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Based on observation, interview, and record review, the hospital failed to ensure the signages for EMTALA rights with respect to the examination and treatment for emergency medical conditions and women in labor were posted conspicuously in the ED and L&D areas where the signages would likely be noticed by the individuals visiting the ED and L&D areas as evidenced by:

1. Failure to ensure EMTALA signage was posted in the dedicated ED security checkpoint and designated outdoor ED waiting areas.

2. Failure to ensure EMTALA signage was posted in the ED treatment and ED pod/extension areas.

3. Failure to ensure EMTALA signage was posted in the L&D rooms of the L&D unit.

These failures had the potential result in the individuals to not be aware of their rights to the examination and treatment in the event of an emergency medical conditions.

Findings:

Review of the hospital's P&P titled EMTALA dated 6/1/21, showed the hospital will post signages specifying the rights of an individuals under the law with respect to examination and treatment conspicuously in the dedicated ED and all areas in which the individuals routinely present for treatment of emergency medical conditions or wait prior to examination and treatment, such as entrance, admitting areas, waiting room, or treatment room. Signages will be in all major languages that are common to the population of the hospital's service areas.

1a. On 9/20/22 at 0904 hours, the initial tour of the ED was conducted with the ED Director and Quality Director 2. A security officer was observed standing at the podium that was approximately 50 feet from the ED main entrance.

On 9/20/22 at 0906 hour, an interview and concurrent review of the document titled Lobby Officer Daily Activity Report (DAR) was conducted with Security Officer 1. Security Officer 1 stated the security podium was the dedicated ED checkpoint. Security Officer 1 stated the individuals presenting to the security podium would be asked for the reason of their visits to the ED. However, there was no EMTALA signage posted at the dedicated ED security checkpoint or in proximity.

b. On 9/20/22 at 0916 hours, a tour of the ED was conducted with Quality Director 1, Quality Director 2, and the ED Manager. Prior to entering the ED lobby or main entrance, the following was observed:

* Multiple chairs were observed outside on the left-hand side and were lined up against the building wall.

* A vital sign machine was observed outside on the right-hand side immediately after a white tent.

The ED Manager stated this outdoor area was a dedicated waiting area for patients who came to the ED.

However, there was no EMTALA signage posted in the outdoor ED waiting area.

On 9/23/22 at 1030 hours, the above findings were shared and acknowledged by the Patient Safety Officer.


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2. On 9/20/22 at 0915 hours, the initial tour of the ED was conducted with the CNO and ED Director. Upon entering the ambulance bay, an EMTALA signage laminated 8 inches by 11 inches was observed to be posted on the wall near the door of the ambulance bay. However, there was no EMTALA signage conspicuously posted in the ED treatment and ED pods/extension areas.

On 9/20/22 at 1018 hours, during an interview with the CNO, the CNO was asked for the EMTALA signage in the ED treatment areas. The CNO showed the EMTALA signage by the door of the ambulance bay and stated there were no other EMTALA signages in the ED treatment areas. When asked for the EMTALA signage at the ED pod/extension area, the CNO stated there was no EMTALA signage at the ED pod/extension area.

3. On 9/20/22 at 0945 hours, the tour of the L&D unit was conducted with the CNO, the ED Director, and RN 5. An EMTALA signage was observed posted on the hallway where the patients would come into the L&D unit. However, there was no EMTALA signage posted in Rooms A, B, and C. RN 5 was asked for the process when a pregnant patient came in the L&D unit. The RN stated when the patient came to the unit, the RN checked the patient's vital signs and gestation to identify if the patient was over 20 weeks or less than 20 weeks pregnant. If the patient was less than 20 weeks pregnant, the RN would triage the patient further. The patient was checked in with the unit secretary and the Charge Nurse was notified. The patient then would be taken to the rooms and triaged if the patient could wait until active labor. If actively laboring, the patient would go directly to the L&D room. If patient was still on early stage of laboring the patient could go to Room A. Room C was used as the testing area for blood draw and ultrasound.

On 9/23/22 at 0945 hours, an interview with the L&D Nurse Manager and Quality Director 1 was conducted. When asked for the EMTALA signage in the L&D unit and the rooms of the OB unit, the L&D Nurse Manager stated the EMTALA signage was posted in the hallway of the L&D unit; there was no EMTALA signage at the OB Unit. The patients were triaged at the L&D Unit. The L&D rooms did not have EMTALA signage.

