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Based on observations, interviews, and document review, it was determined the facility failed to ensure that EMTALA-related signage was conspicuously posted and made reasonably available in all entrances and treatment areas of the Emergency Department.

The findings include:

On 10/16/23 at 1:22 pm, the surveyor conducted tour of the Emergency Department (ED) with the assistance of Staff Member #1 and Staff Member #4. During tour, the surveyor met with Staff Member #5 (Director of the ED) and received notification by Staff Member #4 that the facility had one (1) sole ED which comprised of two (2) triage rooms, three (3) "fast track" treatment areas, and sixteen (16) treatment beds.

The surveyor identified three (3) unique entrances in which a patient could reasonably present to the ED which included the main ED lobby/waiting area for walk-in patients, the EMS ambulance entrance, and from the hallway leading from the main hospital entrance.

During tour, the surveyor observed only one (1) instance of EMTALA-related signage which was located in the ED lobby/waiting area for "walk-in" ED patients.

Additionally, despite the signage being large in size, the signage was not clearly viewable and for conspicuous viewing as the signage was posted in the far back corner of the ED lobby area. The surveyor was unable to make out the signage from both the seating area of the ED lobby and ED "walk-in" entrance.

The surveyor toured the EMS ambulance entrance, main ED treatment area and hallway, and main hospital entrance and found no instance of any other EMTALA-related signage [i.e., The right to be screened for the presence of an emergency medical conditional, to include women in active labor, and to receive stabilizing treatment or appropriate transfer, when applicable].

The surveyor interviewed Staff Member #1, Staff Member #4, and Staff Member #5 during tour whether any other EMTALA-related signage was available besides the one present in the corner of the ED waiting area. Following verification by the staff, the surveyor received confirmation by Staff Member #1 that no additional EMTALA-related signage was present within the ED, to include the areas of the main ED treatment rooms, ED hallways, "fast track" treatment areas, and two (2) triage rooms.

In the afternoon of 10/17/23, the surveyor was provided the facility policy titled, "Medical Screening and Transfer EMTALA Policy" (with last review date of 02/28/23) by Staff Member #3.

Under "Administrative Requirements" section of page twelve (12), the policy states, in part, "B. Signage. The Hospital must post signs in the ED and other appropriate locations. The signs must state the rights of individuals under EMTALA and whether the Hospital participates in the Medicaid program".

The surveyor disseminated the survey findings with Staff Member #2 (Chief Nursing Officer), Staff Member #3 (Director of Accreditation and Licensure), Staff Member #4 (CEO), and Staff Member #16 (Vice President of Emergency Services) during exit conference on 10/17/23 at 6:15 pm.