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Based on review of the DED (Dedicated Emergency Department) and OB (Obstetrical) Emergency Medical Treatment and Labor Act (EMTALA) logs for March 2020, incident report review and staff interviews, the hospital failed to provide a medical screening examination for an obstetrical patient that presented to the hospital with an emergency medical condition. Hospital staff failed to follow the hospital's policy to offer a medical screening examination and document the patient's refusal of the medical screening examination for 1 of 8 sampled obstetrical patients that presented with an emergency medical condition. (Patient #21).

The findings include:

Cross refer to 489.24(a), Medical Screening Exam - A2406.

Based on review of the DED (Dedicated Emergency Department) and OB (Obstetrical) virtual tour images, the hospital failed to post conspicuous signs that specified the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor at the OB point of presentation and the OB receptionist desk.

The findings include:

Virtual tours of the DED and obstetrical area where patients presented for emergency care revealed appropriate EMTALA (Emergency Medical Treatment and Labor Act) signage was not posted at the obstetrical area where patients present. Review of the OB signage revealed EMTALA signage was posted on the wall to the right of the OB receptionist desk in the doorway to the birthing center. Tour image revealed a patient would need to focus their visual field in that direction to see the sign upon walking up from the elevator. Tour image revealed when the electronic doors are opened the signage on the left side of the doorway is not visible at all. There is another signage on the right doorway wall which would be behind the patient presenting for medical care.

Interview on 04/28/2020 at 1150 with the Vice-President of Compliance revealed he provided the images of the EMTALA signage in the DED and obstetrical area where patients present for medical examination.

Based on review of the DED (Dedicated Emergency Department) and OB (Obstetrical) Emergency Medical Treatment and Labor Act (EMTALA) logs for March 2020, incident report review, and staff interviews, the hospital staff failed to maintain a complete DED and OB EMTALA Log by failing to include an obstetrical patient that presented to the hospital with an emergency medical condition on the central log for 1 of 8 sampled obstetrical patients that presented with an emergency medical condition. (Patient #21).

The findings include:

Review of Hospital A's DED and OB EMTALA logs for March 2020 showed no documented evidence that Patient #21 presented for a medical screening examination (MSE).

Review of Hospital A's incident report dated 03/17/2020 revealed Hospital B notified Hospital A's Risk Management staff that Patient #21 "said she came to (Hospital A) ED and was asked who her doctor was for the pregnancy. Patient said a receptionist told her since she had a (Hospital B) doctor, she would need to go there to be treated. Patient left (Hospital A) and went to (Hospital B). Patient arrived to (Hospital B) around 1900. Patient 22 weeks pregnant with SROM (spontaneous rupture of membranes) ..." The incident report indicated Patient #21 presented to Hospital A on 03/16/2020. Follow up investigative notes documented on 04/20/2020 revealed "It appears the patient (Patient #21) thought (Hospital A) was (Hospital B) and had been told by her (Hospital B) MD (Medical Doctor) to come to the hospital to be seen (likely intending for her to go to (Hospital B) instead of (Hospital A). Since the couple was new to the community, they were unaware that (Hospital B) was in a different location. The Birthing Center nurse, who is the night nurse manager, reports that she stepped in to urge the patient to be examined here, but the FOB (Father of the Baby) refused because (Hospital B) is relatively nearby. Unsure whether some sort of registration should be performed for these high-risk/EMTALA related care refusals. Perhaps in the future, a refusal of treatment form should be given for signature and then filed with Risk Mgt. (Management) ..." The Incident Report resolution and outcomes section revealed the Obstetrical unit secretary stated Patient #21 and the father of the baby presented to the Obstetrical unit. Patient #21 informed the unit secretary that she was a patient of an identified local OB Services Group and was supposed to meet her physician at the hospital. The unit secretary informed Patient #21 that the identified local OB Services Group did not come to Hospital A. Patient #21 informed the unit secretary that she had just moved to this area and did not realize there were two hospitals. The unit secretary indicated the father made the statement "You mean we have to go to another hospital to be seen". The Registered Nurse (RN) overheard the father's comment and advised Patient #21 and the father that they could treat them at Hospital A. Patient #21 was "adamant" about seeing their own physician. The unit secretary stated the father of the baby checked his phone and stated, "(Hospital B) is only 11 minutes from here (Hospital A), we will just go there." Patient #21 and the Father of the Baby left Hospital A to go to Hospital B. "Recommendations for System Improvement" documented on the incident report revealed "The person entering was not registered as a patient, had not been triaged. The RN did try to get the patient to stay and they made the decision to leave. Questions for education of staff: Should we have had her sign a REFSTAY (Refusal to Stay form) even though she wasn't registered as a patient and if so, what happens to that paper since she wasn't registered as a patient. Do we keep, file away, send to RM (Risk Management) ... Should we have completed a short registration? Would they have provided any information to do that? I think this is definitely something we can have a process for but need investigations and some answers to the questions."

