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Based on observation, interview, and policy review, the hospital failed to post the required signage for patients entering the Emergency Department (ED) from the ambulance entrance. This failure precluded patients and/or their representatives from having the information regarding their right to have an examination and treatment for medical conditions, including women in labor, and if the hospital participated in the State Medicaid program.

Findings:

During a tour of the ED on 9/18/18 at 1:19 p.m., no postings for patients rights examination, treatment, or Medicaid participation were observed at the exterior of the ambulance entrance, in the ambulance bay, or in the adjacent hallways.

In a 9/19/18, 10:30 a.m. interview with the Risk Manager (RM), Interim Director of the ED (DED), and Charge Nurse 2 (CN 2), they all acknowledged and agreed there was only one sign posted in the ED at the triage, registration, and waiting room area. The RM, DED, and CN 2 acknowledged patients or patient representatives coming into the ED via the ambulance entrance would not see this posting.

The hospital policy, "Transfer of Individual With or Without Emergency Medical Condition", effective 2/8/16, established under Procedures, "1. Signage: Signs are conspicuously posted in the lobbies, waiting rooms, admitting areas and treatment rooms where examination and treatment occurs... the signs specify the rights of individuals to examination and treatment for emergency medical conditions and indication... a. STCH [Sutter Tracy Community Hospital] participates in the MediCal program. Signs shall be posted in the following areas: ED..."

Based on interview and record review, the hospital failed to provide a Medical Screening Examination (MSE) for 1 of 22 sampled patients (Patient 1) when Patient 1 presented to the Emergency Department (ED) by ambulance. This failure resulted in Patient 1 not being screened to determine if an emergent medical condition existed and had the potential to cause serious harm if not treated or stabilized.

Findings:

According to the "Documented Report", provided by the County Sheriff's Department, an officer was dispatched to a home on 7/2/18 at 2026 [8:26 p.m.] regarding a suspicious female. The report indicated the, "female arrived to the front door, knocked and let herself in. After walking inside the residence, she was not making sense and 'passed out' in the middle of the living room." The document indicated the reporting party did not know her. The report continues, "I [Officer] found the above mentioned white female lying on the floor in the middle of the living room... I was able to determine this was [Patient 1] due to past experiences and encounters with law enforcement. I knew from past encounters that [Patient 1] suffers from mental health issues and also suffers from substance abuse."

A 7/2/18 "Patient Care Report" written by the Emergency Medical Services (EMS) ambulance crew included, "Pt (Patient 1) knocked on front door of a home requesting entry into said home. Family did not recognize Pt and called 911. [Law enforcement agency] advised Pt appears to be under the influence... transport to local ER (Emergency Room) for medical evaluation and clearance..." The report continued upon the arrival to the hospital, "Pt demographics given to ER registration and Pt [received] a wrist band ... Pt... became verbally aggressive towards staff, calling staff vulgar names... Pt proceeded to yell at staff and advised that she would kick [staff name] in the face. After statement was made, ER charge RN [name- Charge Nurse 1 (CN 1)] advised that they are calling the police on Pt and that they are 'not accepting Pt as she threatened my staff and we have a zero violence/threat policy'... Pt escorted outside of the facility and outside of ER doors..."

The report indicated city police responded to the hospital and Patient 1 would not be accepted at county jail and needs to be medically cleared first.

The report revealed the EMS ambulance crew, "advised VRECC [Valley Regional Emergency Communications Center] of the delay at [hospital]... and base contact is being made to receive a base order to transport Pt to [second hospital ER]... Departed [hospital] at 21:48 (9:48 p.m.)."

A review of the "Event Log" in the hospital electronic medical record of Patient 1 included the following:

"21:14 (9:14 p.m.) Patient arrived in ED"

"21:14 (9:14 p.m.) Arrival Complaint ETOH [alcohol]"

"ED Notes Addendum", written by Charge Nurse 1 (CN 1), "Patient brought in by ambulance in 4 point restraints [both arms and both legs being tied down] for ETOH intoxication. Per EMS [Emergency Medical Service] no other medical complaint. ED staff approached patient take her to room and patient became verbally abusive. Patient attempted to kick staff member in the face and started shouting out threats of harm to ED staff. Patient was kicking and screaming and would not allow ED staff to talk to her or assess her. Patient looked at ED tech and states in a loud voice, 'I'm going to kill you, [obscenities]'. At that point, I clarified with the medic that patient does not have any other medical complaints. Medic clarified ..."

