Based on observations; staff interviews; clinical record and document reviews; and review of the hospital's policies and procedures Critical Access Hospital A's (CAH A) noncompliance with the requirements under EMTALA occurred when- 1. Signage, visible to the public, was not posted in the Emergency Department [C2402]; 2. The "Physician On-call List" failed to clearly identify specialist available with their contact information [C2404]; 3. ED Staff did not enter Patient 101 into the ED Log [C2405]; 4. CAH A did not perform a Medical Screening Exam for one of 20 Patients (Patient 101) when he presented on the hospital's property seeking medical attention [C2406].

Based on observations and staff interviews, the hospital failed to prominently post signage in its Emergency Department (ED) informing the public of their rights to seek and receive emergency services with respect to- 1. Examination and treatment of emergency medical conditions including women in labor, and 2. The hospital's participation in Medicare or Medicaid Program. This failure has the potential for the public to be unaware they could receive care and treatment in an emergency without the fear of the inability to pay for the services they receive. Findings: During a tour of the Emergency Department (ED) on 2/8/16 at 2:10 p.m., which included a registration area, waiting room, and four bays (location for gurneys where patients are seen by emergency room staff) there was no visible signage specified by the Social Security Act §1867. During an interview on 2/8/16 at 2:20 p.m., Administrative Staff D stated emergent patients are taken directly back into the ED bays. They do not wait in the ED's waiting room. During an observation with concurrent interview on 2/9/16 at 2:15 p.m., EMTALA signage was located on an eight and one half by 11 inch paper on a bulletin board behind the registration desk with verbiage as specified in the regulation. However, Patient Financial Services Staff J stated there are only two reasons an individual waiting to be seen in the ED would go beyond the registration desk 1) to use the restroom or 2) if the 4 seats in the ED waiting room are full there are chairs in the hallway for "overflow". During a third observation with concurrent interview on 2/11/16 at 8 a.m., of the waiting room, registration area, the four bays and beyond the registration desk (where the EMTALA sign was located), Administrative Staff D corroborated there were no visible signs posted to inform the public of their rights with regards to EMTALA. On two occasions a request was made for the hospital's policy on EMTALA signage. Administrative Staff D stated she could not locate a policy related to signage.

Based on observations, staff interviews, and document reviews, the Critical Access Hospital (CAH A) Emergency Department's Physician On-call List failed to clearly identify the specialists available and their contact information. This failure allowed the potential for errors in the ability to transfer patients with critical conditions to appropriate receiving hospitals with the appropriate specialists available for consultation. Findings: Review of the hospital state license indicated CAH A has "Standby Emergency Medical Services". During the entrance interview, on 2/8/16 at 1:45 p.m., the Chief Nursing Officer (CNO) explained that CAH A's Emergency Department physicians were independent contractors that rotated weekly Wednesday to Wednesday shifts. A list of CAH A's Medical Staff was provided by the CAH and reviewed. The list included seven Emergency Department (ED) physicians. During an observational tour of ED with a concurrent interview on 2/8/16 at 2:10 p.m. CAH A's Physician On-call List was written on a whiteboard (markerboard, dry-erase board, dry-wipe board) as follows: Specialties CAH BB [Critical Access Hospital BB] Ortho (-) Hospital C Ortho (+) [Orthopaedics-skeletal system] Neuro (+) [Neurology- the nerves] Neuro Surg (+) [Surgery- brain or nerve tissue] Plastics (+) [Plastic Surgeon-surgery dealing with the repair or replacement of malformed, injured, or lost organs or tissues of the body.] ENT(+) [Ears, Nose and Throat] Urology(+) [Urinary tract] Gastro (+) [Gastroenterology - Digestive system i.e. stomach] The plus (+) and (-) indicates if physician specialists are available. The physicians' names and contact numbers were not listed. The Chief Nursing Officer stated the Physician On-call List is updated once a day when CAH A calls CAH BB for the updated information. The Chief Nursing Officer went on to state because CAH A does not have a CT Scanner [a diagnostic medical test that produces multiple images or pictures of the inside of the body. CT Scan typically provide greater detail than traditional x-rays, particularly of soft tissues and blood vessels]; a MRI [a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body]; and an ultrasound [Ultrasound, also called sonography, uses sound waves to develop ultrasound images of what's going on inside the body], patients are sent to other hospitals with those diagnostic capabilities. During an interview on 2/11/16 at 8 a.m., Administrative Staff D stated that CAH A calls CAH BB and Hospital C every morning to check their physician specialist coverage. During review of the hospital's Policy and Procedures on 2/10/16 at 8:30 a.m., Administrative Staff D marked the policies and procedures pertaining to EMTALA. There was no policy provided by the hospital referencing how CAH A would utilize the Physician On-call Schedule to provide the treatment necessary to stabilize patients after their initial examination; or a description to CAH A's approach on meeting the needs of those patients with available resources.

