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Based on document review, observation and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to ensure signage was posted conspicuously in places that are noticed by all individuals entering the Emergency Department and the wording was in languages of the population served by the hospital. (A- 2402)

2. The hospital failed to ensure that Pt. #1 was registered in the ED log. (A-2405)

3.The hospital failed to ensure a medical screening examination was conducted to determine if an emergency medical condition existed. (A-2406 A)

4. The hospital failed to provide a medical screening exam, including reassessment of patients while waiting for medical screening by a qualified practitioner, to determine if an emergency medical condition existed. (A-2406 B)

Based on document review, observation, and interview, it was determined that the Hospital failed to ensure signage was posted conspicuously in places that are noticed by all individuals entering the emergency department and the wording was in languages of the population served by the hospital.

Findings included:

1. The Hospital's policy titled, "Emergency Medicine - General Patient Care Triage Policy (Revised 3/2022) was reviewed and did not included any provision regarding posting of EMTALA signage as required.

2. A tour of the emergency department (ED) was conducted with the Director of Nursing (E#11), Nurse Informatics Coordinator (E#10), and the Chief of Clinical, Quality and Patient Safety Officer (E#9) on 2/10/2025 from 10:30 AM - 11:50 AM. An EMTALA signage (in English) was located on the wall by the walk-in entrance to the ED, the signs were approximately 8 by 11 inches and blended in with other signage. No EMTALA signage was posted by the ambulance entrance.

3. During the tour, an interview was conducted with the ED Manager (E#5). E#5 stated that no EMTALA signage is posted by the ambulance entrance.

Based on document review and interview, it was determined that for 1 of 20 patients' (Pt. #1) clinical records reviewed who presented to Hospital A's ED (emergency department), the Hospital failed to ensure that Pt. #1 was registered in the ED log.

Findings include:

1. On 2/10/2025, the hospital's policy titled, " Registration Log - Emergency Department" (2023) was reviewed and included, "Policy: All patients will be registered by the Registrar after she/he has been triaged. All pertinent data will be obtained and entered into the computer where an account number is assigned. 1. The Log, a continuously maintained control register, provides a reference for treatment and disposition of patients presenting to the Emergency Department ..."

2. On 2/10/2025, Hospital A's ED (Transferring Hospital) logs from October 21, 2024, through October 24, 2024, were reviewed. The logs did not indicate that Pt. #1 presented to Hospital A's ED on 10/22/2024.

3. On 2/10/2025, Hospital A's incident report for Pt. #1 was reviewed. The incident report indicated, " ... Event Date: 10/22/2024 ... Time: 6:00 PM ... (Location): Emergency Department ... Entered by: (E #5/ED Manager) ... (Pt. #1) arrived by (Name of Ambulance Company). Per (Ambulance Company) EMS (emergency medical services), (Pt. #1) was discharged from (Hospital B) today. (Pt. #1) was supposed to have O2 (oxygen) delivered. When (Pt. #1) arrived home, there was no supplies... (Ambulance Company) EMS called their dispatch, reported to come to (Hospital A ED). When arrived, per (Hospital A's) ER/emergency room MD (MD #2/ED Attending Physician), not appropriate. (MD #2) asked (E #5) to wait to put the patient on the tracker..."

4. On 2/10/2025 at approximately 11:45 AM, an attempt to review Pt. #1's clinical record at Hospital A with E #13 (Nursing Informatics Coordinator). E #13 stated that Pt. #1 was not entered into the hospital's ED log/ED tracker; therefore, no clinical record was created for Pt. #1.

5. On 2/10/2025 at approximately 1:40 PM, an interview with E #5 (ED Manager) was conducted. E #5 stated, "I wrote the incident report. According to (Name of Ambulance Company) EMS crew, (Pt. #1) was recently discharged from (Hospital B). When they arrived to (Pt. #1's home), the mother refused to accept because there was no oxygen delivered. The crew was running out of oxygen. They called their EMS dispatch, and they were advised to take (Pt. #1) to (Hospital A) for proper care. It was a learning experience for us. We acknowledge that the patient should have been registered into the ED log."

A. Based on document review and interview, it was determined that for 1 of 20 patients' (Pt #1) clinical records reviewed seeking care in the ED ((Emergency Department), Hospital A (Transferring Hospital) failed to ensure a medical screening examination was conducted to determine if an emergency medical condition existed.

