HospitalInspections.org

Based on record reviews, staff interviews, facility incident reports, and facility policies, it was determined the facility failed to report 2 of 2 patients (#18 and #19) whose records were reviewed for potential EMTALA violations. This had the potential to cause a delay in obstetric care. Findings include:

A facility policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," effective 2/10/23, stated:
"Reporting Potential EMTALA Violations...
Each Transfer Center employee working with the DED, medical staff member, house staff member, hospital employee, or contracted individual who works in the DED or other area where EMTALA requirements are applicable and who has reason to believe that a potential violation of the law has resulted in an inappropriate transfer to the hospital as a receiving hospital or from the hospital as a transferring hospital must report the incident to the CEO or CEO's designee such as the Risk Manager or the ECO immediately for investigation."

Additionally, the policy stated, "Receiving Hospitals. Receiving hospitals have a duty to report an inappropriate transfer received from a transferring institution. A hospital that suspects it may have received an improperly transferred individual (transfer of an unstable individual with an EMC who was not provided an appropriate transfer according to 42 C.F.R 489.24(e)(2)), is required to promptly report the incident to the Centers for Medicare & Medicaid Services ("CMS") or the state agency within 72 hours of the occurrence. Failure to report within 72 hours may result in an EMTALA violation by the receiving facility."

This policy was not followed. Examples include:

1. Patient #18 was a 23-year-old pregnant (38 week) female who presented to Hospital A on 8/25/23 with a chief complaint of spontaneous labor. Patient #18 was chosen from an incident report that stated, "Patient presented at (Hospital B) for labor, (Hospital B) turned pt away."

The ECO, was interviewed on 10/17/23 beginning at 12:50 PM. He stated he called Hospital B and spoke to a person in the Quality Department about Patient #18's claims. The ECO stated approximately 2 days later Hospital B called him and stated they reported the possible EMTALA violation to the State Agency. Additionally, the ECO stated he thought since Hospital B reported the possible violation he did not have to.

Patient #18's OB RN, Staff #2, was interviewed on 10/17/23 beginning at 1:55 PM. She confirmed that Patient #18 went to Hospital B and was told the hospital was on divert. The RN also confirmed that Patient #18 was 5cm dilated on arrival and delivered her baby approximately 3 hours after arriving to Hospital A.

2. Patient #19 was a 24-year-old pregnant (26 week) female who presented to Hospital A on 8/21/23 with a chief complaint of OB check after a fall. Patient #19 was selected from an incident report that stated, "possible EMTALA violation from another facility."

The ECO was interviewed on 10/17/23 beginning at 12:50 PM. He stated he spoke to the Quality Manager at Hospital C regarding the possible inappropriate transfer of Patient #19. The ECO stated, Patient #19 went to Hospital C due to a fall and wanted to have her baby checked. Patient #19 asked questions about if she delivered at 26 weeks and was told by Hospital C staff that she would have to transfer to Hospital A; as Hospital C does not have NICU capability and Patient #19 should just go to Hospital A after signing an AMA form.

Patient #19's OB RN, Staff #3, was interviewed on 10/17/23 beginning at 1:55 PM. The RN was asked what made her report this incident as a possible EMTALA violation. The RN stated a nurse from Hospital C called and said Patient #19 was coming to Hospital A. The RN was asked what she was told by Patient #19 about her situation with going to Hospital C. The RN stated, Patient #19 went to Hospital C's ED and was told to go to L&D. The patient had to drive around the building to find the L&D unit and, once she found it, she was told she would have to go to Hospital A. The RN stated Patient #19 was concerned Hospital C did not check her or her baby after her fall. Hospital C is approximately a 40 minute (30 mile) drive from Hospital A.

The facility failed to report Patient #18 and #19 as a possible EMTALA violation.