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Based on observation, medical record review, facility records and policy review, and staff interviews the facility failed to ensure the facility kept their EMTALA (Emergency Treatment and Labor Act) policies current and failed to ensure staff followed EMTALA policies. 1 of 20 sampled patients (Patient 10) failed to have stabilizing treatment provided after being assessed by staff and having a cardiac/respiratory arrest. The facility also failed to have signage to ensure patients were notified of their rights under EMTALA. Findings are:

A. Record review of untimed narrative Nursing Notes (NN) by Licensed Practical Nurse (LPN)-A, dated 5/12/09, documents the death of Patient 10, a visitor. Patient 10 was staying with her spouse who was a Hospice patient in the hospital. LPN-A's notes describe the following: At 6:30 AM on 5/13/09 the Nurse Aides requested the LPN's assistance in waking Patient 10. Patient 10 was in bed with the spouse. The LPN shook the patient by the arm and was unable to arouse her. Patient 10 was noted to be lying on her stomach beside the husband with her face turned slightly to the side. The LPN documented Patient 10 had regular respirations. LPN-A noted Registered Nurse (RN)-B and RN-C were notified of the situation. At 6:45 AM the patient's daughter arrives and is updated on the situation concerning her mother. After going into the room the daughter comes out and asks for help. LPN-A, RN-B, LPN Certified (LPNC)-D, and Respiratory Therapist (RT)-E all entered the room. LPN-A documented Patient 10 was "rolled to her back, is found to be warm to the touch. [Name of RN B] checks for pulse and listenes [sic] for breath sounds, initially a weak, thready pulse is felt." RN-B asked someone to get Physician Assistant (PA)-F who was in the building. The daughter enters the room and states "She is a full code." LPN-A notes PA-F "assesses [name of Patient 10] for pulse and breath sounds, which were unable to asculate (sic) and no pulse was felt, pupils were fixed and dilated." LPN-A then documented PA-F states "There is no point in initiating CPR, she's gone."

Progress Notes by PA-F dated 5/13/09 noted that the patient was found unresponsive by the daughter. PA-F noted "she was still warm, but she was not breathing and she had no peripheral pulses." PA-F documented "The physical examination showed no palpable pulse, no respiratory breathing, and the patient was cyanotic. She had no evidence of any spontaneous movement. Her eyes did not respond and no CPR [Cardiopulmonary Resuscitation] was initiated."

B. Staff interview with LPN-A on 6/3/10 at 9:30 AM stated that about 1:00 AM on 5/13/09 Patient 10's daughter brought pills in at Patient 10's request. LPN-A stated it "was not unusual to have trouble waking [name of Patient 10] up in the morning." LPN-A stated that Patient 10's daughter came out of the room after about 2 minutes. LPN-A recalled the daughter was holding empty pill bottles stating "Will someone please help me, I think my mom has overdosed, I cannot wake her up." LPN-A recalled the RN-B stating the patient had a weak thready pulse. LPN-A related that when the PA came in the room Patient 10 "was in full arrest by appearance." She also stated that her daughter "told us she was a full code when everyone was in the room including [Name of PA F]."

C. Interview with MD-G on 6/2/10 at 11:00 AM confirmed the patient did not have any stabilizing treatment provided. MD-G stated that "if find someone unconscious, expectation is to assess and initiate CPR." MD-G stated she recommended a code should have been called at the onset.

D. Record review of facility policy titled "ER [Emergency Room] General ER Policies, Rules & Regulations" written 5/00 with last revision 6/07 states "First aid measures and or ACLS [Advanced Cardiac Life Support] may be carried out by the registered nurse before the physician or PA's arrival, if necessary to preserve a patient's life." The policy also states "All patients will receive treatment for survival unless the patient has an advanced directive related to their religious preference and/or personal preference." Record review of facility policy titled "Emergency Examination and Transfer Policy" written 5/96 with last revision date of 4/00 includes a definition of "Emergency Medical Condition". The policy defines an Emergency Medical Condition (EMC) as "A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and or symptoms of substance abuse) such that absence of immediate medical condition (sic) could reasonably be expected to result in: "1. Placing the health of the individual in serious jeopardy." Patient 10, who was assessed by an RN as having a weak thready pulse and unconscious, would meet the definition of having an EMC. The same policy states that "If the individual has an emergency medical condition, further medical examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the emergency medical condition." Personnel file review of RN-B and PA-F confirmed they were certified in CPR and ACLS yet did not make any attempt to resuscitate/stabilize Patient 10 who had an EMC.

