HospitalInspections.org

Based on review of the Emergency Department (ED) policies and procedures, medical executive committee meetings, ED minutes, and staff interviews, the Governing Body failed to establish policies and procedures, related to the Emergency Medical Treatment And Labor Act (EMTALA) regulations.

Findings included...

On 01/10/19 at approximately 2:20 PM, the surveyor conducted a review of the ED policies and procedures, medical executive committee meetings from 07/18 to 11/18, ED minutes, and the quality improvement plan. The review lacked evidence of EMTALA policies and procedures, as well ED and Quality Assurance Performance Improvement (QAPI) minutes, specifically related to EMTALA regulations and QAPI monitoring and/or remedial activities, in the emergency department.

The practice lacked evidence that the Governing Body established and enforced EMTALA policies and procedures to ensure safe practices and performance improvement.

During a face to face interview on 01/10/19 at approximately 12:51 PM, with Employee #1, ED Medical Director, he directed to check with the quality staff to obtain EMTALA policies and procedures.

During a face to face interview on 01/11/19 at approximately 12:00 PM, with Employee #8, Director of Accreditation and Regulatory Readiness, she acknowledged that there were no written EMTALA policies and procedures or QAPI plan.

Based on observation and staff interview, the hospital staff failed to ensure compliance to Emergency Medical Treatment And Labor Act (EMTALA) regulations, related to Sign Posting.

Findings included...

During a tour of the Emergency Department (ED) on 01/10/19 at approximately 3:30 PM, with Employee #10, ED Nursing Manager, the surveyor observed one sign, posted in the back of the ED ambulance entrance that detailed women in labor and patients with emergency medical conditions' rights for health care services. The sign did not indicate whether or not the hospital participated in the Medicaid program.

The practice lacked evidence that the hospital staff noticeably posted signage, to be seen by all patients entering the ED, and ensured the signage included the hospital was a Medicaid participant.

During a face to face interview on 01/10/19 at approximately 4:00 PM, with Employees #7, Executive Director of Quality Improvement and Accreditation, she acknowledged the findings. She explained Employee #8, Director of Accreditation and Regulatory Readiness, would address the matter on 01/11/19.

During a subsequent face to face interview on 01/11/19 at approximately 10:00 AM, with Employees #8 and #11, ED Nursing Manager, they were queried regarding how the practice was in compliance to EMTALA regulations. Employee #11 explained that the signs were posted; however, they were removed because the walls were painted and staff forgot to put them back up. Employee #8 explained she would ensure the signs would be posted, with the appropriate language. Both Employees acknowledged the findings.