Findings include:

1. On 2/10/2025, the hospital's Medical Staff Bylaws and Rules and Regulations (2024) indicated, " ... Department of Emergency Medicine ... Medical Screening: 1. All patients who request care must be medically screened by a physician ... 2. The extent of treatment rendered will be based on the medical screening by the Emergency Department physician on duty ..."

2. On 2/10/2025, the hospital's policy titled, "General Patient Care Triage Policy" (2022) indicated, "Policy: 1. Triage is the screening of patients to determine their relative priority treatment. 2. The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department into Resuscitative (Level 1), Emergency (Level 2), Urgent (Level 3), Semi-urgent (Level 4) or Routine categories (Level 5). 3. All patients who request care must be medically screened by a physician..."

3. On 2/10/2025, Hospital A's incident report for Pt. #1 was reviewed. The incident report indicated, " ... Event Date: 10/22/2024 ... Time: 6:00 PM ... (Location): Emergency Department ... Entered by: (E #5/ED Manager) ... (Pt. #1) arrived by (Name of Ambulance Company). Per (Ambulance Company) EMS/emergency medical services, (Pt. #1) was discharged from (Hospital B) today. (Pt. #1) was supposed to have O2 (oxygen) delivered. ... When arrived, per (Hospital A's) ER/emergency room MD (MD #2/ED Attending Physician), not appropriate..."

4. On 2/10/2025 at approximately 11:45 AM, a review of Pt. #1's clinical record at Hospital A was attempted with E #13 (Nursing Informatics Coordinator). E #13 stated that Pt. #1 was not entered into the hospital's ED log/ED tracker; therefore, no clinical record was created for Pt. #1.

5. On 2/10/2025, the clinical record for Pt. #1 from Hospital B (Receiving Hospital) was reviewed:

- On 10/22/2025 at 6:55 PM, (Name of Ambulance Company) run sheet for Pt. #1 indicated, " ... Incident Location: (Hospital A ED) ... (Blood Pressure) 168/94 (normal is 120/80), Heart Rate 93 (irregular), Respiratory rate 22 (Rapid) ... Confused conversation, but able to answer questions ... Narrative ... (Hospital A ED nurse and MD #2) stopped us from leaving the hospital property and demanded that we take (Pt. #1) back to (Hospital B) because they did not want to accept (Pt. #1). (MD #2) said that it was (Hospital B) and (Name of Ambulance Company's) fault for not properly discharging (Pt. #1) back home ... Per (MD #2), we weren't allowed to leave unless we transported (Pt. #1) back to (Hospital B) ... We went to (Pt. #1's) bedroom to obtain a set of vital signs, (Pt. #1) was already connected on the hospital's vital (signs) machine. Upon observation, (Pt. #1) was agitated and (Pt. #1's) vital signs were high and abnormal ... (MD #2 and the charge nurse) came into (Pt. #1's bedroom) and asked us why we were taking a long time to get the patient onto our stretcher ... We transferred (Pt. #1) onto our stretcher ... Upon arrival to (Hospital B's ED), the staff were expecting us ..."

- On 10/22/2024 at 7:42 PM, the ED nurse's progress note indicated, "(Pt. #1) presents to (Hospital B's) ED via (name of Ambulance Company) from (Hospital A). Per EMS, (Pt. #1) was admitted to (Hospital B) recently with (a diagnosis of) respiratory failure (status post) intubation ... (Pt. #1) normally on 6 (liters of oxygen) since discharge, but no equipment was available at home so (Pt. #1) was brought to closest hospital (Hospital A). (Hospital A) transferred (Pt. #1) to (Hospital B) since (Pt. #1) received care most recently here ... Patient Acuity (2/Need care within 15 minutes) ..."

- On 10/22/2024 at 7:54 PM, the ED physician's progress note indicated, "(Pt. #1) ... recent discharge from this facility earlier today after hospitalization secondary to pneumonia brought in by EMS (emergency medical services) for readmission to the hospital as (Pt. #1) did not have his available medical equipment at home upon discharge today.. Medical Decision Making ... past medical history ... including Trisomy 21 (chromosomal abnormality causing developmental/intellectual delay) ... (Pt. #1) is not able to fully participate in history given (Pt. #1's) baseline mental status... Plan for admission to ... unit for social worker and case management to assist patient in obtaining ... needed home equipment ... Impression and Disposition: Encounter for Social Work Intervention ..."