E. Interview with the Director of Nursing (DON) 6/2/10 at 10:45 AM revealed the DON had reviewed Patient 10's death and found "a lot of slippy slop things that were not appropriate. CPR should have been started by RN-B who assessed the patient." The DON stated that "CPR should have been done - pt has an Emergency Medical Condition - daughter confirms the pt is a code - No CPR - PA-F comes in, also no CPR."

The DON related that she started in January 2010 reviewing policies and procedures including the CPR policy, emergency treatment policies and medical staff policies. The DON related she still has a huge job reviewing policies and procedures. The DON stated the "policies lacked review yearly, some were outdated with inappropriate recommendations." The CPR policy did not follow American Heart Association standards. The Emergency evaluation policy was last reviewed 4/00. The DON stated that at the time of Patient 10's death the Emergency treatment policy referred to patients who present and seek emergency treatment and definitions of an EMC. The DON related the policy does not include visitors to our facility and need emergency treatment. The DON confirmed the policy had not been revised at this point. She revised the CPR policy effective 5/10 and reported most, but not all, staff have reviewed and signed receipt of the new policy. The DON "confirmed the facility is still in progress of addressing concerns found related to this case."

F. Observations with tour of the Emergency Department (ED) on 6/3/10 at 1 :00 PM revealed a lack of signage related to EMTALA at the entrance to the ED or the waiting area. The only sign in the department was located on the wall behind patients as they entered the doors of the ED.

Observations with tour of the Obstetric Labor and Delivery area on 6/3/10 at 1:20 PM revealed a lack of signage related to EMTALA. Interview with the ED Manager, Registered Nurse (RN)-H, during tour confirmed pregnant patients greater than 28 weeks are taken to this area for their Medical Screening Examination and treatment.

Record review of the facility policy titled "Emergency Examination and Treatment" written 5/96 and last updated 4/00 stated "Signs shall be posted conspicuously in the Emergency Department and in all areas where individuals present for treatment specifying the rights of individuals under Social Security Act 1867 with respect to examination and treatment for emergency medical conditions."

The facility failed to have conspicuous signs in the Emergency Department area and Obstetric Labor and Delivery areas notifying patients of their EMTALA (Emergency Medical Treatment and Labor) rights. Findings are:

A. Observations with tour of the Emergency Department (ED) on 6/3/10 at 1 :00 PM revealed a lack of signage related to EMTALA at the entrance to the ED or the waiting area. The only sign in the department was located on the wall behind patients as they entered the doors of the ED.

B. Observations with tour of the Obstetric Labor and Delivery area revealed a lack of signage related to EMTALA. Interview with the ED Manager and Registered Nurse (RN)-H, during tour confirmed pregnant patients greater than 28 weeks are taken to this area for their Medical Screening Examination and treatment.

C. Record review of the facility policy titled "Emergency Examination and Treatment" written 5/96 and last updated 4/00 stated "Signs shall be posted conspicuously in the Emergency Department and in all areas where individuals present for treatment specifying the rights of individuals under Social Security Act 1867 with respect to examination and treatment for emergency medical conditions."

Based on facility record review, staff interview and review of policies and procedures, the facility failed to ensure 1 of 20 sampled patients (Patient 10) received stabilizing treatment for an Emergency Medical Condition. Findings are:

A. Record review of untimed narrative Nursing Notes (NN) by Licensed Practical Nurse (LPN)-A, dated 5/12/09, documents the death of Patient 10, a visitor. Patient 10 was staying with her spouse who was a Hospice patient in the hospital. LPN-A's notes describe the following: At 6:30 AM on 5/13/09 the Nurse Aides requested the LPN's assistance in waking Patient 10. Patient 10 was in bed with the spouse. The LPN shook the patient by the arm and was unable to arouse her. Patient 10 was noted to be lying on her stomach beside the husband with her face turned slightly to the side. The LPN documented Patient 10 had regular respirations. LPN-A noted Registered Nurse (RN)-B and RN-C were notified of the situation. At 6:45 AM the patient's daughter arrives and is updated on the situation concerning her mother. After going into the room the daughter comes out and asks for help. LPN-A, RN-B, LPN Certified (LPNC)-D, and Respiratory Therapist (RT)-E all entered the room. LPN-A documented Patient 10 was "rolled to her back, is found to be warm to the touch. [Name of RN-B] checks for pulse and listens [sic] for breath sounds, initially a weak, thready pulse is felt." RN-B asked someone to get Physician Assistant (PA)-F who was in the building. The daughter enters the room and states "She is a full code." LPN-A notes PA-F "assesses [name of Patient 10] for pulse and breath sounds, which were unable to asculate (sic) and no pulse was felt, pupils were fixed and dilated." LPN-A then documented PA-F states "There is no point in initiating CPR, she's gone."

