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Based on interview and documentation review of twenty emergency department records, it was determined that in one of twenty patients (patient #1) who presented to the hospital requesting emergency services, the hospital #1 failed to ensure compliance with the requirements of 42 CFR 489.24 as evidenced by the deficient practice cited at 42 CFR 489.24 (r), 489.24 (c), and 489.24 (e)(1-2). Refer to tags 2406 and 2409. Findings include:

Based on interviews and documentation review, hospital #1 failed to ensure that each patient who presented to the emergency department (ED) with an emergency medical condition received an appropriate medical screening examination (MSE), stabilizing treatment, or an appropriate transfer/discharge in one of twenty patients reviewed (patient #1).
Findings include:

Patient #1, who was 38 weeks pregnant, presented to the ED in labor requesting to be assessed. Patient #1 was told that the OB department was on divert and that they would not be able to accommodate her labor. After being informed of the divert status and that she would not be able to be treated at the hospital, the patient was offered an assessment and ambulance transfer which she declined.

Patient #1 was interviewed on 5/10/2013 at 10:34 a.m., and stated that on 4/27/2013, she was having contractions, and called her physician. Her physician advised her to go to hospital #2, as she was registered for delivery at hospital #2. She and her significant other went to hospital #1 instead, to be checked, before they drove the twenty minutes to hospital #2. She went to the ER desk of hospital #1 on 4/28/2013 between 1:00-1:30 a.m., RN (A) came to the ER waiting area to talk to patient #1. Patient #1 was told by RN (A) that there was not available staff, and they were not able to admit her for labor. She stated that RN (A) talked to her about her labor, but did not complete an assessment at hospital #1. RN (A) asked her if she could make the trip to hospital #2, and did offer an ambulance transfer to hospital #2, but she was not offered an assessment in the ER.

Employee (G)/Patient Care Liaison was interviewed on 5/13/2013 at 10:27 a.m. and stated that patient #1 came into the ED on 4/28/2013 after midnight. Patient #1 stated that she was 38 weeks pregnant, and was having contractions and cramping. Employee (G) notified the OB department of patient #1's arrival, and was told by an OB nurse that the OB department was on divert status, due to a staffing issue, and was unable to accept patients. Employee (G) then called RN (A)/house supervisor. Employee (G) was told by RN (A) to talk to patient #1 and let her know that she could not be seen, but then stated that she would come down to the ED to talk with patient #1. RN (A) talked with patient #1 in the waiting room, and offered an assessment and ambulance ride to hospital #2, but patient #1 declined, and left the hospital with her significant other. Employee (G) stated that patient #1 was cramping and was "worried," Employee (G) verified that patient #1 was at hospital #1 for approximately twenty minutes, and left the hospital without a medical screening examination, and was not seen by an OB physician.

RN (A)/House Supervisor was interviewed on 5/9/2013 at 12:34 p.m. and stated on the night of 4/28/2013, she received a call from the ED admissions desk that patient #1 was in the ED, was 38 weeks pregnant, and was in labor. She stated that the hospital was on OB diversion at the time, due to staffing issues, so she went down to the ED department to talk to patient #1. She spoke with patient #1, and told her that they were not able to accommodate her labor at the hospital. RN (A) then offered an assessment in the ED and an ambulance transfer to hospital #2. Patient #1 declined the assessment and ambulance transfer, and was transported by her significant other to hospital #2. She stated that patient #1 had one contraction in the ten minutes that she spoke with her in the ED, and did not appear to be in distress.

RN (F)/ED nurse was interviewed on 5/9/2013 at 2:33 p.m. and stated that on the night of 4/28/2013, she received a call from employee (G) and was told that patient #1 was at the ED admissions desk, was 38 weeks pregnant and having contractions. Employee (G) told Employee (F) that patient #1 was requesting to be checked, as she was concerned that her contractions were five minutes apart, and wasn't sure if she was safe to continue on to hospital #2. RN (F) talked with patient #1. She stated that patient #1 was alert and calm, but was concerned about her labor.

A review of patient #1's 4/28/2013 ED record from hospital #1 revealed that patient #1, who was 38 weeks pregnant, arrived at the ED admission desk at 1:30 a.m. on 4/28/2013 with cramping and contractions approximately five minutes apart for two hours. The admission note documents that patient #1 "looked concerned." A late entry note dated 5/2/2013 at 12:30 p.m., documents that patient #1 told RN (A) that it was her first pregnancy, was 37 weeks gestation, and was 1 cm dilated at her last prenatal check. Patient #1 denied vaginal drainage or rupture of her membranes. The record documents that patient #1 was informed by Nurse (A) that the hospital would be "unable to accommodate her labor process." RN (A) offered patient #1 an assessment in the ED, and transfer to hospital #2. Patient #1 declined the assessment, as she stated that the baby was actively moving. Patient #1 also declined the ambulance transfer to hospital #2. Patient #1's record did not include documentation of a medical screening examination (MSE) or any stabilizing treatment completed with patient #1 prior to leaving hospital #1 for transport to hospital #2.

