A. 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: 1. During a tour of the ED,conducted on March 2, 2017 at approximately 10:35 AM, it was revealed that there were no EMTALA signs posted in the following areas: a. Hospital main entrance/Lobby b. ED entrance c. ED main ambulance entrance d. ED Registration areas e. Fast track area f. ED main desk 2. Observation of the ED waiting room, revealed one (1) EMTALA sign posted in an area that is not visible where all patients are seated. 3. Observation in the Triage Room, was one (1) Spanish sign. The sign was not conspicuously posted and the font was small, making visualization difficult. 4. Observation of Exam Room #1, #2, #5, #6, #7(GYN Room), revealed signage was posted in each room. No Spanish signage noted. 5. Observation of Exam Rooms #3 and #4 revealed no signage posted. 6. Observation of the Isolation Room/Chest Pain Center, consisting of two (2) bays, showed one (1) Spanish language sign in the room. The sign was not conspicuously posted and the font was small, not likely to be noticed by all individuals. 7. Observation of the fourth (4th) floor, Labor and Delivery Unit, revealed no EMTALA signage in the unit. 8. Observation of the third (3rd) floor, Observation Rooms #305 and #306 had no signage posted. 9. The above findings were confirmed by Staff #4, #2, #11. B. Based on observation, facility record review and staff interview, it was determined that the facility failed to post EMTALA signage in the language(s) that are understandable by the population served by the hospital. Findings: Reference: Facility Document: 2016 Patient Population indicated, " ...SPA 3138 - 10%..." 1. During a tour of the facility conducted on March 2, 2017, the following was noted: a. The waiting room signage was written only in English. b. Treatment Rooms #1, #2, #5, #6 and #7 had signage in English only. 2. Facility record review indicated that the Spanish population accounts for ten (10) percent of the population served by the hospital. 3. The above findings were confirmed by Staff #2 and #5.

Based on review of ED on-call lists and staff interviews, it was determined that the facility failed to ensure that a physician on call list, that identifies the name of an individual physician on call for a specialty, is maintained. Findings include: 1. On 3/2/17, a tour of the ED was conducted in the presence of Staff #2 and Staff #4. a. Upon request, Staff #8 provided a binder for review containing physician on-call lists. i. The March, 2017 physician on-call list for the ED, March 4, 7 PM - 7 AM and March 31, 7 PM - 7 AM listed "TBD" under the name of the covering physician. ii. Upon interview, Staff #4 indicated that "TBD" was placed on the on-call list when the facility was not sure who was going to be covering during that time. b. On 3/2/17, review of the on-call lists from July, 2016 - March, 2017 revealed the following: i. On July 30, 2016, from 7 PM to 7 AM, the physician on-call was listed as "TBD". ii. On August 13, 2016 from 7 PM to 7 AM, August 20, 2016 from 7 PM to 7 AM, and August 28, 2016 from 7 PM to 7 AM, the physician on call was listed as "TBD". iii. On October 15, 2016 from 7 PM to 7 AM, October 16, 2016 from 7 AM to 7 PM, October 17, 2016 from 7 AM to 7 PM, October 20, 2016 from 7 AM to 7 PM, October 22, 2016 from 7 PM to 7 AM, and October 29, 2016, 7 AM to 7 PM and 7 PM to 7 AM, the physician on call was listed as "TBD". iv. On November 24, 2016 from 7 PM to 7 AM, November 25, 2016 from 7 PM to 7 AM, November 26, 2016 from 7 AM to 7 PM and 7 PM to 7 AM, and November 27, 2016 from 7 AM to 7 PM and 7 PM to 7 AM, the physician on-call was listed as "TBD". v. On December 24, 2016, December 25, 2016 and December 31, 2016, there was no name listed for physician on-call coverage on the Hospitalist Night Shift schedule. 2. Staff #1, Staff #2, and Staff #4 confirmed the above findings.

Based on medical record review, review of the ED log, and staff interview, it was determined that the facility failed to ensure that the ED log contained accurate information. Findings include: 1. Medical Record #4 documented the disposition of the patient as "discharged home". The ED log documented the disposition of the patient as" transferred". 2. Medical Record #10 documented the disposition of the patient as "discharge home". The ED log documented the disposition of the patient as "transferred". 3. Staff #19 confirmed the above findings.