Based on staff interviews, review of the Emergency Department's Log (log) and Critical Access Hospital A's (CAH A) policy and procedure, CAH A failed to maintain the log for one of 20 Patients (Patient 101) when he presented to the Emergency Department with symptoms of chest pain, shortness of breath and a cough and Patient 101's information was not entered into the log. This failure resulted in the inability of the CAH A to track the patient's care. Findings: During an interview, on 2/10/16 at 1 p.m., ED Licensed Staff H stated Patient 101 presented at CAH A's Emergency Department (ED) with symptoms of chest pain, shortness of breath and a cough on 2/3/16 and was seen briefly by CAH A's Licensed Staff H on the hospital's property. Review, on 2/9/16 at 10:15 a.m., of the clinical record for Patient 101, indicated Patient 101 presented at CAH BB's ED with symptoms of chest pain, shortness of breath and a cough on 2/3/16 at 11:15 a.m. During review of CAH A's ED log on 2/9/16, there was no documented entry indicating Patient 101's information had been entered into the log. Review of CAH A's policy and procedure on 2/11/16 with the title, "emergency room Register" dated 2016, indicated, "It is the policy....to maintain a register of every individual who presents to the emergency room ("ER") for medical care. It is the responsibility of the ER nurse to make sure that every individual who presented during his/her shift is logged in the registry book prior to the end of his/her shift." Review of the hospital's policy and procedure titled, "Assessment and Evaluation of All Patients Presenting to the emergency room " reviewed 2015, indicated, "...all patients presenting to the ER will be entered into the ER log and their disposition documented..."

Based on observation, interview, document review, review of the hospital's policy and procedure, and photographs, Critical Access Hospital A (CAH A) Emergency Department Staff failed to provide a Medical Screening Exam (MSE) for one of 20 Sampled Patients (Patient 101). This failure led the patient to drive an additional 50 miles to Critical Access Hospital BB (CAH BB) for medical care which resulted in delays in his treatment for: 1. His presenting symptoms of [DIAGNOSES REDACTED] 2. Missing his second dose of medication for his recent diagnosis of [DIAGNOSES REDACTED][DIAGNOSES REDACTED]. The bacteria usually attack the lungs though other organs may be involved. TB is spread through the air from one person to another. The bacteria are released into the air when a person with TB disease of the lungs coughs, sneezes, speaks, or sings.) These failures had the potential to spread [DIAGNOSES REDACTED] and worsening of the patient symptoms. Findings: 1. During an interview, on 2/10/16 at 1 p.m., ED Licensed Staff H stated Patient 101 was on CAH A's property when he sought medical attention for complaints of chest pain, shortness of breath and a cough. Patient 101 was met by the CAH A's ED Licensed Staff H on the ambulance ramp/driveway outside of CAH A's Emergency Department (ED) [Photographs I and II]. The ED Licensed Staff identified Patient 101 and after conversing with him, Patient 101 drove 50 miles to Critical Access Hospital BB (CAH BB) for treatment. Review, on 2/9/16 at 10:15 a.m., of the clinical record for Patient 101, indicated Patient 101 presented at CAH BB's ED with symptoms of [DIAGNOSES REDACTED]. CAH BB's ED physician diagnosed Patient 101 with pericarditis (an infection of the inner lining of the heart). Patient 101 was not aware of the diagnosis for he had left CAH BB and did not start on the medication prescribed for his pericarditis until 2/5/16. CAH A's Dedicated Emergency Department had the capabilities, including ancillary services, to complete the tests performed at CAH BB. CAH A's on-call ED physician was onsite at the time Patient 101 presented. 2. During interview, on 2/10/16 at 2:50 p.m., the County Public Health Case Manager stated Patient 101 had been diagnosed with [DIAGNOSES REDACTED]' s required). Patient 101 had left the CAH BB before he received a diagnosis and his discharge orders because he had an appointment at home to receive his second dose of the [DIAGNOSES REDACTED] medication regime. During an interview on 2/10/16 at 2:50 p.m., the County Public Health Case Manager (Case Manager F) stated the following: 1. She was responsible for the coordination of Patient 101's [DIAGNOSES REDACTED] care. 2. Patient 101's sister called her on 2/3/16 stating her brother was complaining of chest pain, shortness of breath and a cough. 3. Case Manager F called Patient 101 and he told her he was having trouble breathing and pain in the chest. 4. She advised Patient 101 to call 911 and take an ambulance to the nearest hospital (CAH A). Case Manager F told Patient 101 twice to take an ambulance. Patient 101 told Case Manager F he felt capable of driving himself. 5. She left a message on CAH A's Infection Preventionist's voice mail on 2/3/16 that Patient 101 was coming to CAH A's ED. 6. She notified her colleague, County Public Health Nurse G of the incident since he had been providing direct care to Patient 101. 