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Based on record review and interview, the hospital failed to adopt policies to ensure compliance with the requirements of EMTALA (Emergency Medical Treatment and Labor Act).

This failed practice had the potential for staff, including medical staff, to be uninformed of their responsibilities under EMTALA (Emergency Medical Treatment and Labor Act) requirements.

Findings:

A review of the hospital document titled, "Medical Staff Rules and Regulation (dated 05/06/17) showed the document did not contain any EMTALA requirements for the medical staff to include, but not limited to: physician on-call, medical screening exam (MSE), emergency medical condition (EMC), and necessary stabilizing treatment, appropriate in and out transfers, and whistleblower protection.

The surveyors were provided 13 different policies regarding ED processes and guidelines. A review of these policies showed the policies failed to clearly communicate EMTALA requirements and actions in a comprehensive and concise manner. The policies failed to define requirements for the ED central log, who is qualified to do a MSE, the requirements regarding the EMC, necessary stabilizing treatment, and whistleblowing information.

The hospital had the following ED policies:
*"Emergency Room Definition: Purpose, Definition, Objectives # 6.000 (dated 07/31/17)": the documented listed the purpose of providing triage and treatment. The policy does not address MSE, EMC, necessary stabilizing treatment .
*"Emergency Room Definition: Purpose, Definition, Objectives # 6.000.1 dated 07/31/17" has no purpose or introduction that connected this policy to version 6.000. The documented contained definitions.
*"Emergency Room Treatment 07/31/17"- the policy documented, "all persons presented to the hospital for medical assistance will be evaluated through the ER... Each patient in the ER receives an assessment and evaluation by a RN". The policy does not address MSE and EMC.
*"Emergency Rules and Regulations: Emergency Section of Hospital Bylaws": the document only defined the RN's responsibilities of evaluation, monitoring, and other actions. The policy does not address such as: physician on-call, medical screening exam (MSE), emergency medical condition (EMC), and necessary stabilizing treatment, appropriate in and out transfers, and whistleblower protection.
*"Triage 07/31/17"
*"Standard of Care 07/31/17" which primarily contained assessment and triage information.
*Assessment & Evaluation" 07/31/17 documents RN expectations and the minimum medical record components for a MSE.
*"Leaving Against Medical Advice (AMA) 02/28/17"
*"Transfers 07/21/17" contains information regarding MSE, by failed to defined who is qualified to perform them. The EMC was defined , but fails to address the qualified provider's responsibility to determine and document the existence of the EMC.
*"Transfer Policy 07/31/17"
*"Transfer by Air Ambulance 07/37/17"
*Emtala Transfer 07/31/17"
*Nurse for Transfer 07/31/17"
.
On 09/06/17 at 2:47 am, the Chief Nursing Officer, Staff C, and Staff O, stated the Medical Staff Bylaws contained no expectations of the medical staff regarding EMTALA requirements.

On 09/06/17 at 11:13 am, the Chief Nursing Officer, Staff C, stated the surveyors were provided all the Emergency Department policies.

Based on record review, interview, and observation, the hospital failed to post proper signage at all entrance points for individuals seeking emergency medical attention.

This failed practice had the potential for all presenting emergent patients, entering the hospital through the main entrance, to be uninformed of their rights under EMTALA (Emergency Medical Treatment and Labor Act).

Findings:

A review of the hospital's "Policy and Procedure Manual" and "Medical Staff Rules and Regulations" showed no directive regarding signage as required by EMTALA, to include, but not limited to: specify the rights of individuals with EMCs and women in labor, and whether the facility participates in the Medicaid program,

On 09/08/17 at 11:06 am, the Chief Nursing Officer, Staff C, stated that the hospital had no Emergency Department (ED) /EMTALA signage policy. She said patients presented to the hospital for ED service by entering by the front [main] and back [ambulance] door.

On 09/07/17 at 4:00 pm, the ED Manager, Staff D, stated ED patients enter through the back door and the front door of the hospital.

On 09/5/17 at 10:15 am, surveyors entered through the front main entrance and no EMTALA signage was observed.

On 09/05/17 surveyors observed the EMTALA signage in the ED waiting area. It was an 8.5 inch x 11 inch framed sign written in English. The sign was not a size with lettering that could be readily visible to be noticeable for all individuals who entered the ED.

Based on record review and interview, the hospital failed to maintain an accurate Emergency Department (ED) central log that consisted of the names and required information for all individuals presenting to the ED seeking medical services.

This failed practice resulted in the hospital's inability to track each individual who came to the hospital seeking care for an emergency medical condition, and would impair the hospital's ability to determine compliance with EMTALA requirements.

Findings:

A review of the hospital's ED policies showed no policy addressed the ED central logs completion requirements. A review of hospital policy titled, "[ED] Assessment and Evaluation 07/31/17" documented, "All patients who are evaluated in the emergency room are entered in the emergency room logbook upon arrival."

ED log entries from 2016 to 09/2017 were reviewed and compared to other hospital documents, such as incident reports showed 4 missing entries of individuals presenting to the ED for medical service.

The missing entries were as follows:
*On 02/20/17 at 11:36 am, Patient #22 presented to the ED as evidenced by electronic medical record documentation and incident reporting. Patient #22 was not entered on the ED log.
*On 08/18/17 at 8:41 am, Patient #6 presented to the ED as evidenced by electronic medical record registration records. Patient #6 was not entered on the ED log.
*On 08/19/17 at approximately 2:00 am, Patient #6 presented to the ED identified through 7 interviews of employees and other individuals involved in an incident. Patient #6 was not entered on the ED log.
*On 02/20/17 at 7:54 am, Patient #23 presented to the ED as evidenced by electronic medical record documentation and incident reporting. Patient #23 was not entered on the ED log.

On 09/08/17 at 2:00 pm, Staff C and Staff B stated Patients #6, 22, and 23 were not documented on the ED log.

On 08/17/19 at (no time listed), an entry was written as "confidential", and had no number identification and no disposition. On 09/08/17 at 11:06 am, Staff C stated she had only seen it written 1 time on the log and thought it was a patient who was sexual assaulted.