Based on observation, interview, and record review, the hospital failed to ensure an MSE was provided in a timely manner to determine whether or not an EMC existed for five of 24 sampled patients (Patients 2, 3, 4, 5, and 22) as evidenced by:

1. For Patient 22, there was no documented evidence to show the physician or healthcare provider conducted an MSE for the patient before the patient was escorted out of the ED on 8/31/22.

2. Patient 22 was restricted from entering the ED. In addition, the EMTALA training was not consistently provided to the hospital's staff whose responsibilities were affected by the hospital's P&P titled EMTALA.

3. For Patient 2, the ED nursing staff failed to reassess the patient's pain levels when the patient complained of chest pressure on arrival to the ED.

4. For Patient 3, the ED nursing staff failed to reassess the patient's pain levels after providing the pain medication to the patient.

5. For Patient 4, the ED nursing staff failed to assess the pain levels when the patient complained of the right arm pain.

6. For Patient 5, the ED nursing staff failed to provide the pain interventions and reassess the patient's pain levels when the patient complained of abdominal pain with the pain level of 8 out of 10.

These failures had the potential to result in poor clinical outcomes and serious adverse events for the patients in the hospital.

Findings:

Review of the hospital's P&P titled EMTALA dated 6/1/21, showed to ensure the individuals presenting to the hospital's ED receives an appropriate MSE and stabilizing treatments or an appropriate transfers in accordance and that requests for transfers to the hospital are accepted or declined in accordance with the Emergency Medical Treatment and Labor Act of 1986 (EMTALA). All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy.

Review of the hospital's P&P titled Standard of Care, All Ages dated 1/28/22, showed to ensure all ED patients receive the same quality of care. All patients in the ED shall consistently receive quality care based on the established standards. Baseline vital signs will be documented in the electronic medical record nursing triage page at the time of initial assessment or arrival to the ED. Vital signs are defined as temperature, pulse, respiration, pulse oximetry, blood pressure and pain. Updated assessments and/or vital signs will be documented at change of shift, at least every 90 minutes and as appropriate to patient needs. Medications and treatments will be completed on timely basis. Timely documentation and reassessment will be made on the nursing notes when any medical treatment or nursing procedure is done.

Review of the hospital's P&P titled Triage: Role of the Emergency Department RN dated 2/25/22, showed to ensure prompt care is given and that patients are seen based on acuity. Patients who are triaged and categorized as Levels 3, 4, and 5 will have a complete triage decision based on acuity and resource utilization. When the patient presents to the ED lobby, the triage nurse will maintain the flow of information between triage and waiting room, triage and treatment area, treatment area and waiting room; and determine patient acuity by performing initial assessment of the A (Airway), B (Breathing status), C (Circulatory status), D (Disability, including neurological status), obtaining patient history of chief complaint, and taking vital signs.

Review of hospital's P&P titled Pain Management review dated 4/29/22, showed to provide the pain assessment and management guidelines for the patients in either acute or chronic pain, or for anticipated procedural pain. Patients will be evaluated and screened on admission for the presence of pain using the following criteria as appropriate for age and mental status: location, intensity, quality of pain, physical examination of the pain site and referring patterns. The pain assessment should be based on the patient's self-report of the level and the intensity of pain. Any changes in vital signs or behaviors may be used as additional criteria to support interventions. Ongoing assessments and documentation of pain will be charted on designated unit flow sheets and nurse's outcome notes. Assessments and documentation will occur with each report of pain and after pain relieving intervention. Healthcare providers are encouraged to use the Pain Scale (1-10) or the following descriptive terms to complete the indication for use of pain medications:

- For the pain scale from 1 to 3, the patient has mild pain.

- For the pain scale from four to six, the patient has moderate pain.

- For the pain scale from seven to 10, the patient has severe pain.

Review of Job Description of the ED RN (undated) showed this position is responsible for the nursing care delivered to patients in ED. The ED RN utilizes the nursing process (assessment, nursing diagnosis, planning, intervention, and evaluation) throughout the patient's stay in the ED, from triage to discharge/admission; communicates effectively with other ED team members to ensure appropriate, timely and professional care to all patients; and demonstrates knowledge of resources available within the hospital and the community. The ED RN's essential duties include the following:

- Performs examinations competently and efficiently within department protocol.

