screening examination or treatment for their emergent medical condition, including active labor.

Findings:

On 9/6/2022 at 10:30 a.m., a tour was conducted of the hospital ED. No postings or signage related to patient rights to examination, treatment, or Medicaid participation were observed in the ED entrance, in the ambulance entrance, or the triage area of the L&D unit.

An 8x11 Emergency Medical Treatment and Labor Act (EMTALA) sign posted in English and Spanish was observed behind clear plexiglass room divider (an acrylic glass like substance used as an alternative to glass sheeting) in a designated area for respiratory patients. This area was across from the waiting room and triage area and could not be seen from the waiting room.

During the tour conducted on 9/6/2022 at 10:30 a.m., the ED Manager (EDM) stated the EMTALA sign posted behind the respiratory area to the left of the patient check-in station was the only EMTALA sign posted in the ED.

An additional tour was conducted of the Birthing Center (BC) on 9/6/2022 at 10:52 a.m. with the Manager of L&D (MLD) and Assistant Nurse Manager (ANM). The MLD indicated laboring and emergent patients arrive on their own or are sent by their provider. The patients encounter the security officer (SO) in the main lobby entrance and the SO informs the BC. The patient enters the locked double doors of the BC, passes through the nursing station to fill out a short form (confirms name and address) and triaged in the Labor Delivery (L&D) room. An EMTALA sign was observed outside the double doors and on the wall before the nursing station. The MLD and the ANM both confirmed that there is no EMTALA signage in the triage areas.

On 9/7/2022 at 9:35 a.m., an interview and observation were conducted with the Chief Nurse Executive (CNE) and Infection Control Nurse (ICN) in the ED. The CNE and the ICN both confirmed that the EMTALA signs were placed on the wall behind the separate respiratory area. The area has six chairs which is separated by a clear plexi-glass room divider. Both CNE and ICN confirmed that this is the only sign in the ED waiting room, triage area and reception area. The signage is in English and Spanish and in small print. CNE stated "that is how it is, otherwise, you will have the signage very big." She further stated that the other signage is in the hallway leading from the ambulance bay and not at the entrance of the ambulance bay.

Review of the hospital policy titled, "Treatment and Transfer" dated 1/1/2013 and revised on 9/17/2018 indicated, "Signage: Conspicuous signs are posted in the ED, L&D Department, Admitting Department and hospital entrance that states the rights of individual to emergency treatment."

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Based on interview, record review, and hospital policy review, the hospital failed to enter all patients who come to the emergency department seeking assistance into a central log when Patient 1 arrived by ambulance to the hospital and was subsequently diverted (rerouted) to another hospital and then was not included in a central log.

This failure could potentially result in a lack of tracking of patients who come to the emergency room seeking assistance and then do not receive a medical screening exam to determine if a medical emergency condition exists.

During an interview on 9/7/22, at 9:10 a.m., with Emergency Department Physician (EDP) 1 and Emergency Department Medical Director (EDMD), it was stated by EDP 1 that Patient 1 arrived by ambulance to the Sutter Davis Hospital (SDH) ambulance bay: located immediately outside the doors to SDH dedicated emergency room] either late the evening of 9/26/20 or early the morning of 9/27/20—"around midnight" presenting for examination or treatment after an unwitnessed fall. It was also confirmed by EDP 1 and EDMD that Patient 1 was not entered in the central log—a document titled ED EMTALA Log SADV EMERGENCY from 09/01/2020 to 9/30/2020. EDP 1 stated that Patient 1 was "not here long enough" to be entered into the electronic health record. Therefore, there is no way to capture Patient 1 into the central log, even though Patient 1 had come to the emergency department (ED), by ambulance, seeking emergency assistance.

During a concurrent interview and document review on 9/7/22, at 11:00 a.m., with Interim Director Quality and Patient Safety (IDQPS) and Acute Quality and Patient Safety Senior Director (AQPSSD), the document titled, ED EMTALA Log SADV EMERGENCY from 09/01/2020 to 9/30/2020, was reviewed and it was confirmed that Patient 1 was not entered in the central log and could not be found in the central log.

During concurrent interview and document review on 9/7/22, at 11:15 a.m., with IDQPS, the minutes from October through December 2020 for both the Multi-disciplinary Physician Performance Improvement Committee (MDPPIC) meetings and the Quality and Patient Safety Council (QPSC) meetings were reviewed. IDQPS stated that copies could not be provided because these are protected quality improvement activities. Visual review of records and the interview confirmed that a patient safety report was generated for Patient 1 not obtaining a medical screening exam. However, there was no documentation of the failure to include Patient 1 in the central log nor a process initiated to correct the system deficiency that resulted in Patient 1 (and potentially other patients) coming to the ED for emergency care and not being placed into the central log.

During interview on 9/6/2022 at 3:45 p.m. with IDQPS, it was stated that the document titled Treatment and Transfer (effective date 9/17/2018) was the "active EMTALA policy and procedure" in effect during the self-reported Patient 1 event and that this policy was replaced with the document titled, Compliance with Emergency Medical Treatment (effective date 5/16/2022)—the current active policy.

