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Based observation and interview, it was determined the facility failed to post a sign conspicuously in the emergency department likely to be noticed by all individuals entering the emergency department specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor in two (2) of two (2) of the hospital's emergency departments.

Findings:

Observations were conducted at the facility's Freestanding Emergency Department at 9:30 AM on 10/31/22. The Emergency Department (ED) Clinical Director (staff member # 5) accompanied the surveyors. During observations of the ED it was noted that from the main waiting area there was no visible signage related to the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor and information indicating whether or not the hospital participated in the state Medicaid program. The ambulance bay and emergency medical services(EMS)/stretcher entrance area also had no visible signage related to patient's rights under the Emergency Medical Treatment and Labor Act (EMTALA).

A tour was conducted at the hospital's main Emergency Department 10/31/22 at 10:50 AM with the Senior Emergency Room Director (staff member #4) assisting in the tour. No signage related to patients' rights under EMTALA was present in the ED's ambulance bay or ambulance/stretcher entry into the ED. A sign related to EMTALA rights was noted to be mounted on the wall near the ED's registration desk; however a large free standing sign related to workplace violence was placed directly in front of the EMTALA signage, obscuring the EMTALA sign from view of patients waiting the the waiting area.

Observations were again conducted in the facility's main emergency department on 11/01/22 at 2:00 PM with the Regulatory Consultant (staff member #6) and staff member #4 accompanying the surveyors. The surveyors asked the staff members whether or not there was EMTALA signage visible to patients who arrive via EMS as the surveyors had not seen the signs in this area in this ED or the Freestanding ED. The staff members confirmed there were no signs posted in this entrance area to the hospital. The large free standing sign was again noted to be in front of the EMTALA signage in the registration area, obstructing the view of EMTALA signage from the patient waiting area. The sign was pointed out to staff member #6 who confirmed the free standing sign was obstructing the EMTALA sign. Staff member #6 relocated the freestanding sign to another area of the ED after this observation.

The facility's policy, EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act was reviewed, but contained no information related to posting of EMTALA signs.

Based on observations, interviews, and document review, it was determined the facility failed to maintain an emergency department central log to include all required dispositions to track the care provided to each individual.

The findings include:

On 10/31/2022 at 10:30 a.m., the surveyors conducted the entrance conference at the hospital's main facility and provided Staff Member (SM) 6 with a list of requested items, including the emergency department (ED) log for two (2) months.

On 10/31/2022 around 12:00 p.m., the facility provided an electronic version of the central log dated August 2022 through October 2022. The central log did not contain the patient ' s disposition (whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted, and treated, stabilized and transferred, or discharged). A central log which included the patent ' s disposition was requested.

On 10/31/2022 around 1:00 p.m., the facility provided an electronic version of the central log dated October 2022. There was no disposition included. A central log which included the patent ' s disposition was requested.

During an interview on 10/31/2022 at 1:18 p.m., SM4 stated that ED physicians, nursing and leadership review logs daily and physicians will call patients who left against medical advice (AMA). SM4 stated that SM4 maintains a running Excel spreadsheet that contains only statistics about patients who left without being seen (LWBS) and transfer statistics.

On 10/31/2022 at 1:28 p.m., the surveyors toured the labor and delivery (L&D) unit of the main hospital facility. During the tour of the L&D unit, SM11 provided the surveyors with a paper log of all patient's presenting to L&D, including date, a name sticker, complaint, and disposition. SM11 stated that all patient information is also maintained in the facility's electronic medical record (EMR) system, EPIC.

On 10/31/2022 at 2:00 p.m., the surveyors received a third electronic Excel spreadsheet that contained the patient's ED encounter date, last name and first initial, and included the patient's disposition. The dispositions included labels such as "never arrived", "still a patient", names of various facilities, and some dispositions were left blank. Transfers were not specifically noted on the log and the surveyor was unable to determine which patients were "transfers".

During an interview on 10/31/2022 at 2:50 p.m., SM4 reviewed the third log with the surveyor. SM4 was unsure about the meaning of certain disposition labels and could not determine from the log provided if the label meant that the patient was transferred or admitted to a facility. SM4 stated that this third log did not contain patients from the free-standing ED, as the surveyors had requested during the entrance conference.

At this time, the surveyors again requested a log for all hospital emergency department locations containing the disposition of each patient to include whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted, and treated, stabilized and transferred, or discharged.
On 11/1/2022 at 9:45 a.m., the surveyors were provided with the fourth ED log. This log included dispositions such as "dismiss", "eloped", "left prior to being seen after triage", "left prior to being seen before triage", "left prior to treatment complete", and "transfer". During an interview with SM4 after reviewing the fourth log, SM4 explained that "Dismiss" could possibly mean that the patient was taken off of the patient tracking board, or that the patient never arrived, or that the patient was "seen, treated, and discharged" but never made it back to an ED room. SM4 was unsure how the label "eloped" was differentiated from the "left prior to" labels.

On 11/1/2022 around 2:00 p.m., the surveyors toured the ED with SM4 and SM6. The surveyors asked SM4 if the facility maintained a "triage sign-in sheet" as per the facility's policy. SM4 stated that they did not maintain a triage sign-in sheet or a paper log in the ED.

On 11/1/2022 at 2:46 p.m., SM6 provided the surveyors with the Emergency Medical Treatment and Labor Act (EMTALA) training provided to all staff. The training did not cover the emergency department central log. The surveyor discussed with SM6 the concerns about the ED central log with SM6.

A review of the facility's policy titled "EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act" states in part:
...J. Additional Requirements
1. Central Log. Each [Facility] Dedicated Emergency Department shall maintain a central log (i.e. a triage sign-in sheet) that includes the name of each individual who presents to the Dedicated Emergency Department seeking medical attention. The following information shall also be maintained in the central log:
a. whether the individual refused treatment;
b. whether individual was refused treatment; or
c. whether the individual was:
i. transferred, treated and admitted;
ii. stabilized and transferred; or
iii. discharged...