- Completes basic charting, interprets orders correctly, investigates vague or seemingly incorrect orders.

- In the absence of supervisor, assures department policies and procedures are followed and productivity meets standards.

1. On 9/22/22 at 1000 hours, an interview and concurrent review of Patient 22's medical record was conducted with Quality Manger 2.

Patient 22's medical record showed Patient 22 presented to the ED on 8/31/22 at 0346 hours.

Review of the Event Log dated 8/31/22 showed Patient 22 was triaged by the RN at 0350 hours.

Review of the ED Triage Form - Text dated 8/31/22 at 0350 hours, showed Patient 22's chief complaint was the right hip, left arm, and left hip pain. The patient stated the patient was getting hit by a car and ambulated to the ED.

Review of the Nursing Note dated 8/31/22 at 0358 hours, showed "Pt (patient) verbally abusive toward staff. Pt attempting to smoke in ED lobby. Pt warned multiple times by staff to put mask on, pt refusing to listen/getting aggressive. Pt escorted out of lobby. ED security notified."

Review of the ED Discharge Form -Text dated 8/31/22 at 0400 hour, showed the following

* The ED Disposition section showed "LWOT."

* The Mode of Discharge section showed "Ambulatory."

* The ED Condition section showed "Stable."

There was no documentation showing an MSE was completed for Patient 22 or any other actions were taken in response to Patient 22's LWOT before the patient was escorted out of the ED lobby.

On 9/22/22 at 1030 hours, Quality Director 2 confirmed there was no further documentation found in Patient 22's medical record for the ED visit on 8/31/22 at 0346 hours.

2. On 9/20/22 at 0904 hours, the initial tour of the ED was conducted with the ED Director and Quality Director 2.
A security officer was observed standing at the podium that was approximately 50 feet from the ED main entrance.

On 9/20/22 at 0906 hour, an interview and concurrent review of the document titled Lobby Officer Daily Activity Report (DAR) was conducted with Security Officer 1. Security Officer 1 stated the security podium was the dedicated ED checkpoint. Security Officer 1 stated the individuals presenting to the security podium would be asked for the reason of their visits to the ED. Security Officer 1 stated the individuals seeking emergency care, and the individuals accompanying patients who were seeking for emergency care and visitors would be screened for Covid 19 and rashes or a sign of monkeypox virus prior to entering the ED. Security Officer 1 stated significant observations or activities that occurred during their shift were documented on the DAR.

On 9/20/22 at 1102 hours, an interview was conducted with Security Officer 2. Security Officer 2 was questioned about EMTALA. Security Officer 2 stated the patients could not "legally" be prohibited from entering the ED if they were "here to receive medical treatment."

Security Officer 2 stated it was not uncommon to receives directives from the nurses to not allow patients to return to the ED after the patients had received treatment, had "checked out," or left AMA. Security Officer 2 stated the nurses were "fed up" and would state "this person is out, they can't come back" including "homeless" patients or patients that were "nuisances." Nurses would say "no they cannot return." Security Officer 2 stated that it had been reported multiple times to the Security Manager and Post Commander that the ED nurse had asked to turn patients away and to not allow the patients back in the ED. Security Officer 2 stated the response from the Security Management was that it was the "culture" of the ED staff and "that's the way it is." Security Officer 2 stated Security Officer 2 had been confronted by nurses on many occasions and had witnessed nurses confronting other security officer for allowing patients to return to the ED after they had been instructed not to. Security Officer 2 stated on one occasion, the ED nurses stated, "Why did you let them back in, we already treated them." Security Officer 2 stated to the nurse, "Yes, but they want to be seen again." Security Officer 2 stated Security Officer 2 was "constantly having to educate ED staff" about EMTALA "it's a clinical law."

