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Based on observation, record review and interview, 1. Staff failed to ensure that Emergency Medical Treatment and Labor Act (EMTALA) signs regarding patient rights were posted in all areas where the signs would be noticed by emergency patients seeking treatment in 2 of 2 departments observed (Emergency Department, Maternal Health Department); and 2. Staff failed to accurately complete the patient transfer form information in 4 of 5 medical records reviewed of patients transferred to other facilities out of a total of 21 records reviewed (Patient # 7, 15, 16, and 19).


Findings include:

Facility staff failed to ensure all areas that would be noticed by emergency patients seeking treatment have EMTALA signs. See tag A2402.

Facility staff failed to complete transfer forms per the guidance on the form. See tag A2409.


The cumulative effect of these systematic failures has the potential to affect all emergency patients seeking care at this facility.

Based on observation, record review and interview, staff failed to ensure that Emergency Medical Treatment and Labor Act (EMTALA) signs regarding patient rights were posted in all areas where the signs would be noticed by emergency patients seeking treatment in 2 of 2 departments observed (Emergency Department, Maternal Health Department).

Findings include:

The facility's policy titled, "Emergency Medical and Treatment (EMTALA)," #7586830, dated 2/12/2020, revealed in part, "Documentation and Signage, 1. Signage. The Hospital will conspicuously post signs in its Dedicated Emergency Departments explaining an individual's right to emergency screening and treatment, and that the Hospital participates in the Medicaid program. Signs should be placed in entry/waiting areas, triage areas and all exam rooms where it is likely to be seen by patients."

An observational tour of the emergency department was conducted on 7/15/2020 at 10:50 AM accompanied by Quality Manager A and Director of Nursing H. There was no EMTALA sign at the emergency entrance of the building where emergency patients would enter for treatment. In an interview with Director H regarding the signs, Director H stated that new signs had been ordered and were being put up.

In an interview with Maintenance K (who was putting up a new sign in the emergency department waiting room) on 7/15/2020 at 10:55 AM regarding signage for the emergency department entrance, Maintenance K stated, "I was not asked to put a sign up at the entrance."

An observational tour of the maternal health unit was conducted at 11:05 AM on 7/15/2020 accompanied by Quality Manager A, Director of Nursing H and Nurse Manager I who confirmed that there was no EMTALA sign in room 167 of the maternal health department.

Based on record review and interview, staff failed to accurately complete the patient Emergency Medical Treatment and Labor Act (EMTALA) transfer form information per guidelines on the transfer form in 4 out of 5 medical records reviewed of patients transferred to other facilities out of a total of 21 medical records reviewed (Patient # 7, 15, 16, and 19).

Findings include:

The "Authorization For Transfer (EMTALA)," dated 6/17, revealed six sections. Section 1-Patient Status, had check boxes for stable or unstable and Physician Request/Attestation. Section 2 Transfer Requirements had 7 check boxes within the section depicting directions for unstable patients, if receiving facility had space, medical records to be sent, transportation, orders, acceptance by the receiving facility. Section 3-Physician Certification for Transfer. Section 4-Transfer Requested by. Section 5-Transfer Consent. Section 6-Transfer Request (when transfer is requested by a party other than the sending facility.

Embedded in Section 1 under Physician Request/Attestation was a paragraph that revealed, "Based upon the information available at the time of the individual transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at a another medical facility outweigh the increased risks of transfer, if any, to the individual's emergency medical condition, and in the case of labor, to the unborn child. Physician written description of specific risks/benefits in layman's terms required."

In an interview with Emergency Department Lead Nurse J on 7/15/2020 at 11:25 AM regarding who is responsible to complete the EMTALA transfer form, Nurse J stated, "It is filled out between the physician and the RN (Registered Nurse)."

Patient #7's medical record was reviewed on 7/15/2020 at 11:27 AM accompanied by Quality Manager A and Emergency Department Lead Nurse J who confirmed, per interview, the following findings: Patient #7 presented to the Emergency Department (ED) on 3/29/2020 with suicidal ideations and an ibuprofen overdose at 10:52 PM. At 1:38 AM Patient #7 was transferred to an alternate facility for psychiatric care. On the transfer form, in Section 1 under Physician Attestation in the Risks area, the box for transportation risks is checked and there are no specific risks written in. In the Benefits section boxes for specialized medicine and specialized personnel are checked and there were no specific benefits written in.

Patient #15's medical record was reviewed on 7/15/2020 at 11:28 AM accompanied by Quality Manager A and Emergency Department Lead Nurse J who confirmed, per interview, the following findings: Patient #15, a 9 month old, presented to the ED on 3/19/2020 at 1:22 PM with diarrhea and fever and a potential diagnosis of pancytopenia (deficiency of all three cellular components of the blood-red cells, white cells, and platelets). Patient #15 was transferred to an alternate facility for a higher level of specialized care at 4:45 PM. Section 2 of the transfer form revealed that Patient #15 was unstable. Section 1 of the transfer form did not indicate Patient #15 was unstable or why. In Section 1 under Physician Attestation in the Risks area, the following boxes were checked but there were no written description of risks: loss of function, physical deterioration, psychological deterioration, transportation risks.

Patient #16's medical record was reviewed on 7/15/2020 at 11:36 AM accompanied by Quality Manager A and Emergency Department Lead Nurse J who confirmed, per interview, the following findings: Patient #16, a 14 year old, presented to the ED on 4/15/2020 with homicidal and suicidal ideations 1:19 AM. At 3:10 AM Patient #16 was transferred to an alternate facility for psychiatric care under chapter 51 by police. On the transfer form, in Section 1 under Physician Attestation there were no risks marked. In the Benefits section boxes for specialized medicine and specialized personnel are checked and there were no specific benefits written in. In an email communication with Quality Manager A on 7/14/2020 at 4:44 PM regarding documentation for risks and benefits, Manager A responded, "(S/he) was a pediatric patient requiring behavioral treatment inpatient. (This facility) doesn't offer that so it's always a transfer. This patient was on a hold from the police department as well so there was no additional documentation." In a follow up email from Quality Manager A on 7/14/2020 at 7:04 PM, Manager A responded, "I talked with the provider, h/she did not document the specific risks/benefits other than the consent.

Patient #16's transfer form did not include a verbal consent from a parent/guardian. In an email from Quality Manager A on 7/14/2020 at 7:04 PM, Manager A responded, "H/she was a Chapter patient and the guardian was contacted. The (family member) verbally signed the consent form on page 23." A review of the consent form signed by the family member revealed that this was a consent to treat form and was verbally signed at 1:30 AM. There was no repeat contact or verbal consent from the family member indicated on the transfer form. In an interview with Lead Nurse J on 7/15/2020 at 11:38 AM, Nurse J stated, "They should have written verbal consent was obtained but nothing was specifically written."

Patient #19's medical record was reviewed on 7/15/2020 at 11:40 AM accompanied by Quality Manager A and Emergency Department Lead Nurse J who confirmed, per interview, the following findings: Patient #19, a 4 month old, presented to the ED on 4/3/2020 with an enlarged right thigh at 8:07 PM. At 12:25 AM on 4/4/2020 Patient #19 was transferred to an alternate facility for a higher level of specialized care after x-rays showed a spiral fracture of the right femur. On the transfer form in Section 1 under Physician Attestation in the Risks area, transportation risks was checked but had nothing written in to indicate what those risks might have been. In the Benefits section, specialized medicine was checked but had nothing written in to indicate what the specialized medicine was. Section 3 also did not include a time the physician signed the transfer form.