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Based on record reviews, incident report, policies and procedures, and interviews, the hospital failed to ensure 3 of 21 patients presenting to the hospital requesting care for potential emergency maternal symptoms was provided a Medical Screening Exam (MSE) and stabilizing treatment for an Emergency Medical Condition (EMC). This affected Patient #5, Patient #13, and Patient #21, and had the potential to affect all individuals presenting to the hospital.

The findings are:

Refer to A2406.

Based on reviews of the hospital's log, titled, "Patewood Medical Campus EMTALA (Emergency Medical Treatment And Labor Act) Log", and interview, the hospital failed to ensure a log was maintained on each individual who comes to the hospital seeking assistance for a potential emergency condition and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred , or discharged for 3 of 21 sampled patients presenting to the hospital, (Patients #5, #13, and #21).

The findings are:

1. Patient #21

On 06/05/2023 at 11:30 AM, review of the hospital's log, titled, "Patewood Medical Campus EMTALA Log" revealed documentation that on 05/11/2023 at 9:00 PM, a "female adult entered the hospital lobby", "complaint 'look for ER', and "comments 'need ER'.
Under the column labeled "Medical Assistance Offered? (yes or no), documentation showed "yes". Under the column labeled "Medical Assistance accepted? (yes or no)", "No" was documented. The last column showed Security Officer #1's signature.

In an interview on 06/05/2023 at 10:15 AM, the Quality Manager reported "We don't have an ED (Emergency Department) so we use an unofficial EMTALA log for people who show up asking for help. People come to the front desk, and we get as much information as we can, but we don't always get their name if they leave."

2. Patient #5

On 06/05/23 at 3:21 PM, review of Patient #5's documentation revealed the patient presented at the hospital on 05/18/23 at 4:14 AM with complaint of "Water may have broken". Review of the hospital's "EMTALA Log" dated 03/01/23 through 06/05/23 revealed Patient #5 had not been captured on the hospital's "EMTALA Log".

In an interview on 6/06/23 at 2:25 PM, the Assistant Nurse Manager of Family Birthplace verified the findings.

3. Patient #13

On 06/06/23 at 9:25 AM, review of Patient #13 documentation revealed Patient #13 presented at the hospital on 05/15/23 at 10:27 AM with complaint of nausea and vomiting. Review of the hospital's "EMTALA Log" dated 03/01/23 through 06/05/23 revealed Patient #13 had not been captured on the hospital's "EMTALA Log".

In an interview on 06/06/23 at 2:07 PM, the Assistant Nurse Manager of Family Birthplace verified the findings.

Refer to A2406 for additional findings.

Based on record reviews, incident report, policies and procedures, and interviews, the hospital failed to ensure 3 of 21 patients presenting to the hospital requesting care for potential emergency maternal symptoms was provided a Medical Screening Exam (MSE) and stabilizing treatment for an Emergency Medical Condition (EMC). This affected Patient #5, Patient #13, and Patient #21, and had the potential to affect all individuals presenting to the hospital.

The findings are:

1. Patient #5 medical record review revealed she presented to the hospital's family birthplace on 05/18/23 at 4:14 AM with chief complaint of "Thinks her water may have broken. States she has had trickle of clear fluid from vagina starting at 0200 [2:00 AM]. States occasional contractions. Denies VB (Vaginal Bleeding) and states +FM (positive fetal movement) at 37 weeks gestation pregnancy." Vital signs completed at 4:24 AM revealed: blood pressure (BP) 135/87, Temperature (T) 97.9, Pulse (P) 82, and Respirations (R) 18. A vaginal pH amniotest was completed on the patient at 4:28 AM which resulted as 6.0, a negative result for ruptured membranes. A manual cervical exam was completed by a Labor and Delivery Registered Nurse (RN) at 4:28 AM with the fetus noted at -3 station and 0 effacement, external os 1 centimeter. Fetal Heart rate (FHR) was present and moderate at 145 beats with no decelerations noted. At 4:38 AM, the Registered Nurse called the obstetrical physician on call and received physician orders to discharge Patient #5 home. The patient was discharged at 4:55 AM home with labor precautions and to follow up with normal scheduled appointment. Further review of the patient's chart revealed there was no documentation of a physician assessment and/or additional physician orders to determine if premature rupture of membranes (PROM) existed for the patient. Further review of the chart revealed no documentation of a physician's Medical Screening Examination (MSE), no cervix check, history and physical review, sterile speculum examination to check for pooling of amniotic fluid, ferning check and/or nitrazine testing to determine if premature rupture of membranes (PROM) truly existed.

During an interview on 06/05/23 at 11:01 AM with Assistant Nursing Manager for the Family Birthplace, the Assistant Nurse Manager stated, "Anyone pregnant goes up to postpartum. They are signed in at the desk and go to a triage room. The nurse puts history in computer and the MD (Medical Doctor) assesses the patient. (We) call the particular provider for that patient. If not affiliated with an OB (obstetrics) provider, use our on-call list for anyone who walks in door. Thirty-five weeks and up a labor check is done."