Security Officer 2 stated the DAR for 9/4/22, should be reviewed as there was documentation of a patient being restricted from reentering the ED. Security Officer 2 stated Security Officer 2 could not recall other dates when patients had been restricted from entering the ED; however the DARs should be reviewed. Security Officer 2 stated the DAR was the document that the security officers documented significant events that had occurred during the shift.

a. Review of the Significant Observations/Activities section of the DAR showed an entry made by Security Officer 3 on 9/5/22 at 0529 hours, showing "Patient "[Name of Patient 22]" AMA'd. not allowed back into ER."

On 9/22/22 at 0656 hours, an interview and concurrent review of the DARs was conducted with Security Officer 3. When questioned about the DAR entry made on 9/5/22 at 0529 hours, Security Officer 3 stated the nurse stated Patient 22 had left AMA. Security Officer 3 stated he remembered the "nurse coming out" and "she just did not want him (referring to Patient 22) back in (referring to the ED)."

b. On 9/22/22 at 1000 hours, an interview and concurrent review of Patient 22's medical record was conducted with Quality Manger 2.

Patient 22's medical record showed Patient 22 presented to the ED on 9/22/22 at 0043 hours, complaining of right arm swelling and left leg pain.

Review of the ED Note-Physician dated 9/23/22 at 0801 hours, showed the following:

* The Time Seen section showed Patient 22 was seen on 9/22/22 at 0051 hours.

* The Chief Complaint section showed the patient complained of right arm swelling and left leg pain and swelling. The patient replied "I don't know" to all follow up questions.

* The History of Present Illness section showed the physician saw the patient yesterday for the same thing along with leg swelling. The patient apparently eloped yesterday. The patient started rambling and using profanity. The patient then threatened the physician and the nurse here by stating that there would be a half-mast, flag flown and half-mast which was when somebody died. The patient then left.

* The Review of Systems section showed it was unable secondary to the patient being uncooperative.

* The Physical Exam section showed the patient was alert and oriented. The patient was in a jacket so the physician could not evaluate his extremity again.

* The Impression/Plan section showed the patient had right arm pain.

* The Disposition section showed the patient eloped.

Review of the ED Discharge Form - Text dated 9/22/22 at 0111 hours, showed Patient 22 eloped. There was no further documentation showing any other actions were taken in response to the threats made by Patient 22 to the ED staff, including contacting law enforcement or security, and if any attempts were made to locate the patient.

Quality Manager 2 confirmed there was no further documentation found in Patient 22's record for the ED visit on 9/22/22 at 0043 hours.

Review of the Significant Observations/Activities section of the Break Officer DAR showed Security Officer 4 made an entry on 9/22/22 at 0240 hours, showing "Nurse at ER said to keep a patient that was discharged out of the ER because he was causing problems...blue jacket gray shirt and shorts." The patient' name was not documented.

Review of the Significant Observations/Activities section of the DAR showed an entry for 9/22/22 at 0310 hours, showing "Informed by valley 2 [sic- unidentified symbol, not legible] nursing staff of physical description of discharged patient who is no longer allowed back in.... (Patient 22's name)."

On 9/22/22 at 0620 hours, an interview and concurrent review of the DAR was conducted with Security Officer 3. Security Officer 3 stated on 9/22/22 at approximately 0310 hours, Security Officer 3 received a call from Security Officer 4 that "nursing staff told her" Patient 22 had been discharged from the ED, "but if he comes back, he is not allowed to come back in." Security Officer 3 stated that Patient 22 was a "regular" and "unfortunately homeless."

On 9/22/22 at 0652 hours, a telephone interview was conducted with Security Officer 4. Security Officer 4 stated Patient 22 was known for "causing problems" in the ED. Security Officer 4 stated that on 9/22/22 at approximately 0245 hours, a nurse "walked Patient 22 out, telling him to leave;" the nurse told Security Officer 4 if the patient came back, the security officer would "tell him to leave." Security Officer 4 stated in reference to "any transient," or a certain group of patient population, the ED nurses would say "if they come back tell them to go away." Security Officer 4 stated that Security Officer 4 had responded back to the nurses by saying, "We can't turn them (referring to patients that presented to the ED for emergency care) away." Security Officer 4 stated the ED nurses "give attitude and walk away." Security Officer 4 stated, "We can't tell them (referring to patients that presented to the ED for emergency care) to leave." Security Officer 4 stated that at approximately 0245 hours, Security Officer 4 made an entry on the Break Officer DAR indicating that the ED nurse had given instructions not to allow Patient 22 back in the ED. Security Officer 4 stated the DAR had been submitted to the Security Department.

c. On 9/22/22 at 0618 and 0620 hours, Security Officer 3 was observed at the dedicated ED checkpoint or the security podium. Quality Director 1 and Quality Director 2 remained near the security podium but stepped away to allow for privacy during the interview with Security Officer 3.

