Based on findings from document review and interview, the hospital failed to comply with the requirements at 489.24 and related requirements at 489.20. Please reference findings at Tags A2402, A2406 and A2411

Based on findings from observation and interview, the hospital failed to post EMTALA (Emergency Medical Treatment & Active Labor Act) signage in all areas likely to be noticed by all patients arriving to the emergency department (ED). Specifically, EMTALA signs were not posted in the ambulance entrance area of the ED or the Pediatric ED. Findings include: -- During a tour of the ED 1/3/17 at 9:30 am, there was no EMTALA signage posted in the entrance to the ED where patients arrive via ambulance. -- During a tour of the Pediatric ED (on the 4th floor) on 1/3/17 at 9:45 am, there was no EMTALA signage in the waiting room, registration area or triage area. -- During interview of Staff A on 1/3/17 at 9:30 am and 9:45 am, he/she acknowledged the lack of EMTALA signage.

Based on findings from document review and interview, the hospital's bylaws and Emergency Medical Treatment and Labor Act (EMTALA) policy and procedure (P&P) lacked description of a physician extender. Also the P&P was not approved by the Governing Body. Findings include: -- Review of hospital P&P titled "EMTALA (Emergency Medical Treatment and Labor Act) and COBRA (Consolidated Omnibus Reconciliation Act) Management and Compliance," last revised 4/2015, revealed that a medical screening exam should be provided by a physician or physician extenders. The P&P did not identify categories of health professionals considered by the hospital to be physician extenders. Additionally, there was no documentation to indicate the P&P was approved by the Governing Body. -- Review of Article 7 of Upstate University Hospital (UUP) Medical staff bylaws addressing health professionals revealed the following statements: Physician assistants and Nurse Practitioners assigned to the ED will perform their duties according to written policies and treatment protocols established by the Emergency Medicine department and adopted by the Medical Executive committee. -- During interview of Staff B on 1/3/17 at 4:00 pm, the above findings were acknowledged.

Based on findings from document review and interview, in 3 of 20 referral cases reviewed (Patients #1, #2, #3), the hospital failed to accept patients who required inpatient care despite having specialized services and the capacity to treat the patient. Findings include: University Hospital (UH) documents information about transfer requests received from referring hospitals in the Upstate Triage and Transfer Center (Transfer Center) Transfer Summary Report (Transfer Report), in narrative report documentation completed by Transfer Center nursing staff and in audio recordings of telephone calls between UH and referring hospital staff. Patient #1 -- Review of the transferring hospital's (Hospital A's) medical record (MR) for Patient #1 revealed that the patient presented to Hospital A's emergency department (ED) on 12/12/16 with complaints of sudden onset of mid thoracic back pain, left arm numbness and headache. Examination and testing found Patient #1 had a dissection of the ascending aorta extending into the left subclavian artery and required evaluation by a cardiothoracic surgeon. (Hospital A does not have cardiac surgery services.) Hospital A's ED physician contacted the UH (Transfer Center) to arrange transfer. -- Review of the audio recording and handwritten time line documented by Transfer Center nurse indicated that at 2:27 am, Hospital A's ED physician spoke with Staff C (cardiothoracic surgeon) regarding Patient #1 and the need for transfer. Even though UH had capacity, Staff C indicated he/she could not accept the patient because he was a locums (contracted physician) and was leaving in 3 hours. Hospital A's ED physician indicated that another hospital would be contacted to accept the transfer. Staff C indicated he/she would call the physician coming on and and get back to Hospital A's ED physician. During the subsequent call, Hospital A's ED physician informed Staff C that another hospital had accepted the patient. Patient #2 - {on 2 PC status (two physician certification for involuntary admission)} -- Review of Transfer Center nursing staff narrative report documentation dated 7/3/16 between 9:31 am and 1:42 pm described an initial call from Hospital B inquiring about a psychiatric bed for a patient with depression and suicidal ideation. Transfer Center nursing staff confirmed with the nursing supervisor at UH Community Campus that a bed was available. Subsequent documentation of calls revealed that Patient #2 was not accepted for admission to the psychiatric unit as Staff E (Community Campus Psychiatric Nurse Practitioner) felt the patient needed an alcohol substance program and recommended that the patient be presented again the following morning. -- Additional Transfer Center nursing documentation regarding Patient #2 revealed that at on 7/3/16 at 5:54 pm, Hospital B again contacted UH requesting to transfer Patient #2 and that Staff F (Community Campus Psychiatric Nurse Practitioner) stated the case would not be reviewed until the following day. Staff G (Psychiatric Attending Physician) was contacted, who stated that 5 West (Community Campus psychiatric unit) received 5 new patients that day and would not accept any more new patients that day. Patient #3 - on 2 PC status -- Review of a Transfer Center Report referral dated 7/3/16 at 5:54 pm, revealed a telephone call from Hospital B regarding referral of a ED patient with suicidal ideation and depression to psychiatry. -- Review of Transfer Center nursing staff narrative documentation dated 7/3/16 at 8:02 pm indicated that Staff F stated the case would not be reviewed until the following day. Staff G was contacted and stated that the psychiatric unit at Community Campus received 5 new patients that day and even though beds were available, he/she would not accept any new patients that day. Despite having capacity with documentation indicating that the psychiatric unit at the Community Campus had 11 available beds on 7/3/16 at 7:00 am, UH did not accept the patients for transfer. -- During interview of Staff B on 1/9/17 at 11:00 am, the above findings were acknowledged.