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Based on observations made during Hospital tours conducted on 7/9/13 and 7/10/13, it was determined that signage specifying the individual's right to have an examination and treatment for an emergency medical condition and information related to the Hospital's participation in the Medicaid Program (EMTALA signage) was not conspicuously posted in the Emergency Department (ED) Waiting Room or anywhere in the Labor and Delivery (L&D) Area.

Findings include:

A tour of the ED conducted at 9:00 A.M. on 7/9/13. During the tour, the Surveyor observed there was no EMTALA signage anywhere in the very large Waiting Room. The Surveyor interviewed the Director of Emergency Services during the Tour. The Director of Emergency Services said the (new) ED was opened on 12/19/12 and the posting of EMTALA signage in the Waiting Room was overlooked.

The Surveyor interviewed the Clinical Manager of L&D during a tour of the L&D Unit conducted at 1:30 P.M. on 7/10/13. The Clinical Manager said obstetric patients present to the L&D Antenatal Testing Area for labor evaluations and to L&D for labor (an emergency medical condition). During the tour, the Surveyor observed there was no EMTALA signage anywhere in the L&D Area.

Based on interviews and review of the Emergency Department (ED) Log and documentation related to 31 patients presenting to the Hospital's ED during the time period of 4/4/13-7/1/13, the Surveyor determined that the Hospital failed to provide a medical screening examination (MSE) to 1 of the 31 patients (Patient #31 on 6/24/13).

Findings include:

A written Complaint, dated 6/28/13, indicated Patient #31, an 89 year old nursing home resident, fell while visiting at a family member's home on the evening of 6/24/13. The written Complaint indicated family members transported Patient #31 to the Hospital's ED, assisted him/her to a wheelchair and wheeled him/her into the ED.

The 6/24/13 ED Log indicated Patient #31 presented to the ED at 8:06 P.M. following a fall.

The 6/28/13 written Complaint indicated Patient #31 was screaming, crying and gripping the top of his/her leg. The written Complaint indicated the ED was very busy and Family Member #1 asked the Registrar if he/she should take Patient #31 back to his/her nursing home and call an ambulance. The written Complaint indicated the Registrar told Family Member #1 she would talk with the nurse. The written Complaint indicated that approximately 30 minutes after talking with the Registrar, Family Member #1 returned to the Registrar, told her Patient #31 was in extreme pain, and asked if Patient #31 could be taken into the ED.

The Surveyor interviewed ED Registrar #2 at 3:10 P.M. on 7/10/13. ED Registrar #2 said the ED was extremely busy on the evening of 6/24/13 and Family Member #1 was very upset because Patient #31 was in pain and had to wait for an ED evaluation. ED Registrar #2 said Family Member #1 asked if he/she should take Patient #31 back to the nursing home and call an ambulance. ED Registrar #2 said she advised Family Member #1 to remain in the ED Waiting Room.

The Surveyor interviewed Triage Nurse #1 at 2:50 P.M. on 7/9/13. Triage Nurse #1 said the ED was extremely busy on the evening of 6/24/13. Triage Nurse #1 said she was attending to a patient with chest pain when Registrar #2 told her Patient #31 was brought to the ED following a fall and Family Member #1 wanted Patient #31 to go into the ED right away. Triage Nurse #1 said she could not leave the patient with chest pain and instructed the Registrar to call Charge Nurse #1. Triage Nurse #1 did not know if the Registrar called Charge Nurse #1. Triage Nurse #1 said she had already asked Charge Nurse #1 for help in Triage and Charge Nurse #1 said he did not have an extra nurse.

The 6/28/13 written Complaint indicated the Registrar spoke with a nurse and the nurse said the ED was very busy, some of the people in the Waiting Room had been waiting for 4 or 5 hours, and Patient #31 would have to wait. The written Complaint indicated Family Member #1 said Patient #31 was in too much pain to wait and asked if it was possible for Patient #31 to be directed to another hospital. The written Complaint indicated the nurse suggested that Family Member #1 take Patient #31 to the ED at Hospital B (another Hospital System campus) because there were only 4 people waiting for an ED evaluation at Hospital B.

