Healthcare leaders are carefully weighing the wording of signs aimed at reducing workplace violence out of concern about violating the Emergency Medical Treatment and Labor Act.
Among an array of efforts to minimize and prevent violence in healthcare settings — such as legislation that categorizes violence against a healthcare worker as a felony — there is an unanswered question that has been raised for years: Do signs in EDs discouraging violence also dissuade continuation of emergency care?
In 1986, Congress enacted EMTALA, which requires emergency departments to provide medical screening examinations to anyone who requests evaluation or treatment, regardless of the person’s insurance status or ability to pay. EMTALA also compels EDs to provide stabilizing treatment for patients with an emergency medical condition.
Becker’s reviewed thousands of EMTALA hospital surveys with deficiency statements and found a few examples of anti-violence signage mentions. For instance:
- A hospital in Amarillo, Texas, was cited after failing to complete a medical screening exam on a patient who was combative. Surveyors noted a sign outside a behavioral health access entrance that read, “There’s a zero tolerance for workplace violence.”
- At a hospital in Vancouver, Wash., security told a patient who was yelling and swearing in the waiting area to leave. No medical screening exam was completed. “The patient was advised of the [hospital’s] directive and signage that verbally abusive, aggressive and threatening behavior could result in the patient being asked to leave. The patient ‘left of their own doing.’”
As rates of incivility and violence increase in healthcare facilities, organizations representing U.S. healthcare workers have been seeking clarity on lawful, appropriate signage in EDs to discourage threats and violence. They have not received an answer.
In a Jan. 20 letter to CMS, the American College of Emergency Physicians, American Hospital Association and eight other national healthcare organizations asked the agency to clarify what signage could be interpreted as deterring patients from seeking or continuing care, which risks violating EMTALA.
“[E]nforcement to date has been uneven, with hospitals reporting that surveyors sometimes question or cite even neutral workplace violence signs as potential EMTALA violations,” the letter said.
When asked for guidance, CMS has said it discourages signs that could deter patients from seeking or staying for medical screening examinations and stabilizing treatment, but the agency does not recommend specific phrasing.
The organizations that penned the letter told Becker’s the agency has not responded as of Feb. 27.
Eric Sean Clay, vice president and chief security officer of Baton Rouge, La.-based FMOL Health, said this question over anti-violence signs and EMTALA has circulated for years.
Mr. Clay, who joined FMOL Health in October 2025 after serving as vice president of security services at Memorial Hermann Health System in Houston, said healthcare organizations can comply with EMTALA and manage violent behavior at the same time — as long as there are sufficient security protocols and investments.
“Security, de-escalation, environmental controls and even law enforcement involvement are all permissible as long as they do not delay, discourage or deny a medical screening exam or stabilizing care,” he said. “EMTALA violations typically occur when hospitals use violence or disruptive behavior as a reason not to conduct the medical screening exam, discharge patients prematurely or transfer them without stabilization.”
“It’s important to consider that violent behaviors and aggression is part of the emergency condition for many behavioral health patients,” he added. “It is an EMTALA violation to discharge them instead of fully evaluating and stabilizing them, even to reduce disruptions to the care of other patients.”
Mr. Clay, who held security leadership roles at Springfield, Mo.-based CoxHealth and The Walt Disney Co. and served in the U.S. Federal Air Marshal Service, has more than 30 years of experience in security and law enforcement. He said workplace violence is the biggest threat to the healthcare industry.
Although workplace violence is underreported, healthcare’s rate of injuries, illnesses and fatalities remains far above the national average, according to 2021-22 data from the Bureau of Labor Statistics. Healthcare and social assistance has an incidence rate of 14.2 per 10,000 full-time workers; the average across all industry sectors is 2.2.
Dangerous workplace conditions are prompting nurses to consider leaving the industry at a time when demand for healthcare is expected to continue rising. Mr. Clay said this issue will “have a detrimental impact on patient outcomes, on the cost of healthcare and the timeliness of healthcare.”
When it comes to ED signage, Mr. Clay suggested that signs declaring a “zero tolerance” policy on violence could dissuade patients.
Laura Wooster, the American College of Emergency Physicians’ associate executive director of advocacy and practice affairs, told Becker’s that a surveyor could deem a “zero tolerance” sign as an EMTALA violation, while another might not.
“We don’t have details of the specific language surveyors have cited or raised concerns about,” Ms. Wooster said. “My understanding is that enforcement has been inconsistent and uneven among surveyors, which is not surprising given the lack of clear guidance for them to work from.”
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