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Based on review of hospital policies/procedures, medical records, hospital documents, and staff interviews, it was determined that the hospital failed to enforce policies/procedures that comply with the requirements of 42 CFR 489.24, Responsibilities of Medicare Participating Hospitals in Emergency Cases, as demonstrated by:

489.24(a) A-2406: failure to require medical screening exams (MSE) for all patients presenting to the Emergency Department requesting emergency services.

Based on observations during tours, and staff interviews, it was determined that the hospital failed to conspicuously post EMTALA signage in the Emergency (ED) and Obstetrics (OB) departments.

Findings include:

The hospital policy titled EMTALA - Medical Screening Examination and Stabilization Treatment #2795.10 (last reviewed 07/09) requires, "...Signage specifying:..The rights of individuals with EMC's (emergency medical conditions) and women in labor and...Whether the Hospital participates in the applicable state Medicaid program must be posted in a place or places likely to be noticed in the Dedicated Emergency Department, admitting, and in such other locations whether individuals are waiting for examination and treatment...."

The following was observed during a tour of the OB department, conducted on 11/08/10 at 0930:

The OB triage area includes a reception desk and 6 patient Triage Rooms. There is no waiting room in this area. All 6 rooms were vacant at the time of the tour, and all were inspected. There was no EMTALA signage in any of the 6 rooms, nor at the reception desk. The staff confirmed that there was no EMTALA signage, and stated that the sign was removed (and not replaced) when the walls were painted several weeks ago. The staff located the EMTALA sign in the Staff Restroom, on the floor, behind the linen hamper.

The OB department includes 3 Induction Rooms; A, B, and C. Two (2) of the 3 rooms were inspected and found without EMTALA signage (the 3rd room, B, was occupied and not observed).

The 15 labor rooms, were observed as follows:

Labor Room 1: "back-up pharmacy", now vacant.
Labor Room 11: storage.
Labor Rooms 10, 9, 8, 5, 7, were occupied and not observed.
Labor Rooms 4, 16, 12, 14 and 15 were not occupied. The surveyor inspected the rooms and found no EMTALA signage.

The 1 OB waiting room had no EMTALA signage. The 10 antepartum rooms, #268 through 276, were observed as follows:

Rooms 268, 267, 270, 271, and 273 through 276, were occupied and not observed.
Rooms 269, and 272, were not occupied. They were inspected and found with no EMTALA signage.

The following was observed during a tour of the ED, conducted on 11/08/10 at 1030:

There was no EMTALA signage outside the pedestrian entrance to the ED. There was no signage at the reception area, nor any area in the waiting area, with the exception of a sign on the far northwest alcove wall, facing the vending machine. The ED staff indicated that patients presenting to the ED, sign in at the reception desk on the far east side of the room. The waiting room had several people during the time of the tour, most were on the east side of the ED waiting room. The staff indicated that at times, patients register at the desk and go directly to 1 of the 3 triage rooms (located on the west side of the waiting area) and never pass the only EMTALA sign on the other side of the room facing the vending machine.

None of the 3 Triage rooms had EMTALA signage.

The Orange zone contains 20 beds/bays for non-monitored, none emergency, stable patients, Emergency Severity Index (ESI) 3 through 5. There is 1 waiting alcove for physician triage, and one "waiting for results" room. Neither had EMTALA signage. 19 of 20 rooms were occupied and not observed. There was no EMTALA signage in the 1 empty room that was observed.

The Red pediatrics zone contains a waiting room, and 11 beds/bays: Rooms #38 through 41, 45 through 47, 50 and 51. Four (4) rooms were occupied and not observed during tour. Rooms #40 - 42, are designated "waiting test results". None of the observed patient rooms, nor the waiting room, had EMTALA signage.

The ambulance entrance is outside the Red zone. No EMTALA signage was noted in or outside the entrance door. The staff indicated that when ambulances arrive, they proceed directly to the Silver zone (trauma bay) or stop at the "fishbowl" nurses station. No signage was noted at the "fishbowl". When the surveyor asked where the EMTALA signage was, the Nurse Manager #13, responded, "...we don't have EMTALA signage here - isn't it in the waiting room?...."

The Green zone contains 9 beds/bays for monitored ESI 2 and 3 patients. Two (2) rooms, #5 and 6, were vacant and observed without EMTALA signage. The remaining 7 occupied rooms were not observed.

The Gold zone contains 9 beds/bays for monitored patients. The 1 empty room, #30, had no EMTALA signage. The remaining 8 rooms were occupied and not observed.

The Blue zone contains 9 beds/bays. Rooms #8, 10, 13 and 16, were vacant and had no EMTALA signage. The remaining 5 occupied rooms were not observed.

The Silver zone (Trauma Unit) has 4 bays. None of the beds were occupied at the time of the tour, and no EMTALA signage was observed.

