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Based on medical record review, policy and procedure review, and staff interview, the hospital failed to ensure that 1 of 20 sampled obstetric patients who presented to the Obstetrics Department (OB) requesting care received a medical screening exam within the hospital's capability and in accordance with the hospital's policies and procedures (Patient # 24). The hospital had an average of 40 patients that presented to the obstetrics department requesting care monthly.

Failure to enforce the hospital's policy that patients receive an appropriate medical screening examination for an emergency medical condition resulted in the patient's discharge to the jail where the patient delivered a baby approximately 4 hours later without medical assistance.

Findings include:

1. Patient #24's prenatal record was available to the ED via the electronic medical record. The patient's last prenatal visit on 8/26/13, revealed the patient was G5P3 with expected date of delivery to be 9/13/13. (G5P3 means the patient had been pregnant 5 times and 3 of these pregnancies were successfully delivered as live births.) The patient had had 3 deliveries, the first delivery in 12/2001 with labor of 14 hours that resulted in a vaginal delivery, the second delivery in 4/2008 with labor of 8 hours that resulted in a vaginal delivery, and the third delivery in 4/2012 with labor of 4 hours that resulted in a vaginal delivery. The prenatal record identified risks as late to care (prenatal care began at 24 weeks) and drug, alcohol and tobacco use during pregnancy.

2. Review of Patient #24's medical record revealed the 25 year old came from the jail to the hospital and arrived in the obstetrics (OB) department by wheelchair on 8/29/12 at 3:20 AM. At that time, the initial triage nursing assessment by Registered Nurse (RN) B revealed the patient presented to OB with complaints of headache, dizziness, pressure and contractions.

RN B documented a vaginal examination completed by Provider A, the on-call OB physician, a transitional year resident (intern), on 8/29/13 at 4:11 AM, revealed the patient was 4 of 10 cm (centimeters) dilated and 50 % effaced and at a -2 station.

Provider A, documented the patient's chief complaint was elevated blood pressures, nausea, headache, and low back pain. The history of present illness showed the patient was G5P3 at 36 weeks 3 days gestation with expected date of delivery to be 9/13/13. The 8/29/13 medical record showed the patient had experienced a blood pressure of 145/70 at 10:30 AM and 154/101 at 2:00 PM the prior day. The patient complained of not feeling well all day (8/28/13) and believed she was having contractions although had been unable to time them due to the unavailability of a clock. The patient stated she has had burgundy/yellow vaginal discharge.

Provider A documented the patient was 4 of 10 cm dilated, 50 % effaced and at a -2 station. Provider A documented the patient was not in active labor and educated the patient on active labor and to come in should signs present. The medical record lacked documentation of examination by or consultation with the attending OB physician.

At 5:05 AM, RN B documented the patient had mild and irregular contractions. At that time, the patient complained of back pain and was unsure how often the contractions occurred. Heat was applied to her back. RN B documented a vaginal examination completed by Provider A on 8/29/13 at 5:28 AM revealed the patient was 4 of 10 cm dilated, 50% effaced and at a -2 station. The patient was discharged back to jail on 8/29/13 at 5:42 AM.

3. Review of Patient #24's medical record revealed a 25 year old incarcerated patient arrived in the obstetrics (OB) department a second time on 8/29/12 at 1:41 PM. At that time, the initial triage nursing assessment by Registered Nurse (RN) C revealed the patient presented to OB with complaint of contractions began on 8/29/13 at 12:30 PM. RN C documented a vaginal examination completed on 8/29/13 at 1:59 PM revealed the patient had contractions every 1.5 minutes lasting 40 to 50 seconds, was 4 of 10 cm dilated and 100 % effaced.

The OB physician on call, Provider B, a first year resident, documented the patient presented for concerns of increasing frequency of contractions. Provider B documented the patient felt like the contractions were every 30 minutes this morning and now are more often, anywhere from every 2 - 15 minutes and last 2 minutes. The patient stated the contractions are stronger and she is still having bloody discharge but no gush of fluids. Provider B documented the patient was 4 of 10 cm dilated, 50 % effaced and at a -2 station. Provider B documented the patient was not in active labor and educated the patient on active labor and to return should signs present.

At 4:10 PM, RN C documented it was difficult to trace [contractions] due to patient movement and the patient stated that she had had about 4 big contractions since arriving at the hospital. RN C documented a vaginal examination completed by Provider B and RN C on 8/29/13 at 4:22 PM revealed the patient was 4 of 10 cm dilated, 100 % effaced and at a -2 station. The medical record lacked evidence of examination by or consultation with the OB attending physician who was ultimately responsible for the patient's care and the determination if the patient was in the latent phase of early labor or experiencing false labor prior to either discharge.

