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Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure signage pertaining to the Emergency Medical Treatment and Active Labor Act (EMTALA) and corresponding patient rights' was posted in all areas likely to be notice by patients entering the Emergency Department (ED) or waiting for treatment. This had potential to affect all patients presenting to the ED seeking care and treatment.

Findings include:

On 12/10/19, at 1:41 p.m. the ED was toured with the director of in-patient nursing (RN)-A. The ED utilized one main entrance and the space immediately inside the entrance contained a single registration desk which shared space immediately adjacent to a waiting room filled with several chairs and visitors. On the wall next to the registration desk, and visible to people sitting inside the waiting area, two white colored signs were posted on the wall which outlined a patient's rights pertaining to EMTALA. Next to this posted signage, a badge-accessed doorway to the physical ED was present. Inside, the ED consisted of two (2) triage rooms, two (2) trauma bays, four (4) treatment rooms, four (4) observation rooms, and three (3) examination rooms. Examination Room #8 and Trauma Bay #2 were inspected with RN-A present. Both of the rooms lacked any signage or information pertaining to a patient's right under EMTALA. RN-A stated all of the examination rooms and trauma bays were "the exact same," and lacked signage. The single ambulance garage entrance was then observed including the hallway connecting the garage to the physical ED. The garage and connecting hallway both lacked any displayed signage or information pertaining to a patient's rights regarding EMTALA. RN-A verified the lack of signage posted inside the physical ED.

During the tour, RN-A explained while the ED used one main entrance, labor and delivery (L&D) patients who presented were sent to different areas of the hospital for triage and treatment based on how far along they were in their pregnancy. All patients over 20 weeks were sent directly to the L&D department and not sent to the physical ED which had just been toured. RN-A and the surveyor toured the L&D department which consisted of a total four (4) rooms. Neither the rooms or hallways connecting the rooms displayed any signage or information pertaining to a patient's rights contained under EMTALA. RN-A verified the lack of posted signage.

When interviewed immediately following the completed tour, RN-A stated she thought the ED Manager had discussed hanging more signage in the ED, however, RN-A was not sure where in the process this was at.

On 12/10/19, at 1:54 p.m. the patient access representative (PAR)-A was interviewed at the front registration desk. PAR-A stated when a patient presented to the ED through the main entrance, they would first come to the registration desk. PAR-A stated they provide each patient with a booklet of rights and provided these booklets for review. The book outlined a patient's Federal and State rights, however, lacked any language or information on EMTALA or a patient's right under the act.

When interviewed on 12/10/19, at 1:57 p.m. ED registered nurse (RN)-B stated the nursing staff typically did not give patients any information on EMTALA. Further, RN-B stated she did not believe any additional signage pertaining to EMTALA and a patient's rights therein were posted anywhere in the ED besides next to the main reception desk.

On 12/11/19, at 8:04 a.m. the ED Manager (RN)-C was interviewed. RN-C explained the hospital had just recently re-located the displayed signage next to the reception desk from inside the locked ED doors so it would be more visible. RN-C and the surveyor toured the ambulance garage and attached spaces. RN-C verified it lacked any posted signage pertaining to EMTALA. RN-C stated there had been signage displayed, however, it must have been taken down at some point. Further, RN-C acknowledged some additional EMTALA signage needed to be displayed in the ED, including the ambulance garage.

A hospital policy on EMTALA signage was not provided.

Based on interview and document review, the critical access hospital (CAH) failed to ensure reasonable steps were taken to ensure patients who had declined care were apprised of the risks associated and obtain, or attempt to obtain, a signed refusal demonstrating such from 2 of 2 patients (P4, P12) reviewed who had left the Emergency Department (ED) without being seen.

Findings include:

A hospital provided Leaving Against Medical Advice (AMA) - Enterprise policy, dated 5/2017, identified a procedure to be used when a patient left AMA. The policy outlined a patient wanting to leave AMA would be counseled on the current plan of care along with the benefits and risks of leaving AMA, and then a signed copy of a Leaving AMA form would be placed in the patient's medical record. If the patient refused to sign the Leaving AMA form, the policy directed, " ... the provider and/or nursing staff will document this in the patient's medical record." Further, the policy identified, "If a patient simply leaves without notifying the health care provider or nursing staff, reasonable efforts should be made to contact the patient to discuss recommended care. Those efforts should be documented in the patient's medical record."

A hospital provided, blank copy of a Leaving AMA form was reviewed and outlined the patient would be told the risks of refusing care and treatment and released Sanford and it's staff of responsibility which may result from leaving AMA. The form required the patient's name, the patient's signature, the date and the time to be completed. Further, the form provided three statements which required a checkmark or symbol be placed next to in order to identify other actions taken with the form including:

1) "Patient/Legal Representative Refused to Sign Form,"

2) "Patient Left Without Being Seen by a Doctor," and,

3) "Patient Left Without Being Assessed by a Doctor."

P4's Patient Care Timeline dated 8/19/19, identified P4 presented to the ED on 8/19/19, with a chief complaint of dental pain which had worsened since for several hours prior to her presenting at the ED. P4 rated her pain a 9 our of 10 and described the pain in her mouth as, "Sharp." P4 was placed in an ED room at 8:48 p.m., however, a subsequent note timed 9:25 p.m. identified, "Patient no longer in room, LWBS."

P4's medical record was reviewed and lacked any evidence or dictation demonstrating what reasonable attempts or steps had been taken to contact P4 after she had left the ED without being seen to explain the risks of leaving without being seen. Further, the record lacked any evidence a Leaving AMA form had been completed, nor any documentation it had been attempted to be completed during or after P4's admission to the ED.

P12's ED Arrival Information identified P12 presented to the ED on 8/24/19, at 7:21 p.m. for a chief complaint of, "Jaw Pain." A single progress note was entered into P12's medical record which read, "Went to get [P12] to bring him back to the room and he bolted out of the building."

P12's medical record was reviewed and lacked any evidence or dictation demonstrating what reasonable attempts or steps had been taken to contact P12 after they had left the ED without being seen to explain the risks of leaving without being seen. Further, the record lacked any evidence a Leaving AMA form had been completed, nor any documentation it had been attempted to be completed during or after P12's admission to the ED.

On 12/11/19, at 8:48 a.m. P4 and P12's medical record(s) were reviewed with the operations supervisor (OS)-A and ED Manager (RN)-C. P4 had left without being seen, and RN-C verified a Leaving AMA form had not been completed, nor did the medical record reflect what steps, if any, had been taken to contact P4 to discuss the risks of not being seen. RN-C stated a Leaving AMA form should have been completed and scanned into the medical record. P12 had presented to the ED and then "bolted out" when staff went to go get him from the waiting area. OS-A and RN-C verified a Leaving AMA form had not been completed, nor did the medical record reflect what steps, if any, had been taken to contact P12 to discuss the risks of not being seen. RN-C stated she expected a Leaving AMA form be completed for P12 despite him never being roomed in the ED.