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Based on observation, record review and interview, the facility failed to ensure compliance with EMTALA (Emergency Medical Treatment and Active Labor Act) regulations in 3 of 11 required areas (Sign Posting, Patient Log, Medical Screening Examination). Failure to comply with these requirements has the potential to affect all patients presenting to the Emergency Department.

Findings include:

The facility failed to ensure signage is posted in all patient care areas. See tag C2402.

The facility failed to maintain a complete and accurate log of patients presenting the Emergency Department. See tag C2405.

The facility failed to perform a medical screening exam for all patients presenting to the Emergency Department. See tag C2406.

Based on observation, record review and interview, the facility failed to ensure signage is posted and visible in 2 of 5 Emergency Department treatment rooms observed (Room #3, Room #6).

Findings include:

Facility policy "EMTALA (Emergency Medical Treatment and Active Labor Act: Medical Screening Exams and Transfer of Patients)" No. 017-380-01, reviewed on 6/5/2017, states: "General: 1. Signs are posted in Emergency Department (ED) entrance, ED waiting area, ED patient rooms, Registration, Family Center patient rooms and waiting area..."

During a tour and observation of the Emergency Department on 6/5/2017 at 12:15 PM, the EMTALA sign in treatment room #6 was located behind the Sharps container and only partially visible. There was no sign posted in treatment room #3.

During an interview with Emergency Director A at the time of observation, A stated "they are supposed to have one in each room."

Based on record review and interview, the facility failed to maintain a log of patients presenting to the Emergency Department (ED) in 2 of 21 patients reviewed (Patient #1, Patient #2). This has the potential to affect all patients seeking emergency services at this facility.

Findings include:

Facility policy "EMTALA (Emergency Medical Treatment and Active Labor Act: Medical Screening Exams and Transfer of Patients)" No. 017-380-01, reviewed on 6/5/2017, states: "4. The ED log will indicate all patients presenting themselves and the disposition."

Review of the facility policy "ED Registration/Greeter Expectations" No. 650-006-01, 6/6/2017, revleaed that "5. ...If they request to be seen in the Emergency Department, they should not be sent to another area. ...6. Gather appropriate starting information, i.e., Name, Date of Birth, and chief complaint. 7. Enter patient into [Electronic Health System]."

During an interview with Emergency Department Director A on 6/5/2017 at 2:00 PM, A stated not all patients that go the Emergency Department registration desk are looking for ED services. A stated "the problem is we only have 2 entrances [into the hospital]. Patients will come in through the Emergency Department looking for the walk in clinic or other parts of the hospital. Registration has to determine if the patient is seeking ED services."

Interview on 6/5/2017 at 1:50 PM with Registration Coordinator G revealed that when patients present to the Emergency Department it is registration's job to register the patient by entering their name and date of birth into the electronic health system. When asked if there are patients who present to the Emergency Department and do not get entered into the electronic health system, G stated "yes, sometimes patients come in for the walk-in clinic or for regular doctor appointments...if they say they are here for ER then we enter them [in the system] and call the ER to say we have the patient here."

1. Review of the facility's Emergency Department log on 6/5/2017 at 2:30 PM shows no evidence that Patient #1 presented to the Emergency Department seeking services on 5/30/2017.

During an interview on 6/7/2017 at 1:15 PM, Registration Coordinator F stated Patient #1 and Patient #1's friend presented to the Emergency Department registration desk on 5/30/2017. F stated "[Patient #1] stated 'I want to dry out.'" Per F, the facility does not provide detox services, so Patient #1 was offered to stay and wait to be seen or to go to another facility that is known to provide detox services. F states Patient #1 and Patient #1's friend opted to leave to seek services at the other location. When asked why Patient #1 wasn't registered in the system, Registration Coordinator F stated Patient #1 "didn't lead with 'I'd like to be seen'...it stumped me."

2. Review of the facility's paper Emergency Department log on 6/5/2017 at 2:30 PM shows Patient #2's presented to the ED on 5/16/2017 at 6:25 PM with a chief complaint of flank pain. The paper log had Patient #2's entry into the log had a line through it with no indication as to why the entry was crossed off.

Review of Patient #2's medical record on 6/5/2017 at 3:00 PM revealed that triage notes were included in the medical records, but no there was no other documentation.

Interview on 6/6/2017 at 11:30 AM with Emergency Department Director A revealed that Patient #2 was entered into the ED log in error and had not presented to the ED. The medical record for Pt #2 had been created in error. The visit correlated to Patient #22 and "the wrong patient was registered."

When asked what the process is when a patient is registered incorrectly, Registration Director B stated on 6/6/2017 at 12:35 PM "I would assume there would be a note that the wrong patient was registered."

In the event a wrong patient is registered, Quality Improvement Coordinator D stated on 6/6/2017 at 12:15 PM that an incident report "would be an expectation."

