Based on observation and staff interview, it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1867 of the Act, with respect to examination and treatment of emergency medical conditions and women in labor, or information indicating whether or not the hospital participates in the Medicaid program. Findings include: 1. A tour was conducted on 10/9/18 at 10:00 AM and revealed that there were no EMTALA signs posted in the following areas: a. Hospital Main Entrance/Lobby b. Labor & Delivery (L&D) Triage Registration Rooms A and B. 2. On 10/9/18 at 10:10 AM, the above findings were confirmed by Staff #4.

A. Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure that patients with an emergency medical condition receive an appropriate transfer. Findings include: Reference: Facility policy titled, "Emergency Care" states, "... IV. POLICY ... Capital Healthtransfers [sic] individuals from a Dedicated Emergency Department to another facility where the transfer is appropriate under the terms of this policy. ... V. Procedure ... C. Emergency Medical Condition 1. An "Emergency Medical Condition" is a medical condition manifesting itself by acute symptoms of [DIAGNOSES REDACTED]... D. Medical Screening Examination ... 3. Documentation ... c. Continued monitoring according to he [sic] individual's needs until it is determined whether the patient has an Emergency Medical Condition and, if he/she does, until he/she is stabilized or appropriately transferred, and, d. If the patient is determined to be stable, a notation certifying this, with additional evaluation prior to discharge or transfer as dictated by the patient's condition. ..." 1. A review of Medical Record #19, revealed the following: a. Patient #19 arrived via ambulance at 7:17 AM with complaints of respiratory illness, fever, and feeling his/her pacemaker go off twice. Patient #19 was assigned an Emergency Severity Index (ESI) of "2". The physician orders included an evaluation of the patient's pacemaker. The evaluation was completed by a technician from Boston Scientific. b. A physician's history and physical (H&P) dated 8/17/18 states, "... in the ED [emergency department] today after [his/her] defibrilator [sic] fired twice this morning. ..." c. A physician's note dated 8/17/18 states, "... Dicussed [sic] patients complicated history with Dr. [name] [phone number], Cardiologist from [other hospital name]. Patient recieves [sic] all care there, scheduled for biopsy and further Oncologic evaluation. ICD [Implantable Cardioverter Defibrillator] interrogated, appears that the device fired erroneaously [sic] for SVT [supra[DIAGNOSES REDACTED]], rate 200s. on [sic] review of rhythm strip there is also electrical alternans consistent with known moderate pericardial effusion. Arranged with Dr. [name] patient transfer to the [other hospital name] ED for evaluation and admission. Do not feel the needs [sic] to be transferred via ambulance as [he/she] is hemodynamically stable. Patient will be discharged and transported to [other hospital name] by car." 2. During an interview on 10/10/18 at 1:42 PM, it was confirmed with Staff #3 that while the medical record indicated that the patient required continued treatment and a transfer to another facility, the patient was discharged from the ED. Reference (continued): Facility policy titled, "Emergency Care" states, "... J. Appropriate Transfers 1. Capital Healthonly [sic] transfers patients from a Dedicated Emergency Department in the following circumstances: a. The patient requests the transfer; or b. The patient's medical condition requires the provision of a services [sic] not available at the Capital Healthfacility [sic], and the risks of the transfer to the other facility are outweighed by the benefits associated with the patient receiving care at the specialized facility; or c. The patient has been stabilized such that no Emergency Medical Condition exists. ..." 3. Review of Patient #19's discharge instructions revealed the "Condition at Dispo" was documented as "improved"; but does not specify if the patient was stable. a. The patient's discharge instructions state, "Please Report Directly to [name of hospital] for evaluation by Oncology and Cardiology." b. The medical record lacked evidence that the patient received treatment for the ICD erroneously firing. c. The medical record lacked evidence of the person that was driving Patient #19 to the second hospital. Reference (continued): Facility policy titled, "Emergency Care" states,"... 2. Use the following procedure to transfer patients from the Dedicated Emergency Department who have not been stabilized or who are in labor. Do not transfer patient unless all of the following steps are complete: a. Provide medical treatment within the capacity of the Capital Healthtransferring [sic] facility that minimized the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child. b. Confirm that there is a facility available with specialized services and qualified personnel available to treat the patient, that the facility has space available to treat the patient and that the facility has accepted the patient. i. Provide a "nurse to nurse" report of the patient's condition and treatment." 4. The medical record lacked evidence that the ED staff confirmed with the receiving facility that space and qualified personnel were available to treat the patient. 5. The medical record lacked evidence of a "nurse to nurse" report of the patient's condition and treatment. Reference (continued): Facility policy titled, "Emergency Care" states, "... J. Appropriate Transfers ... 2. ... c. The transferring physician explains to the patient or to the patient's medical decision maker, the risks and benefits associated with the transfer. i. The physician provides the patient with an explanation of the risks and benefits of the transfer that is specific to the condition of the patient; ii. The transferring physician accurately and completely documents in the medical record the explanation of the risks and benefits provided to the patient in the patient's Medical Record; ... d. A physician informs the individual of the risks and benefits of the transfer and obtains the individual's consent on the form attached as Appendix B of this policy. ..." 6. The medical record lacked evidence that the physician provided education to the patient regarding the risks and benefits of receiving treatment at a different facility. Reference (continued): Facility policy titled, "Emergency Care" states, "... J. Appropriate Transfers ...2. ... g. At the time of the transfer, send to the receiving facility copies of all medical records related to the individual's condition that are available at the time of transfer, including, but not limited to: i. Available history; ii. Records related to the individual's Emergency Medical Condition; iii. Observations of signs or symptoms; iv. Preliminary diagnosis; v. Results of diagnostic studies or telephone reports of the studies; vi. Treatment provided; vii. Results of any tests; viii. Informed written consent of individual being transferred and physician certification; ..." 7. The medical record lacked evidence that a copy of the medical record was sent to the receiving facility. Reference (continued): Facility policy titled, "Emergency Care" states, "... h. Document compliance with this policy using the Emergency Department's Transfer Checklist form, which, at a minimum will include the following elements: i. Patient condition ii. Physician certification iii. Risks and benefits of transfer iv. Patient consent, or refusal, or request for transfer against medical advice, as applicable v. Reason for transfer vi. Vital signs vii. Receiving physician and facility information vii. [sic] Copy of medical records viii. Patient belongings..." 8. The medical record lacked evidence of a completed "Emergency Department's Transfer Checklist" form. 9. The above findings were confirmed with Staff #3 on 10/10/18 at 1:42 PM. B. Based on medical record review and staff interview, it was determined that the facility failed to ensure that the Emergency Department Patient Transfer form is completed in its entirety for all patients transferred out of the Emergency Department (ED). Findings include: 1. The Emergency Department Patient Transfer form for Medical Record #5 lacked documentation of when the Transport Service arrived and departed the ED with the patient. a. Under the section titled, "Transport Service Time," the arrival and departure times were left blank. 2. On 10/10/18 at 11:25 AM, Staff #5 confirmed the above findings.