Telephone interview on 04/28/2020 at 1345 with Unit Secretary #1 revealed she remembered the incident. Interview revealed the Patient #21 was brought to the floor in a wheelchair by a male. Interview revealed Unit Secretary #1 asked for and was given Patient #21's name and date of birth. Interview revealed Patient #21 said she received pre-natal care at an identified local OB Services Group and was leaking fluids. Interview revealed Unit Secretary #1 notified the patient that the identified local OB Services Group did not come to Hospital A. Interview revealed they are "not a patient until they are taken back to a room, then the patient is registered."

Interview on 04/29/2020 at 1250 with the Administrator of the Women and Children's Services revealed Patient #21 was never registered and she was unsure if staff was given the patient's name and medical problem. Interview revealed Patient #21 was not documented on the log. Interview revealed Hospital A was unable to provide documentation of any new processes or changes that had been implemented in the Obstetrical unit, for patients presenting for MSE, since the reported incident on 03/17/2020.

Based on review of the DED (Dedicated Emergency Department) and OB (Obstetrical) Emergency Medical Treatment and Labor Act (EMTALA) logs for March 2020, incident report review, Medical Records, Policies and Procedures, and staff interviews, the hospital staff failed to provide a medical screening examination for an obstetrical patient that presented to the hospital with an emergency medical condition. Hospital staff failed to follow the hospital's policy to offer a medical screening examination and document the patient's refusal of the medical screening examination for 1 of 8 sampled obstetrical patients that presented with an emergency medical condition. (Patient #21).

The findings include:


Review on 04/28/2020 of the Obstetrical department policy titled "Triage-Outpatient Testing and Evaluation" last revised on 12/11/2018 revealed " ... Every patient arriving to Triage will be evaluated by a MD (Medical Doctor), Certified Nurse Midwife, and/or specialty trained RN (registered nurse) to determine whether an Emergency Medical Condition (EMC) exists. The evaluation consists of a Medical Screening Exam (MSE)/OB Assessment. If the patient refuses the MSE, Refusal to stay for Medical screening must be signed by the patient ..."

Review on 04/28/2020 of the hospital policy titled "Emergency Medical Screening" last revised on 12/06/2019 revealed "... Should a patient refuse a medical screening examination (i.e., decided to leave before being seen for the initial screening examination), ... hospital staff will take all reasonable steps to obtain informed written consent from the patient for refusing the examination, ... Staff will explain to the patient ... the risks and benefits of refusing the examination, determine if the patient is competent to refuse, and will exercise every effort to obtain the patient's signature on the Refusal to Stay form (REFSTAY) ... Should a patient refuse to sign the consent form, a hospital representative will document this refusal on the Refusal to Stay form indicating that the patient was offered but refused the examination and consent for the same ..."

Review of Hospital A's DED and OB EMTALA logs for March 2020 showed no documented evidence that Patient #21 presented for an MSE.

