Based on record review, observation, and interview the facility failed to ensure compliance with EMTALA (Emergency Medical Treatment and Active Labor Act) requirements in 3 of the 7 required areas (Posting of Signs; Medical Screening Exam; Appropriate Transfer). Findings include: 1) The facility failed to complete an appropriate medical screening exam for 2 of 2 patients (Patient #1 and 2) who presented to the Emergency Department or to the grounds of the facility with potential emergency medical conditions. The total patient sample was 21. (Reference A 2406) 2) The facility failed to ensure all patients being transferred from the Emergency Department to an alternate facility had complete and accurate transfer consent forms in 4 out of 4 transferred patients out of a total of 21 medical records reviewed (Patient #6, 13, 14, and 19). (Reference A 2409) 3) The facility failed to post EMTALA (Emergency Medical Treatment and Active Labor Act) signs where they are highly visible and likely to be seen by patients waiting for emergency treatment in 2 of 2 areas observed where patients receive emergency treatment (Emergency Department and Obstetrics unit). (Reference A 2402)

Based on observation and interview, this facility failed to post EMTALA (Emergency Medical Treatment and Active Labor Act) signs where they are highly visible and likely to be seen by patients waiting for emergency treatment in 2 of 2 areas observed where patients receive emergency treatment (Emergency Department and Obstetrics unit). Failure to post EMTALA signs in highly visible places for patients has the potential to affect all patients seeking emergency treatment in this facility. Findings include: A tour of the Emergency Department was conducted on 1/30/2017 at 10:10 AM accompanied by Emergency Department Manager B. The following areas were observed not to have EMTALA signs: --Emergency Department entrance --Emergency Department waiting room --18 of 18 treatment rooms Per interview with Manager B during the tour of the Emergency Department at 10:15 AM regarding the lack of EMTALA signs in the department, Manager B stated, "We asked for them about a year ago and haven't gotten them yet." A tour of the Obstetrics unit was conducted on 1/30/2017 at 11:45 AM accompanied by Compliance Program Coordinator C and Manager of Family Birth Center D. Manager D stated that the Obstetrics department routinely receives patients that need to be medically screened. There are no EMTALA signs in the waiting area of the Obstetrics department and Manager D stated D was not aware it was a requirement.

Based on record review and interview, staff in the Emergency Department of this facility failed to ensure that patients presenting to the Emergency Department/grounds of the facility with a potential emergent condition receive an appropriate Medical Screening examination in 2 of 2 patients diverted for treatment out of a total of 20 medical records reviewed (Patient #1 and 2). Failure to perform appropriate medical screening examinations has the potential to affect all patients seeking emergency treatment at this facility. Findings include: The facility's policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," #755 dated 5/1/2015 was reviewed on 1/30/2017 at 11:10 AM. The policy states in part, "Any individual who presents to the Emergency Department for emergency care of the hospital shall undergo a medical screening examination to determine whether that individual is experiencing an emergency medical condition." Patient #1's Emergency Department record was reviewed on 1/30/2017 at 12:06 PM. Patient #1 arrived at this emergency department at 6:24 PM on 1/11/2017, accompanied by a family member, with reported suicidal ideation and thoughts of self-harm. Registered Nurse K completed triaging Patient #1 at 6:33 PM and directed Patient #1 and family member to the waiting room. Per phone interview with Registered Nurse Care Manager J on 1/30/2017 at 1:56 PM regarding the events of 1/11/2017 when Patient #1 presented to the emergency department, Care Manager J stated, "I'm the guilty party. The biggest mistake I made was saying we were really busy." Care Manager J talked with Patient #1 and family member in a confidential location off of the emergency department waiting room and discovered that the family member's initial thought was to take Patient #1 to the alternate facility but just got new insurance for the new year and was not sure what facility was covered so brought Patient #1 to this facility. Care Manager J said, "We are more than happy to help you, but there is about a 2 hour wait time to see the doctor and we would have to transfer [#1] after that anyway because we do not offer adolescent psychiatric care here." Care Manager J stated that J offered to make calls to investigate coverage for family member, who agreed. It was determined that the other facility was covered under the new insurance. This information was relayed to the family member and Care Manager J asked the family member what they would like to do. Family member directed Care Manager J to see if there was an opening at the other facility and if they would take Patient #1. Care Manager J stated that J called the other facility, 5th floor psychiatric unit to inquire about placement, was asked what kind of insurance the patient had and then stated, "I don't remember if I called back or [nurse from other facility] did, but I was transferred to their emergency department and talked to a [gender specific] nurse to let them know Patient #1 would be on the way." After that Patient #1 and family member left to go to the other facility. Care Manager J did not document these phone calls or the names of who was called from the other facility. Care Manager J stated, "My agenda was not to dump. My agenda was to look at a [AGE] year old suicidal ideation and get [#1] the help [#1] needed. I don't remember who I talked to. I didn't realize they had to sign out AMA (against medical advice) or whatever and left [#1] go on [#1's] way. [Family member] was okay with the plan, the [Patient #1] was okay with the plan." Per review of Patient #2's police report reviewed on 1/30/2017 at 1:30 PM, on 1/12/2017 at 7:11 PM police officers were dispatched to attend to Patient #2 who was brought to the grounds of this facility via taxi cab due to not being able to stay at a warming shelter Patient #2 presented to earlier in the evening due to intoxication. The taxi pulled up outside of the emergency department entrance of this facility. Per interview with Registered Nurse Paramedic G on 1/30/2017 at 1:40 PM regarding the events of 1/12/2017 when Patient #2 was brought to the grounds of this facility, Paramedic G stated, "My partner went to the ER [emergency room ] to see where the patient was, the ER knew nothing about it. We found [Patient #2] at the end of the vestibule by the outside doors. Police helped [#2] in to a wheelchair, they brought [#2] in because it was cold. Officers requested we transport to [alternate facility] so we did." Paramedic G stated that no one from this facility, that G was aware of, asked where the patient was, but [#2] was on the premises. Per phone interview with Paramedic I on 1/30/2017 at 1:46 PM regarding the events of 1/12/2017 when Patient #2 was brought to the grounds of this facility, Paramedic I stated, "We got a rare 911 call to respond to the hospital. I walked to the ED [emergency department] to see what was going on, talked to staff, no one had any idea. One staff said 'I saw some cops at the entrance, that must be what it is.' We found the patient at the vestibule with police. Police told the story of what happened and they brought the patient inside to wait. Police directed us to take [Patient #2] to [alternate facility]." When asked if any of this facility's staff came out to assist or see what was happening, Paramedic I stated that security staff came out to see what was going on but no one from the ED responded. Per interview with Registration Clerk M on 1/30/2017 at 3:20 PM regarding the events of 1/12/2017 when Patient #2 was brought to the grounds of this facility, Registration Clerk M stated, "I remember a police officer standing there but I had no idea what was going on. I called security because there was police on campus. That's all I know, I'm not even sure if this was the same day or not." Per interview with Emergency Department Manager B on 1/30/2017 at 4:05 PM regarding why emergency department staff would not respond to a potential patient in need on the grounds of their facility, inside the building at the emergency department entrance, Manager B stated, "Typically we would go out to see what's going on if there are police on site. I don't know why, in this instance, no one did." Patient #2 was diverted to an alternate facility by police officers, however Patient #2 presented to the grounds of this facility, at the emergency room entrance, and was not registered as a patient, or given a medical screening examination.

