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Based on observation, interview, and document review, the hospital failed to ensure compliance with requirements at 42 CFR 489.24 as evidenced by the deficient practice cited at 42 CFR 489.24(a) and 489.24(c).

Based on observation, interview, and document review, the hospital failed to post sufficient signage in the emergency department (ED) specifying the rights of individuals under Section 1867 of the Social Security Act with respect to emergency medical treatment and women in labor for individuals that presented to the ED for an examination and treatment.

Findings include:

On 10/25/2016, at 1:15 p.m. during a tour of the ED with the ED Nurse Manager observations revealed the ED consisted of a public entrance with a registration desk facing the entrance, a waiting room to the right of the entrance, and a triage room behind the registration desk behind a secured door. The ED had eight rooms, two of those rooms were trauma bays. The ED garage was not for public use. Directly inside the public entrance to the left and secured to a wall was one sign in English and Spanish specifying the rights of individuals presenting to the ED for examination and women in labor (EMTALA) and one sign in English indicating the hospital's participation in Medicaid. There were no signs at the registration desk, in the waiting room, triage room, or any of the eight ED bays.

On 10/25/2016, at 1:15 p.m. interview with the ED Nurse Manager established there was no additional EMTALA signage in the ED. The waiting area was rarely utilized as patients were usually roomed immediately upon arrival. The majority of patient waiting occurred in the exam rooms.

Review of the hospital's policy and procedure titled Cobra Guidelines with an effective/approval date of 9/24/2013, did not address the posting of EMTALA signage in the ED. On 10/26/2016, at 10:00 a.m. the ED Nurse Manager confirmed the policy titled Cobra Guidelines was the hospital's EMTALA policy and procedure.

Based on documentation review and interview, the hospital failed to ensure that each patient who presented to the emergency department (ED) received an appropriate medical screening examination (MSE) for 1 of 20 (P1) patients reviewed. The hospital's failure to complete a medical screening exam posed an immediate threat to P1's health and safety and had the potential to effect all patients that presented to the ED with an emergency medical condition.

Findings include:

Review of P1's Comprehensive Report (ground ambulance report) dated 10/15/2016, at 1:17 p.m. revealed an advanced life support (ALS) ambulance responded and arrived at P1's home to take over P1's care from first responders. Upon arrival to P1's home, the first responders had placed P1 on oxygen at 15 liters for an oxygen saturation of 60%. According to family present, P1 was very weak and less responsive and had bloody stools for the last week. P1's hands were cool to touch and covered with feces. The ALS paramedic cleaned P1's fingers and was able to established an oxygen saturation of 80%. P1's lung sounds were clear. P1 was placed on an EKG or cardiac monitor that showed tachycardia or rapid heart rate with ST depression a sign of ischemic or shortage of oxygen to the heart muscle. At 1:22 p.m. P1's blood pressure (BP) was 60/30, respirations 14, pulse 106, and an oxygen saturation of 88% on 15 liters of oxygen. P1's Glasgow coma score was 14 on a scale of 1 to 15 with 15 considered fully conscious and alert. At 1:35 p.m. P1's BP was 60/28, pulse of 100, respirations 14, and an oxygen saturation of 88%. P1 was less responsive with a Glasgow coma score of 10. At 1:38 p.m. the ALS ambulance was in route with P1 to the nearest medical facilty (hospital #1). After multiple attempts made by the paramedic (PM)-C, intravenous (IV) access was established. At 1:40 p.m. PM-C made two unsuccessful attempts to insert a naso-pharyngeal airway to assist P1 with breathing. P1 was provided ventilation with an ambu bag, positive pressure, and oxygen. At 1:40 p.m. PM-C provided P1 with two types of inhaler medications without an improvement in his respiratory status. At 1:42 p.m., P1's BP was 110/44, pulse 102, respirations 14, oxygen saturation of 89%, with the Glasgow coma scale score of 10. At 1:50 p.m., P1's BP was 98/54, pulse 104, respirations 12, oxygen saturation of 74%, with a Glasgow coma scale score of 9. P1 was less responsive with minimal verbal responses. At 1:57 p.m., P1's BP was 86/48, pulse 100, respirations 14, oxygen saturation of 89% with a Glasgow coma score of 9. During P1's transport to the hospital which was approximately 25 minutes from P1's home, hospital staff requested the ambulance divert to another hospital which was an additional 45 minutes from the first hospital. Despite the hospital's request for the ALS ambulance to divert, PM-C requested assistance by the ED staff to stabilize P1. When the ALS ambulance arrived with P1, the hospital's ED physician (MD)-A told the crew that the helicopter ambulance crew currently in the hospital's ED would take over P1's care. MD-A left the ED trauma bay and gave over P1's care to the helicopter ambulance crew (a RN and paramedic) and RN-B an ED staff nurse.

Review of the hospital's ED log revealed P1 presented to the ED at 2:03 p.m. with a diagnoses of not otherwise specified and disposition listed as hospital #2.

Review of P1's ED medical record dated 10/15/2016, at 2:03 p.m. revealed the only documentation was a hospital's flow sheet titled Critical Care Flowsheet documented by RN-B. At 2:03 the documentation stated P1 arrived in the hospital's ambulance garage via ALS ambulance. The ambulance crew requested assistance from the hospital with intubation or placing a tube into P1 lungs to assist with breathing. At 2:10 p.m., a RN crew from the helicopter air ambulance inserted an intraosseous (I/O) infusion or access placed directly into P1's bone marrow. At 2:23 p.m. and 2:25 p.m. IV anesthesia and a paralytic were given by RN-B and at 2:27 p.m. the air crew intubated P1. At 2:28 p.m. P1's BP was 67/29, pulse 92, with breath sounds present bilateral. At 2:30 p.m., P1's BP was 117/95 with a pulse of 90. At 2:39 p.m., P1 was transferred to the helicopter for air transport to another hospital. An EKG strip in the medical record indicated P1 was in sinus rhythm or normal rhythm with possible ischemia of the heart. There was no documentation that MD-A completed a medical screening examination (MSE) for P1.

