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Based on medical record review, provider interview and review of policies and procedures related to EMTALA the facility failed to provide 1 of 10 obstetrical patients (Patient 13) reviewed a MSE (Medical Screening Examination) sufficient to determine if the patient had an EMC (Emergency Medical Condition). This failure has the potential to place all Emergency Department (ED) patients presenting to the ED at risk of serious harm or death from an untreated EMC. A total sample of 20 ED/OB patients presenting for care was reviewed. The ED/OB ED see's an average of 1240 patients a month.

Findings are:

A. Review of facility policy titled Emergency Medical Treatment and Active Labor Act (effective 8/10/22) stated "A medical screening examination is provided at (facility) to any person presenting themselves anywhere on the (facility) campus who is seeking emergency services to determine whether that person has an emergency medical condition." The medical screening data is collected by qualified personnel identified as physicians, nurse practitioners, physician assistants licensed by the state of Nebraska. A Registered Nurse in the Maternal Child Department in consultation with a physician and who meet the criteria established by the Maternal Child Department under protocols approved by the Obstetrics Committee. The final determination of whether an emergency medical condition exists can only be made by a physician. The medical screening includes: a) a brief, general history; b) appropriate physical examination including the presenting complaint; c) supportive diagnostic evaluation; d) consultation to the extent felt necessary by physician; e) the level of complexity/acuity may require the use of ancillary services; f) each medical staff member must assure timely availability (physically available within 30 minutes). Labor is defined as the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman having contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor. Except in the case of certified false labor, a pregnant woman experiencing contractions is legally unstable until delivery of baby and placenta.

B. Review of the facility policy titled "OB Evaluation", effective date 3/30/2023, revealed the following:
-Definition of Labor: The process of childbirth beginning with the latent or early phase of labor, moving into active labor and culminating with the infant birth and delivery of the placenta. A woman having contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor. A pregnant woman experiencing labor is legally unstable until delivery of the baby and placenta.
-Patients 20 weeks gestation or greater with obstetrical presentations will receive a medical screening examination in the Family Care Center Labor and Delivery unit. The procedure includes: An initial assessment and repeat at approximately 20 minute intervals, unless the patient's labor progresses or fetal distress obviates the need for further assessment prior to the admission decision. Score the patient on the OB Medical Screening Exam flowsheet. Essential steps in conducting the obstetrical screening exam included observe the patient for a minimum of one hour, assess the patient's presenting complaint, vital signs and fetal heart tones, verbal medical/surgical/ obstetrical history, pain assessment, monitor uterine activity for contractions, evaluation of edema, UA and ongoing vital signs, fetal heart tones and vaginal exams as indicated. Patients receiving an obstetrical score of 9 or more will be admitted for further observation or delivery. Patients with 9 or more points, after "clearing by a physician, may be discharged, or transferred upon writer order of the examining physician with the following conditions.
-No likelihood of delivery in the next 6 hours.
-No likelihood of deterioration of the condition of the mother or fetus.
-Discharge does not pose a threat to the health or safety of the mother or fetus.

C. Review of the Electronic Medical Record for Patient 13 revealed the patient arrived to the obstetrics labor and delivery department (OB/ED) on 5/28/23 at 01:57 AM via private vehicle. Chief complaint is listed as "uncomfortable contractions (tightening and relaxing of the uterus muscle)."

Patient 13's history and physical at 3:18 AM by the APRN-Certified Nurse Midwife [(Nurse Practitioner-(CNM)] revealed:
-a medical history which included anxiety, depression, ADHD (attention deficit hyperactivity disorder), intellectual disability and gestational hypertension.
-was pregnant with her 2nd child and the pregnancy had been complicated by anxiety and depression.
-had 1 living child (Gravida 2 Para 1) and had delivered her first child at 36 weeks and had experienced gestational hypertension (elevated blood pressure during pregnancy.
-was having uncomfortable moderate contractions every 1.5 minutes that spaced out to mild contractions every 4-5 minutes after IV (intravenous) hydration.
-the vaginal exam found the cervix to be dilated (opened) to 3 cm,70 % effaced (the thinning of the cervix in preparation for birth), -2 station (the level the baby's head is in the birth canal).

The CNM "Encounter Notes" identified that "Patient 13 was at 36 weeks 2 days gestation who present to labor and delivery earlier tonight complaining of uncomfortable contractions. At time of presentation she reported active fetus, no vaginal bleeding or leaking of fluid. Fetal heart tones (FHT) reactive. On admission she was having moderate contractions every 1.5 minutes that spaced out to every 4-5 minutes after IV hydration. She was found to be dilated to a 3, 70% effaced and -2 station.

The CNM gave a telephone order to RN A on 5/28/23 at 2:08 AM for:
-Urinalysis (UA) with culture and sensitivity.
-Amniotic fluid screen.
-Vital signs every 4 hours.
-External fetal monitoring and tocometry (TOCO-records contractions and fetal heart rate on a timed strip) continuous.
-Notify physician when medical screening exam is complete.
-Vaginal exam, one time.
-Peripheral IV insertion and administration of a bolus of 1000 ml (milliliters) of lactated ringers solution.

