Based on observation and staff interview conducted on 9/6/16, it was determined that the facility failed to conspicuously post signage, specifying the rights of individuals under section 1866 of the Act, with respect to examination and treatment of emergency medical conditions and women in labor. Findings include: 1. Observation of the Emergency Department main entrance and waiting room revealed two (2) signs posted in an area that were not easily read from where patients were seated. The signs were not conspicuously posted and the font was small, making visualization difficult. 2. Observation of the Triage Room revealed signage obstructed by a hanging bag. 3. Observation of the Decontamination Room revealed no signage posted. 4. Observation of the Nurse's Station revealed no signage posted. 5. Staff #3 and Staff #4 confirmed the above findings.

Based on staff interview and review of physician on call lists, it was determined that the facility failed to ensure the physician on call list identifies an individual physician's name for each specialty on call. Findings include: 1. Review of Cardiology on call lists revealed two (2) physician names listed as on call for March 14, 2016 through March 27, 2016; April 18, 2016 through May 1, 2016; May 23, 2016 through June 5, 2016; June 27, 2016 through July 10, 2016; August 1, 2016 through August 14, 2016; and September 12, 2016 through September 25, 2016. a. A specific physician's name for Cardiology was not listed. b. Staff #3 was unsure of which Cardiology physician from the call list staff should call. 2. Review of ENT [Ear, Nose, Throat] on call lists revealed four (4) physician names listed as on call for March 1, 2016 through March 31, 2016; April 1, 2016 through April 30, 2016; May 1, 2016 through May 31, 2016; June 1, 2016 through June 30, 2016; July 1, 2016 through July 14, 2016; July 19, 2016 through July 31, 2016; August 1, 2016 through August 31, 2016; and September 1, 2016 through September 30, 2016. a. A specific physician's name for ENT was not listed. b. Staff #3 was unsure of which ENT physician from the call list staff should call. 3. Review of ENT on call list indicates "NO COVERAGE" on July 15, 2016 through July 18, 2016. a. There was no evidence of an ENT physician on call. 4. Review of Neurosurgery on call lists show three (3) physician names listed as on call for March 1, 2016 through March 31, 2016; April 1, 2016 through April 30, 2016; May 1, 2016 through May 31, 2016; June 1, 2016 through June 30, 2016; July 1, 2016 through July 31, 2016; August 1, 2016 through August 31, 2016; and September 1, 2016 through September 30, 2016. a. A specific physician's name for Neurosurgery was not listed. b. Staff #3 was unsure of which Neurosurgery physician from the call list staff should call. 5. Staff # 3 confirmed the above findings.

Based on staff interview, review of facility policy and procedure and review of Emergency Department (ED) central logs, it was determined that the facility failed to ensure the maintenance of an accurate central log for all patients seen in the ED. Findings include: Reference: Facility policy titled Emergency Department Log states, "... A. Emergency Department data will be maintained electronically and will include but not limited to... 4. Time of discharge, admission to hospital... ." 1. Review of the ED central log dated 6/1/16 through 6/10/16 indicated Patient #11 arrived to the ED on 6/7/16 at 9:18 AM with a complaint of chest pain. a. The ED log states Patient #11 left the ED against medical advice (AMA) at 5:33 PM. The ED log also states patient left "TO FLOOR." b. Review of the medical record revealed that Patient #11 was admitted from the ED to the telemetry unit on 6/7/16 at 5:33 PM. c. The ED central log did not accurately reflect Patient #11's discharge status and disposition. 2. Staff #1 confirmed the above findings.

Based on staff interview, review of facility policy and procedure, and medical record review, it was determined that the facility failed to ensure all Emergency Department (ED) patients received an appropriate medical screening exam (MSE), which includes classification from the triage nurse based on the Emergency Severity Index (ESI). Findings include: Reference: Facility policy titled "Triage Procedures and Guidelines" states, "... D. All patients must have a documented triage assessment, which includes... the designated acuity and care area... H. The triage nurse classifies the patient into one of five levels, utilizing the Emergency Severity Index... ." 1. Review of Medical Record #8 indicates that the patient arrived to the ED on 6/5/16 at 11:55 AM with a complaint of shortness of breath. a. The patient was triaged at 11:56 PM. b. There was no documentation of an ESI classification performed by the triage nurse in the medical record. 2. Review of Medical Record #12 indicates that the patient arrived to the ED on 6/3/16 at 3:29 PM with a complaint of a head laceration. a. The patient was triaged at 3:40 PM. b. There was no documentation of an ESI classification performed by the triage nurse in the medical record. 3. Staff #1 and Staff #2 confirmed the above findings.