Progress Notes by PA-F dated 5/13/09 noted that the patient was found unresponsive by the daughter. PA-F noted "she was still warm but she was not breathing and she had no peripheral pulses." PA-F documented "The physical examination showed no palpable pulse, no respiratory breathing, and the patient was cyanotic. She had no evidence of any spontaneous movement. Her eyes did not respond and no CPR [Cardiopulmonary Resuscitation] was initiated."

B. Staff interview with LPN-A on 6/3/10 at 9:30 AM stated that about 1:00 AM on 5/13/09 Patient 10's daughter brought pills in at Patient 10's request. LPN-A stated it "was not unusual to have trouble waking [name of Patient 10] up in the morning." LPN-A stated that Patient 10's daughter came out of the room after about 2 minutes. LPN-A recalled the daughter was holding empty pill bottles stating "Will someone please help me, I think my mom has overdosed, I cannot wake her up." LPN-A recalled RN-B stating the patient had a weak thready pulse. LPN-A related that when the PA came in the room Patient 10 "was in full arrest by appearance." She also stated that her daughter "told us she was a full code when everyone was in the room including [Name of PA F]."

C. Interview with PA-F on 6/2/10 at 5:20 PM revealed Patient 10 was not one of his patients nor was her husband. PA-F stated he"knew she had myelodysplasia syndrome." Myelodysplasia syndrome is a blood disorder related to abnormal cell development in the bone marrow. He related he had seen Patient 10 in the Emergency Department (ED) for treatment of a laceration in the past. PA-F works in the hospital medical clinic practice which included Patient 10's physician. PA-F stated his assessment of the patient was a Medical Screening Examination. He related that he made the decision not to do CPR. He related that no one mentioned to him the possibility of an overdose causing the cardiopulmonary arrest.

D. Facility Record review of Physician Peer Review by Medical Doctor (MD)-G dated 5/21/10 states "At the point where nursing identified a weak, thready pulse with limited respirations a code should have been called. By the time [Name of PA-F] arrived no pulse or respirations present - code could have been called at this time as well." A "code" is a term used to identify use of a resuscitation techniques to support airway, breathing and cardiac function as well as providing rescue medications to revive the patient. In response to a question on the "Mortality Review" form used for the peer review which stated "In retrospect, was the death inevitable and not preventable?" MD-G responded by checking "No".

E. Interview with MD-G on 6/2/10 at 11:00 AM confirmed the patient did not have any stabilizing treatment provided. MD-G stated that "if find someone unconscious, expectation is to assess and initiate CPR." MD-G stated she recommended a code should have been called at the onset.

F. Record review of facility policy titled "ER General ER Policies, Rules & Regulations" written 5/00 with last revision 6/07 states "First aid measures and or ACLS [Advanced Cardiac Life Support] may be carried out by the registered nurse before the physician or PA's arrival, if necessary to preserve a patient's life." The policy also states "All patients will receive treatment for survival unless the patient has an advance directive related to their religious preference and/or personal preference."

Record review of facility policy titled "Emergency Examination and Transfer Policy" written 5/96 with last revision date of 4/00 includes a definition of "Emergency Medical Condition". The policy defines an Emergency Medical Condition (EMC) as "A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and or symptoms of substance abuse) such that absence of immediate medical condition (sic) could reasonably be expected to result in: 1. Placing the health of the individual in serious jeopardy." Patient 10, who was assessed by an RN as having a weak thready pulse and unconscious, would meet the definition of having an EMC. The same policy states that "If the individual has an emergency medical condition, further medical examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the emergency medical condition." Personnel file review of RN-B and PA-F confirmed they were certified in CPR and ACLS, yet did not make any attempt to resuscitate/stabilize Patient 10 who had an EMC.