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The hospital failed to comply with the provisions of 42CFR489.24 when it failed to provide a medical screening examination within its licensed capability and capacity for one patient, Patient 8, who presented to the hospital's ED by ambulance, with a request to be seen by a physician.
Cross reference A 2406 and A 2411.

Based on observation and interview, the hospital failed to conspicuously post signage in the ED waiting rooms and treatment rooms and in the L&D (Labor and Delivery) waiting room and registration area. This could result in patients being unaware of their rights for examination in the event of an emergency medical condition.

Findings:

1. On 11/9/11, at 1330 hours, the hospital's ED was toured with the ED Director. The Director stated the ED had three waiting rooms. The initial waiting room, Waiting Room One was the initial entry point for all non-ambulance patients arriving at the ED. Immediately to the left of Waiting Room One a screening nurse was stationed. To the right, a security officer was stationed. Past the screening nurse, also on the left, were the patient registration area and the entrance to triage. To the right there were seats for patients and visitors. No signage specifying the rights of individuals for examination and treatment with respect to emergency medical conditions and women in labor in the ED was visible in Waiting Area One.

On the wall of the hallway leading to Waiting Rooms Two and Three the required emergency treatment signage was observed. The print font of the sign, according to the Director, was sufficient in size. However, it was difficult to read if a person was more than one foot away.

At 1345 hours, an interview was conducted with the parents of Patient 9, an ED pediatric patient waiting to be seen. When questioned about signs they had seen stating their child's rights to receive emergency treatment, both parents stated they had not noticed the signs.

During a tour of the treatment areas of the ED no conspicuous posting of signage was observed in locations 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.


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2. The L&D area was toured with the L&D Nurse Manager and the Director of Regulatory on 11/9/11 at 1340 hours. The Nurse Manager stated if a patient who was more than 20 weeks pregnant presented to the ED with problems related to the pregnancy the patient would be brought to the L&D unit for examination and observation.

Observation of the small waiting area outside of the patient registration room as well as the inside of the patient registration room did not show signage specifying the rights of individuals for examination and treatment with respect to emergency medical conditions and women in labor and notice the hospital participated in the Medicaid program.

The required signage was found located inside of a room the Nurse Manager stated was used to triage the pregnant patients waiting for an examination.

Based on interviews, document review and a tour of the ED, the hospital failed to maintain a complete on-call list of physicians in order to provide necessary treatment to stabilize individuals with an emergency medical condition. This could potentially lead to a delay in the stabilizing treatment of patients with an emergency medical condition.

Findings:

During a tour of the ED on 11/9/11 at 1410 hours, the on-call list of specialty physicians was requested for review. Review of the on-call list dated 11/9/11, posted on the desk of the ED Unit Secretary, did not show the contact phone number for the urology physician.

On 11/10/11, review the on-call list of specialty physicians dated 11/10/11, showed "Associated" instead of the name of the physician designated as the urology specialist.


On 11/10/11 at 1440 hours, an interview was conducted with the ED Unit Secretary. The Unit Secretary was asked to state the meaning of "Associated" as found on the on-call list of specialty physicians dated 11/10/11. The Unit Secretary stated "Associated" was a urology physician's group. The Unit Secretary stated he would call the phone number listed and one of the three physicians in the Associated group would call back.

The Unit Secretary was then asked how he would contact the urology physician on-call for 11/9/11, without the phone number. The ED Unit Secretary stated he would look the number up in the MD phone book on the computer system. After checking the MD phone book on the computer, the Unit Secretary stated he was unable to locate the physician's contact number. The Unit Secretary stated he would then consult the Directory of Specialists booklet to locate the phone number; however, after checking the booklet, the Unit Secretary stated he was unable to locate the physician's phone number. The Unit Secretary stated the urology physician listed as on-call for 11/9/11, might be a brand new physician. In that case, the Unit Secretary stated he would have to call the medical staffing office for the physician's number.

Based on interview and document review, the hospital failed to ensure one of 22 sampled patients who presented to the ED seeking medical assistance was entered into the ED log (Patient 8).

Findings:

On 11/9/11 review of the EMTALA complaint and interviews with ED staff confimed Basic Life Support (BLS) EMT personnel brought Patient 8 to the ED by ambulance on 12/17/10. The EMT personnel had been directed to the nearest hospital for confirmation of Patient 8's death by medical personnel as the EMS personnel are not allowed by law to pronounce a patient's death. Upon arrival at the hospital the EMS personnel were requested not to unload the patient from the ambulance, as the ED staff stated there were no available beds. There was no documentation to show the patient was entered in the ED log.

The ED Nurse Manager was interviewed on 11/10/11 at 1410 hours. Review of the ED log dated 12/17/10, did not show documentation of the arrival of the ambulance with Patient 8 and the request for medical assistance. The Nurse Manager confirmed she was unable to locate any additional documentation regarding the circumstances of the event.

Based on interview and document review, the hospital failed to ensure a medical screening examination (MSE) was provided to one of 22 sampled patients in order to confirm the death of the patient (Patient 8). Basic Life Support (BLS) EMT personnel brought the patient to the ED by ambulance on 12/17/10. The EMT personnel had notified the hospital the patient, who had a DNR (Do Not Resuscitate) order, had passed away while en route from Hospital 1, located in a neighboring county, to a skilled nursing facility in Orange County. The EMT personnel had been directed to the nearest hospital for confirmation of the death by medical personnel as the EMS personnel are not allowed by law to pronounce a patient's death.

Upon arrival at the hospital the EMS personnel were requested not to unload the patient from the ambulance, as the ED staff stated there were no available beds. There was no documentation to show the patient was given a medical screening examination. This resulted in the ambulance, after waiting outside of the ED for one hour, returning the patient to Hospital 1, 49 miles away for confirmation of the patient's death.

Cross reference A 2411.