HospitalInspections.org

Based on document review, observation, and interview, it was determined that for 1 of 1 Emergency Department (ED) and 1 of 1 ED waiting area, the Hospital failed to post signage, related to the rights of the individual with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA), and whether the Hospital participates in the Medicaid program, conspicuously in a place likely to be noticed by all individuals entering the ED, as well as those individuals waiting for treatment, as required.

Findings include:

1. The Hospital's policy titled, "EMTALA Guidelines" (revised 3/2019), was reviewed on 12/1/2021 and included, "...meet [Hospital's name] obligation under the Emergency Medical Treatment and Active Labor Act (EMTALA) (Sections 1866 and 1867 of the Social Security Act 42 U.S.C. & 1395dd)." The policy did not include any specifics related to posting signage regarding rights of patients under EMTALA.

2. The Hospital's Medical Staff Bylaws (revised 8/24/2021) were reviewed on 12/1/2021 and did not include the requirement for posting signage regarding rights of patients under EMTALA.

3. An observational tour of the Emergency Department (ED) was conducted on 11/30/2021, at approximately 9:57 AM. The entrance/waiting room/admitting area did have not have a sign posted related to the rights of the individual with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA), or whether the Hospital participates in the Medicaid program. Upon entering the ED, an EMTALA sign was noted to be posted on a column; however, the signage was not completely visible as it was being covered by a refrigerator with a box of supplies on top of it. The only words that could be read on the English language sign were, "It's the Law! If you have a medical emergency or an in labor you have the right to receive within the capabilities of this hospital's staff and facilities: An appropriate medical." The sign did not indicate whether the Hospital did or did not accept Medicaid. During a second tour of the ED on 12/1/2021, at approximately 8:00 AM, the sign was still covered by the refrigerator and box of supplies.

4. An interview was conducted with the Nursing Supervisor (E#3) and the Quality Coordinator (E#6) during the tour of the ED on 11/30/2021, at approximately 10:57 AM. E#3 stated that this was the only sign for EMTALA and signage should be posted where visible in the ED.

5. During an interview on 12/1/2021, at approximately 11:47 AM, the Quality Coordinator (E#6) stated that there were no other policies for posting signage regarding rights of patients under EMTALA , and this requirement was not included in the EMTALA policy or the Bylaws.

Based on document review and interview, it was determined that for 20 individuals who presented to the ED from 6/17/2021-11/21/2021, the Hospital failed to ensure that the Emergency Department (ED) centralized log was maintained to include the disposition of each individual who presented to the ED.

Findings include:

1. The Hospital's policy titled, "EMTALA Guidelines" (revised 3/2019), was reviewed on 12/1/2021 and included, "...meet [Hospital's name] obligation under the Emergency Medical Treatment and Active Labor Act (EMTALA) (Sections 1866 and 1867 of the Social Security Act 42 U.S.C. & 1395dd)." The policy did not include any specifics related to maintaining an ED centralized log.

2. The Hospital's Medical Staff Bylaws (revised 8/24/2021) were reviewed on 12/1/2021 and did not include the requirement related to maintaining an ED centralized log under EMTALA.

3. The Hospital's ED centralized logs, from 6/17/2021-11/3/2021 and 11/21/2021, were reviewed on 11/30/2021 and lacked documentation of the patient's disposition on the following dates:
- 6/17/2021: 1 of 10 patients
- 6/30/2021: 1 of 8 patients
- 7/11/2021: 1 of 5 patients
- 7/13/2021: 1 of 15 patients
- 7/19/2021: 1 of 9 patients
- 8/7/2021: 1 of 9 patients
- 8/26/2021: 1 of 8 patients
- 8/30/2021: 1 of 10 patients
- 9/9/2021: 1 of 10 patients
- 9/11/2021: 1 of 9 patients
- 9/17/2021: 1 of 11 patients
- 9/20/2021: 2 of 18 patients
- 9/24/2021: 1 of 6 patients
- 9/29/2021: 4 of 13 patients
- 10/8/2021: 1 of 11 patients
- 10/14/2021: 1 of 9 patients

4. An interview was conducted with Nursing Supervisor (E#3) on 12/1/2021, at approximately 11:00 AM. E#3 stated that completion of the ED logs are the responsibility of the ED nurses and/or supervisors. E#3 stated that the expectation is that each section of the log is completed, which includes the patient's disposition (if patient was admitted, discharged, or transferred). E #3 stated that the requirement for the ED log under EMTALA was not included in the Hospital's EMTALA policy or Bylaws.

5. During an interview on 12/1/2021, at approximately 11:47 AM, the Quality Coordinator (E#6) stated that there were no other policies regarding EMTALA regulations for the ED log, and this requirement was not included in the EMTALA policy or the Bylaws.