During an observation with Quality Director 1 and Quality Director 2 on 9/22/22 at approximately 0630 hours at the dedicated ED checkpoint or the security podium, the following was observed:

* A patient (Patient 22) was observed presented to the dedicated ED checkpoint and stated to Security Officer 3 that the patient was there to check in to the ED. Security Officer 3 was observed stated to the patient that the patient "cannot be let back in" to the ED. The patient was observed walking away from the ED toward the parking lot. Within seconds of the event, Security Officer 3 was advised that Security Officer 3 could not turn patients away from the ED if they requested emergency care. Then, the patient was immediately asked to return and check in at the dedicated ED checkpoint. Quality Director 1 and Quality Director 2 were immediately made aware that Patient 22 had been turned away from the ED by Security Officer 3.

* Within a few minutes, Patient 22 was observed walking back towards the dedicated ED checkpoint. Patient 22 was asked if the patient had checked in with the ED nurse. Patient 22 stated, "No, she won't let me." Quality Director 1 and Quality Director 2 immediately intervened and assisted Patient 22 back to the ED.

On 9/22/22 at 0656 hours, an interview and concurrent review of the DARs was conducted with Security Officer 3. Security Officer 3 was asked about EMTALA. Security Officer 3 stated if a nurse gave the directive to not allow patients back in the ED, including after they had been discharged, left AMA, or eloped, his understanding was that those patients could not return to the ED for a period of 24 hours. When Security Officer 3 was asked why he restricted Patient 22 from entering the ED, Security Officer 3 stated he was following the directive given by the nurse earlier in the shift; Security Officer 3 referenced the DAR entry he had made on 9/22/22 at 0310 hours that shift.

On 9/22/22 at approximately 0700 hours, the findings were shared, discussed, and acknowledged by Quality Director 1 and Quality Director 2.

d. On 9/23/22 at 0755 hours, an interview and concurrent record review was conducted with the ED Manager and the ED Director. When asked, the ED Manager stated the ED RNs were required to take the EMTALA training annually.

Review of the list of RNs showed RN 7's date of hire was 6/28/22. Review of the Learning Plan for RN 7 showed the completion deadline of the 2022 Fundamentals of EMTALA training course was 10/31/22; and RN 7 had not started the 2022 Fundamentals of EMTALA training course yet.

When asked, the ED Manager stated the new hire ED RN would have 90 days to complete the EMTALA training. However, the Learning Plan for RN 7 showed the completion deadline for the 2022 Fundamentals of EMTALA was 10/31/22, or 125 days after the date of hire.

On 9/23/22 at 0820 hours, an interview and concurrent record review was conducted with the L&D Nurse Manager and Quality Director 1. When asked for the EMTALA training for the RN of L&D or OB unit, the L&D Nurse Manager stated the OB RNs' most recent EMTALA training was provided in 2019. Quality Director 1 verified the finding.

On 9/23/22 at 1200 hours, an interview was conducted with Quality Director 2 and the Quality. The Quality was asked about the EMTALA training and the hospital's policy related to the EMTALA training. The Quality stated all staff were required to take the EMTALA training, and there was no hospital's policy addressed the EMTALA training. The EMTALA training would be assigned to the staff automatically on the "Learned Share" or an online program for all staff of the corporate website. The Education or Compliance Officer monitored the completion of the training, and the nurses would receive alert what needed to be completed.



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3. On 9/22/22 at 1454 hours, an interview and concurrent review of Patient 2's medical record was conducted with Quality Director 2 and the Quality.

Patient 2's medical record showed the patient Patient 2 came to the hospital's ED on 8/6/21 at 1530 hours, and was LWOT at 1858 hours (or three hours and 28 minutes later).