Review of RN A's documentation revealed:
-2:11 AM-blood pressure (BP) 139/98, temperature 98 degrees, heart rate 92 and respirations 18, the fetal monitors applied.
-2:18 AM- the amniotic fluid screen test was completed and noted negative results (a test used to check if the mother had ruptured membranes.) The UA results showed a trace of protein, epithelia cells and bacteria.
-2:19 AM- a cervical exam was completed and found to be dilated to 3 cm (10 cm is complete), 70% effaced, -2 station.
-3:18 AM- a cervical exam was completed and found to be dilated to 3 cm (10 cm is complete), 70% effaced, -2 station. The Bishop score of 7 (a score which ranges from 0-13 used to predict how close one is to labor).

Review of an OB assessment conducted by RN A showed at:
-2:30 AM-TOCO (measures pressures during contractions) applied and recorded contractions occurring every 1-3 minutes lasting 50-100 seconds in duration and were regular.
-4:30 AM-IV fluids had been administered and the frequency of the contractions were 2-3.5 minutes apart and lasting 60-80 seconds in duration. Fetal heart rate (FHR) was in the 120-130 range.
-4:45 AM- TOCO documentation showed FHR 125, moderate variability, contractions every 2-3.5 minutes lasting 60-80 seconds and were regular.

Review of the OB EMTALA Exam completed by RN A at 2:30 AM; 2:50 AM; 3:10 AM and 3:20 AM showed that Patient 13 was 34-37 weeks pregnant, was dilated 1-3 centimeters, contractions were less than 5 minutes apart and were lasting greater than 60 seconds. RN A recorded an obstetrical score of 9 for each assessment.

Review of Patient 13's flowsheet for blood pressure assessments showed the following:
-2:11 AM- 139/98
-2:45 AM- 131/92
-3:00 AM- 130/91
-3:15 AM- 133/92
-3:30 AM- 112/79
-3:45 AM- 129/88
-4:00 AM- 141/88
-4:15 AM- 132/86
-4:30 AM- 133/94
-4:45 AM- 143/87
-5:00 AM- 123/81

The pain assessment at 5:00 showed that her pain was an 8 (1-10 range with 1 being least), located in abdomen, described as cramping, frequency intermittent and associated with uterine contractions.

Review of the CNM dismissal instructions included, Vistaril 25 mg (milligram-an antihistamine with sedative properties used to treat anxiety and tension) for 1 dose for therapeutic rest, Reviewed labor warning signs, keep follow up appointment at office as scheduled or sooner prn (as needed).

Review of the discharge instructions provided and a copy sent with Patient 13 at 5:15 AM revealed:
-comfort measures
-warm bath for irritable cramping
-rest as needed
-if appropriated, Tylenol as directed
-contact your provider, or return to the hospital with the following symptoms; contractions that are regular (every 2-3 minutes), increase in length and intensity; your water breaks, it may be a gush or a slow trickle of clear fluid; bright red heavy vaginal bleeding (like a heavy period); rectal pressure or the urge to push.

Patient 13 was discharged home on 5/28/23 at 5:30 AM.


D. An interview with the CNM (6/14/23 at 3:20 PM) revealed, the CNM was in house with another laboring patient, RN A notified the CNM that Patient 13 arrived and provided RN A with orders. The CNM stated there were no changes in her cervical exam. CNM went to Patient 13's bedside and provided instructions for labor changes, etc, and what to watch for to return to have contractions evaluated. CNM informed Patient 13, "You don't need to be in the hospital with no cervical changes." "No concern with the baby, labs okay, a gravida 2 para 1, history of delivery at 36 weeks, felt she could go home to rest and gave her a Visteral tablet to help her rest." "Had no concerns at all sending her home."

Review of the medical recorded showed no documentation that a physician had been involved in determining if Patient 13 had an emergency medical condition.

E. Review of the Prehospital Care Report (ambulance report) dated 5/28/23, identified that the ambulance had been dispatched at 7:17 AM to Patient 13's home with a report of term pregnancy with contractions. Upon arrival at 7:21 AM emergency personnel documented, "arrived on scene, a female holding a newly delivered infant. Blood loss is minimal. Placenta had not been delivered. Patient 13 secured on cot and in squad and was taken directly to Labor and Delivery."

D. Review of Patient 13's Electronic Medical Record (dated 5/28/23 at 7:39 AM) identified that the patient was brought to the hospital by ambulance after having delivered prior to arrival of the ambulance at home. The obstetrical specialist Dr F, arrived and completed a History and Physical (H&P) at 8:07 AM and documented that Patient 13 presented with complaints of a precipitous (rapid labor and delivery). The patient had previously been to the hospital with contractions and was discharged at 5:30 AM with no cervical change. Upon examination it was noted the placenta was delivered spontaneously and the cervix, vagina and perineum were carefully inspected for lacerations (a tear in skin) and hematoma's (a pooling of blood outside the blood vessel). Patient 13 was stable and taken to postpartum care.