Based on medical record review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to provide stabilizing treatment, within the capabilities of the facility, for all patients who present to the ED. Findings include: Reference #1: Facility policy titled Emergency Department Triage Guidelines states, "... To determine priority of care of patients, the classification is as follows: Triage Acuity Levels... 1. Immediate... Includes patients with critical, life-threatening injuries or illness, needing immediate evaluation and intervention. Examples of Immediate situations include:... Chest Pain/Dysrhythmia... 2. Emergent. A patient will be classified as emergent when prompt medical attention is required, but is not immediately life or limb threatening. ... ." Reference #2: Facility policy titled Patients Presenting with Chest Pain states, "... All patients who present to the Emergency Department with classic cardiac chest pain: severe, crushing, sub-sternal, pressure like, tearing, ... will be triaged and assigned at a minimum an emergent acuity. ... Chest pain associated with a past medical history of: Myocardial Infarction, Coronary Artery Disease, Coronary Artery Bypass Graft (CABG), Angioplasty, Cardiac Catheterization... . " Reference #3: Facility policy titled Pain Assessment and Management states, "... 3. The RN, with the assistance of nursing assistants, shall assess, treat and document pain management techniques applied to individual patients. Pain management shall be included in the patient's Plan of Care. ... 6. With a report or identification of indications of pain and discomfort, a full assessment shall be completed by an RN. Appropriate pain interventions shall be instituted. ... 8. The RN shall evaluate and document the patient's response to the intervention within sixty (60) minutes, and then minimally every shift, unless more frequent interventions are required. Evaluation of effectiveness of pain treatment shall be documented on the appropriate tool. ... ." 1. Review of Medical Record #6 on 3/3/17 revealed the following: a. Patient #6 arrived to the ED on 2/16/17 at 5:04 PM with complaints of chest pain and shortness of breath. Past medical history includes angina, hypertension, MI (heart attack), CABG (heart bypass surgery), cardiac catheterization, and cardiac stents x 4. The patient was triaged at 5:23 PM. The initial triage assessment indicated the patient's pain was rated an 8 out of 10. The patient was assigned an ESI level of 3 (Urgent). The patient received an MSE (medical screening exam) at 5:20 PM. The patient left against medical advice at 6:45 PM. b. The Medical Record #6 showed no evidence that patient received any intervention for pain. Staff #19 indicated that the MAR (medication administration record) showed the patient did not receive any medication during his/her visit. c. The patient's significant cardiac history and presentation of chest pain warranted an assignment of an ESI level 1 (Immediate), or minimally, an ESI level 2 (Emergent), based on facility policies. The patient was assigned an ESI level 3 (Urgent), which is a lower triage acuity. 2. The facility failed to follow its policies regarding pain intervention, triage acuity assignments, and patients with chest pain. 3. Staff #1 and Staff #2 confirmed the above findings. Based on medical record review, review of the ED log, and staff interview, it was determined that the facility failed to ensure that the ED log contained accurate information. Findings include: 1. Medical Record #4 documented the disposition of the patient as "discharged home". The ED log documented the disposition of the patient as" transferred". 2. Medical Record #10 documented the disposition of the patient as "discharge home". The ED log documented the disposition of the patient as "transferred". 3. Staff #19 confirmed the above findings.