Review of the ED Triage Form - Text dated 8/6/21 at 1531 hours, showed Patient 2 complained of chest pressure and had celiac vomiting syndrome. The patient's pain level was 7 out of 10 (or the patient had severe pain). The patient's BP was 95/61 mmHg. The patient's HR was 99 beats per minute. The patient's RR was 18 breaths per minute. The patient's oxygen saturation level was 98% on room air.

When asked for the documented evidence to show if the pain intervention was provided for Patient 2's chest pressure of 7 out of 10, the Quality Director 2 stated the patient had left. When asked for the reassessment of the pain before the patient left, the Quality Director 2 was unable to find documented evidence showing Patient 2's pain level was reassessed.

4. On 9/21/22 at 1015 hours, an interview and concurrent review of Patient 3's medical record was conducted with the ED Manager, Quality Director 1, and Quality Director 2.

Patient 3's medical record showed the patient came to the ED on 5/29/21 at 1734 hours and eloped from the ED at 2325 hours (or five hours and 51 minutes later).

Review of the ED Triage Form - Text dated 5/29/21 at 1735 hours, showed Patient 3 complained of the right lower back pain and chest pain. The patient had abscess on the buttock area. The patient's pain level was 9 out of 10 (or the patient had severe pain).

Review of the physician's order dated 5/29/21 at 1741 hours, showed to administer ibuprofen (a pain medication) 600 mg PO to the patient.

Review of the EMAR showed the ED RN administered the medication to the patient on 5/29/21 at 1859 hours. When asked for the reassessment of Patient 3's pain level after the pain medication was administered, the ED Manger could not find documentation to show the nursing staff reassessed the pain level for the patient after the pain medication was administered to the patient. When asked, Quality Director 1 stated there was no specific policy for the ED reassessment of pain; the hospital's P&P related to pain management applied for all nursing units. The ED Manager was asked what her expectation of the ED RNs for the reassessment of pain level was, the ED Manager stated she expected the ED RNs were to reassess the patient's pain levels after an hour if the pain intervention was provided to the patient.

5. On 9/21/22 at 1605 hours, an interview and concurrent review of Patient 4's medical record was conducted with the Patient Safety Officer, Quality Director 1, and Quality Director 2.

Patient 4's medical record showed the patient came to the ED on 6/20/21 at 2244 hours, and was LWOT at 2359 hours (or one hour and 15 minutes later).

Review of the ED Triage Form - Text dated 6/20/21 at 2244 hours, showed Patient 4 complained of the right arm pain. When asked for the pain level assessment, Quality Director 2 could not find documented evidence to show Patient 4's pain level was assessed when the patient complained of the right arm pain.

6. On 9/22/22 at 1044 hours, an interview and concurrent review of Patient 5's medical record review was conducted with Patient Safety Officer, Quality Director 1, and Quality Director 2.

Patient 5's medical record showed the patient came to the ED on 6/1/21 at 1857 hours and eloped from the ED at 2259 hours (or 4 hours and 2 minutes later).

Review of the ED Triage Form-Text dated 6/1/21 at 1901 hours, showed Patient 5 complained of the abdominal pain with cramps for three weeks. The patient was eight-week pregnant. Patient 5's pain level was 8 out of 10 (or the patient had severe pain).

Review of the physician's order dated 6/1/21 at 1902 hours, showed to administer Norco (a narcotic pain medication) 325 mg-5 mg STAT to the patient.

Review of the ED Note-Physician dated 6/1/21 at 2259 hours, showed Patient 5 was seen immediately upon arrival. The patient had "abdominal pain in pregnancy" and eloped from the ED.

Review of the Patient Called for Care showed Patient 5 was called on 6/1/21 at 2221 (or three hours and 20 minutes) and at 2251 hours, after the patient complained of pain on 6/1/21 at 1901.

When asked what time the Norco was administered to Patient 5, Quality Director 2 stated the Norco was not administered to the patient because the patient had eloped. Quality Director 2 was unable to find documented evidence to show the Norco was administered to the patient. When asked for Patient 5's reassessment of pain levels, Quality Director 2 could not find documented evidence the show the nursing staff reassessed the pain levels for Patient 5.

Quality Director 2 was asked how the ED staff knew Patient 5 eloped from the ED. Quality Director 2 showed the ED RN called Patient 5 on 6/1/21 at 2221 and 2251 hours.