Based on observation, policy/procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the required EMTALA signage was posted and visible to all patients entering the obstetrics department including 5 of 5 obstetrics rooms where patients would wait for and receive treatment. The CAH staff reported approximately 90 deliveries per month. Failure to post signs informing patients of their rights could potentially result in patients not knowing their rights to receive an examination and treatment for any emergency medical conditions. Findings include: 1. During tour of the obstetrics department on 4/1/14 at 11:50 AM with Staff B, Registered Nurse - Obstetrics, revealed the lack of required EMTALA signage posted and visible at the entrance to the unit and in 5 of 5 obstetric exam rooms where patients would enter, wait for, and receive treatment. 2. Review of CAH policy/procedure titled "Transfer and Emergency Examination", dated 10/11/06, revealed the following in part, "...Women requesting examination for confirmation of the onset of labor shall be examined in the Obstetrics Department...Signs specifying the rights of individuals under EMTALA shall be posted conspicuously in the Dedicated Emergency Departments (DEDs) and in a place or places likely to be noticed by all individuals ...as well as by individuals waiting for examination and treatment areas..." 3. During an interview at the time of the tour, Staff B acknowledged the lack of required EMTALA signage posted and visible at the entrance and in 5 of 5 obstetrics rooms where patients would enter, wait for, and receive treatment.

Based on review of policies/procedures, medical staff rules and regulations, medical staff roster, on-call physician schedule, and staff interviews, the Critical Access Hospital (CAH) failed to maintain a list of specialty physicians on call to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. The CAH staff identified an average of 516 patients presenting to the ED requesting emergency care per month. Failure to maintain a list of on-call specialty physicians available for consultation for ED patients could potentially result in patients not receiving an appropriate evaluation and/or a delay in stabilizing treatment for their emergency medical conditions. Findings include: 1. Review of CAH policy/procedure titled "Transfer and Emergency Examination", dated 10/11/06, revealed the following in part, ". . . Physician On-Call List. A list shall be maintained of physicians who are on call to provide necessary treatment to stabilize an individual presenting with an EMC. . . ." 2. Review of Medical Staff Rules and Regulations, approved May 2013, revealed the lack of a requirement for on-call responsibilities for specialty physicians to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. 3. Review of the CAH's Medical Staff roster revealed one general surgeon with surgical privileges at the CAH was listed. Review of the monthly emergency room physician schedules from July 2014 through March 2015 revealed the general surgeon was not listed on the on-call list. 4. During an interview on 4/1/15 at 12:55 PM, Staff A, Chief Nursing Officer, stated one surgeon was on-call most of the time, but no list was available to verify when the surgeon was on-call. Staff A acknowledged the lack of any policy/procedure that addressed a requirement for on-call responsibilities for specialty physicians to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition.

Based on review of policy/procedure, medical record documentation, and staff interview, the hospital failed to provide an adequate medical screening examination (MSE) for 1 of 56 sampled patients who presented to the Emergency Department (ED) requesting emergency care between July 1, 2014 and March 30, 2015 (Patient # 30). The hospital administrative staff identified an average of 516 patients presented to the emergency department requesting emergency care monthly. Failure to provide an adequate medical screening examination in the ED for patients requesting emergency care could result in staff providing inadequate care or ineffective care to treat the emergency medical condition (EMC) and result in decline of the patient's condition. Findings include: 1. Review of CAH policy/procedure titled "Transfer and Emergency Examination", dated 10/11/06, revealed the following in part, ". . . Any individual who is not otherwise a patient of the hospital, shall be provided an appropriate MSE [Medical Screening Examination] within the capabilities of the Emergency Department (including ancillary services routinely available to the Emergency Department as follows: . . . Upon presentation at a DED [Dedicated Emergency Department] of hospital, and upon a request for examination or treatment for a medical condition. Such a request will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition. . . ." Review of Medical Staff Rules and Regulations, approved May 2013, revealed the following in part, ". . . All patients presenting to Myrtue Medical Center (MMC) requesting examination and or emergency treatment shall be treated in accordance with MMC policies and procedures governing emergency medical screening in compliance with he Emergency Medical Treatment and Active Labor Act (EMTALA). All practitioners are required to be familiar with and follow the transfer requirements of EMTALA. The on-call medical practitioner will be called for all emergency department patients. It is the on-call practitioner's responsibility to respond, examine, and treat patients with emergency medical conditions. . . ." 2. Review of Patient #30's medical record revealed the patient presented on Wednesday, 10/15/14 at 11:57 AM after the patient called the ED and stated she took 10 tablets of Tylenol and was drinking. The patient told nursing staff she woke up with scratches to the left forearm. Nursing staff documented the patient was at Behavioral Health at approximately 11:00 AM earlier in the day. Practitioner A, Physician Assistant (PA) documented the following information. The patient has a long history of attempting overdose and depression. The patient presents to the ED admitting to wanting to harm herself but denies wanting to commit suicide or kill herself. The patient had some cutting behavior to her left forearm which is noted. The patient admits that she had a recent argument with her grandmother that prompted this harming episode. The patient admitted to drinking more and took 10 - 500 mg tablets of acetaminophen that morning at approximately 8:00 AM and then drank 3 alcoholic beverages at approximately 11:30 this morning. The patient was at Behavioral Health department earlier that day and had a consult with one of the social workers at 10:30 AM. Staff did call the Behavioral Health staff who met with the patient to discuss the patient's current condition. The patient stated to the Behavioral Health staff that she wanted to feel physical pain so she does not feel emotional pain. The patient did not have a plan at this time for continued self-harm. The patient reported she had stopped taking her psychotropic medication on Sunday because she did not feel it was helping and does not feel the Behavioral Health department was helping her. The patient's psychiatrist was contacted who stated the patient could be discharged if she was medically stable and Behavioral Health staff could continue to be available as necessary should the patient choose to return for assistance. The patient was dismissed to her grandmother's home in stable condition. Behavioral Health staff had met with the patient on 10/15/14 from 12:30 PM - 1:30 PM and documented the following. The patient stated she wants to feel physical pain so that she doesn't feel emotional pain. The patient stated she did not want to die, just to feel pain. The patient does not have a plan for continued self-harm. The patient's psychiatrist was contacted who stated that once the patient was medically stable the patient should be discharged . Laboratory test revealed the following. Acetaminophen level 29 (Reference 10 - 30), Alcohol 47 (Reference 0 - 100). The patient was discharged to home at 1:45 PM. Review of medical records revealed Patient #30 returned to the ED on 10/15/14 at 3:29 PM with the police after the patient climbed up on the roof and threatened to throw herself off the roof this afternoon. Practitioner B, PA, documented the patient had been seen earlier in the ED and the patient denied any thoughts of suicide at that time or even plans. The patient had stopped her medications. During the earlier ED visit the patient stated she liked cutting herself because it made her feel alive. At that visit the patient was seen by Practitioner A and mental health was consulted as well as the patient's psychiatrist and at that time there was no finding of any acute threat. Now the patient is claiming that she wants to commit suicide by drinking antifreeze as well as the initial threatening to throw herself off the roof of the house. The patient was then transferred to an acute care hospital for inpatient psychiatric care. 3. During an interview on 4/1/15 at 12:55 PM, Staff A, Chief Nursing Officer, acknowledged Patient #30 returned to the ED after being discharged from the ED earlier in the day.