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Based documentation and interview, the hospital failed to comply with the requirements of 42 CFR 489.24 by failing to provide labor and delivery patients with a medical screening examination by appropriately trained staff (refer to data tags A-2406) and failed to accept an emergency transfer of a patient requiring specialized medical care (refer to data tag A-2411).

Based on observation, the hospital failed to conspicuously post a sign specifying the rights of individuals under Section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor. Findings:

The hospital received patients requesting emergency care through the emergency room and labor and delivery department (for patients 20 plus weeks pregnant).

On 11/14/11 at 11:45 a.m., during a tour of the labor and delivery department, it was noted that a sign regarding patient rights for emergency care was posted in a corridor beyond the nurses station where patient registration occurs. The patients would not see this sign unless they go past the nurses station and stop in the hall.

The sign was not posted in a place likely to be viewed by individuals seeking emergency care.

Based on observation, interview, and record review the hospital failed to maintain a central log for individuals seeking emergency care in a manner that included all disposition of patients. Findings:

The hospital received patients requesting emergency care through the emergency room and through the labor and delivery department (for patients 20 weeks pregnant). Logs were kept in both departments to track these patients. Both logs, covering a six-month period of time, were reviewed.

During review of the hospital's central log for patients requesting emergency medical services through the emergency room on 11/15/11 at 1:30 p.m. it was noted not all patient seeking emergency care had information regarding their disposition. The central log had missing discharge times and disposition of patients. Out of the 26 entries chosen for review in the central log 7 had missing disposition information and discharge times. This inconsistency remained throughout the review.

During a tour of the emergency department on 11/16/11 at 10 a.m. it was observed patients were required to fill out and time stamp a form explaining the reason for their emergency department visit. The time stamp machine for patient use was located outside the admitting station.

During review of patients' medical records who seek emergency services it was noted the patients were not time stamping their registration forms on arrival therefore making the documented time of arrival inaccurate. Inaccurate arrival times makes it difficult to decipher if medical treatment was delayed.

Based on documentation and interview, staff conducting medical screening examinations (MSE) in the labor and delivery department (L&D) were not qualified to conduct this examination per hospital policy.

Findings:

1. On 11/15/11 according to the hospital policy, conducting medical screening examinations for patients presenting in the labor and delivery department was delegated to the registered nurse who met the requirements to conduct such examinations. Those nurses qualified to perform the procedure must be certified (competency validated) for labor and delivery emergency medical screening examination. The initial competency must include initial training, observation of procedure by a qualified registered nurse and competency validation by a physician. Annual competency requirements include completion of the annual labor and delivery competency skills review.

On 11/15/11 the director of labor and delivery was interviewed regarding L&D nurses who are qualified to perform the MSE. She stated that all nurses (57 nurses) on the unit were qualified. Fourteen (14) nurse records were selected for review.

During the review, it was noted that a post test was taken as part of the annual competency requirement. The test indicated a 100% score is required to meet competency. In 3 staff records (Staff 4, 5 and 10), there was no score on the test and none could be found. In 1 record (Staff 4) the nurse failed the test but was still on the list as able to perform the MSE. In 14 of 14 records (Staff 1 -14) there was no identifier as to who scored the test and no key to determine what the correct answers were. Three (3) of fourteen (14) staff records (Staff 1, 9 and 12) did not have an initial physician validation as required.

2. According to the director of L & D, she validated the MSE annual competency for the assistant head nurse (AHN) who in turn signed off the L & D staff nurses. Further review revealed the director had not passed the MSE competency requirements thus she was not qualified to validate the AHN. It was also noted the competency form did not indicate how the skill set for conducting the MSE was validated, e.g., observation, chart review, staff input, etc.

Based on documentation and interview, the hospital failed to accept a patient transfer from another hospital's emergency room for one of 36 sampled patients (Patient 36) in need of specialized services.

Findings:

On 9/10/11 at 2:22 p.m. Hospital A made a telephone request to transfer Patient 36 from their emergency room with an acute gastric intestinal bleed to Good Samaritan Hospital. The nurse supervisor (Staff B) for Good Samaritan Hospital took the call and conversed with Hospital A's transfer center. The transfer center staff stated they were looking for a gastroenterologist. Staff B responded by saying, "you haven't found any closer hospitals?" The transfer center stated they tried many places in their area with no success. Staff B then asked what the (other hospital's) responses were. The transfer center stated "no GI or beds." Staff B then commented about the cost of sending the patient and returning the patient. She wanted the transfer center to "try harder" in locating a closer hospital. She further stated if they "can't find anything to call back. The transfer center stated, "I guess are you saying no?" Staff B said "yes."

Staff B was interviewed by this evaluator in regard to her contact with Hospital A on 11/14/11 at 10:50 a.m. She received the call from Hospital A but was not sure to whom she spoke. She asked the caller if there was a hospital closer and was the patient stable. She was told they did not know and would call back. Staff B stated Hospital A never called back.

On 11/14/11 at 11:30 a.m. a telephone interview was conducted with the Emergency Department Medical Director (Physician C) at Hospital A. Physician C stated the Transfer Center handles placement of their ED patients who need to be transferred to other hospitals. Physician C further stated the Transfer Center records all telephone calls.

On 11/15/11 the recording was reviewed by this evaluator and verified Hospital A's account of the communication between the Transfer Center and Good Samaritan Hospital.

A review of the physician on-call list at Good Samaritan Hospital, Emergency Department revealed that a gastroenterologist was on call that day (9/10/11) and the hospital had beds available. Thus, the hospital had the capacity and the capability to care for this patient.