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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 an appropriate medical screening to a patient in labor and failed to implement policies and procedures to ensure compliance with EMTALA (refer to 489.24(r) and 489.24(c) Medical Screening Exam).

Based on record review the hospital failed to maintain a central log for individuals seeking emergency care in a manner that would accurately track the patient's care.

Findings:

The hospital receives 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.

On 3/7/12 the labor and delivery log was reviewed. During this review it was noted not all patients seeking emergency care had information regarding their disposition, e.g., discharged home, admitted, transferred, etc. Two patients (Patients 5 and 7) did not have a disposition documented in the log, thus making it difficult to determine what occurred after the patient was seen.

The log also had large gaps between entries thus providing an opportunity to make unauthorized entries. It was also noted that staff routinely used white-out to cover information in the log regarding a patient's visit These errors were consistent throughout the review.

Failing to maintain an accurate and complete log of patients seeking emergency care makes it difficult to compile information regarding the quality of care provided to patients seeking emergency care.

Based on documentation and interview, medical and nursing staff failed to conduct an appropriate medical screening examination (MSE) for two of 29 sampled patients (18 and 19).

Findings:

1. The record review on 1/13/12 at 10 a.m. indicated Patient 18 arrived at Labor and Delivery (L&D) on 1/5/12 at 9:24 a.m. The labor and delivery drop in sheet (log) indicated "labor" was the reason for Patient 18's visit. The Physician Orders L&D Triage Orders included "obtain maternal vitals signs".

At 9:47 a.m. the nurse's OB (obstetrics) triage note recorded the patient's level of consciousness as "lethargy". There was no record of the patient's blood pressure or heart rate in the record. The "OB provider admission history and physical" record did not include Patient 1's vital signs or address the lethargy. On 1/15/12 at 10:20 a.m. Attending Physician A discharged Patient 18 home without a review of vital signs or comment on the patient's lethargy.

Registered Nurse B (RN B) stated during a telephone interview on 1/17/12 at 12:15 p.m. she thought she had recorded the vital signs while she assessed Patient 1 in the examination room. The medical record indicated the fetal monitor recorded the baby's heart rate but the strip did not include the mother's blood pressure and heart rate.

Attending Physician A was interviewed on 1/13/12 at 2 p.m. and acknowledged there was no blood pressure or heart rate recorded in the patient's record. The physician stated she would have asked for the vital signs if she had noticed they were missing but remained confident the patient was stable and there were no indications of potential changes in her medical condition.

During an interview on 1/13/12 at 10:20 a.m., the chief of obstetrics and gynecology (COOBG) stated he was notified by a physician at another local hospital, Patient 18 arrived by ambulance on 1/6/12 and died in the receiving hospital's emergency room. The COOBG acknowledged an MSE would include an examination of the patient and a review of vital signs. Although the patient's complaint was not unusual for their department, nursing and medical staff were required to document the MSE.

2. The record review on 3/7/12 indicated Patient 19 arrived in the emergency department on 1/25/12 at 4:25 p.m. The labor and delivery drop in sheet (log) indicated the reason for the visit was decreased fetal movement. The OB provider admission history and physical indicated Patient 19 was discharged at 4:52 p.m. as stable without evidence the physician reviewed the patient's blood pressure and heart rate.

According to the regulation individuals coming to labor and delivery for emergency visits must be provided an appropriate MSE.