In an interview on 9/19/18 at 8:30 a.m. with CN 1, he stated the medics that transported Patient 1 by ambulance had communicated with the ED prior to arrival. Upon arrival to the ambulance bay and adjacent hallway, Patient 1 was in 4 point restraints as applied by EMS crew. Patient 1 was described as combatively kicking and screaming. CN 1 stated he and ED Tech 2 were attempting to calm Patient 1 and she continued to threaten and attempted hit ED Tech 2. CN 1 said, "We have a zero tolerance policy for violence toward staff." CN 1 confirmed the city Police Department was called. The patient was taken out of the ED to the outside of the building with EMS crew, CN 1, and ED Tech 1 to await city police department arrival. CN 1 stated Patient 1 was not triaged and added she was not "accepted" or "admitted".

CN 1 stated, "A physician never saw the patient." When asked if CN 1 thought Patient 1 was a threat to herself or others he stated, "I think at that moment, she was definitely a threat to my staff, may have been the alcohol, not sure about a threat to self." When asked what responsibility the hospital had in regards to EMTALA regulations, CN 1 stated, a "MSE [Medical Screening Exam] for every patient that arrives... that was the step we missed." When asked if EMS crew or law enforcement can make the decision to remove a patient from the ED, CN 1 stated, "The MD [Medical Doctor] makes the decision."

During a concurrent electronic record review and interview with Charge Nurse 2 (CN 2), CN 2 was able to locate Patient 1 on the ED log. Patient 1's arrival time was documented as 9:14 p.m. and the chief complaint was, "ETOH [alcohol]. No ED provider or physician was listed. The disposition was listed as "Discharge" at 2200 [10:00 p.m.]

In an interview on 8/22/18 at 12:05 p.m., with the Quality and Safety Director (QSD) and the Chief Nurse Executive (CNE), the CNE stated Patient 1 was "probably a danger to self or others" after reviewing the note as written by CN 1 on 7/2/18.

The QSD stated there was no note from the physician and confirmed Patient 1 was not seen by a physician. The QSD confirmed there was not any other documentation in Patient 1's medical record for the encounter on 7/2/18.

The facility policy, "Transfer of Individual With or Without Emergency Medical Condition (EMTALA)", last revised 2/8/16, directed to following:

"Sutter Tracy Community Hospital will identify available resources, including on-call physicians, to provide ongoing evaluation and stabilizing treatment as required by law. The hospital may not transfer the patient for care that is within the scope of its services, privileges of the medical staff and facility."

The policy directs, for Medical Screening Exam (MSE), "must be provided to any individual who presents and requests an exam for a medical condition...", and, "Based on the individual's appearance or behavior a "prudent layperson" observer would believe that the individual needs examination or treatment for a medical condition."

The policy defined a Medical Screening Exam as, "the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist. The hands-on, patient clinical assessment is required of every EMTALA encounter to identify or rule out the existence of an emergency medical condition.

The policy defined an Emergency Medical Condition as, "A medical condition manifesting itself by acute symptoms of sufficient severity (including... psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in... placing the health of an individual... in serious jeopardy...", and, "Psychiatric emergency medical condition is a mental disorder manifested by acute systems of sufficient severity that render that patient as being... an immediate danger to himself or herself or others..."

The policy stipulated, "An initial MSE is to be done by the emergency department physician, physician assistant or other qualified physicians on duty who the facility deems qualified to provide an MSE", and, "Individuals who present with a psychiatric emergency will be provided an MSE by the ED physician."

A review of the Medical Staff Bylaws, revised in March 2017, established, "Patients presenting to the Emergency Department must be triaged and have a medical screening exam by and [sic] Emergency Department physician/attending physician to rule out an emergency medical condition..."