7. Public Health Nurse G notified CAH A that Patient 101 was on his way and that he had active TB. During an interview on 2/10/16 at 3:05 p.m., County Public Health Nurse G stated the following: 1. He currently provided direct care and face to face medication administration (along with other county staff) to Patient 101. 2. Patient 101 missed his second medication treatment dose for his recently diagnosed TB when he was being seen at CAH BB's Emergency Department. 3. Patient 101 did not start medication for treatment of the pericarditis until 2/5/16. During an interview on 2/9/16 at 3:15 p.m., Physician L , CAH A ED physician stated on 2/3/16, he spoke with ED Licensed Staff H before Patient 101 arrived at CAH A. Physician L stated, he was told Patient 101 was coming by ambulance with complaints of chest pain, shortness of breath and a cough. He was aware Patient 101 had active TB and had just recently started a medication regimen treatment and was still in the window of being infectious. Physician L stated "[CAH A had] no means to care for patients with active TB." During an observation and concurrent interview on 2/10/16 at 1 p.m., ED Licensed Staff H stated she had spoken with Patient 101 face to face on CAH A's ambulance ramp on 2/3/16. ED Licensed Staff H demonstrated meeting Patient 101 on the ambulance driveway/ramp, adjacent to two bright yellow stationary posts at the driveway edge. Photograph I demonstrates the perimeter of the hospital property in relation to bright yellow stationary posts at the edge of the ED driveway. Photograph II demonstrates the relation of the yellow posts to the entrance to the ED. ED Licensed Staff H's recollection of the events before, during and after she encountered Patient 101 are as follows: 1. The Patient Financial Services Staff I (PFS I), informed her she had received a call from County Public Health saying there was a patient coming into the ED with active TB. 2. She notified CAH A's on-call physician (Physician L) of the call. Per her conversation with Physician L, CAH A did not have the resources to take care of a patient with active TB- no equipment, labs, isolation. Physician L told ED Licensed Staff H to do a "bypass". 3. ED Licensed Staff H stated, "I was waiting for the ambulance to arrive. I did not hear from the ambulance dispatch, I did not receive any report. It must have been 45 minutes [after the initial call]. I could see the radius of the hospital. I could see from the window that a black car had stopped . A male got out of the car. He had a steady gait. He was wearing a N 95 mask." (A N 95 mask provides filtration of 95% of airborne particles and is used to control transmission of airborne infections). "I went outside. I stated Patient 101's birthday first. Then I said, "Hey, are you (name)?" The individual confirmed that he was [Patient 101]. I asked why didn't you call 911? Patient 101 stated he did not need 911. 4. ED Licensed Staff H stated she told Patient 101 [CAH A] did not have the services to care for you. ED Licensed Staff H stated, "I told him we are planning to transfer him because the CAH A did not have a CT Scanner", (a diagnostic medical test that produces multiple images or pictures of the inside of the body. CT typically provide greater detail than traditional x-rays, particularly of soft tissues and blood vessels). He [Patient 101] turned around, walked to his car. He was by himself. I offered to let us [CAH A] do the "homework to transport him" to another hospital. Patient 101 stated he was going to drive to CAH BB. I told him I would call CAH BB. ED Licensed Staff H went on to say, "[Patient 101 was] pale, slightly ashen. [He] didn't look right." 5. When ED Licensed Staff H was queried to what "bypass" meant she gave the example of a patient with a closed head injury would be someone CAH A could not take care of [due to their limited services]. She also mentioned there were no other patients in the ED at the time Patient 101 arrived at the ED. 6. ED Licensed Staff H stated she tried to call CAH BB's ED nurse, but the connection was lost. "I spoke with the house supervisor. I wanted to give them a "heads up". It was in speaking with CAH BB's staff when I was made to realize it was a potential EMTALA. 7. ED Licensed Staff H stated she immediately spoke with the Chief Nursing Officer (CNO) about the incident and potential EMTALA violation. ED Licensed Staff H stated the CNO gave her the hospital EMTALA policy and procedures to read. ED Licensed Staff H stated after she read the EMTALA regulations she understood why the incident was a possible EMTALA violation. 