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Based on interviews and a review of selected documents provided by the hospital, the hospital failed to comply with the provisions of 42CFR489.2 when it failed to adopt and enforce a policy to ensure compliance with 42CFR489.24 (EMTALA) regulations. This could lead to violations of 42CFR489.24.

Findings:

An onsite visit was made to the hospital on 7/27/10 and 7/28/10. An interview was conducted with the Medical Director at 1130 hours on 7/27/10. When requested a policy titled "Interfacility Transfer of Patients; Medical Screening of Patients" dated 6/2003 was produced. However, the hospital was unable to produce a policy and procedure that had adopted the requirements of 489.24 and the related requirements of 489.20. The Medical Director agreed that a formal policy for the requirements of the EMTALA regulations had not been adopted.

Based on observation and interview during a tour of the hospital, the hospital failed to post signage that was conspicuously displayed, informing patients with respect to examination and treatment of emergency medical conditions and women in labor in the waiting area of the ED, as well as in treatment areas. The hospital failed to post conspicuous signage in the waiting and treatment areas of the ED informing patients whether the hospital participates in the Medicaid program. This could lead to patients being unaware of their rights for examination in the event of an emergency medical condition.

Findings:

During an onsite visit to the hospital conducted on 7/27/10 at 0900 hours, a visit was made to the various locations within the ED. The waiting area contained a small sign informing patients of their rights. However, the sign was largely obscured by a security guard and security stand, posted directly in front of the signage. This sign contained no information indicating whether the hospital participated in the Medicaid program. The Quality Advisor for the hospital and the Patient Safety Officer were present on the tour. Both stated they were unaware of the requirement for signage as noted in the EMTALA regulations. A tour of the treatment areas of the emergency department revealed no conspicuous posting of signage, in a location likely to be noted by patients, informing them of their right to a medical screening examination regardless of the ability to pay and whether the hospital participated in the Medicaid program.

Based on interviews, document review and a tour of the ED, the hospital failed to maintain an on-call list of physicians to provide necessary treatment after the initial examination to stabilize individuals with an emergency medical condition. This could lead to a delay in the stabilizing treatment of patients seeking treatment for an emergency medical condition.
Findings:

1. During a tour of the ED conducted at 0905 hours on 7/28/10, an on-call list was requested. Examination of the on-call list revealed that "Ortho PA" (Physician Assistant) was listed on the on-call list for Tuesday 7/27/10. When interviewed, PCT G stated the "Orthopedic Surgeons who were on-call frequently sent the PA down to the emergency department to provide a consultation for the Orthopedic Surgeon."

An interview was conducted with the Medical Director of the ED at 0905 hours. Present during the interview were three surveyors from the California Department of Public Health as well as the Quality Advisor for the hospital and the Patient Safety Officer. The Medical Director stated that he was unaware that a PA was not permitted to perform a consultation in the ED, in place of the summoned back up specialist physician.

When reviewed, the "Rules and Regulations of 10/21/09" stated "medical screening examinations in the ESD (emergency services department) will be conducted by physicians." Nursing and hospital staff seemed unaware of the rules and regulations of the medical staff. When interviewed, at 0905 hours on 7/27/10 the Medical Director was unaware that, in the State of California, a physician, must respond to the ED physician's request for back up specialty coverage for a patient requiring further stabilizing treatment or consultation.

2. The on-call list of specialty physicians, dated 7/27/10, was comprised of physician groups instead of individual physicians for cardiology, pediatric neurosurgery, pediatric GI (gastroenterology), and ENT (ears, nose and throat).

Based on a review of 34 medical records, the hospital failed to ensure the provision of a medical screening examination by qualified individuals as defined in the medical staff rules and regulations for 2 of 34 sampled patients (Patients 13 and 17) presenting to the hospital for the evaluation of an emergency medical condition. This could lead to an incorrect determination if an emergency medical condition existed.

Findings:

1. Patient 13 came to the emergency department of the hospital on 1/2/10 with a complaint of head trauma. The physical examination for Patient 13, was performed by PA S (Physician Assistant).

According to the medical staff rules and regulations of 10/21/09 provided by the hospital, "Medical screening examinations in the ESD (emergency services department) will be conducted by physicians." The provision of a medical screening examination by a physician assistant was in violation of the medical staff rules and regulations.

2. Patient 17 came to the ED of the hospital at approximately 1958 hours on 1/1/10 with a complaint of pain and deformity of the left elbow. The medical screening examination was performed by PA D, in violation of the medical staff rules and regulations of 10/21/09.