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Based on interview and document review, the hospital failed to ensure compliance with the requirements of 42 CFR 489.24 as evidenced by the deficient practice cited at 42 CFR 489.24 (r) and 489.24 (c).

Based on observations and interview, the hospital failed to post conspicuously in the ED or in a place likely to be noticed by all individuals entering the ED, as well as those individuals waiting for examination, signs specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment in the emergency department and women in labor.

Findings include:

A tour of the ED was conducted with nurse (A)/manager of the ED at 1:56 p.m. on August 16, 2012. The hospital ED entrance had a registration desk that faced the entrance. There was one sign referencing a patient's EMTALA rights posted to the right of the registration desk however, the sign was difficult to locate because the color and printing on the sign closely matched the color of the wall. The registration area had four waiting rooms, two of which were frequently used for patients waiting to be seen in the ED. There were no visible signs posted in the four waiting rooms. In addition, there were two triage rooms behind the registration desk used for ED patients that had no visible signs posted referencing a patient's EMTALA rights.

This lack of signs was confirmed with employee (A) during the tour.

Based on a review of the central log maintained by the hospital's Emergency Department (ED), the hospital failed to ensure that every patient that presented to the ED was entered on the log for 1 of 21 (#21) patients reviewed and failed to ensure the central log accurately reflected the discharge disposition for 5 of 20 (#1, #9, #11, #14, #20 ) ED patient records reviewed.

Findings include:

The ED log for the hospital was reviewed from January 1, 2012 through July 31, 2012. Review of the log revealed no information on Patient #21 who on May 27, 2012, had been transported by a basic life support ambulance to the hospital's ED garage and was immediately transferred into an advanced life support ambulance and transported to another hospital.

Review of the hospital's ED log from January 1, 2012 through July 31, 2012, revealed numerous patient entries that lacked the disposition of the patient.

Review of the ED log for Patient #1 revealed the patient presented to the ED on May 6, 2012 with chest pain. The central log did not indicate the disposition of Patient #1. Review of Patient #1's ED record indicated that Patient #1 was admitted to the Intensive Care Unit.

Review of the ED log for Patient #9 revealed the patient presented to the ED on May 27, 2012 with minor multiple trauma. The central log did not indicate the discharge disposition for Patient #9. Review of Patient #9's ED record indicated the patient was discharged home.

Review of the ED log for Patient #11 revealed the patient presented to the ED on May 27, 2012 with nausea, vomiting and diarrhea. The central log did not indicate the discharge disposition for the patient. Patient 11's ED record indicated that patient #8 was discharged home.

Review of the ED log for Patient #14 revealed the patient presented to the ED on May 29, 2012 for general complaints. The central log indicated Patient #14 was transferred however, the patient's ED record revealed the patient was admitted to the hospital for observation.

Review of the ED log for Patient #20 revealed the patient presented to the ED on May 27, 2012 with congestive heart failure. The central log indicate Patient #20 was admitted to the hospital. Review of Patient #20's ED record indicated the patient left the ED against medical advise (AMA).

Interview with nurse (B)/director of critical care services at 12:02 p.m. on August 16, 2012, confirmed all patients presenting to the emergency department need to be entered on the ED central log. Nurse (B) stated Patient #21's information should have been entered on the ED log.

Interview with nurse (B) at 5:00 p.m. on August 16, 2012, confirmed entries on the ED log lacked the disposition of patients.

Based on documentation review and interview, the hospital failed to ensure that each patient who presented to the emergency department (ED)/hospital property received a medical screening examination for 1 of 21 (#21) patients reviewed. The hospital's failure to complete a medical screening exam posed an immediate threat to Patient #21's health and safety and had the potential to effect all patients that present to the ED with an emergency medical condition.

