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Based observation, record review, policy review and staff interview, the facility failed to post Emergency Medical Treatment and Active Labor Act (EMTALA) signage conspicuously in the Emergency department and Obstetric Triage that specified the rights of patients with respect to medical screening examination and treatment for emergency medical conditions (A2402). The facility failed to maintain the medical record for individuals transferred to another hospital (A2403). The facility failed to ensure a qualified medical person performed a medical screening examination to determine whether or not an emergency medical condition existed and failed to ensure qualified medical personnel was approved by the hospital's governing board as qualified to administer a medical screening examination (A2406). The facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer (A2409).

Based on observation, facility policy review, and staff interview, the facility failed to post Emergency Medical Treatment and Active Labor Act (EMTALA) signage conspicuously in the Emergency department and Obstetric Triage that specified the rights of patients with respect to medical screening examination and treatment for emergency medical conditions. This had the potential to affect all patients presenting to the Emergency Department for care.

Findings include:

1. The facility's Maternity unit, including Obstetric Triage, High Risk Antepartum, Labor and Delivery, Postpartum, and NICU, and 1 Blue were toured on 02/04/2020 at 9:00 AM. No EMTALA signage was observed in the seven-bed Obstetric Triage unit. Obstetric Triage room #1 was toured. There was no EMTALA signage posted within the room. Staff Q, present during the tour, revealed that identical signage was posted in the remaining six triage rooms. Staff Q also revealed there was no dedicated waiting area for patients, family members and visitors in Obstetric Triage and that patients, family members, and visitors utilized the waiting room on 1 Blue, the main entrance to the hospital. 1 Blue was toured. Again, no EMTALA signage was noted on walls and/or pillars in the area.

The facility policy titled Compliance with the Emergency Medical Treatment and Active Labor Act (Number: OH.POL.P-100.xxx), issued 08/15/10, was reviewed on 02/04/2020 at 1:30 PM. Review of the policy revealed the hospital will post conspicuously at any Emergency Department or in a place(s) likely to be noticed by individuals entering the Emergency Department, as well as individuals waiting for examination and treatment in areas other than the Emergency Department (such as entrance, admitting, waiting areas, treatment areas), a sign, in the CMS-approved form, specifying the rights of individuals under EMTALA, and a sign, in the CMS-approved form, indicating that the hospital participates in Medicare and Medicaid.

Interview with Staff E on 02/04/2020 at 2:00 PM verified that no EMTALA signage was posted in the facility's Maternity unit, including Obstetric Triage, High Risk Antepartum, Labor and Delivery, Postpartum, and NICU, and 1 Blue as instructed by facility policy.


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2. During tour of the Emergency Department on 02/03/2020 at 4:13 PM, the EMTALA sign was observed to be on one side of a four-sided pillar in the center of the waiting room facing one set of chairs. The sign did not face the entrance to the waiting room, the entrance to the triage area which led to the rest of the emergency department, or the other set of chairs in the waiting room. No additional EMTALA signs were observed in the remainder of the emergency department, including the ambulance entrance. On 02/06/2020 at 10:50 AM, this was verified in an interview by Staff D.

Based on medical record review and staff interview, the facility failed to maintain the medical record for individuals transferred to another hospital for two of five medical records of transferred patients reviewed (Patient #12 and #14). A total of 22 medical records were reviewed.

Findings include:

1. Review of the medical record for Patient #12 revealed an arrival date of 11/12/19 at 6:23 AM to the emergency department. The medical record contained documentation the patient was suicidal and an order for a medical hold (involuntary admission) was dated 11/12/19 at 6:30 AM. The medical record revealed the patient was transferred to a psychiatric facility on 11/14/19 at 9:34 AM. The medical record lacked documentation of an "Application for Emergency Admission" or "Pink Slip" or a transfer document that listed the risks and benefits of the transfer signed by the physician.

2. Review of the medical record for Patient #14 revealed an arrival date of 11/07/19 at 9:11 AM to the emergency department. The medical record contained documentation the patient was suicidal and an order for a medical hold (involuntary admission) was dated 11/07/19 at 9:30 AM. The medical record revealed the patient was transferred to a psychiatric facility on 11/07/19 at 10:59 PM. The medical record lacked documentation of an "Application for Emergency Admission" or "Pink Slip" or a transfer document that listed the risks and benefits of the transfer signed by the physician.

On 02/06/2020 at 3:23 PM, Staff L verified the transfer document and "Pink Slip" were not in the medical records for Patients #12 and #14. Staff L stated the original would have gone with the patients when they were transferred. The facility had since contacted the receiving facility and obtained a copy of the "Pink Slip" for Patient #12.

A. Based on record review and staff interview, the facility failed to ensure a qualified medical person performed a medical screening examination to determine whether or not an emergency medical condition existed for two of 22 patients (Patient #18 and Patient #19).

Findings include:

The medical record of Patient #17 revealed the patient, a Gravida 3 Para 2 preterm with twins at 22.2 weeks gestation, presented to Obstetric Triage on 06/24/17 at 9:35 AM with complaints of a sudden onset of vaginal bleeding and abdominal cramping. The patient described the bleeding to be as heavy as a period. It was also noted the patient reported a brief episode of cramping the night before that resolved and the patient easily went to sleep. The patient reported the cramping returned after the bleeding began that morning. The patient was found to be in preterm labor with cervical dilation apparent on transvaginal ultrasound with hourglassing membranes. The patient reported normal fetal movement for both fetuses. The patient was admitted to the High Risk Antepartum unit at 11:00 AM for observation and neonatology was consulted for counseling of patient regarding fetal viability.

