Based on a tour of the Emergency Department (ED) and staff interview conducted on April 6, 2015 at approximately 10:15 AM, 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 for emergency medical conditions and women in labor or information indicating whether or not the hospital participates in the Medicaid program. Findings include: 1. During a tour of the ED, in the presence of Staff #1, #6, and #8, the following areas lacked conspicuous posting of signage related to EMTALA: a. In Pediatric Rooms #35 & #36, the signs were posted behind the doors to the rooms, and could not be seen when the doors were open. b. In Holding Rooms A, B, & C, the EMTALA signage posted in Bay B is not visible to patients in Bays A and Bay C. c. In Room #32 A & B, the EMTALA signage posted in Bay B is not visible to patients in Bay A. d. There is no visible EMTALA signage near Hallway Stretcher Beds 25-B, 26-B, 32-C, and 33-B. 2. The above was confirmed by Staff #6.

Based on review of the facility's physician on-call lists, review of policy and procedure, and staff interview, it was determined that the facility failed to maintain a physician on-call list in the Emergency Department (ED), for all physician specialties. Findings include: Reference: Facility policy titled Physician Coverage - Emergency Department, states, "... Outcome Criteria: The Emergency Department will be staffed by a licensed Physician 24 hours a day and also have various services on call 24 hours a day, 7 days a week. Process Criteria: ... The on-call schedule is maintained on [-website name-] and the daily on-call is listed by the unit clerk in [-facility's computer program name-]. ..." 1. On 4/6/15, review of the monthly physician on-call lists for the ED, from October 2014 to April 2015, revealed there were no physician names designated for Oral Maxillo-Surgery (OMS) for the months of December 2014, January 2015, March 2015 and April 2015. 2. The above was confirmed by Staff #1, Staff #6 and Staff #9. 3. Staff #6 stated in interview on 4/7/15 at 2:05 PM, that the facility has two Oral Maxillo-Facial Surgeons on staff, and the ED staff will try to call one of them first. If the two OMS physicians are not on-call, then ED staff will call the on-call physician for the OMS service at [another hospital within this hospital's healthcare system]. 4. Staff #1 was interviewed on 4/7/15 at 2:05 PM regarding the on-call service for the ED, for the specialty of Oral Maxillo-Facial Surgery. Per Staff #1, this facility has only two Oral Maxillo-Facial surgeons on staff, and they cannot cover the on-call service for the twelve months of the year. Staff #1 stated that one OMS takes call for four (4) months, the other for three (3) months. The facility has five (5) months of the year without coverage. a. Staff #1 provided documentation that one of this hospital's partnering hospitals, in their shared healthcare system, has agreed to cover the months of January, March, April, September, and December of 2015 for the OMS service. During these months, patients in need of the OMS service will be on divert to the partnering hospital. b. There was no documented evidence provided that the partnering hospital agreed to cover this facility's OMS on-call service for any months in 2014, or January and February in 2015. This was confirmed by Staff #1. Staff #1 stated in interview, that this arrangement was in effect in 2014, but was not "memorialized" [sic], as it is now.

Based on medical record review, review of facility documentation, and staff interview, it was determined that not all patients presenting to the ED are provided a medical screening exam by qualified medical personnel. Findings include: Reference: Medical Screening Criteria of Obstetrical Patients policy and procedure states, "Purpose: ... These guidelines describe criteria for the obstetrical registered nurse to perform an obstetrical medical screening examination and criteria for such screening in the OB Department. ... Policy: Patients 20 weeks gestation or greater, who present with an obstetrical problem (other than for scheduled procedures) will receive a medical screening examination in the OB Department consistent with this Policy. ... Guidelines: ... [4th bullet] an obstetrical medical screening examination performed in the OB Department is performed by licensed obstetrical physicians and certified nurse midwives; or registered nurses who have been credentialed, ... working in consultation with licensed physicians or certified nurse midwives who have been granted obstetrical privileges to treat patients in the OB Department in conformity with MHC's Medical Staff Bylaws and each hospital's Rules and Regulations." 1. Review of Medical Records #1, and #9 revealed the following: a. Medical Record #1 - The patient arrived at the labor and delivery department on 10/19/15 at 3:20 PM, was registered, and placed in a room. The patient was triaged at 3:26 PM. There was no documentation that qualified medical personnel examined the patient. b. Medical Record #9 - The patient arrived at the labor and delivery department on 2/18/15 at 11:43 AM, was registered, and placed in a room. The patient was triaged at 11:55 AM. There was no documentation that qualified medical personnel examined the patient. 2. The examination must be conducted by an individual who is determined qualified by hospital bylaws or rules and regulations. a. On 4/7/14 at 2:00 PM, the Medical Staff Bylaws Rules & Regulations were reviewed in the presence of Staff #1. There was no evidence of a definition of a Qualified Medical Person that can conduct a Medical Screening Examination. This was confirmed by Staff #1. 3. The bylaws or the rules and regulations do not define registered nurses as a qualified medical person who can provide a medical screening exam, as per the policy referenced above. 4. Staff #13 confirmed the above findings.