8. ED Licensed Staff H stated, "Looking at the whole picture, my head was wrapped around to protect the facility [CAH A]". ED Licensed Staff H during the interview process stated her visual assessment of Patient 101, however offered no accounting of the complaints of chest pain, shortness of breath and the cough that originally led Patient 101 to call his County Public Health Case Manager. During an interview on 2/9/16 at 4:40 p.m., the Chief Nursing Officer (CNO) stated she had been approached by ED Licensed Nurse H when she arrived at work shortly after Patient 101's presentation to and departure from the CAH A's ED. ED Licensed Nurse H told the CNO that she was afraid she had made a big mistake, and related to her the incident with Patient 101 coming to the ED. The CNO stated she agreed that she had probably violated EMTALA regulations; "It was a big communication flub". When the Chief Nursing Officer was queried if CAH A was ready for any patient with an infectious disease in the event they came to the ED she replied, "Yes". CNO related that CAH A had provided outpatient lab services to Patient 101 prior to 2/3/16 after his diagnosis of [DIAGNOSES REDACTED] During an interview on 2/10/16 at 2:20 p.m., the Infection Preventionist stated she had received a message on her voice mail indicating Patient 101 was coming into CAH A via car or ambulance. She had not received the message until she had returned to work on 2/5/16, two days after Patient 101 came to the ED to be seen for chest pain, shortness of breath and a cough. Infection Preventionist stated CAH A was capable of caring for patients in the ED with potential airborne infections such as TB. Infection Preventionist stated if an airborne disease was suspected CAH A had appropriate protective masks for staff and patients, gowns, and respiratory precaution signs. The Infection Preventionist stated the ED observation room could be closed off and used for isolation until a transfer to a hospital with a negative pressure room was arranged. During interview on 2/9/16 at 9:15 a.m., with staff at Critical Access Hospital BB (CAH BB), ED Assistant Manager PP stated the following: on 2/3/16 at approximately 9:45 a.m., she received a call from ED Licensed Staff H at Critical Access Hospital A (CAH A) who stated Patient 101 was on the way to CAH BB by private vehicle. ED Licensed Staff H stated Patient 101 had active TB and complained of chest pain, shortness of breath and a cough. ED Assistant Manager PP stated ED Licensed Staff H told her the ED physician stated (CAH A) couldn't take care of the patient. ED Licensed Staff H said she had waited in the parking lot and told Patient 101 that he couldn't be treated at CAH A. ED Assistant Manager PP stated she told ED Licensed Staff H, "You can't do that", and started to explain to ED Licensed Staff H why sending Patient 101 was a probable EMTALA violation. ED Assistant Manager PP stated ED Licensed Staff H said, "What? ...Oh ...! What do I do?" ED Assistant Manager PP advised ED Licensed Staff H to speak with her supervisor. ED Assistant Manager PP stated an hour later, Patient 101 arrived by private vehicle at CAH BB. During interview on 2/9/16 at 11 a.m., CAH BB ED Licensed Staff OO stated Patient 101 arrived at the CAH BB ED on 2/3/16 wearing a mask. The ED nurse stated Patient 101 was immediately roomed in the ED negative pressure room, (a negative pressure room is engineered to prevent contaminants from flowing out of the room). ED Licensed Staff OO stated she followed the hospital cardiac patient protocol; Patient 101 had blood drawn for cardiac enzymes and other lab values, an EKG, and a chest X-ray. ED Licensed Staff OO stated that Patient 101 became anxious that he would miss an appointment with the (County Public Health) nurse that brought his TB medications to him at home. ED Licensed Staff OO noted that Patient 101 was no longer in the negative pressure room at 3 p.m. and his IV was lying intact in the room. Review of clinical records from CAH BB indicated Patient 101 was triaged in the ED on 2/3/16 at 11:15 a.m. The Physician ED Report indicated Patient 101 complained of squeezing anterior chest pain that had resolved spontaneously just prior to his arrival at CAH BB. The chest X-ray report indicated Patient 101 had probable pneumonia. The EKG report diagnosed Patient 101 as having acute pericarditis, swelling and inflammation of the thin membrane that surrounds the heart. Lab work indicated Patient 101 had an elevated white blood count, indicative of infection, and elevated TSH (thyroid stimulating hormone). The clinical record included documentation that Patient 101's Primary Care Provider was notified of the abnormal findings. During a review of CAH A's policy and procedure on 2/10/15 titled, "Emergency Medical Screening Treatment" with a review date of 2015, indicated "It is the policy of the...to ensure that all individuals presenting to the hospital or outpatient clinic for emergency services or care will receive a prompt Medical Screening Examination ("MSE") sufficient to determine whether an individual has an Emergency Medical Condition ("EMC")..." A second policy titled, "Medical Screening Exam" ("MSE"): An MSE is an ongoing and tiered process of increasingly complex medical evaluations to identify or rule out the existence of an EMC. A MSE will be provided to the extent of the capacity of the hospital's emergency room and will include ancillary services routinely available to the emergency room ." A review of CAH A's policy and procedure titled, "Patient Triage" with a review date of 2015, indicated, "The following types of patients should RARELY be classified as non-urgent: ...patients with a chief complaint of acute: headache, chest pain, abdominal pain, neck pain and back pain."