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Based on medical record review, staff interview and document review it was determined the facility failed to provide an appropriate medical screening exam for one (1) of twenty (20) medical records reviewed who presented to the Labor and Delivery Unit and requested treatment (Patient #1). This failure has the potential for all patients who come to the hospital for emergency treatment to recieve substandard care (See tag A-2407 and A-2409).

Based on medical record review, staff interview and document review it was determined the facility failed to transfer a patient with an emergency medical condition to another facility that offers psychiatric care in one (1) of twenty (20) medical records reviewed who presented to the Labor and Delivery Unit and requested treatment (Patient #1). This failure has the potential for all psychiatric patients who have an emergency medical condition who come to the hospital for emergency treatment to receive substandard care.

1. Review of the medical record for Patient #1 revealed the patient was brought to the hospital by the Emergency Medical Services (EMS) on 10/05/17 at 5:28 p.m. at the request of the police for complaints of pregnancy and abdominal pain. The patient was diagnosed with a thirty-three (33) week intrauterine pregnancy and delusions. Registered Nurse #1 documented in part on 10/05/17 at 6:44 p.m., "est gest age is 33 wks. Patient cleared with pregnancy to be taken to another facility for mental health and drug detox. The patient threatened every nurse on unit that she would "hurt you, whip your ass, kick your face off"... The patient's family stated she is dangerous. The patient was escorted off the unit by security and Beckley police department to meet EMS in parking lot to be taken to Beckley Appalachian Regional Hospital (BARH)." It further revealed no documentation for a transfer to another hospital had been attempted by Physician #1 or the midwife who cared for the patient. Further review revealed no documentation of the physician speaking to another hospital for a transfer for an emergency medical condition.

2. A telephone interview was conducted on 10/16/17 at 3:10 p.m.with the security officer/Beckley police. When asked if he remembered the patient, he stated, "Yes". When asked to explain how he came to take the patient to the parking lot. he stated, in part, "She was discharged and when we got to the parking lot she threatened to kill me and she had threatened harm to the nurses on the unit and she was given a choice to go to get help or go to jail and she said she couldn't go to jail she'd get help, so I called EMS and they pulled into the Krogers parking lot and took her to BARH." When asked if she was a transfer or a discharge he stated, "A discharge."

3. An interview was conducted with the Labor and Delivery (L&D) midwife on 10/17/17 at 8:10 a.m. When asked if she remembered the patient she said, "Yes". She stated that due to a police officer being at the nurse's station she thought the patient was in police custody. She stated the police officer had a gun and she was not going to stop him from taking the patient into custody and risk getting arrested. She reported she did not have EMTALA training.

4. An interview was conducted with the Obstetrics Physician on 10/17/17 at 12:30 p.m. When asked if he remembered the patient, he said, "Yes". He stated a Beckley Police officer accompanied the patient to the L&D floor, (she wasn't brought up by EMS) and she came to L&D by blue transport chair and staff. He reported he did not see EMS staff at all and he assumed the patient was under arrest or a possible involuntary commitment hold. He stated if the police had not been there the patient wouldn't have been discharged; she would have been sent back to the Emergency Department because she wasn't okay to go home. He stated, "This is definitely an EMTALA violation." During the interview the Chief Medical Staff of Obstetrics arrived to sit in on the interview with the permission of the Obstetrics physician. She concurred with his findings this was an EMTALA.

5. Review of the policy titled, "Medical Screening", last reviewed 04/16 states, in part: "The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED) or when an individual request emergency medical care on hospital property other than in a DED. If an Emergency Medical Condition (EMC) is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer."

6. An interview was conducted on 10/17/17 with the Director of Quality at approximately 1:20 p.m.and she concurred with the above findings.

Based on medical record review, staff interview and document review it was determined the facility failed to transfer a patient with an emergency medical condition to another facility that offers psychiatric care in one (1) of twenty (20) medical records reviewed who presented to the Labor and Delivery Unit and requested treatment (Patient #1). This failure has the potential for all psyciatric patients who have an emergency medical condition who come to the hospital for emergency treatment to receive substandard care.