The patient was discharged back to jail on 8/29/13 a second time at 4:42 PM without the ability to freely return to the hospital if her contractions increased in frequency and intensity.

4. Review of Patient #24's medical record revealed documentation that the patient returned to OB on 8/29/13 at 10:05 PM after the patient delivered, without any medical attention while laying on a mattress on the floor of the jail cell at 9:18 PM, approximately 4.5 hours after being discharged from the hospital.

5. The hospital's Clinic Services Provision of Patient Care policy titled, "Transfer of Patients to Other Health Care Facilities", dated 8/2012, included the following relevant Emergency Medical Treatment and Labor Act (EMTALA) guidance for staff:

a. Policy: In accordance with Federal EMTALA laws, Broadlawns Medical Center will provide, within its capabilities, an appropriate medical screening examination for each individual who comes to the Emergency Department and a request is made on the individual's behalf for an examination or treatment of a medical condition; or who has presented on hospital property and requests examination or treatment for what may be an emergency medical condition or has the request made on his/her behalf, or a prudent lay person, based on individual's appearance, would believe the individual needs emergency treatment. In the event that the medical screening examination identifies an emergency medical condition, the medical center will: provide necessary treatment to stabilize the patient to the best of our ability and minimize risk, and/or 2) provide for an appropriate transfer if necessary, once the patient is stabilized to the best of our ability. Decisions regarding a patient's evaluation and emergency treatment will be made based on the medical needs or documented request of the patient and will be made without regard to age, sex, diagnosis, financial status, race, color, national origin, religion, or disability.

b. Definitions: Labor: The process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician /approved medical screener certifies that after a reasonable time of observation the woman is in false labor.

c. EMTALA Requirements: Medical Screening Examinations: All individuals who present to the medical center requesting an unscheduled examination or treatment for a medical condition including women in labor will have an appropriate medical screening examination performed within the normal capability of the medical center's available staff and facilities in order to determine if an emergency medical condition exists.

d. Family Birthing Center (1) Physicians: Any physician medical staff member with appropriate obstetrical privileges is authorized to perform medical screening examinations in any location on the medical center premises.

6. Review of the hospital's policy A-0708, titled, "Institutional Policies for Residents' Supervision", dated 2/2012, revealed, I. Purpose: In the clinical learning environment, each patient must have an identifiable, appropriately credentialed and privileged attending/faculty physician who is ultimately responsible for that patient's care. IV. A. [Hospital] through its Graduate Medical Education Committee, ... provides institutional oversight to assure that residents are appropriately supervised.

7. When asked about Patient #24 during an interview on 9/25/13 at 4:35 PM, Physician C, Attending Physician, reported the residents examine the patients. The residents are instructed that none of the patients should leave the OB Department unless the residents call one of the on-call attending physicians. Physician C stated the resident and attending physician decide whether the patient should be discharged or kept in the hospital. Physician C stated that during the last visit, Patient # 24 thought she was having contractions. The patient's cervix was checked every time by a resident and there was no difference in the dilation. The patient did not have any more contractions and the patient looked comfortable. Physician C stated it did not look like the patient was in active labor and the patient was discharged back to jail. Physician C stated the residents called him to discuss the patient's case before the patient was discharged and returned to jail.

Based on observations and staff interview, the hospital failed to ensure staff placed signs specifying the rights of individuals and women in labor regarding their right to an examination and treatment for emergency medical conditions and whether or not the hospital participates in the Medicaid program. The signs should be visible to all patients entering the emergency department by ambulance. The hospital had an average of 109 patients per month arrive at the hospital and entered the Emergency Department through the ambulance entrance. The hospital had an average of 2988 patients per month in the Emergency Department.

Failure to post signs informing the patients of their rights potentially results in patients misunderstanding their rights to receive an examination and stabilizing treatment when they come to the hospital for a medical emergency and or to avoid seeking treatment at the hospital for a medical emergency.

Findings include:

Tour of the Emergency Department on 9/23/13 at 3:10 PM with Staff A, Charge Nurse, revealed 20 of 20 emergency department rooms and 1 of 1 ambulance entrance lacked posted signs displaying the required information to help patients understand their rights to examination and stabilizing treatment of their emergency medical condition. During the tour, Staff A acknowledged 20 of 20 emergency department rooms and 1 of 1 ambulance entrance lacked the required posted signs and persons entering the ED through the ambulance entrance may not see the required signage.

