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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 A2402.

The facility failed to maintain a complete and accurate log of patients presenting to the Emergency Department. See tag A2405.

The facility failed to perform a medical screening exam for all patients receiving care in the Emergency Department. See tag A2406.

Based on observation, record review and interview, the facility failed to post EMTALA signage in 2 of 3 patient holding rooms (Triage, Vertical Treatment room).

Findings include:

Review of facility policy "Emergency Medical Treatment and Labor Act (EMTALA), CI-18" ID #1347710, dated 6/24/2016, states: "I. Signage. The Hospital Organization shall conspicuously post signs in all areas where individuals wait for examination and treatment..."

During a tour and observation of the Emergency Department on 4/6/2017 at 8:30 AM, there were no EMTALA signage posted in the patient triage room and in 1 of 2 vertical treatment rooms. These findings were confirmed at the time of the observation with Emergency Services Director A. During an interview on 4/6/2017 at 8:45 AM, Director A confirmed both rooms without signs are patient care areas. Director A stated "the vertical treatment room is new" since last fall, and "we will have to get signs posted."

Based on record review and interview, the facility failed to maintain a log of patients presenting to the Emergency Department with complaints of sexual assault in 3 of 3 sexual assault patients reviewed (Patient #1, Patient #2, Patient #3). This has the potential to affect all patients presenting to the facility seeking sexual assault services.

Findings include:

Review of facility policy "EMTALA: Medical Screening, Stabilization/Treatment and Transfer for Emergency Medical Conditions" No. 1622878, dated 7/3/2015, states: "The Hospital will maintain a centralized log on each person who comes to the Dedicated Emergency Department seeking emergency medical screening and treatment."

Review of facility policy "Emergency Department Logs - Creation and Maintenance to Meet EMTALA Requirement" No. 2168474 states: "1. Every individual who presents to Patient Access and/or the ED and requests any interaction with staff, nurses, or physicians or any other medical/behavioral health service MUST be registered and a chart/record created."

Review of facility policy "RC PA-1700 Emergency Department Logs" No. 3468234, dated 4/12/2016, states: "1. Patient Access Services will maintain an Emergency Department log to record an encounter when a patient refuses registration or further emergency department treatment. ...3. The log will capture data elements as follows: A. Date/time of encounter. ...E. Reasons for leaving without being registered."

During an interview on 4/6/2017 at 9:20 AM, Patient Access Representative C stated a patient [Patient #1] had presented to the Emergency Department (ED) on 3/29/2017 requesting a sexual assault examination. Per C, the facility did not have a sexual assault nurse examiner (SANE) on site, and C referred Patient #1 to another facility. When asked if Patient #1 was registered on the ED log or entered in the registration system or electronic health record, C stated "first, I wanted to see if we had one [SANE nurse] on staff before entering [Patient #1's] name...they're not supposed to show up in [the ED electronic health record]." C stated when patients present with sexual assault, the registration is done differently in the electronic health record. When asked if there are any other situations in which patients are not registered upon presenting to the ED, Patient Access Representative C stated "sometimes a patient comes in and asks how long the wait is and then they walk out."

On 4/6/2017 at 10:00 AM, the facility produced a list of 19 patients that were seen by a SANE nurse in the ED in the previous 12 months, from 5/2016 through 4/6/2017. During a review of the facility's ED log on 4/6/2017 at 10:30 AM, the log did not include any patients with a presenting complaint of sexual assault. ED Director A stated on 4/6/2017 at 10:30 AM that sexual assault patients are not on the log because they are registered differently for "confidentiality."

Per medical record review on 4/6/2017 at 11:00 AM, Patient #2 presented to the ED on 2/11/2017 with complaints of sexual assault. There is no record of Patient #2 on the ED log on 2/11/2017.

Per medical record review on 4/6/2017 at 11:10 AM, Patient #3 presented to the ED on 1/28/2017 with complaints of sexual assault. There is no record of Patient #3 on the ED log on 1/28/2017.