Review of the air ambulance Prehospital Care Report Summary dated 10/15/2016, at 2:03 p.m. revealed P1's Glasgow Coma score was 8 with decreased responsiveness. At 2:28 p.m. IV fluids through the I/0 were set for 1000 cc per hour or at a wide-open rate due to P1's hypotension or low BP. Prior to leaving the ED, at 2:35 p.m., P1's BP was 44/26, pulse 105, respirations 6 on a ventilator. At 2:39 p.m. P1's BP was 51/34, pulse 108, respirations of 5 on the ventilator, and an oxygen saturation of 100%. Vital signs at 2:45 p.m. were a BP of 45/33, pulse of 107, ventilator respirations of 10, and an oxygen saturation of 100%. At 2:47 p.m. the air crew gave P1 another dose of anesthesia and at 2:50 p.m. gave a dose of norepinephrine or medication to increase P1's BP. An IV infusion of norepinehrine was started at 3:00 p.m. According to the air crews documentation, MD-A listened to P1's lungs, obtained a patient history from the ALS ambulance crew, and advised the air ambulance crew to intubate P1. Following P1's intubation, lung sounds were equal bilateral without epigastric or stomach sounds meaning the intubation tube was in a proper location to ventilate P1's lungs. No chest X-ray to confirm the tube placement was taken in the ED. During the air transport, P1 required an increase in the norephinephrine drip rate due to P1's continued hypotension. The helicopter left the hospital at 2:45 p.m. and arrived at the receiving hospital at 3:01 p.m.

Review of P1's ED medical record from the receiving hospital (hospital #2) dated 10/15/2016, at 3:13 p.m. revealed P1 arrived by air ambulance in acute respiratory failure and shock. P1's initial labs revealed a hemoglobin (Hgb) of 5 and P1 required blood transfusions. P1's EKG revealed ST depressions and an elevated troponin level or protein released by a damaged heart muscle likely due to lack of oxygen from the low Hgb. P1 was taken to surgery and diagnosed with a perforated duodenal ulcer. Medications to reduce the amount of stomach acid were given. After discussion with P1's family, P1 was provided comfort care. On 10/16/2016, at 7:30 p.m. P1 was extubated or staff removed the intubation tube and placed P1 on 2 liters of oxygen through a nasal cannula. Staff provided P1 with pain medications discontinued all IV medications and drips. On 10/16/2016, at 3:35 a.m. P1 died at the receiving hospital.

Interview with RN-B on 10/25/2016, at 2:35 p.m. revealed she was working in the ED when P1 arrived on 10/15/2016. Immediately prior to P1 being brought into the ED by the ALS ambulance crew, RN-B requested the crew divert to another hospital. The ED was full with eight patients and six patients in the waiting room. In addition, another patient in the ED was in cardiac arrest and an air ambulance had been contacted to transport that patient. The patient died and the air ambulance crew was in the ED when the ALS crew arrived with P1. MD-A requested the air ambulance crew take over the care of P1. RN-B stayed in the trauma bay to assist the air ambulance crew. RN-B said MD-A did not examine P1.

Interview with MD-A on 10/26/2016, at 12:46 p.m. revealed P1 arrived in the ED accompanied by the ALS ambulance crew requesting a place to intubate P1. The air ambulance crew had just arrived at the hospital to transport another patient who had died. MD-A said the air ambulance crew agreed to take over the care for P1 in the ED. MD-A listened to P1's heart and lungs but did not document the interaction. MD-A had no further contact with P1 indicating he did not want to delay P1's transport to a higher level of care. MD-A said he thought the ALS ambulance had contacted the receiving hospital. MD-A did not contact the receiving hospital with a physician-to-physician report or to determine whether the hospital had the capability and capacity to treat P1.

Interview with paramedic (PM)-C on 10/27/2016, at 12:00 p.m. established she transported P1 from his home to the ED. The ambulance went to the hospital despite being told by the hospital to divert. P1 respirations were becoming more shallow and ineffective and P1 was less responsive. PM-A said MD-A met the ambulance crew in the ED garage where they were told the air ambulance crew would take over P1's care. PM-C saw MD-A listen to P1's lungs and leave the trauma room.

Review of the Documentation of Death certificate dated 10/16/2016, revealed P1's immediate cause of death was due to severe hemorrhagic and septic shock as a result of a perforated duodenal ulcer. The underlying cause resulting in death was acute upper gastrointestinal bleed and acute renal failure.

Review of the hospital's policy and procedure titled COBRA Guidelines with an effective/approval date of 9/24/2013, stated, all patients would receive a medical screening examination (MSE) that included providing all necessary testing and on-call services within the capacity of the hospital to reach a diagnosis. If a patient required transferring due to medical necessity, a physician certification that the risks of transfer outweigh the potential benefits must be documented and maintained in the patient's record. The receiving hospital must give acceptance in advance and that must be documented. The medical screening examination must include at a minimum the patient's triage, vital signs, history, physical examination of affected systems, exam of known chronic conditions, necessary testing to rule out an emergency medical condition, notification of on-call personnel to assist as necessary, vital signs upon transfer or discharge, and completed documentation of the MSE.