The hospital's policy titled Triage in Emergency and Urgent Care, dated 11/8/11, directs staff that "patients in labor or experiencing a problem with pregnancy after 20 weeks will be transported to the OB/GYN nursing station for evaluation as directed by an obstetrician."

The EMTALA Diversion of Patients Triage of Emergency and Urgent Care policy, dated 8/1/2012, revealed "a transfer of a pregnant woman in labor to another medical facility may be made after an assessment by a physician or by a registered nurse deemed competent in labor and delivery nursing care. If the registered nurse or other credentialed provider assesses the patient, they must consult with a physician who must reasonably determine that the benefits of such transfer for the woman and unborn child, including the benefits of not waiting for the physician to physically see the patient, outweigh the risk of the transfer to the woman and unborn child. The physician will co-sign the appropriate documentation and forms within the designated time period required by the hospital. No matter who assessed the patient, the documentation shall include a review of the benefits of the transfer versus the risks of the transfer."

Based on interviews and documentation review, hospital #1 failed to ensure that each patient who presented to the emergency department (ED) with an emergency medical condition received an appropriate transfer/discharge in one of twenty patients reviewed (patient #1) who was 38 weeks pregnant and in active labor. Findings include:

Patient #1's 4/28/2013 ED record from hospital #1 revealed that patient #1 arrived at the ED admission desk at 1:30 a.m. on 4/28/2013. She was 38 weeks pregnant, and presented with cramping and contractions approximately five minutes apart over the last two hours. The record documents that patient #1 was told by RN (A) that the hospital would be "unable to accommodate her labor process." Patient #1's record did not include documentation of stabilizing treatment (vital signs or fetal monitoring) or that a medical screening examination (MSE) was completed with patient #1 prior to leaving hospital #1. In addition, a risk and benefits statement was not completed with patient #1, or documentation that a physician was notified that patient #1 was at the admission desk of the ED, or approved the transfer to hospital #2. No documentation that hospital #2 accepted the transfer of patient #1 was found in the record.

A review of patient #1's 4/28/2013 OB record (3:20 a.m. admission) from hospital #2 indicated that patient #1 was 37 and 5/7 weeks pregnant, and was having contractions. She was admitted to the OB department with cervical changes and labor. Patient #1 experienced active labor beginning at 4:30 a.m., with spontaneous rupture of membranes at 9:30 a.m. Patient #1 delivered her infant at 1:54 p.m. on 4/28/2013. The Vaginal Delivery Note documents that patient #1 had a normal first pregnancy and a normal vaginal delivery.

Patient #1 was interviewed on 5/10/2013 at 10:34 a.m., and stated that on 4/27/2013, and stated she went to the ED admission desk of hospital #1 on 4/28/2013 between 1:00-1:30 a.m., and was told by RN (A) that there was not available staff, and they were not able to admit her for labor. RN (A) asked her if she could make the trip to hospital #2. The nurse did offer an ambulance transfer to hospital #2, but did not complete any vital signs or fetal monitoring while in hospital #1. Patient #1 also verified that she was not assessed by a physician, or given transfer paperwork to hospital #2.

Employee (G)/Patient Care Liaison was interviewed on 5/13/2013 at 10:27 a.m. and stated that patient #1 came to the ED admission desk on 4/28/2013 after midnight. Patient #1 stated that she was 38 weeks pregnant, and was having contractions and cramping. She verified that patient #1 left the hospital before a physician was notified of her arrival or or had assessed patient #1 prior to leaving for hospital #2.

RN (A) was interviewed on 5/9/2013 at 12:34 p.m. and stated on the night of 4/28/2013, she received a call from the ED admissions desk that patient #1 was in the ED, and was in labor. She stated that the hospital was on OB diversion at the time, due to staffing issues. She spoke with patient #1 in the ED, and told her that they were not able to accommodate her labor at the hospital, and offered an assessment in the ED and an ambulance transfer to hospital #2. Patient #1 declined the assessment and ambulance transfer, and was transported by her significant other to hospital #2. RA (A) verified that no vital signs or fetal monitoring was completed and she did not notify a physician regarding an assessment or transfer of patient #1. In addition, she stated that no paperwork was sent with patient #1 to hospital #2. RN (A) stated that she contacted hospital #2's OB department, after patient #1 left hospital
#1's ED to inform them that patient #1 was on the way to hospital #2.

The hospital's policy titled EMTALA Diversion of Patients Triage of Emergency and Urgent Care policy, dated 8/1/2012, revealed "a transfer of a pregnant woman in labor to another medical facility may be made after an assessment by a physician or by a registered nurse deemed competent in labor and delivery nursing care. If the registered nurse or other credentialed provider assesses the patient, they must consult with a physician who must reasonably determine that the benefits of such transfer for the woman and unborn child, including the benefits of not waiting for the physician to physically see the patient, outweigh the risk of the transfer to the woman and unborn child. The physician will cosign the appropriate documentation and forms within the designated time period required by the hospital. No matter who assessed the patient, the documentation shall include a review of the benefits of the transfer versus the risks of the transfer."