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Based on interview, review of an incident report, the facility's policies, Emergency Department (ED) log, and medical by-laws it was determined the facility failed to ensure a medical screening and medical services were provided for one (1) of twenty (20) patients (Patient #1) that presented to the ED of the facility seeking treatment. Patient #1 presented to the ED and reported he/she was having labor contractions and requested medical services. The patient was informed by Patient Registration Clerk #1 that the facility did not offer obstetric services, that she needed to seek treatment from a facility in an adjacent community, and the patient left the facility. The facility failed to provide a medical screening or medical services to Patient #1.

The findings include:

A review of the facility's policy titled "Patient Transfer and Emergency Medical Treatment and Labor Act," dated December 2013, revealed any person who presented to the facility and that requested assistance for a potential emergency medical condition/emergency services would receive a medical screening and persons with a medical emergency condition would be treated and their condition stabilized. Further review of the policy revealed patients of the facility had the right to an appropriate medical screening examination, necessary stabilizing treatment (including treatment of an unborn child), and an appropriate transfer to another facility.

A review of the "Medical Staff By-Laws," undated, revealed the ED Medical Staff would consist of those physicians who were employed or contracted by the hospital to provide emergency medical care in the Emergency Room. The facility designated and approved the ED Medical Staff to perform medical screening examinations for patients that requested medical treatment in the ED.

Review of the facility's incident report revealed the House Supervisor became aware on 07/02/14, that on 07/02/14, Patient Registration Clerk #1 directed a patient (Patient #1) that had presented to the facility with complaints of having labor contractions to go to another facility because the facility did not provide obstetric services. Documentation revealed the House Supervisor initiated an investigation on 07/02/14 and interviewed Patient Registration Clerk #1 to obtain details of the incident. Continued review of the report revealed the Chief Nursing Officer (CNO) continued the investigation and brought the incident to the attention of the Administrator of the facility. Further review of the incident report revealed the facility suspended Patient Registration Clerk #1 from employment immediately after the incident was reported to the Administrator.

An interview with Patient Registration Clerk #1 on 09/04/14 at 4:00 PM revealed she worked in patient registration on the night of 07/02/14. She stated at approximately 2:00 AM, Patient #1 presented to the registration desk and stated he/she was having labor contractions and that the patient's water had "broken." Patient Registration Clerk #1 stated she informed the patient the facility did not offer obstetrical services and that he/she needed to go to another facility. Patient Registration Clerk #1 stated she did not ask the patient's name and did not log the patient into the ED log. According to Patient Registration Clerk #1, the patient left the facility and did not receive a medical screening or medical services.

Interview with Registered Nurse (RN) #1 on 09/04/14 at 4:30 PM revealed Patient Registration Clerk #1 informed her of the incident on 07/02/14 and she had immediately attempted to locate the patient in the facility's parking lot but was unsuccessful. RN #1 stated she informed the facility's Chief Nursing Officer (CNO) of the incident.

The Chief Nursing Officer (CNO) confirmed in interview conducted on 09/03/14 at 11:55 AM that RN #1 informed her of the incident on the morning of 07/02/14. The CNO stated she immediately began an investigation into the incident and reported the incident to the Administrator of the facility.

Interview with the facility's Administrator on 09/02/14 at 2:00 PM also confirmed the CNO informed her of the incident on 07/02/14. The Administrator stated Patient Registration Clerk #1 was suspended immediately after the incident occurred. In addition, according to the Administrator, although the facility had provided staff with information and training related to providing all patients that presented to the ED with a medical screening prior to the incident, the facility immediately began retraining all facility staff, including Patient Registration Clerk #1, of the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements, to include the provision of medical screening.

The facility located in the adjacent community, that Patient Registration Clerk #1 had directed Patient #1 to, Facility #2, was contacted in an effort to obtain information related to patients that had presented to their facility on 07/02/14 in active labor. Facility #2 provided a copy of a medical record of a patient that had presented to Facility #2 in active labor; however, attempts to contact the patient on 09/05/14, 09/06/14, 09/07/14, and 09/08/14 were unsuccessful.

Refer to 42 CFR 489.24 (A2406).

Based on interview, and a review of the Emergency Department's registration logbook, investigation, and policies, the facility failed to ensure a medical screening was provided for one (1) of twenty (20) patients (Patient #1) that presented to the facility's Emergency Department (ED) for treatment. Interview revealed a patient presented to the facility on 07/02/14 and informed Patient Registration Clerk #1 that he/she was having labor contractions and that the patient's "water" had broken. However, interview revealed Patient Registration Clerk #1 informed Patient #1 the facility did not offer obstetric services and that he/she needed to go to another facility. Patient Registration Clerk #1 stated she failed to obtain the patient's name and did not enter the patient in the facility's ED log. The facility failed to provide medical services or perform a medical screening of Patient #1 before he/she left the facility to ensure the patient's condition was stable.