2. Patient #13 medical record review revealed the patient presented to the hospital on 05/15/23 at 10:27 AM with complaint of nausea and vomiting with pregnancy. Vital signs completed at 10:42 AM with BP 124/65 and Pulse 105. Normal saline bolus was started at 11:25 AM with Phenergran 12.5 mg (milligrams) administered intravenously at 11:30 AM and 11:45 AM. A PO (by mouth) bolus challenge of sprite or ginger ale and crackers was offered to the patient but Patient #13 refused the offer at 12:43 PM per nursing documentation. The obstetrician was notified of the refusal and was at the patient's bedside at 12:45 PM. Suggestions of nausea medications, over the counter (OTC) medications and prescription medications ordered by MD was discussed with the patient per nursing documentation. Patient #13 was discharged to home at 1:05 PM with discussion to contact office for prenatal visit. Further review of the patient's chart revealed there was no documentation of lab work, no gestational age, no fetal heart rate, and no additional physician orders to determine if Patient #13 was experiencing other pregnancy distress.



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3. Patient #21. A review of a reported incident identified as a potential violation of the Emergency Medical Treatment and Labor Act (EMTALA) revealed the incident occurred on 05/11/2023 at approximately 9:11 PM when Patient #21 and the patient's spouse presented to the hospital's lobby and encountered Security Officer #1 stationed at the main desk in the hospital's lobby. The report showed Patient #21 informed the security officer that she was looking for the emergency room (ER), and the Security Officer responded, "Told her we don't have an ER." Patient #21 and spouse exited the hospital. There was no evidence Patient #21 received a Medical Screening Examination (MSE) in the hospital. In an interview with Patient #21 on 06/06/2023, the patient verified that she was directed to the emergency room in a nearby hospital by the security guard stationed in the hospital's lobby.

In a telephone interview on 06/05/2023 from 3:10 PM to 3:20 PM, Security Officer #1 revealed, "I was at the front desk and approached by a young woman who came in by herself. She said, 'I want to see a doctor. I need an ER or I need to be seen by a doctor. ' I told her we don't have an ER. She said 'You don't have an ER.' I said 'no' and told her where to go for the nearest ER. Go straight across the street to the hospital kittycorner across the street."

On 06/06/2023 from 10:03 PM to 10:20 AM, during a telephone interview with Patient #21 and spouse, Patient #21 revealed, "My husband and I went in. Supposed to deliver in August. Nobody around but the security guard. We asked for an emergency room and the security guard told us there was no emergency room." The spouse revealed, "We went in through the front door, and there was no activity. The security guard was at the front desk. We asked if there was an emergency room on site, and the guard said 'no', but the guard did say they had people on site. Told us the nearest ER was across the street."

Hospital Policy: EMTALA for Hospitals without an Emergency Department: Upstate, effective 8/02/22

Medical Screening Exam (MSE)

1. The process required to reach, with reasonable clinical confidence the point at which it can be determined whether the individual has an Emergency Medical Condition or not. The MSE should be performed by the examining physician or Qualified Medical Personnel that is within the capability of the hospital, both as to ancillary services and available personnel, is the same or similar to the screening provided to all patients presenting to the ED complaining of the same condition or exhibiting the same symptom or condition, and is sufficient within reasonable clinical confidence to determine whether or not an individual has an Emergency Medical Condition, including being in labor.

Qualified Medical Personnel (QMP)

2. Those medical personnel determine qualified under this policy and who are approved by the Prisma Health-Upstate Board of Directors to perform medical screening exams. QMPs are determined qualified in accordance with this policy. The designation of the QMP is set forth in this policy which is approved by the Board of Directors. The scope of providing an MSE must be with the scope of licensure for the QMP and any non-physician QMP must function under medically approved protocols.

Prisma Health Hospitals without an emergency department will provide, within its capacity and capability, a medical screening examination (MSE) by Qualified Medical Personnel (QMP) and stabilizing treatment or facilitate the appropriate transfer to an individual who is not an inpatient and seeks care from the obstetrical department or otherwise presents for emergency care from the hospital. Recognizing that Prisma Health Patewood Hospital does not have an emergency department, but Prisma Health Patewood Hospital does provide obstetric services, and the Hospital's capability for emergency care and treatment is limited.
Nothing in this policy shall be interpreted to require these hospitals without an emergency department to provide services beyond those required by the EMTALA law or other state and federal law.

Procedure for all other individuals seeking emergency care at Prisma Health Patewood Hospital

1.1 Procedure for Pregnant Woman Presenting to Prisma Health Patewood Hospital:

1.1.1. "In the event a pregnant woman...presents at thirty-five (35 0/7) weeks or greater gestation, the OB nurse...will perform the MSE for labor check/rule out labor only."

1.1.2. "In the event a pregnant woman who is not an established Patewood Hospital OB patient, presents to the Hospital, regardless of gestation, the physician on call or a QMP mid-level who is designated for non-established patients, will perform the MSE."

2.1.1. If any individual presents to the hospital and requests emergency care (or when the individual's appearance suggests that she/he needs emergent care), the team will call a Medical Alert-Medical Emergency. Emergency Services will be called for visitors and team members seeking emergency care.

There was no documentation hospital staff called a Medical Alert-Medical Emergency or notified Emergency Services to assist Patient #21.