When asked about patients who had presented to the ED when a SANE nurse was not available, such as Patient #1, SANE RN E stated during an interview on 4/6/2017 at 10:55 AM "it doesn't happen, patients don't present to the ED and not get seen by SANE." Neither RN E nor Director A were able to explain how the facility can confirm that no patients had presented to the ED without being seen by a SANE nurse without including sexual assault patients on the central ED log.

During an interview on 4/6/2017 at 11:20 AM, Emergency Services Director A stated sexual assault patients "are not" on the ED log, "our focus has been protecting patient privacy." Director A confirmed that there is a different registration process for patients presenting with complaints of sexual assault and all records are on paper, not within the electronic health system the ED uses for other patients. Director A stated that the facility was unable to identify patients that had presented to the ED with a presenting complaint of sexual assault because of this process.

Based on record review and interview, the facility failed to ensure patients received a medical screening exam by qualified medical personnel for 3 of 20 patients reviewed (Patient #1, Patient #4, Patient #5).

Findings include:

Facility policy "EMTALA: Medical Screening, Stabilization/Treatment and Transfer for Emergency Medical Conditions" No. 1622878, dated 7/3/2015, states: "G. Medical Screening Examination - The process required to reach with reasonable clinical confidence the point at which it can be determined whether an emergency medical condition exists. The medical screening examination must be the same medical screening examination that the hospital would perform on any patient coming to the hospital's emergency department with those signs and symptoms...Key Point: A triage exam may initiate a Medical Screening Examination but does not constitute a Medical Screening Examination in and of itself. ...I. Qualified Medical Person (for Medical Screening Examination) - Physicians, Physician Assistants, Certified Nurse Midwives, Clinical Psychologists, Nurse Practitioners, Advance Practice Nurse Prescriber, and OB registered nurses can provide a medical screening exam. ...C. Patient Who Come to the Emergency Department: 1. Patients who come to the Emergency Department at the main campus requesting service will receive a medical screening examination by the designated screening qualified medical person."

Patient #1 presented to the ED on 3/29/2017 with a chief compliant of sexual assault. During an interview on 4/6/2017 at 9:20 AM, Patient Access Representative C stated "[Patient #1] came and said [Patient #1] wanted a rape kit done...I told [Patient #1] we didn't have a SANE nurse on staff but [Hospital B] did...I offered directions." C stated the patient left the facility and drove to Hospital B.

During an interview on 4/6/2017 at 9:30 AM, SANE RN E stated that there are different processes for sexual assault patients presenting to the ED depending on whether or not there is a SANE nurse on site and/or available. RN E stated "if a SANE nurse is available to see the patient, the SANE RN performs all the SANE care for the patient." If the SANE nurse is not available, the patients "first have to get screened, have to determine if the patient is safe...then may be transferred or discharged...[to get a SANE exam elsewhere]."

During an interview on 4/6/2017 at 8:30 AM, Emergency Services Director A stated there wasn't a SANE RN working that day [that Patient #1 presented to the ED] and went on to describe the process of how "it's supposed to happen" when a patient presents to the ED when a SANE RN is not onsite: "screen patient, offer plan B and send to an area hospital with a SANE nurse." Director A confirmed Patient #1 did not received screening at the facility prior to being sent to another hospital.

Patient #4 presented to the ED on 4/1/2017 at 2:27 AM with a chief complaint of anxiety. Patient #4's ED records show "Patient visited by [MD] at 2:39 AM. Patient #4 received anti-anxiety medication at 3:18 AM. At 3:29 AM, "Patient came out of room asking to leave...doesn't want to wait for the doctor to discharge..." There is no provider documentation in Patient #3's chart.

Patient #5 presented to the ED on 4/1/2017 at 9:14 PM with complaints of chest pain. Patient #4's ED chart documents "Patient medically screened" on 4/1/2017 at 10:22 PM. There was no documentation of the medical screening exam in Patient #4's chart.

The records of Patient #4 and Patient #5 were reviewed on 4/6/2017 at 12:30 PM. ED Director A stated in an interview at the time of the review "the medical screening exam should be in the chart" if a patient was seen and screened by the provider.