Based on observation, staff interviews, and facility record review, it was determined that the facility failed to ensure a reasonable registration process for patients seeking treatment that will unduly discourage individuals from remaining for further evaluation. Findings: Reference: Facility Policy: Emergency Department Triage Guidelines states, " ...1. All patients arriving ambulatory to the E.D. will be seen by the Registrar and the patient's name and date of birth will be entered into the registration system ...a) Assess every patient who presents in the Emergency Department prior to being registered by a clerk." 1. During an interview conducted on March 2, 2017, Staff #1 stated that all consents are obtained at the same time when the patient is registered in the ED. 2. Medical record review conducted on March 3, 2017, revealed 15 of 20 patients were fully registered before triage. a. Medical Record #1 indicated that on 5/27/16, the patient arrived at the ED at 1151, signed the consent for treatment (registered) at 1200 and was triaged at 1207. b. Medical Record #2 indicated that on 2/24/17, the patient arrived at the ED at 1802, signed the consent for treatment (registered) at 1802 and was triaged at 1817. c. Medical Record #3 indicated that on 2/5/16, the patient arrived at the ED at 0332, signed the consent for treatment (registered) at 0332 and was triaged at 0403. d. Medical Record #4 indicated that on 2/22/17, the patient arrived at the ED at 1937, signed the consent for treatment (registered) at 1937 and was triaged at 1952. e. Medical Record #5 indicated that on 2/7/17, the patient arrived at the ED at 0027, signed the consent for treatment (registered) at 0027 and was triaged at 0052. f. Medical Record #6 indicated that on 2/16/17, the patient arrived at the ED at 1704, signed the consent for treatment (registered) at 1704 and was triaged at 1723. g. Medical Record #7 indicated that on 2/20/17, the patient arrived at the ED at 2005, signed the consent for treatment (registered) at 2005 and was triaged at 2019. h. Medical Record #8 indicated that on 7/25/16, the patient arrived at the ED at 1331, signed the consent for treatment (registered) at 1331 and was triaged at 1342. i. Medical Record #9 indicated that on 7/18/16, the patient arrived at the ED at 0752, signed the consent for treatment (registered) at 0752 and was triaged at 0805. j. Medical Record #10 indicated that on 5/2/16, the patient arrived at the ED at 0657, signed the consent for treatment (registered) at 0657 and was triaged at 0725. k. Medical Record #13 indicated that on 7/19/16, the patient arrived at the ED at 1106, signed the consent for treatment (registered) at 1106 and was triaged at 1114. l. Medical Record #14 indicated that on 5/6/16, the patient arrived at the ED at 0325, signed the consent for treatment (registered) at 0325 and was triaged at 0333. m. Medical Record #15 indicated that on 5/15/16, the patient arrived at the ED at 1756, signed the consent for treatment (registered) at 1750 (as signed on the patients consent) and was triaged at 1813. n. Medical Record #17 indicated that on 2/5/17, the patient arrived at the ED at 0639, signed the consent for treatment (registered) at 0639 and was triaged at 0657. o. Medical Record #18 indicated that on 7/15/16, the patient arrived at the ED at 1016, signed the consent for treatment (registered) at 1016 and was triaged at 1037. 3. This is a possible deterrent to individuals seeking treatment, unduly discouraging patients from remaining for further evaluation. 4. The above findings were confirmed with Staff #1 and #2.

Based on medical record review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to provide an appropriate patient transfer. Findings include: Reference: Facility policy titled Transfer of admitted Patient to Acute Care Facility states, "... 9. The Clinical Manager (or the Administrative Manager during off shift) will review the chart and Hospital Transfer Form to ensure compliance with EMTALA regulations, prior to the patient's transfer. ... 10. -[Facility Name]- RN shall make a follow-up phone call to the receiving facility RN within two hours of transfer to ascertain the condition of the patient at arrival. ... ." 1. Review of Medical Record #16 on 3/3/17 revealed the following: a. Patient #16 arrived to the ED on 7/2/16 at 4:09 AM with complaints of chest pain, shortness of breath and right arm numbness. Lab results indicated an elevated troponin. The patient was transferred to another facility for NSTEMI (heart attack). b. The Hospital Transfer form dated 7/2/16 lacked the following documentation: i. Name of Ambulance transporting the patient. ii. Documentation that the following items were sent with the patient: copies of the medical record, laboratory results, x-rays, EKG, or original transfer form. iii. Name of facility RN the report was given to. iv. Patient status upon transfer. v. Signature of RN writing exit note. vi. Follow-up information which includes: name of RN contacted, date/time contacted, name of the recipient facility, patient condition on arrival, was the correct information sent, and was the patient/family satisfied with the transfer? c. The facility failed to ensure the hospital transfer form was completed according to its policy. 2. Staff #1 and Staff #2 confirmed the above findings.