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Based on staff interview, policy review, incident report review, and OB walk in log review, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This resulted in the failure to provide stabilizing treatment prior to discharge for a patient who presented to the ED seeking services. Findings include:

Refer to A2405 as it relates to the failure of the hospital to ensure all patients presenting to the hospital for emergency services were logged.

Refer to A2406 as it relates to the failure of the hospital to ensure all patients presenting to the hospital for emergency services were provided an MSE

Based on policy review, incident report review, OB walk in log review, and staff interview, it was determined the facility failed to ensure all patients presenting to the hospital for emergency services were logged in the emergency walk-in log for 1 of 20 patients (Patient #18) whose records were reviewed. This caused an OB patient who presented to the hospital for emergency services not to be captured as presenting to the hospital. Findings include:

A hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", effective 2/23/23 stated, "Central log. The Hospital will maintain a central log on each individual who comes to the hospital seeking assistance 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." This policy was not followed. An example includes:

Facility incident reports were reviewed. One incident report dated 8/21/23 was reviewed. The incident report stated, "[name] received a phone call from [name], from [area hospital] stating they had this patient come to their facility for evaluation due to she fell and wanted to be checked out. The patient reported to them that she came first to our hospital but she was told we could not do anything for her because her doctor was not did not [sic] deliver at our facility and she would need to go to [area hospital]. She stated that she was not monitored or evaluated by us. It was also reported that she was 26 week [sic] pregnant and had fallen at home and was concerned."

The incident investigation for the above incident was requested and reviewed. It stated Patient #18 was involved in the incident. It stated, "It appears [Patient #18] made the decision to leave without being evaluated. An AMA form was signed before she left (see attached). [OB Manager name] has sent out a reminder to staff that it is best practice to get the patients admitted before the evaluation is fully completed so we can chart the evaluation if possible if it is apparent that the patient needed medical treatment treat the patient and get the patient admitted as soon as possible."

The OB Director was interviewed by phone on 10/18/23 beginning at 3:38 PM. She confirmed Patient #18 presented to the OB department to be assessed after a fall. She stated she did not believe Patient #18 was logged due to not being able to register her.

Surveyors conducted observations on the OB unit on 10/18/23 beginning at 4:00 PM. The OB walk in log for the previous 3 month was reviewed for evidence of Patient #18 presenting to the OB department for emergency services. Patient #18 was not listed on the OB walk in log. The Risk and Quality Director was present for the observations and confirmed Patient #18 was not in the OB walk in log

The OB charge nurse was interviewed during the OB observations on 10/18/23 beginning at 4:00 PM. She stated for a patient to be put on the log they would have to be registered and given a unique FIN number. She stated without the FIN number there would be no way to log the patient. When asked what information was needed to generate a FIN number and registration, she stated first and last name, date of birth, and physician.

Patient #18 presented to the hospital for emergency services but was not logged.

Based on policy review, incident report review, OB walk in log review, and staff interview, it was determined the facility failed to provide an MSE for 1 of 20 patients (Patient #18) whose records were reviewed. This resulted in the patient going to a different hospital for emergency services and had the potential for a negative outcome for the patient. Findings include:

A hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," effective 2/23/23 stated, "if a person comes to Madison Memorial Hospital and a request is made for their emergency care ... then qualified medical personnel will, within the hospital's capability and capacity, conduct and document an appropriate medical screening examination reasonably calculated to identify an emergency medical condition." This policy was not followed. An example includes:

Facility incident reports were reviewed. One incident report regarding Patient #18 dated 8/21/23 was reviewed. The incident report stated, "[name] received a phone call from [name], from [area hospital] stating they had this patient come to their facility for evaluation due to she fell and wanted to be checked out. The patient reported to them that she came first to our hospital but she was told we could not do anything for her because her doctor was not did not [sic] deliver at our facility and she would need to go to [area hospital]. She stated that she was not monitored or evaluated by us. It was also reported that she was 26 week [sic] pregnant and had fallen at home and was concerned."

The incident investigation for the above incident was requested and reviewed. It stated, "It appears [Patient #18] made the decision to leave without being evaluated. An AMA form was signed before she left (see attached). [OB Manager name] has sent out a reminder to staff that it is best practice to get the patients admitted before the evaluation is fully completed so we can chart the evaluation if possible if it is apparent that the patient needed medical treatment treat the patient and get the patient admitted as soon as possible."

The OB manager was interviewed on 10/19/23 at 9:39 AM. The incident with Patient #18 was reviewed. She confirmed Patient #18 did not have an MSE. When asked why there was no MSE, she stated the staff put Patient #18 in a room and were starting the admission process, and Patient #18 mentioned her OB provider was at a different hospital about 40 minutes away. She stated Patient #18 and the nursing staff had a discussion and told Patient #18 if she delivered at their hospital, the baby would be transferred to a different hospital where they could care for 26 week old babies. She said Patient #18 did not want to be separated from her baby and chose to drive to the other hospital. She confirmed Patient #18 should have had an MSE.

The facility failed to ensure an MSE was provided to Patient #18.