Review of document, Treatment and Transfer (effective date 9/17/2018), indicated the following:

"Electronic or paper logs will be maintained by the Emergency Department and Labor and Delivery on each person who comes to the hospital seeking emergency care. Patient disposition (e.g., admit, discharge, transfer, elopement, and leaving against advice) will be noted in the electronic/paper log."

"The campus of a hospital will be defined by CMS regulations as the following: i. The physical area immediately adjacent to the hospital ' s main buildings; ii. Other areas and structures that are not strictly contiguous to the main buildings, but are located within 250 yards of the main building;"

During interviews with EDP 1 and EDMD on 9/7/22, at 9:10 a.m., and interviews with Chief Medical Executive (CME), EDMD, Medical Staff Coordinator (MSC), and Interim Medical Staff Coordinator (IMSC) on 9/7/2022 at 10:10 a.m., it was stated that a patient who does not get entered into the electronic health record will then, by default, not be included in the central log despite coming to the emergency department seeking emergency assistance—the example of Patient 1.

Based on interview, record review, and hospital policy review, the hospital failed to provide a Medical Screening Exam (MSE, the initial medical exam performed by a qualified medical person when a patient arrives at a dedicated emergency department) for 1 of 23 sampled patients (Patient 1), when Patient 1 arrived by ambulance to the hospital and was subsequently diverted (rerouted) to another hospital without an MSE to determine whether a medical emergency condition existed.

This failure caused a delay with Patient 1 to receive an MSE to determine whether a medical emergency condition existed, and there was a potential for an existing medical emergency condition to worsen without necessary treatment.

Findings:

A review of the hospital's self-reported incident to the California Department of Public Health (CDPH), dated 9/27/2020, indicated that, upon Patient 1's arrival by ambulance to the hospital, the ambulance was redirected to another hospital that had trauma capabilities.

A review of Patient 1's Medic Ambulance report dated 9/26/2020 indicated that the paramedics arrived at a nursing home where Patient 1 was residing at 11:36 p.m., because Patient 1 had an unwitnessed fall. The report indicated that the paramedics found Patient 1 on the floor in the bathroom with no signs of traumatic (physical) injury. The report further indicated that the paramedics called the physician at the base station (a hospital that provides direct medical control to prehospital providers, which is not the facility in question), and she stated the paramedics should take Patient 1 to the hospital that the family was requesting if there were no signs of head trauma, no vital signs outside expected limits, and Patient 1 was acting within her normal baseline. All 3 were appropriate, and Patient 1 was sent to the requested hospital. The ambulance report further indicated that, upon arrival to the hospital, the Emergency Department Physician (EDP) 1 walked out to the ambulance at the hospital's ambulance entrance and stated that Patient 1 would not be seen at the hospital and needed to be seen at a trauma hospital. The report further indicated EDP 1 refused to evaluate Patient 1 and denied entry into the hospital. The paramedics contacted the base station physician and arrangements were made to transfer Patient 1 to a receiving hospital.

During an interview with the Chief Medical Executive (CME) on 9/6/2020 at 10:25 a.m., he stated there was no diversion (the rerouting of patients brought in by ambulances away from one hospital to another) in their hospital's county. He further stated that the hospital never turns away patients that arrive by ambulance, including trauma patients.

During a concurrent record review of the hospital's emergency department patient log, dated 9/2020. and interview with the Acute Quality Patient Safety Senior Director (AQPSSD) on 9/8/2022 at 1:15 p.m., the log indicated Patient 1 was not listed as a patient for dates 9/26/2020 or 9/27/2020. AQPSSD confirmed that on 9/26/2020 and 9/27/2020 Patient 1 was not listed on the emergency room log, did not enter the hospital's emergency room, and was sent to the receiving hospital.

During an interview with AQPSSD on 9/7/2022 at 1:40 p.m., she stated an emergency room registered nurse submitted a patient safety report on 9/27/2020 at approximately 2 a.m. which included that EDP 1 didn't refuse Patient 1 but diverted them before an MSE was done and while Patient 1 was still in the ambulance on hospital property.

A review of the hospital's policy titled, Treatment and Transfer, last revised 9/17/2018, indicated: "The hospital will provide a medical screening exam [MSE] by a qualified medical provider to any individual who: i. presents to our dedicated emergency department seeking or needing examination or treatment for a medical condition; ii. presents on hospital property seeking or needing examination or treatment for an emergency medical condition; iii. Is in an air or ground ambulance that is on hospital property for presentation for examination or treatment for a medical condition at our hospital's dedicated emergency department. 1. to determine if the individual has an emergency medical condition; and, if it has been determined that an emergency medical condition exists [EMC], provide the individual with further medical examination and treatment as required to stabilize the emergency medical condition or arrange for transfer of the individual to another medical facility..."