Review of Hospital A's incident report dated 03/17/2020 revealed Hospital B notified Hospital A's Risk Management staff that Patient #21 "said she came to (Hospital A) ED and was asked who her doctor was for the pregnancy. Patient said a receptionist told her since she had a (Hospital B) doctor, she would need to go there to be treated. Patient left (Hospital A) and went to (Hospital B). Patient arrived to (Hospital B) around 1900. Patient 22 weeks pregnant with SROM (spontaneous rupture of membranes) ..." The incident report indicated Patient #21 presented to Hospital A on 03/16/2020. Follow up investigative notes documented on 04/20/2020 revealed "It appears the patient (Patient #21) thought (Hospital A) was (Hospital B) and had been told by her (Hospital B) MD (Medical Doctor) to come to the hospital to be seen (likely intending for her to go to (Hospital B) instead of (Hospital A). Since the couple was new to the community, they were unaware that (Hospital B) was in a different location. The Birthing Center nurse, who is the night nurse manager, reports that she stepped in to urge the patient to be examined here, but the FOB (Father of the Baby) refused because (Hospital B) is relatively nearby. Unsure whether some sort of registration should be performed for these high-risk/EMTALA related care refusals. Perhaps in the future, a refusal of treatment form should be given for signature and then filed with Risk Mgt. (Management) ..." The Incident Report resolution and outcomes section revealed the Obstetrical unit secretary stated Patient #21 and the father of the baby presented to the Obstetrical unit. Patient #21 informed the unit secretary that she was a patient of an identified local OB Services Group and was supposed to meet her physician at the hospital. The unit secretary informed Patient #21 that the identified local OB Services Group did not come to Hospital A. Patient #21 informed the unit secretary that she had just moved to this area and did not realize there were two hospitals. The unit secretary indicated the father made the statement "You mean we have to go to another hospital to be seen". The registered nurse (RN) overheard the father's comment and advised Patient #21 and the father that they could treat them at Hospital A. Patient #21 was "adamant" about seeing their own physician. The unit secretary stated the father of the baby checked his phone and stated, "(Hospital B) is only 11 minutes from here (Hospital A), we will just go there." Patient #21 and the Father of the Baby left Hospital A to go to Hospital B. "Recommendations for System Improvement" documented on the incident report revealed "The person entering was not registered as a patient, had not been triaged. The RN did try to get the patient to stay and they made the decision to leave. Questions for education of staff: Should we have had her sign a REFSTAY (Refusal to Stay form) even though she wasn't registered as a patient and if so, what happens to that paper since she wasn't registered as a patient. Do we keep, file away, send to RM (Risk Management) ... Should we have completed a short registration? Would they have provided any information to do that? I think this is definitely something we can have a process for but need investigations and some answers to the questions."

DED record review revealed, Patient #21 arrived to Hospital B's DED by private vehicle on 03/10/2020 at 1900 with a "complaint of leaking fluid". Review of "Fetal Monitoring Annotations: dated 03/10/2020 at 1904 revealed the fetal monitor was placed on Patient #21 and the "abdomen palpates soft; small amount clear fluid noted". Review of the DED record revealed Patient #21's vital signs taken at 1910 were, (Temperature) 98.4, (Pulse) 67, (Respirations) 18, (Blood Pressure) 126/72, and Lower Abdominal and Back Pain with a score of 4 out of 4. Patient #21's (SpO2) was 100% on Room Air. Review of the results of the "Urinalysis" dated 03/10/2020 at 1913 revealed " ... UA (Urinalysis) Appear: Cloudy; UA Blood: 3+ Reference range: Negative; UA Protein: 1+ Reference range: Negative ... UA Microscopic UA WBC (white blood cell) 3-5/HPF (high power field) Reference Range: None Seen; UA RBC (red blood cell) 6-10/HPF Reference Range: None Seen; UA Squam Epithelial: 6-10/LPF (low power field) Reference Range: Negative ..." Review revealed Patient #21 was triaged at 1918. Review revealed MD #4 was at the bedside of Patient #21 on 03/10/2020 at 1930 and reviewed the strip and plan of care. Continued review revealed " ... Fetal Activity: ... Present per patient, Present per palpation ... FHR (fetal heart rate) Baseline: 145; FHR Baseline Description: Normal, 110-160 bpm (beats per minute); FHR Baseline Variability: Moderate variability; FHR Accelerations: Present; FHR Acceleration Description: 10x10 (normal); FHR Deceleration Description: Variable; FHR Deceleration Description: Intermittent; FHR Deceleration Duration: 15 seconds." Review of "Rapid Swab Test, OB" revealed a "Positive; Amniotic Fluid Amount: Small; Amniotic Fluid Color/Description: Clear; Amniotic Fluid Odor: None ..." Review of "Ultrasound" dated 03/10/2020 at 2100 revealed "Impression: 1. Single living intrauterine gestation in cephalic presentation at 21 weeks 1 day by ultrasound measurement. Fetal heart rate 140s. 2. AFI (amniotic fluid index) 9.7 cm (centimeters) 3. Anterior placenta 4. Cervical length 3.4 cm ... Review of the "History and Physical" note dated 03/10/2020 at 2200 revealed Patient #21 was 24-year old, 21 5/7-week pregnant female with an obstetrical history of G5P2022 (5 pregnancies; 2 term pregnancies; 2 aborted/miscarriages/2 living) with intermittent fluid leakage "that had been going on for approximately 36 hours." Continued review revealed "Assessment/Plan: Spontaneous leaking of amniotic fluid at a previable gestation: It is the patient's wish to attempt conservative measures and see if she can carry to viability ..." Patient #21 was admitted to Hospital B on 03/11/2020 at 0618. Review of the inpatient record revealed Patient #21's fluid leakage decreased to just having normal discharge at time of hospital discharge. Patient #21 was discharged home on 03/18/2020 at 1145 with follow up appointments scheduled for the next day with a MFM (Maternal Fetal Medicine) Provider.