1. Review of the medical record for Patient #1 revealed the patient was brought to the hospital by the Emergency Medical Services (EMS) on 10/05/17 at 5:28 p.m. at the request of the police for complaints of pregnancy and abdominal pain. The patient was diagnosed with a thirty-three (33) week intrauterine pregnancy and delusions. Registered Nurse #1 documented in part on 10/05/17 at 6:44 p.m., "est gest age is 33 wks. Patient cleared with pregnancy to be taken to another facility for mental health and drug detox. The patient threatened every nurse on unit that she would "hurt you, whip your ass, kick your face off"... The patient's family states she is dangerous. The patient was escorted off the unit by security and Beckley police department to meet EMS in the parking lot to be taken to Beckley Appalachian Regional Hospital (BARH)." It further revealed no transfer to another hospital had been attempted by Physician #1 or the midwife who cared for the patient.

2. A telephone interview was conducted on 10/16/17 at 3:10 p.m. with security the officer/Beckley police. When asked if he remembered the patient, he stated, "Yes". When asked to explain how he came to take the patient to the parking lot he stated in part, "She was discharged and when we got to the parking lot she threatened to kill me and she had threatened harm to the nurses on the unit and she was given a choice to go to get help or go to jail and she said she couldn't go to jail she'd get help, so I called EMS and they pulled into the Krogers parking lot and took her to BARH." When asked if she was a transfer or a discharge, he stated, "A discharge."

3. An interview was conducted with the Labor and Delivery (L&D) midwife on 10/17/17 at 8:10 a.m. When asked if she remembered the patient she said, "Yes". She stated that due to a police officer being at the nurse's station she thought the patient was in police custody. She stated the police officer had a gun and she was not going to stop him from taking the patient into custody and risk getting arrested. She reported she did not have EMTALA training.

4. An interview was conducted on 10/17/17 at 8:45 a.m. with the L&D charge nurse. When asked if she remembered Patient #1, she stated,. "Yes". When asked if she made a phone call to another hospital to see if they accepted pregnant psychiatric patients she stated, in part, "Yes, the mother wanted the patient to recieve help and I called BARH to see if they would take a pregnant psychiatric patient and talked to the supervisor and he told me they don't take pregnant women and they did not have any psychiatric beds available." When asked if she had a physician's order to begin a transfer request, she stated, "No".

5. A tour of the L&D unit was conducted on 10/17/17 at 9:55 a.m. with the Director of L&D. The patient was in an observation room directly in front of the nursing station. An interview was conducted during the tour with Registered Nurse #2. When asked if there was ever any talk about a transfer to another hospital, she said., "No, we thought she was in custody. The police escorted her out of the hospital and it was our understanding he was going to take her to BARH." When asked to describe the patient's behavior and if the physician was aware of the patient's behavior, she stated, in part, "She was delusional and yelling and threatening us and thrashing around and she was hard to monitor (the baby) ... the physician was at the desk he knew what she was acting like ... it took about 5-6 nurses to take care of her." The Director of L&D concurred with the findings.

5. An interview was conducted with the Obstetrics Physician on 10/17/17 at 12:30 p.m. When asked if he remembered the patient, he said, "Yes". He stated a Beckley Police officer accompanied the patient to the L&D floor (she wasn't brought up by EMS) and she came to L&D by blue transport chair and staff. He reported he did not see EMS staff at all and he assumed the patient was under arrest or possible involuntary commitment hold. He stated if the police had not been there the patient wouldn't have been discharged; she would have been sent back to the Emergency Department because she wasn't okay to go home. He stated "This is definitely an EMTALA violation." During the interview the Chief Medical Staff of Obstetrics arrived to sit in on the interview with the permission of the Obstetrics physician. She concurred with his findings this was an EMTALA.

6. Review of the policy titled, "Medical Screening", last reviewed 04/2016, revealed it states, in part:: "The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED) or when an individual request emergency medical care on hospital property other than in a DED. If an Emergency Medical Condition (EMC) is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer."

7. An interview was conducted on 10/17/17 at approximately 1:20 p.m.with the Director of Quality, she concurred with the above findings.