Based on document review and interviews, it was determined that the hospital failed to report to CMS or the State Survey Agency a suspected incidence of an individual transferred in violation of the Emergency Medical Treatment and Labor Act (EMTALA) for one (1) of twenty (20) emergency department (ED) records reviewed (Record A). The finding includes: On February 15, 2017 at 2:46 PM, the state agency had been notified by a Physician at Hospital A of a possible EMTALA violation related to Hospital A. On February 11, 2017 at approximately 5:00 AM, Sebasticook Valley EMS called Hospital A indicating that they were transporting two (2) patients who had called for an ambulance and were expressing suicidal ideations. Hospital A's ED Nurse told them that they could take one patient but not both. One of the two (2) patients was transported to Inland Hospital. As of February 27, 2017, the state agency had not received notification from Inland Hospital (the receiving hospital) that there may possibly be an EMTALA violation. On February 23, 2017 at approximately 3:24 PM, Paramedic #1, who was assigned to the ambulance that transported both patients on February 11, 2017, was interviewed via telephone. Paramedic #1 stated that she was the driver of the ambulance and was present when the second patient was delivered to Inland Hospital. Paramedic 1 stated "my partner told Inland that the other hospital had refused to take this patient". On February 24, 2017 at approximately 11:50 AM, Paramedic #2 was interviewed via telephone. He stated that he "informed Inland that originally we were going to [Hospital A] with both patients and they refused to take both so we took him/her here." Paramedic #2 also stated "this information was reiterated to the nurse at Inland". Paramedic #2 stated that there was no response to this information other than "an offhand statement that it was odd this happened". The Vice President of Quality at Inland Hospital stated, on February 27, 2017 at approximately 10:30 AM, that the hospital was "in the process of working with legal to determine if we need to report the suspected EMTALA violation that recently occurred" [February 11, 2017]. Hospital Policy "EMHS - System Policy #: 21-007" titled "Emergency Treatment and Transfer Rules" states under part V the following: - "A. If hospital personnel knowingly, willingly, or negligently failed to meet the requirements of this law, the hospital is subject to termination of the Medicare provider agreement". - "I. If the hospital received a patient in transfer in an unstable emergency medical condition in violation of part II of this policy, the department head of the receiving unit must contact the Chief, Emergency Medicine Service who will determine whether a report must be filed with HCFA, after consultation with the EMHS vice president and general counsel." On February 27, 2017 at approximately 10:40 AM, the hospital provided copies of the transporting ambulance service documentation regarding this incident which included the ambulance "run forms" for the patient identified as Record A and the second patient that was transported to Hospital A and written statements by both paramedics. The written statement by Paramedic #1 reported "Inland was notified that [other hospital] refused the second patient". Additionally "(afterward [Paramedic #2] had mentioned that the Charge RN [nurse's name] had said that it wasn't fair for them to have two drunk friends in the same unit)". The written statement by Paramedic #2 stated "On calling [Hospital A] ER (emergency room ) they stated that they would only take one and the other would have to go to Inland. I stated that I was bringing them both pt [patients] and they stated that one would have to go to Inland as they did not feel it was appropriate for both to be in the same ER". Record A was reviewed on February 27, 2017 at approximately 1:00 PM. The record indicated that the patient arrived at the Inland Hospital Emergency Department on February 11, 2017 at 5:30 AM, with a chief complaint of "I am paranoid. My mind is racing. I am hearing voices." Report stated "Hx [history] of multiple suicide attempts. States does not feel safe at home, but does not have suicidal thoughts at this time". On February 27, 2017 at approximately 3:45 PM, the Vice President of Quality confirmed that the hospital had not reported the suspected violation of the EMTALA regulations to either CMS or the State Agency. He/she reiterated "The hospital, through legal, believed that the hospital needed to complete an internal investigation to determine if a violation needed to be reported".

Based on observation and interview, it was determined that the facility failed to conspicuously post a sign specifying the rights of individuals regarding Emergency Medical Treatment and Labor Act (EMTALA) statute in places likely to be noticed by all individuals seeking treatment in the Emergency Department (ED). The finding includes During a tour of the ED on February 27, 2017 at approximately 10:45 AM, it was observed that the notification of EMTALA rights was located in the walk in entrance area in the waiting room. However, it was observed that the ambulance entrance failed to have any sign posted providing EMTALA notification for patients arriving by ambulance. This finding was confirmed by both the Emergency Department Director and the Birthing Center Director (Former ED Director) on February 27, 2017 approximately 10:55 AM. The Birthing Center Director stated "I never thought about the need to place a sign in the ambulance entrance, but that makes sense".