Based on medical record review, policy and procedure review, peer review and staff interview, the hospital failed to ensure that 1 of 20 sampled obstetric patients who presented to the Obstetrics Department (OB) requesting care received an adequate medical screening exam to determine presence or absence of an emergency medical condition (Patient # 24). The hospital had an average of 40 patients that presented to the obstetrics department requesting care monthly.

Failure to provide a complete medical screening examination resulted in the patient's discharge to the jail where the patient delivered a baby approximately 4 hours later without medical assistance.

Findings include:

1. Patient #24's prenatal record was available to ED staff via the electronic medical record. The patient's last prenatal visit on 8/26/13, revealed the patient was G5P3 with expected date of delivery to be 9/13/13. (G5P3 means the patient had been pregnant 5 times and 3 of these pregnancies were successfully delivered as live births.) The patient had had 3 deliveries, the first delivery in 12/2001 with labor of 14 hours that resulted in a vaginal delivery, the second delivery in 4/2008 with labor of 8 hours that resulted in a vaginal delivery, and the third delivery in 4/2012 with labor of 4 hours that resulted in a vaginal delivery. The prenatal record identified risks as late to care (prenatal care began at 24 weeks) and drug, alcohol and tobacco use during pregnancy.

2. Review of Patient #24's medical record revealed the 25 year old came from the jail to the hospital and arrived in the obstetrics (OB) department by wheelchair on 8/29/12 at 3:20 AM. At that time, the initial triage nursing assessment by Registered Nurse (RN) B revealed the patient presented to OB with complaint of headache, dizziness, pressure and contractions.

RN B documented a vaginal examination completed by Provider A, the on-call OB physician, a transitional year resident (intern), on 8/29/13 at 4:11 AM, revealed the patient was 4 of 10 cm (centimeters) dilated, 50 % effaced and at a -2 station.

Provider A, documented the patient's chief complaint was elevated blood pressures, nausea, headache, and low back pain. The history of present illness showed the patient was G5P3 at 36 weeks 3 days gestation with expected date of delivery to be 9/13/13. The 8/29/13 medical record showed the patient had experienced a blood pressure of 145/70 at 10:30 AM and 154/101 at 2:00 PM the prior day. The patient complained of not feeling well all day (8/28/13) and believed she was having contractions although had been unable to time them due to the unavailability of a clock. The patient stated she has had burgundy/yellow vaginal discharge.

Provider A documented the patient was 4 of 10 cm dilated and 50 % effaced and at a -2 station. Provider A documented the patient was not in active labor and educated the patient on active labor and to come in should signs present.

At 5:05 AM, RN B documented the patient had mild and irregular contractions. At that time, the patient complained of back pain and was unsure how often the contractions occurred. Heat was applied to her back. RN B documented a vaginal examination completed by Provider A on 8/29/13 at 5:28 AM revealed the patient was 4 of 10 cm dilated, 50% effaced and at a -2 station. The patient was discharged back to jail on 8/29/13 at 5:42 AM. The medical record lacked documentation of examination by or consultation with the attending OB physician.

3. Review of Patient #24's medical record revealed a 25 year old incarcerated patient arrived in the obstetrics (OB) department a second time on 8/29/12 at 1:41 PM. At that time, the initial triage nursing assessment by Registered Nurse (RN) C revealed the patient presented to OB with complaint of contractions began on 8/29/13 at 12:30 PM. RN C documented a vaginal examination completed on 8/29/13 at 1:59 PM revealed the patient had contractions every 1.5 minutes lasting 40 to 50 seconds and was 4 of 10 cm dilated and 100 % effaced.

The OB physician on call, Provider B, a first year resident, documented the patient presented for concerns of increasing frequency of contractions. Provider B documented the patient felt like the contractions were every 30 minutes this morning and now are more often, anywhere from every 2 - 15 minutes and last 2 minutes. The patient stated the contractions are stronger and she is still having bloody discharge but no gush of fluids. Provider B documented the patient was 4 of 10 cm dilated, 50 % effaced and at a -2 station. Provider B documented the patient was not in active labor and educated the patient on active labor and to return should signs present. The medical record lacked documentation of examination by or consultation with the attending OB physician.