The Purple zone had 6 rooms with a capacity for 12 beds (Behavioral Health patients). The 1 empty room, and the waiting/TV area, had no EMTALA signage. The remaining 5 occupied rooms were not observed.

EMTALA signage was not adequate and conspicuously posted, specifying the rights of patients with respect to examination and treatment of emergency medical conditions.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the hospital failed to provide a medical screening examination (MSE) for 1 of 1 patients presenting to the ED with a reported eye injury: Patient #15.

Findings include:

The hospital policy titled EMTALA - Medical Screening Examination and Stabilization Treatment #2795.10 (last reviewed 07/09) requires, "...An appropriate MSE will be offered to individuals on the Hospital's Campus who request emergency services...Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE...An MSE will be conducted to determine whether the Patient has an EMC (emergency medical condition). The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions...."

Patient #15, has a lengthy history of multiple ED visits for multiple illnesses/injuries, according to the hospital's logs. The patient presented to the Emergency Department (ED) on 09/14/10, at 1052, with complaints of right eye redness and pain. The medical record indicated that the patient suspected a foreign body (metal) in the eye, after using a steel brush at home. The patient was moved post triage, to the Orange Zone, the designated ED area for patients with an Emergency Severity Index (ESI) of 3, 4, and 5. The patient reported pain at 8 at 1131, on a scale of 0-10 (10 being the worst).

Social Worker/Case Manager #9, documented at 1159, "...Received request from (RN #3) to meet with pt. (patient) regarding ER (Emergency Room) abuse due to pt's monthly frequent ER visits. Went in to see pt, introduced myself, and told pt that a request was made to see (the patient) regarding...frequent ER visits. Pt stated 'I think I need to get out of here...No one has addressed my eye and this is (expletive), I'm leaving.' Pt proceeded to get out of bed and walked out of the ER. Notified (RN #3) of pt leaving without be (sic) treated. No further interventions...."

RN #3 documented, "...social worker (employee #9) at bedside to discuss multiple ED visits. Pt stated...was not being treated and left. Pt was not seen by provider (Physician Assistant #28) informed pt left...."

ED Director RN #12, stated during an interview conduted on 11/09/10 at 1000, "...everyone gets an MSE (medical screening exam) no matter how many times they come in...the social worker gets involved...the nurse or the physician can initiate a consultation (with social services)...."

Case Manager RN #14, stated during an interview conducted on 11/09/10 at 1005, "...the social worker can consult with the patient prior to the MSE, and after the triage, to provide the patient community resources...."

ED Medical Director (physician) indicated during an interview conducted on 11/09/10, that the hospital did not have a policy addressing frequent visitors to the ED, and stated that "...the expectation is that every patient gets a MSE - every visit..."

Patient #15, was not provided a medical screening examination on 09/14/10, when s/he presented to the ED requesting treatment for an eye injury.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the hospital required 1 of 1 patient presenting to the ED with an eye injury, to sign a financial agreement prior to the medical screening examination: Patient #15.

Findings include:

The hospital policy titled EMTALA - Medical Screening Examination and Stabilization Treatment #2795.10 (last reviewed 07/09) requires, "...The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions...An MSE and Stabilizing Treatment...will be provided to all individuals regardless of their ability to pay...."

The hospital policy titled EMTALA: Patient Financial Services #3191.4 (last review 11/08), requires: "...Banner PFS (patient financial services) personnel will not initiate discussions regarding financial arrangements until after the medical screening examination is completed...."

The Manager of Patient Financial Services #15, confirmed during an interview conducted 11/08/10, that the patients sign the "Financial Agreement Form" after the physician's MSE.

Patient #15, presented to the ED on 09/14/10, at 1052, with complaints of right eye redness and pain. The medical record indicated that the patient suspected a foreign body (metal) in the eye, after using a steel brush at home. The patient was moved post triage, to the Orange Zone, the designated ED area for patients with an Emergency Severity Index (ESI) of 3, 4, and 5. The patient reported pain at 8, on a scale of 0-10 (10 being the worst), at 1131.

The patient signed the hospital's "Financial Agreement Form" on 09/14/10 at 1140, which requires: "...I agree that in return for the services...I will pay the account...and/or prior to discharge make financial arrangements satisfactory to the hospital and/or any other providers for payment. I will pay the hospital's usual and customary charges...If account is sent to an attorney for collection, I agree to pay reasonable attorney's fees and collection expenses...In Granting Admission Or Rendering Treatment, The Hospital And Other Providers Are Relying On My Agreement To Pay The Account. Emergency Care Will Be Provided Without Regard To The Ability To Pay...."

There was no documented MSE prior to the patient's leaving the ED without treatment at 1159, and after the patient signed the Financial Agreement form at 1140.