The findings include:

A review of Facility #1's policy titled "Patient Transfer and Emergency Medical Treatment and Labor Act," dated December 2013, revealed any person who presented to the facility and requested assistance for a potential emergency medical condition/emergency services would receive a medical screening and persons with a medical emergency condition would be treated and their condition stabilized. Further review of the policy revealed a patient of the facility had the right to an appropriate medical screening examination, necessary stabilizing treatment (including treatment of an unborn child), and an appropriate transfer to another facility.

Review of the facility incident report, initiated by the facility's House Supervisor, revealed on 07/02/14, Patient #1 presented to the facility with complaints of labor contractions. Patient Registration Clerk #1 informed the patient the facility did not provide obstetric services and the patient left the facility. Continued review of documentation revealed the House Supervisor interviewed Patient Registration Clerk #1 to obtain details of the incident. Based on documentation, the facility's Chief Nursing Officer (CNO) was made aware of the incident and continued the investigation. In addition, the CNO informed the facility's Administrator of the incident and Patient Registration Clerk #1 was suspended and was not allowed to return to work until the facility retrained the clerk.

An interview with Patient Registration Clerk #1 on 09/04/14 at 4:00 PM revealed she worked in patient registration on 07/02/14. According to Patient Registration Clerk #1, at approximately 2:00 AM on 07/02/14, a patient presented to the registration desk and stated he/she was having labor contractions and that his/her "water" had broken. Patient Registration Clerk #1 stated she informed the patient the facility did not offer obstetric services and that he/she needed to go to another facility in an adjacent community, Facility #2. Patient Registration Clerk #1 stated the patient left the facility without receiving a medical screening or any medical services to ensure the patient's condition was stable. In addition, Patient Registration Clerk #1 stated she did not obtain the patient's name and did not enter the patient into the facility's ED registration logbook.

Interview with Registered Nurse (RN) #1 on 09/04/14 at 4:30 PM revealed she was working as House Supervisor on the night of 07/02/14 and at approximately 2:00 AM, while she was conducting "rounds" of the facility to observe patient care areas, Patient Registration Clerk #1 informed her a patient had presented to the facility on 07/02/14 at approximately 2:00 AM "in active labor." RN #1 stated Patient Registration Clerk #1 reported she had not obtained the patient's name, the patient had not been assessed by staff from the ED, and did not receive a medical screening. RN #1 stated the clerk informed her she had directed the patient to a facility in an adjacent community, Facility #2. According to RN #1, she and a security guard immediately went to the parking lot to look for the patient but could not find the patient. She stated she returned to the ED, removed Patient Registration Clerk #1 from the ED registration area, and informed her that she had "messed up bad." She stated she informed Patient Registration Clerk #1 that all patients that presented to the ED received a medical screening regardless if the facility offered certain services or not. RN #1 stated she reported the incident to the Chief Nursing Officer on the morning of 07/02/14.

Interview with the Chief Nursing Officer (CNO) on 09/03/14 at 11:55 AM confirmed RN #1 informed her on the morning of 07/02/14 that Patient Registration Clerk #1 had informed an unknown patient that had presented to the ED with complaints of labor contractions that the facility did not provide obstetric services, that he/she needed to go to another facility, and that the patient had not received a medical screening. The CNO stated she immediately initiated an investigation into the incident and reported the incident to the Administrator of the facility.

The facility's Administrator confirmed in an interview conducted on 09/02/14 at 2:00 PM that the CNO informed her of the incident on 07/02/14.

The Administrator indicated that the Patient Registration Clerk #1 was immediately suspended until a thorought nvestigation could be completed and the outcome of the investigation determined.

According to the Administrator, the facility had previously informed and trained staff of the patient's right to obtain emergency services, including stabilization of an emergency condition, in accordance with the Emergency Medical Treatment and Labor Act (EMTALA) requirements prior to the incident that occurred on 07/02/14. In addition, the Administrator stated following the incident the facility immediately began retraining and testing all facility staff related to the EMTALA requirements to ensure all patients that presented to the facility for treatment of a medical condition received a medical screening and stabilization of medical conditions if indicated. The training was presented n staff meetings, online modules and memo posting. The staff meetings were held on 07/11, 14, 17, 18, 21, 22, 23 and 24 of 2014. These staff meetings were conducted by the Chief Nursing Executive.

All new employee if marcum and Wallace will have EMTALA Education and will completed the online learning modules within 90 days of hire. The education will be conducted by the HIM/Compliance Officer for Marcum Wallace.

Marcum Wallace will audit 25 charts monthly for evidence of medical screening tool and evidence of the Release of Responsibility form. This will begin August 2014 and continue for One Year.

Human Resources will provide evidence of EMTALA online education annually in the form of an electronic record of education.

During the investigation, the facility in the adjacent community, Facility #2, was contacted to inquire about information related to patients that had presented to their facility on 07/02/14 in active labor. Facility #2 provided a copy of a medical record of a patient that had presented to Facility #2 in active labor; however, attempts to contact the patient 09/05/14, 09/06/14, 09/07/14, and 09/08/14 were unsuccessful.