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Based on document review and interview, the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to post the rights of individuals on signage in a place to be seen by all individuals entering the Emergency Department (ED). See deficiency A-2402.

2. The Hospital failed to ensure that the 'Bylaws of the Medical and Dental Staff of Ann and Robert H. Lurie Children's Hospital of Chicago' included the person qualified to perform a medical screening exam. See deficiency at A-2406.

3. The Hospital failed to ensure appropriate registration process was followed to prevent potential delay in the examination process. See deficiency A-2408.

Based on observation and interview, it was determined that the Hospital failed to post signage of Patients' rights in places likely to be seen by all individuals entering the Emergency Department (ED).

Findings include:

1. An observational tour of the ED was conducted on 11/8/17 at 10:00 AM. The entrance to the ED, the registration area and waiting room were examined for the rights of individuals signage; however, was not found. When asked where the signage was, the Director of the ED (E#2) walked around the area and was not able to find the signage. Upon entering one of the triage area doors, the signage was noted to be on the wall.

2. During an interview on 11/8/17 at approximately 10:20 AM, the ED manager (E#3) stated, "there are many ways to enter the triage areas and the main ED. Not all patients go this way and will not pass this sign."

Based on document review and interview, it was determined that the Hospital failed to ensure the 'Bylaws of the Medical and Dental Staff of Ann and Robert H. Lurie Children's Hospital of Chicago' included the person qualified to perform a medical screening exam.

Findings include:

1. On 11/8/17 at approximately 3:30 PM, the 'Bylaws of the Medical and Dental Staff of Ann and Robert H. Lurie Children's Hospital of Chicago' (approved 8/13) was reviewed. The Bylaws failed to include who had been deemed qualified to perform medical screening exams in the Emergency Department.

2. On 11/8/17, at approximately 3:40 PM, findings were discussed with E #10 (Senior Director of Accreditation). E #10 stated that the Hospital has the person allowed to perform medical screening exam in a policy.

3. On 11/9/17 at approximately 11:30 AM, findings were discussed with E # 11 (Director of Accreditation). E #11 said, "I did not see it in the Bylaws."

Based on document review and interview, it was determined for 2 of 7 (Pt. #1 and Pt. #3) clinical records reviewed of patients seen in the Emergency Department from October, 2017 through November 9, 2017, the Hospital failed to ensure appropriate registration process was followed to prevent potential delay in treatment and potential discouragement of patients from remaining for treatment.

Findings include:

1. On 11/8/17 at approximately 11:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was an 11 year old female who came to the ED on 10/07/17 with complaints of fever and syncopal episode. The clinical record indicated that registration was completed at 11:35 AM. However, a physician did not sign in as a provider until 12:10 PM on 10/7/17.

2. On 11/8/17 at approximately 12:00 PM, Pt. #1's billing records for service dates 10/7/17 to 10/15/17 were reviewed. The records indicated that a payment of $250 was made on 10/7/17. Details of the $250 payment indicated that the transaction occurred on 10/7/17 at 11:35 AM as "copayment from mom."

3. On 11/8/17 at approximately 1:55 PM, an interview was conducted with E #5 (Patient Relations Representative). E #5 stated that Pt. #1's mother felt that she (Pt. #1's mother) had been required to pay the copay in order for her daughter to be seen.

4.On 11/8/17 at approximately 2:20 PM, an interview was conducted with E #7 (Patient Registration Liaison/Pt. #1's Registration Staff on 10/7/17). E #7 stated, "When a patient is being discharged, that is when you ask for a co pay." When shown Pt. #1's clinical record and the time of registration, E #7 said that, "It was a mistake ... the registration was done before patient was seen by the doctor." E #7 could not remember having a conversation with Pt. #1's mom that she must pay before her daughter could be seen in the ED.

5. On 11/8/17 at approximately 12:30 PM, a telephone and in-person interviews were conducted with MD #1 (ED Medical Director). MD #1 stated, "As soon as the LIP (licensed independent practitioner) signs up on a patient, the MSE (medical screening) starts... Once we have started the history and physical and made a plan, that's when we flip the sign (color-coded signage) so that staff can do the registration."

6. On 11/8/17 at approximately 12:03 PM, an interview was conducted with E #1 (Emergency Department Registered Nurse). When asked regarding ED training, E #1 said, "It was very comprehensive ... Hospital's policy and procedure, EMTALA, ED workflow ... There was also an online training module." Regarding ED workflow, E #1 said, "When patients enter the door, there's a quick registration (e.g. last name, date of birth, and address will be asked) ... patients will then be triaged afterwards. After triage, patients will be assigned a room, and a nurse and a provider (MD). E #1 stated that presently, as of November 1, 2017, providers use color-coded signage (red means not ready, green means ready for registration). Even after the institution of a new process, Pt. #3's registration was completed before being seen by a physician.

7. On 11/9/17 at approximately 9:30 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was an 11 year old male who came to the ED on 11/7/17 with a complaint of fever. The clinical record indicated that the registration was completed at 4:40 PM. However, Pt. #3 was not seen by physician until 5:24 PM.

8. On 11/8/17 at approximately 2:55 PM, an interview was conducted with E #9 (Manager of ED Registration). E #9 said, "... (E #7) asked for the copayment prior to the patient going into the ED room." E #9 stated that the registration process should be done after the patient has been seen by the physician.