. Based on observation and interview the facility failed to ensure posting of the Emergency Medical Treatment and Active Labor Act (EMTALA) signage in areas were individuals seeking or waiting for medical care and services would likely notice. Specifically, no EMTALA signage was posted in patient treatment areas, waiting room/area; or the north entrance. Findings: Observation on 5/21/18 between 2:15 pm - 3:30 pm in the Emergency Department revealed 2 separate entrances to the Emergency Department. The north entrance serves both walk-in patients and ambulance patients. The south entrance was located adjacent to the main hospital entrance waiting room and is for walk-in patients. The required EMTALA was not present in the waiting room off the main entrance; the walk-in/ambulance entrance; or any of the patient care area rooms. One EMTALA sign was present upon entry to the Emergency Department from the south entrance, located off the main entrance waiting room. During an interview on 5/21/18 at 3:30 pm the Emergency Department Director confirmed the findings. .

. Based on record review and interview the facility failed to ensure: 1) patients (#s 1; 2; and 3) who presented to the Obstetrics Department were provided a medical screening exam by a qualified provider to determine if the individual or fetus had an emergency medical condition. Specifically, the facility failed to delineate in the Medical Staff Bylaws who was qualified by the medical staff to perform an emergency medical exam and the bylaws did not define an emergency medical screening exam. Findings: Record review on 5/21-23/18 revealed Patient #1 (MDS) dated [DATE] at 1:34 am with contractions every 6-7 min since 7:00 pm. A "labor/antepartum" exam was documented by the OB RN. The OB MD on call was notified, exam finding along with the NST/toco strip were provided via telephone and verbal discharge instruction were provided. No face to face medical screening exam was completed by a Physician. Record review on 5/21-23/18 revealed Patient #2 (MDS) dated [DATE] at 2:02 pm with concerns of decrease fetal movement. No documentation was provided of the nursing "labor/antepartum" exam or a NST/toco exam. The patient was discharged at 2:04 pm after notifying the Certified Nurse Midwife on call. Record review on 5/21-23/18 revealed Patient #3 (MDS) dated [DATE] at 11:51 pm for an antepartum evaluation after being seen in the Emergency Department with an insignificant labial tear. The RN performed the labor/antepartum exam, notified the OB MD on-call and verbal discharge instructions were provided. No face to face OB Physician medical screen exam was completed. During an interview on 5/23/18 the OB Nurse Manager confirmed the patients #1, 2, and 3, did not have a face to face exam with the Obstetric Physician. During an interview on 5/23/18 at 8:15 am the Chief of Staff/Obstetric Director stated OB patients are registered in an OB room, the nurse completes a current OB health status, and after performing a NST/toco on the patient, calls the on-call OB MD. The MD discusses the current healthy status and reviews the NST/toco strips. Based on those findings makes a decision on whether the MD needs to perform a face to face medical screening. In addition, the Chief of Staff confirmed the current, 2014 Bylaw's did not provide a medical screening exam definition. In addition, confirmed the OB RN's had not been delineated as qualified to perform a medical screening exam in the Bylaws. Record review on5/21-23/18 of the "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance" dated 9/26/16, revealed "Purpose ... to acknowledge PeaceHealth's responsibility to provide a Medical Screening Examination ... as required by the Emergency Medical Treatment and Active Labor Act (EMTALA)." In addition, the policy stated, "Labor: ...A woman is in true labor unless a physician or QMP [Qualified Medical Professional] certifies that, after a reasonable time of observation, the women is in false labor." The policy further defined "Qualified Medical Professionals: Individuals designated by the Medical Staff as qualified to conduct emergency Medical Screening Examinations." .

. Based on record review and interview the facility failed to ensure the risk and benefits of transfers and patient consent had been documented. This finding denied the patient the right to be informed and left the medical record incomplete of cares provided. Findings: Record review from 5/21-23/18 revealed Patient #4 had admitted to the Emergency Department for a medical evaluation after the wife called EMS due to increased confusion. Review of the ED record dated 3/23/18 for Patient #4 revealed the ED Physician contacted the receiving hospital at 1:00 am. Further review of the "Transfer Data Form" dated 3/23/18. revealed Alaska Native Medical Center accepted the patient for transfer at 1:00 am. Review of the "Patient Transfer Order" dated 3/23/18 at 1:40 am revealed the Patient was to be transferred via Guardian Air transport and left the ED at 3:48 am. During an interview on 5/22/18 the Nursing Supervisor was asked if the risk and benefits and consent for transfer were in the medical record. The Nursing Supervisor confirmed the electronic record had no scanned document of consent or risk and benefit of transfer. Record review of the "EMTALA" policy dated 9/26/16, revealed "Transfer form: ..an EMTALA Transfer Form is completed by the physician to document ...the consent, request, or refusal of a transfer ..."