A. Based on observation, staff interviews, review of facility website and review of facility documentation, it was determined that the facility failed to ensure a reasonable registration process for patients seeking treatment, unduly discouraging individuals from seeking emergency medical treatment. Findings include: 1. Upon interview on 9/6/16 at approximately 10:00 AM, Staff #11, Patient Greeter, stated that patients can register online to make an appointment to be seen in the Emergency Department (ED). 2. Upon interview on 9/6/16 at approximately 10:05 AM, Staff #4 and Staff #5 stated that patients can register online to make an appointment for the ED. a. When asked to demonstrate how the patients make their appointments, neither Staff #4 or Staff #5 knew how to access the website. 3. A State surveyor was able to access the InQuicker program through the Care Point Health website on 9/6/16 at approximately 10:07 AM, in the presence of Staff #4 and Staff #5. a. When prompted to: "Select your-check-in time," the following statement came up: "No Upcoming InQuicker times available." 4. Upon interview on 9/6/16 at approximately 11:30 AM, Staff #3 stated that InQuicker was no longer in use as of September 1, 2016, however, this website was able to be accessed after this date. 5. This is a possible deterrent to individuals seeking treatment, unduly discouraging patients from coming in to the ED for evaluation/treatment. 6. Staff #1 and #3 confirmed the above findings. B. Based on staff interview, medical record review, review of the emergency department (ED) central log, and review of facility policy and procedure, it was determined that the facility failed to ensure that all individuals presenting to the ED received a medical screening examination (MSE) prior to providing registration information regarding their insurance status or ability to pay. Findings include: Reference: Facility policy titled "Triage Procedures and Guidelines" states, "... F. All patients will be registered as soon as practical following Medical Screening Exam by the ED attending physician or mid level provider. No emergency or stabilizing care will be delayed by any registration process. ... ." 1. Review of Medical Record #17 indicates that the patient arrived to the ED on 5/31/16 at 6:03 PM with a complaint of swollen feet. a. The patient was triaged at 6:04 PM and received a MSE by a medical doctor at 7:28 PM. b. Review of the ED central log indicates that the patient was registered at 6:12 PM. c. The patient was registered 1 hour and 16 minutes before receiving a MSE. 2. Review of Medical Record #18 indicates that the patient arrived to the ED on 7/19/16 at 8:04 PM with a complaint of a head injury. a. The patient was triaged at 8:04 PM and received a MSE by a medical doctor at 8:44 PM. b. Review of the ED central log indicates that the patient was registered at 8:38 PM. c. Patient was registered 6 minutes before receiving a MSE. 3. Staff #1 and Staff #2 confirmed the above findings.

Based on staff interview, medical record review, and review of facility policy and procedures, it was determined that the facility failed to ensure a transfer form was completed for all patients that are transferred to another facility. Findings include: Reference: Facility policy titled "Transfers to Another Hospital" states, "... The patient's consent is required for transfer to another facility. The emergency department Physician will obtain the consent after explaining all risks and benefits of transfer to the patient and document as such. ... Details of the transfer must be documented on an approved EMTALA form, including: ... name of transport and facility nursing staff taking report of patient's condition... The signatures of the sending physician and the nurse or crisis worker providing details to the sending facility; and the signature of the patient or legal representative indicating that they consent to the transfer. ... ." 1. Review of Medical Record #7 indicates that the patient arrived to the Emergency Department (ED) on 6/4/16 at 8:30 PM with a complaint of a cough with congestion. a. After receiving a medical screening exam (MSE), urinalysis, labwork, and a chest x-ray, the patient was diagnosed with pneumonia and transport to another facility was arranged. b. Review of the "Inter-Facility Transfer Record" revealed the following: (i) The name of the ambulance service transporting the patient was not documented. (ii) The time the ambulance arrived was not documented. (iii) The time the patient left the hospital was not documented. (iv) The time vital signs were taken prior to departure was not documented. (v) Patient's last blood pressure was not documented. (vi) Area of the record marked "Patient Valuables" and "Patient Clothing" indicates patient valuables and clothing were given to the family. There was no signature of family member who received these items. (vii) Area of the record marked "Checklist for Transfers" was incomplete. (viii) There was no documentation of the name of the facility nursing staff taking report of the patient's condition. c. The Inter-Facility Transfer Record was not completed according to facility policy. 2. Review of Medical Record #14 indicates patient arrived to the ED on 6/3/16 at 8:20 PM with a complaint of suicidal thoughts. a. After receiving a MSE, biopsychosocial assessment, and labwork, a determination was made to transfer the patient to another facility. b. Review of the "Inter-Facility Transfer Record" revealed the following: (i) The address of the facility accepting transfer was not documented. (ii) The name of the ambulance service transporting the patient was not documented. (iii) The time the ambulance arrived was not documented. (iv) The time the patient left the hospital was not documented. (v) The vital signs at departure, along with the time they were taken, were not documented. (vi) Area of the record marked "Patient Valuables" and "Patient Clothing" indicate that the patient's valuables and clothing were given to family. There was no staff name or signature or family name or signature for verification. (vii) Area of the record marked "Checklist for Transfers" was incomplete. (viii) The Inter-Facility Transfer Record was not completed according to facility policy. c. There was no evidence of a consent to transfer form signed by the patient or his/her representative. 3. Staff #1 and Staff #2 confirmed the above findings.