Triage Nurse #1 told the Surveyor she did not speak with Family Member #1 or Patient #31 and never suggested that they go to the Hospital B ED. Triage Nurse #1 said she could often see the Hospital B ED census on her computer screen, but not always, and she could not recall seeing it on the evening of 6/24/13.

The Surveyor interviewed ED Technician #1 at 3:20 PM on 7/9/13. ED Technician #1 said Patient #31 was moaning in pain and Family Member #1 was upset that Patient #31 had to wait for an ED evaluation. ED Technician #1 said ED Registrar #2 mentioned that there were only 6 patients in the ED Waiting Room at Hospital B and Family Member #1 asked if he/she should bring Patient #31 to Hospital B or take him/her back to the nursing home and call an ambulance. ED Technician #1 said she told Family Member #1 it was a bad idea to move Patient #31 around more than necessary and that they should not leave the ED. ED Technician #1 said Family Member #1 remained upset and Patient #31 continued to moan in pain.

Registrar #2 said she could not see the Hospital B ED census on her computer screen and she did not tell Family Member #1 anything about Hospital B. Registrar #2 said she thought Family Member #1 telephoned Patient #31's nursing home and nursing home staff told him/her to bring Patient #31 back to the nursing home. Registrar #2 said she spoke with a nurse (she could not recall which nurse or if the nurse was male or female) and the nurse said it was alright for Patient #31 to leave the ED.

ED Technician #1 said a few minutes after she told Family Member #1 that he/she and Patient #31 should not leave, Family Member #1 threw the ED patient pager on the registration desk and said they were leaving. ED Technician #1 said she advised Family Member #1 not to leave, but Family Member #1 said they were leaving and wheeled Patient #31 out of the ED. ED Technician #1 said Family Member #1 and Patient #31 left abruptly and there was no time to get the Triage or Charge Nurse to intervene.

The 6/28/13 written Complaint indicated no one in the ED offered to assist Family Member #1 transport Patient #31. The written Complaint indicated Patient #31's family had a very difficult time getting him/her into their vehicle because of the pain. The written Complaint indicated the Family transported Patient #31 back to the nursing home where an ambulance was called to transport him/her to the Hospital B ED.

Triage Nurse #1 said that when she was ready to triage Patient #31, Registrar #2 said Patient #31 and his/her family left and ED Technician #1 said the Family took Patient #31 back to the nursing home. Triage Nurse #1 said that if she knew Family Member #1 and Patient #31 were contemplating leaving the ED, she would have spoken to them and recommended that they stay. Triage Nurse #1 said she never saw Patient #31.

The 6/24/13 ED Log indicated Patient #31 left the ED prior to transfer at 8:55 P.M.

The Surveyor interviewed Charge Nurse #1 at 1:05 P.M. on 7/10/13. Charge Nurse #1 said the ED was very, very busy on the evening of 6/24/13. Charge Nurse #1 said he could not recall Triage Nurse #1 asking for help, but said he did not have any staff to help her. Charge Nurse #1 said he did not take steps to initiate a Code Capacity (an internal code in which a multidisciplinary team assists in the flow of patients within the Hospital) because ED staff are no longer allowed to call for a Code Capacity.

A Hospital B Triage Note, dated 6/24/13, indicated Patient #31 arrived in the ED at 10:12 P.M. with 8/10 pain in his/her left leg.

Hospital B Physician Documentation, dated 6/24/13, indicated Patient #31 was medicated for pain. Hospital B Physician Documentation indicated x-rays did not reveal a fracture and Patient #31 was discharged back to the nursing home with prescriptions for pain medication and a muscle relaxant.

A Nursing Home Consultation Form, dated 6/27/13, indicated Patient #31 had continued pain and was eventually diagnosed with a non-displaced left hip fracture.