At 4:10 PM, RN C documented it was difficult to trace [contractions] due to patient movement and the patient stated that she had had about 4 big contractions since arriving at the hospital. RN C documented a vaginal examination completed by Provider B and RN C on 8/29/13 at 4:22 PM revealed the patient was 4 of 10 cm dilated, 100 % effaced and at a -2 station. The medical record lacked evidence of examination by or consultation with the OB attending physician who was ultimately responsible for the patient's care and the determination if the patient was in the latent phase of early labor or experiencing false labor prior to either discharge.

The patient was discharged back to jail on 8/29/13 a second time at 4:42 PM without the ability to freely return to the hospital if her contractions increased in frequency and intensity.

4. Review of Patient #24's medical record revealed documentation that the patient returned to OB on 8/29/13 at 10:05 PM after the patient delivered, without any medical attention while laying on a mattress on the floor of the jail cell at 9:18 PM, approximately 4.5 hours after being discharged from the hospital.

5. The hospital's Clinic Services Provision of Patient Care policy titled, "Transfer of Patients to Other Health Care Facilities", dated 8/2012, included the following relevant Emergency Medical Treatment and Labor Act (EMTALA) guidance for staff:

b. EMTALA Requirements: Medical Screening Examinations: All individuals who present to the medical center requesting an unscheduled examination or treatment for a medical condition including women in labor will have an appropriate medical screening examination performed within the normal capability of the medical center's available staff and facilities in order to determine if an emergency medical condition exists.

c. Family Birthing Center (1) Physicians: Any physician medical staff member with appropriate obstetrical privileges is authorized to perform medical screening examinations in any location on the medical center premises.

6. Review of the hospital's policy A-0708, titled, "Institutional Policies for Residents' Supervision", dated 2/2012, revealed 1. Purpose: In the clinical learning environment, each patient must have an identifiable, appropriately credentialed and privileged attending/faculty physician who is ultimately responsible for that patient's care. IV. A. [Hospital] through its Graduate Medical Education Committee, ... provides institutional oversight to assure that residents are appropriately supervised.

7. When asked about Patient #24 during an interview on 9/25/13 at 4:35 PM, Physician C, Attending Physician, reported the residents examine the patients. The residents are instructed that none of the patients should leave the OB Department unless the residents call one of the on-call attending physicians. Physician C stated the resident and attending physician decide whether the patient should be discharged or kept in the hospital. Physician C stated that during the last visit, Patient # 24 thought she was having contractions. The patient's cervix was checked every time by a resident and there was no difference in the dilation. The patient did not have any more contractions and the patient looked comfortable. Physician C stated it did not look like the patient was in active labor and the patient was discharged back to jail. Physician C stated the residents called him to discuss the patient's case before the patient was discharged and returned to jail.

8. Interview of the physician Director of Medical Education for Resident Physicians, on 9/25/13 at 12:20 PM, revealed a transitional resident is one that is here for one year of experience and has been accepted into another specialty. The mechanism of supervision of residents is through the program per the national guidelines. The attending physician does not have to see the patient but are physically present for all deliveries. To determine the patient is not in true labor, the resident would call the attending physician before discharging the patient.

9. Interview of Provider A, on 9/25/13 at 1:30 PM, revealed he is doing a one year residency then will go into radiology. Provider A stated he saw Patient #24 and determined she was not in active labor. He instructed her to come back when symptoms increased.

10. Interview of Provider B, on 9/25/13 at 2:45 PM, revealed she is a first year resident and does everything under supervision meaning the attending physician is in-house. She stated Patient #24 was brought in from jail because she thought her contractions had increased in frequency. Provider B stated at this time that Patient #24 did not have regular contractions and she discussed the patient with the attending physician who ultimately determined the patient was not in active labor.

11. Review of the Physician Peer Review of the ED visit, on 8/29/2013 from 3:20 AM to 5:42 AM, revealed Patient #24 did not receive an adequate medical screening examination. The prenatal record revealed an incarcerated individual with a high risk pregnancy due to drug use, lack of prenatal care and elevated blood pressure the previous day. The medical record revealed examination by a doctor recent graduate of a medical school without examination by a qualified physician.

12. Review of the Physician Peer Review of the ED visit, on 8/29/13 from 1:41 PM to 4:28 PM revealed Patient #24 did not receive an adequate medical screening examination. Patient #24, with a high risk pregnancy, was examined by a physician recent graduate of a medical school, lacked sequential examinations and the quality of the tocodynamometry (fetal monitoring) was indecipherable and useless. The patient was not examined by the attending physician and may have gone from 50% effaced to 100% effaced. since the previous ED visit and was likely to progress rapidly into labor. This patient was incarcerated and could not return to the ED at will.