Telephone interview on 04/28/2020 at 1345 with Unit Secretary #1 revealed she remembered the incident. Interview revealed Patient #21 was brought to the floor in a wheelchair by a male. Interview revealed Patient #21 said she was told we would be expecting her. Interview revealed Unit Secretary #1 asked for and was given Patient #21's name and date of birth. Interview revealed after Unit Secretary #1 confirmed with the Charge Nurse (CN) that no one was expected, Unit Secretary #1 asked Patient #21 where she was receiving care for her pregnancy. Interview revealed Patient #21 said she received pre-natal care at an identified local OB Services Group and was leaking fluids. Interview revealed Unit Secretary #1 notified the patient that the identified local OB Services Group did not come to Hospital A and offered to take Patient #21 to a room and call to get her records from her Obstetrical provider. Interview revealed Patient #21 was determined they would go to Hospital B. Interview revealed Unit Secretary #1 called Hospital B Obstetrical unit to let them know Patient #21 was on the way via private vehicle with her significant other. Interview revealed Unit Secretary #1 did not have anywhere to document this incident or the telephone call to Hospital B as Patient #21 was not considered a patient of Hospital A. Interview revealed they are "not a patient until they are taken back to a room, then the patient is registered."

Telephone interview on 04/28/2020 at 1722 with a RN #2 revealed she remembered the incident. Interview revealed the RN overheard the Charge Nurse (CN) and Unit Secretary #1 talking with a couple that was looking for an identified local OB Services Group doctor that does not come to Hospital A. Interview revealed RN #2 reassured the couple they would be glad to see them and could call to get the records. Interview revealed the couple said multiple times they "will go where their doctor is" and they "want to go where their doctor is." Interview revealed RN #2 reported the incident to her Director either the next day or the next time she worked. Interview revealed RN #2 could not remember the date the incident happened but knew it was prior to her taking her new position as Night Shift Manager and before March 17, 2020. Interview revealed RN #2 did not document the incident anywhere.

Telephone interview on 04/29/2020 at 0845 with RN #3 revealed she was the Charge Nurse (CN) the night of the incident and she remembered the incident but could not remember the date it occurred. Interview revealed a lady in a wheelchair, being pushed by the father of the baby came to the Obstetrical triage receptionist window and told the secretary they were "expecting her (Patient #21)" and they were "here to be seen". Interview revealed the unit secretary asked and RN #3 confirmed Patient #21 was not expected. Interview revealed RN #3 said, "no big deal, we can get your records." Interview revealed RN #3 got pulled away from the conversation and a Registered Nurse #2 stepped in to continue assisting.

Interview on 04/28/2020 at 1320 with the Administrator of the Women and Children's Services, the Director of the Birthing Center, and the Vice-President of Compliance revealed they were made aware of the incident "within a week of the situation". Interview revealed the Director was notified about the incident as she was leaving work. Interview revealed before the Director could notify anyone else of the incident, the Risk Management department had received a call from Hospital B and entered an incident report dated 03/17/2020. Interview revealed Hospital A was unable to provide documentation of any new processes or changes that had been implemented in the Obstetrical unit, for patients presenting for MSE, since the reported incident on 03/17/2020.