Findings include:

A review of Patient #21's hospital's ED record revealed that patient #21 presented to the ED of hospital #1 (transferring hospital) on 5/26/12 at 10:57 p.m. by ambulance for unresponsiveness. Patient #21 had diagnoses that included liver cirrhosis and hepatic encephalopathy. While at hospital #1, Patient #21 was intubated for airway protection, and stabilized. Due to hospital #1 not having ventilators, an airlift transfer was arranged for patient #21 to be transferred to hospital #3 for a higher level of care. Due to inclement weather the air ambulance was unable to transport the patient at that time to hospital #3. Hospital #1 then contacted hospital #2 (receiving hospital) and made arrangements for Patient #21 to be ground transported to hospital #2. Hospital #1 contacted the hospitalist at hospital #2 to arrange for admission.

Review of hospital #2's ( the receiving hospital) Manager Specific Report document dated 5/26/2012, revealed registered nurse (C)/house supervisor was contacted by physician (G)/hospitalist regarding accepting Patient #21 as a transfer to be admitted to hospital #2 (receiving hospital). The documentation indicated nurse (C) arranged for Patient #21 to be admitted to hospital #2's Intensive Care Unit (ICU) because the ED was busy. Nurse (C) did not contact hospital #2's ED staff about Patient #21. Nurse (C) contacted the transferring hospital who informed nurse (C) that Patient #21 was being transported to hospital #2 (receiving hospital) by a basic life support (BLS) ambulance with a physician and registered nurse accompanying the patient. Following that call, nurse (C) contacted hospital #3 after consulting with physician (G) determined Patient #21 could be ground transported from either the transferring hospital or hospital #2 (receiving hospital) to hospital #3 with an advanced cardiac life support (ACLS) ambulance and crew. The documentation indicated nurse (C) arranged for an ACLS ambulance to transport Patient #21 and made unsuccessful attempts to contact the transferring hospital prior to the transport of the patient to hospital #2 (receiving hospital). When nurse (C) was able to contact the transferring hospital, Patient #21 was en route to hospital #2 via the BLS ambulance with a physician and nurse in attendance. According to the documentation, the BLS ambulance arrived at hospital #2's (receiving hospital's) ED garage and the ambulance staff were told by nurse (C) to transfer the patient directly into the ACLS ambulance. Patient #21 was not brought into hospital #2's ED for a medical screening evaluation to determine if further stabilizing treatment was required for the patient prior to transferring the patient to hospital #3.

Review of the ACLS ambulance patient care report dated 5/27/2012, from 1:20 a.m. until 3:50 a.m. revealed the ambulance "intercept" with the BLS ambulance occurred in hospital #2's (receiving hospital's) ED garage. Patient #21 was placed on a ventilator in the ACLS ambulance with an EKG (electrocardiogram) that showed tachycardia with the patient's heart rate of 106 to 120, respirations of 12 given by the ventilator and an oxygen saturation of 98% on 50% oxygen. The documentation indicated Patient #21 had no changes in condition during the two and one-half hour transport from hospital #2 (receiving hospital) to hospital #3.

Interview with physician (G) at 10:08 a.m. on 8/27/2012, established physician (G) had accepted Patient #21 as an admission to hospital #2 (the receiving hospital). Prior to accepting the patient he contacted nurse (C) to ensure the hospital could provide the services required for Patient #21. However, instead of admitting Patient #21, he had asked nurse (C) to arrange transportation to another hospital. Physician (G) did not inform hospital #2's (the receiving hospital's) ED staff that Patient #21 had arrived at hospital #2 prior to transporting the patient to another hospital.

Interview with nurse (C) at 9:40 a.m. on 8/28/2012, revealed nurse (C) had facilitated an ambulance to ambulance intercept at hospital #2's ED garage. Nurse (C) said she did not inform hospital #2's ED staff of Patient #21 and the patient was transferred directly from one ambulance into another. No assessment or evaluation was completed for Patient #21 by hospital #2 (receiving hospital).

Review of hospital #2's (receiving hospital's) policy and procedure titled Transfer/Admission with a review date of 9/2/2005, stated, "...Patients admitted or transferred to (hospital #2) will be provided a medical screening evaluation prior to transfer to another facility..."