Based on observations and interview, it was determined the Facility failed to post signs readable within 20-feet of the vantage point regarding the rights of individuals with emergency medical conditions, women in labor, and whether or not the hospital participated in the Medicaid program. Failure to post signs in areas likely to be noticed by persons waiting for examination or treatment did not allow patients to be knowledgeable of their rights as well as if the Facility was a Medicaid participant or not. The failed practice likely affected any patient waiting for examination or treatment. Findings follow: Observations during the tour at 11:45 AM on 10/09/17 showed one EMTALA sign, approximately eight inches by twelve inches hanging on the wall behind a desk to the right of the intake area in the waiting room. The above observations were made by Surveyors #1 and #2 and verified by the Emergency Department Director at the exit conference at 2:45 PM on 10/10/17.

Based on clinical record review and interview, it was determined that the Facility failed to: 1. effect an appropriate transfer of a suicidal patient, Patient #2; 2. inform patients and/or family members the risks and benefits of transfer specific to the condition of transferred patients. Failure to inform patients and/or family members the risks and benefits did not allow eight (Patients #1, #4, #8, #9, #10, #11, #14 and #23) of eight transferred patients to make an informed decision regarding the need for the transfer along with associated risks and benefits particular to the patient's medical condition. Findings follow: On 9/16/17, at 11:09 p.m., a [AGE]-year-old female was brought to the emergency department (ED) of the hospital by ambulance for a drug overdose. At 01:20 AM on 09/17/17, the ED nurse documented "Patient mother is here to report that she told her oldest son that she was trying to kill herself by taking an unknown amount of pills. Mother brought the patient pill bottles. Percocet 10-325 mg filled on 9-11 is empty # of 120 Methadone 10 mg Filled 9-12 is empty #120." Th ED physician documented at 11:09 on 09/16/17 that patient was "Positive for dysphoric mood, self injury and suicidal ideas." At 04:04 AM on 9/17/17, another ED nurse documented "Informed by nurse in handoff that pt stated she was trying to kill herself because she and her boyfriend had gotten into an emotional fight. She also got into a fight with her oldest son." Review of Patient #2's clinical record did not show that an examiniation by a psychiatrist was done, and no documentation by a physician showing Patient #2's emergency medical condition of suicidal ideation had resolved or lessened. Review of nursing note showed, an ED nursedocumented at 6:19 PM on 09/17/17, "Pt (Patient) has 3 family members in the room that agree to take the patient to the nearest hospital in (Named State) and check her in so that she can be placed in a facility in (Named State)." Review of the ED Provider Note authored by Physician #1 filed at 6:19 PM on 09/17/17 showed the following: "PT (patient) has been in ER (emergency room ) for over 20 hours, she was sent from a (Named State) ER, where she is from, for suicide attempt for ICU (Intensive Care Unit) placement and then psych (psychiatric) placement. She is medically clear but we are unable to transfer her across state lines. Family is now with patient. The patient and family wish to leave, they want to take her to a (Named State) hospital to seek placement in (Named State). Patient and family feel safe with this plan and pt agrees to stay with family until she can get help." Review of the timeline showed the following entry authored by RN #1 at 6:27 on 09/17/17; "Patient discharged . Discharge Destination: Home. General Review with Patient/Caregiver: Discharge instructions reviewed; Healthwise attachments reviewed; Follow up care reviewed; Patient/Caregiver verbalizes understanding of discharge instructions. Mobility at Departure: Ambulatory w/ (with) steady gait. Accompanied by: Family." Review of the clinical records of Patients #1, #4, #8, #10, #11 and #14 showed no documentation of the risks and benefits specific to the condition for which the patient was being transferred. During an interview at 2:40 PM on 10/10/17 the findings were verified by the Emergency Department Quality Nurse with Surveyor #1. Review of the clinical records of Patients #9 and #23 showed no documentation of the risks and benefits specific to the condition for which the patient was being transferred. During an interview at 2:40 PM on 10/10/17 the findings were verified by the Regulatory Compliance Coordinator with Surveyor #2.