Based on record review and interview, the facility failed to perform a medical screening exam for 1 of 21 patients presenting to the Emergency Department (Patient #1) and failed to screen and monitor for suicide risk per facility policy for 4 of 4 patients presenting with suicidal ideation (Patient #7, Patient #11, Patient #18, Patient #19). This has the potential to affect all patients seeking emergency services at this facility.

Findings include:

1. Facility policy "EMTALA (Emergency Medical Treatment and Active Labor Act: Medical Screening Exams and Transfer of Patients)" No. 017-380-01, reviewed on 6/5/2017, states: "Medical Screening Examinations (MSE)s: 1. MSEs will be provided to all patients who: A. Present themselves to the emergency department for treatment, 2. Come to the Birthing Center for treatment, C. Presents themselves to any area of [the facility], if they indicate they have a need for treatment of a medical condition or where a prudent layperson would conclude that the patient needs an examination or medical treatment."

During an interview on 6/7/2017 at 1:15 PM, Registration Coordinator F stated Patient #1 and Patient #1's friend presented to the Emergency Department registration desk on 5/30/2017. F stated "[Patient #1] stated 'I want to dry out.' I know we don't have an in-house facility, so I called back to talk to the nurses in the Emergency Room. The nurse said [Patient #1] can be seen here and then [Patient #1]'s friend can drive [#1] to another facility but that will take a few hours or they can just go there themselves." F stated "So, I told them they can either be seen here in the back and it will take a few hours or you can take [Patient #1] there yourself." Per F, Patient #1 left the Emergency Department to seek care at the other facility.

Interview with Risk Management Director C on 6/5/2017 at 2:30 PM revelaed that Patient #1 was offered a medical screening exam, but declined. C stated there was no documentation of Patient #1 presenting to the Emergency Department, or documentation to support that Patient #1 was offered a medical screening exam or had received a medical screening exam.

2. Facility policy "Procedure: Suicide Assessment/Precautions/Care" No. 017-750-01, reviewed on 6/5/2017, states: "Any patient, who displays, verbalized or is suspect of having suicidal tendencies should be assessed, placed on suicide precautions and cared for as deemed appropriate. ...2. If patient answer yes to the question, "Do you feel like hurting yourself now," then complete the "Suicide Risk Scale." ...Total all point in each level to determine risk. A. Level O = no/low risk - no precautions B. Level I = mild risk for suicide C. Level II = moderate risk for suicide D. Level III = high/severe risk for suicide ...Implement suicide precautions for the patient at the designated risk Level I - III. ...Documentation: A. Level I -requires documentation every 30 minutes. B. Level II and III -require documentation every 15 minutes."

Record review on 6/5/2017 at 3:45 PM revelaed that Patient #7 presented to the ED on 4/26/2017 at 6:52 PM with a chief complaint of depression and suicidal ideation. Patient #7 was discharged at 9:35 PM. There was no evidence in the medical record that a suicide screen or risk assessment had been performed during the ED visit per the facility policy.

Per medical record review on 6/6/2017 at 9:35 AM, Patient #11 presented to the ED on 5/22/2017 at 11:21 PM with a chief complaint of suicidal ideation. Patient #11 responded "yes" to each of the following suicide severity questions: 1. Wish to be dead - yes. 2. Suicidal thoughts - yes. 3. Suicidal thoughts without specific plan or intent to act - yes. 4. Suicidal intent without specific plan - yes. 5. Suicide intent with specific plan - yes. The record does not include a suicidal risk scale form, implementation of suicidal precautions or monitoring of the patient per facility policy.

Record review on 6/6/2017 at 10:30 AM revealed that Patient #18 presented to the ED on 5/9/2017 at 8:41 PM with a chief complaint of suicidal ideation. Patient #18 responded "yes" to each of the following suicide severity questions: 1. Wish to be dead - yes. 2. Suicidal thoughts - yes. 3. Suicidal thoughts without specific plan or intent to act - yes. 4. Suicidal intent without specific plan - yes. 5. Suicide intent with specific plan - yes. There is no suicidal risk scale form in Patient #18's medical record. ED Precautions Interventions list "Suicide" at 9:08 PM with a note of "husband at bedside." There is no evidence of monitoring documented either every 15 or 30 minutes per facility policy.

Per medical record review on 6/6/2017 at 10:40 AM, Patient #19 presented to the ED on 5/25/2017 at 6:40 AM with a chief complaint of suicidal ideation. Patient #19 responded "yes" to each of the following suicide severity questions: 1. Wish to be dead - yes. 2. Suicidal thoughts - yes. 3. Suicidal thoughts without specific plan or intent to act - yes. The record does not include a suicidal risk scale form or frequent monitoring of the patient per facility policy.

Interview on 6/6/2017 at 12:05 PM with Emergency Director A revealed that staff are expected to fill out a complete risk assessment on paper if a patient responds"yes" to having suicidal thoughts. A confirmed there were no suicide risk assessments in the medical records for patients #7, 11, 18 and 19 as expected per facility policy.