Based on record review and interview, staff at this facility failed to complete transfer documents specifying risks and benefits of the transfer that are unique to the patient in 4 out of 4 transfers to other facilities out of a total of 21 medical records reviewed (Patient #6, 13, 14, and 19), and/or failed to ensure proper authentication of transfer documents was complete in 1 out of 5 transfer forms completed out of a total of 21 medical record reviews (Patient #6). Findings include: The facility's policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," #755 dated 5/1/2015 was reviewed on 1/30/2017 at 11:10 AM. The policy states in part, "Transfer:...4. All reasonable steps shall be taken to secure the written consent or refusal of the patient (or the patient's representative) with respect to the transfer. The transferring physician...must inform the patient (or patient's representative) of the risks and benefits of the proposed transfer." The Medical Staff Rules and Regulations, dated 6/2011, were reviewed on 1/30/2017 at 11:12 AM. The Rules and Regulations state in part, "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated." Patient #6's medical record was reviewed on 1/30/2017 at 1:33 PM accompanied by Registered Nurse E who confirmed the following during the record review: Patient #6 arrived at the emergency department on 12/6/2016 with suicidal ideations and was transferred to an alternate facility. The transfer consent that the patient signs identifies the following for reasons for transfer: "Qualified clinical personnel or service unavailable." The benefits of transfer identified are: "Specialized services/equipment at receiving facility." The risks of transfer are identified as: "Deterioration, loss of IV [intravenous], discomfort, accidents or delay, worsening condition, death." The nurse and provider signatures are not authenticated with a time on Patient #6's transfer consent form. Patient #13's medical record was reviewed on 1/30/2017 at 2:26 PM accompanied by Registered Nurse E who confirmed the following during the record review: Patient #13 arrived at the emergency department on 12/1/2016 with symptoms of a stroke and was transferred to an alternate facility. The transfer consent that the patient signs identifies the following for reasons for transfer: "Qualified clinical personnel or service unavailable." The benefits of transfer identified are: "Specialized services/equipment at receiving facility." The risks of transfer are identified as: "Deterioration, loss of IV [intravenous], discomfort, accidents or delay, worsening condition, death." Patient #14's medical record was reviewed on 1/30/2017 at 2:30 PM accompanied by Clinical Informatics Nurse F who confirmed the following during the record review: Patient #14 arrived at the emergency department on 1/5/2017 with markedly elevated blood pressure and slurred speech and was transferred to an alternate facility. The transfer consent that the patient signs identifies the following for reasons for transfer: "Qualified clinical personnel or service unavailable." The benefits of transfer identified are: "Specialized services/equipment at receiving facility." The risks of transfer are identified as: "Deterioration, loss of IV [intravenous], discomfort, accidents or delay, worsening condition, death." Patient #19's medical record was reviewed on 1/30/2017 at 3:00 PM accompanied by Clinical Informatics Nurse F who confirmed the following during the record review: Patient #19 arrived at the emergency department on 1/8/2017 with back pain and was found to have a herniated disc of the lower spine. Patient #19 was transferred to an alternate facility. The transfer consent that the patient signs identifies the following for reasons for transfer: "Qualified clinical personnel or service unavailable." The benefits of transfer identified are: "Specialized services/equipment at receiving facility." The risks of transfer are identified as: "Deterioration, loss of IV [intravenous], discomfort, accidents or delay, worsening condition, death." In an interview with Clinical Informatics Nurse F on 1/30/2017 at 3:11 PM regarding all of the reasons, risks, and benefits of transfer being the same for all patients with the transfer form, Nurse F stated that F assisted to build the computerized form and agreed that they do not reflect the individualized needs of each of the patients. Clinical Informatics Nurse F stated that providers are able to free text in the form to specify the reasons, risks, and benefits.