- On 10/22/2024 at 8:38 PM, Pt. #1 was admitted to the observation unit.

- On 10/23/2024 at 11:29 AM, the physician's discharge summary indicated, " ... Principal Diagnosis: (Acute Hypoxemic Respiratory Failure) ... Brief Hospital Course ... (Pt. #1) presented in acute hypoxemic respiratory failure secondary to severe (obstructive sleep apnea) and not having home (oxygen). (Pt. #1) was admitted for social work to organize home (oxygen) delivery for this patient. Social work was consulted, home oxygen was arranged, and (Pt. #1) was discharged back home with oxygen.

6. On 2/10/2025 at 1:40 PM, an interview with E #5 (ED Manager) was conducted. E #5 stated, "I wrote the incident report. According to (Name of Ambulance Company) EMS crew, (Pt. #1) was recently discharged from (Hospital B). When they arrived to (Pt. #1's home), the mother refused to accept because there was no oxygen delivered. The crew was running out of oxygen. They called their EMS dispatch, and they were advised to take (Pt. #1) to (Hospital A) for proper care. All patients in the ED should be seen by a physician to determine if an emergency medical condition exists. It was a learning experience for us. We acknowledge that the patient should have been registered into the ED log and should have been seen by a physician. There was no documentation to indicate that the patient was triaged and provided a medical screening examination."

7. On 2/11/2025 at approximately 9:12 AM, an interview was conducted with MD #2 (ED Attending Physician). MD #2 stated, "(Pt, #1) was brought to our ED. We did not have an idea what happened at (Hospital B). There was no proper discharge. All patients in the ED should receive medical screening examination. Unfortunately, we do not have documentation that a medical screening examination was provided (for Pt. #1)."

B. Based on document review and interview, it was determined that for 2 of 5 clinical records (Pt. #14 and Pt. #17) reviewed for patients leaving the ED (emergency department) without being seen (LWBS), the Hospital failed to provide a medical screening exam, including reassessment of patients while waiting for medical screening by a qualified practitioner, to determine if an emergency medical condition existed.

Findings include:

1. On 2/10/2025, the hospital's policy titled, "General Patient Care Triage Policy" (2022) indicated, "Policy: 1. Triage is the screening of patients to determine their relative priority treatment. 2. The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department into Resuscitative (Level 1), Emergency (Level 2), Urgent (Level 3), Semi-urgent (Level 4) or Routine categories (Level 5). 3. All patients who request care must be medically screened by a physician..."

2. On 2/13/2025, the hospital's policy titled, "Pain Management" (2021) was reviewed and included, "... Assessment... 2. A pain assessment is done upon arrival to the ED... Pain Management Intervention: 1. Pain relief measures are implemented as needed to maintain patient comfort... 2. Offer non-pharmacologic intervention... 3. Consider the guide below for pharmacologic management of acute pain... Severe pain (7-10) (High dose opioid/type of pain medication, etc... )... Reassessment... The time frame for reassessment is based on type of intervention used. If pain medication is given, the patient will be re-assessed in an hour... If pain intervention is ineffective, other intervention should be taken..."

3. On 2/13/2025, the clinical record for Pt. #14 was reviewed. On 11/21/2024, Pt. #14 came to the ED due to nausea, vomiting, abdominal pain, and dark stool for 2 days. At 10:49 PM, Pt. #14 was triaged with an ESI (Emergency Severity Index) of 3 (needs urgent care). Pt. #14 had a pain rating of 10 (severe abdominal pain). There were no pain intervention or reassessment from 10:49 PM through 1:03 AM (2 hours and 14 minutes). Pt. #14 left the ED at 1:03 AM.

4. On 2/13/2025, the clinical record for Pt. #17 was reviewed. On 11/22/2024, Pt. #17 came to the ED due to right hip pain. At 4:52 AM, Pt. #17 was triaged with an ESI of 5 (needs routine care). Pt. #17 had a pain rating of 9 (severe hip pain). There were no pain intervention or reassessment from 4:52 AM through 8:26 AM (3 hours 34 minutes). Pt. #17 left the ED at 8:26 AM.

5. On 2/13/2025 at approximately 9:30 AM, findings were discussed with E #5 (ED Manager). E #5 stated that there should be documentation of intervention and reassessment of patients' pain while waiting for the medical screening examination by a physician.