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Based on a review of medical records, policy and procedures, observations, and staff interviews, it was determined that the facility failed to ensure that EMTALA signage was posted in the emergency department in places likely to be noticed by all individuals that entered to seek services. Further, the facility failed to ensure that medical records, including radiologic images, were transferred with the patient to the receiving facility in a timely manner.

Findings:

Cross refer to A 2402, as it relates to the facility's failure to post EMTALA signage.

Cross refer to A 2409, as it relates to the facility's failure to ensure an appropriate transfer of P#1 to a receiving medical facility.

Based on review of policy and procedures, observations and staff interviews, it was determined that the facility failed to ensure that EMTALA signage was posted in a conspicuous location in the ambulance entrance.
Specifically, during a facility tour on 6/30/25 at 10:15 a.m. EMTALA signage was not observed at the entrance of the facility's ambulance bay.

Findings:

A review of facility policy titled, "EMTALA Policy" effective 7/30/24 revealed that EMTALA signage was to be posted was referred to as the facility's requirement to post signs conspicuously in the ED in a place or places likely to be noticed by all individuals that entered the ED as well as those individuals waiting for examination and treatment in areas other than the ED located on facility property that informed individuals of their rights under Federal law with respect to examination and treatment for emergency medical conditions EMSs and women in labor.

A tour of the emergency department (ED) was conducted with Chief Executive Officer (CEO) AA, Director of Women's Health (DWH) BB, and Emergency Department Manager (EDM) CC on 6/30/25 at 10:15 a.m. EMTALA signage was absent outside and inside the ED ambulance bay.

An interview was conducted with EDM CC on 7/1/25 at 11:56 a.m. in a conference room. EDM CC stated that she had been the ED manager for the last three years. She agreed that she did not see signage posted at the ambulance bay at the time of the tour on 6/30/25 at 10:15 a.m.

Based on medical record review, staff interviews, and facility policies and procedures, it was determined that the facility failed to ensure that required documentation was transferred with P#1 to the receiving facility on 5/31/25. Specifically, P#1's Consent to Transfer Form failed to show that P#1's medical records and radiologic images were sent to the receiving medical facility in a timely manner.

Findings:

P#1's medical record at transferring facility (Facility A) revealed that Section III Transport Information on P#1's EMTALA Transfer Certificate failed to acknowledge who the report was given to at the receiving facility, the name of the transporter, and whether medical records and imaging were sent with transport to receiving facility B, the receiving medical facility.

A review of P#1's medical record at the receiving facility (Facility B) revealed P#1 arrived at facility B's ED on 5/31/25 at 5:08 a.m. Page 14 of P#1's medical record revealed P#1 received an appropriate MSE, but no image disc was provided from facility A.

A review of facility policy titled, "EMTALA Policy", no number, effective 7/30/24 revealed that an appropriate transfer was defined as one that occurred when (iii) the transferring facility sent to the receiving facility all medical records (or copies) related to the emergency medical condition (EMC) of the patient, available at the time of transfer, including records related to the EMC, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone results of the studies, and informed written consent for transfer or certification, and that any other records that were not readily available at the time of transfer were sent as soon as practicable after the transfer.

An interview was conducted with EDM CC on 7/1/25 at 11:56 a.m. in a conference room. EDM CC stated a transfer form was completed on every patient prior to their transfer to another facility. She said the expectation was for medical records and necessary images to be sent with the patient or that the images be sent electronically if the receiving facility also had Powershare (the facility's means of electronic transfer). She said her facility utilized Powershare (means of electronic transfer), which was a means to electronically send and receive radiologic images from facilities. She said the transporting activity should be documented onto the Consent to Transfer form and input into the patient's electronic medical record. She further stated that the radiology department was responsible for pushing requested images out to the transport receiving facility.