A Progress Note composed by a neonatologist stated the following: "I was asked to speak with these parents shortly after admission. They were understandably upset by this turn of events. Because Mom is currently 22.2 weeks gestation with good dating from 8 week ultrasounds, we do not plan on intervention at this point. Mom asked about steroids and I deferred the question to her OB but remarked that we support it at 22.5 weeks. I was clear with mom that we neither should or would do anything for the babies if or when she delivers in the next 3 days. I explained that in our estimation that is the most humane and appropriate thing to do for them. I encouraged them to spend whatever time they had with the babies holding and loving them. I tried to provide some comfort by reassuring her that the preterm labor was not her fault nor did she in any way cause it...I told her that I would be willing to come when they are born if that would reassure her but only to assess the babies, not to institute any aggressive cares. I also told her that other members of our group might feel differently about attending the delivery at this pre-viable stage."

The Medication Administration Record (MAR) revealed the patient was medicated with Betamethasone (an antenatal steroid given in two doses, 12 milligrams (mg) each, 12 or 24 hours apart to speed up lung development in preterm fetuses) 12 mg subcutaneously on 06/24/17 at 1:37 PM and twenty four hours later on 06/25/17 at 1:37 PM as ordered by an obstetric physician.

An Antepartum Daily Progress note written by a resident obstetric physician on 06/25/17 stated the patient was emotionally upset and crying. The patient asked if staff could promise that her babies would live. She stated the babies were all she and her husband had. When the resident obstetric physician asked if the patient needed to talk to someone from Behavioral Health, the patient was noted to become defensive.

A progress note by the same resident obstetric physician at 4:28 AM on 06/26/17 stated a bedside ultrasound revealed the patient's cervix appeared "more dilated and fetal parts appear to have descended into the hourglassing membranes." No cervix was palpated. The note stated the patient was "extremely distraught with news." The resident physician stated in his/her note that it was reiterated "there is nothing we can change in our care, as babies are previable. NICU is aware of the situation and also had discussed with her that they would not resuscitate at this early gestational age." The patient was encouraged "to relax and lay back." The progress note also stated the resident physician discussed the details of the note with a second resident physician; however, the note did not state the details of the note were discussed with an attending obstetric physician or neonatologist.

A nurse's note at 6:48 AM on 06/26/17 stated the patient was again tearful. She reported rather dying than her babies dying. Staff believed the patient was suicidal and ordered a psychiatric evaluation. The Behavioral Health consult on 06/26/17 stated the patient denied suicidal ideation, plan, or intent.

A nurse's note on 06/27/17 at 1:00 AM stated the staff nurse walked into the patient's room to find her out of bed. The patient reported feeling a baby "come out" and going to the bathroom to see if she could feel them. The patient was encouraged to return to bed and emphasized the importance of remaining in bed and laying flat. The patient reported understanding the instructions. A resident obstetric physician was notified.

The resident obstetric physician's progress note on 06/27/17 at 3:06 AM stated he/she was called to see the patient for the patient's complaints of increased pelvic pressure. The patient was noted to be writhing in bed reporting extreme pressure and the urge to push. The note stated the resident obstetric physician informed the patient of the possibility that delivery was imminent. The patient was offered an epidural but declined. The note further stated the patient again inquired about resuscitation and was informed that "if the patient delivers, the babies are not at a gestational age at which they would survive." The note stated a neonatal nurse practitioner (NNP) from NICU was "updated regarding situation and agreeable to be present at the time of delivery."

A resident obstetric physician's note stated the following: "Called immediately after precipitous delivery" of Twin #1 (Patient #19). "Upon arrival, patient holding infant. Cord had been clamped and cut. NICU staff present at time of delivery. Patient again requesting resuscitation. NICU and nursing staff discussed with patient that resuscitation is unable to be performed given baby's extremely early gestational age." According to the Delivery Summary, the infant was delivered at 4:10 AM with Apgars, assigned by a registered nurse, of one at one minute of life and one at five minutes of life. The male infant weighed 493 grams or 1.087 pounds. The Delivery Summary listed five delivery providers including a resident physician, a delivery nurse, two additional registered nurses, and a neonatal nurse practitioner (NNP). The method of newborn resuscitation was listed as "none." Patient #17's medical record revealed the infant was pronounced deceased 34 minutes after delivery, at 4:44 AM. This delivery note written by a resident physician was not co-signed by his/her attending physician. Patient #17's medical record lacked documentation of a medical screening for Patient #19.

A second resident obstetric physician's progress note stated: "At bedside for morning rounds. Patient reports significant vaginal pain. Spontaneous rupture of membranes occurred. With the next two contractions, non-viable morphologically normal male infant delivered. Infant with weak cry. Cord clamped and cut. Infant placed on maternal chest for skin-to-skin." The note further stated the patient requested resuscitation and was informed that resuscitation could not be performed due to the early gestational age and small infant size. The Delivery Summary noted the second twin (Patient #18) delivered at 6:15 AM. The delivery providers included the same delivering clinician and delivery nurse as Patient #19. Patient #17's medical record lacked documentation resuscitative treatment was implemented. This infant was noted to live for 90 minutes before being pronounced deceased. Patient #17's medical record lacked documentation any staff from NICU attended the delivery. It was also noted the delivery note was not co-signed by the resident physician's attending obstetric physician.

Interview with Staff Q on 02/05/2020 at 11:30 AM revealed that the facility does have a neonatal intensive care unit that can care for and treat extremely premature and very low birth weight infants. Staff Q further stated that Patients #18 and #19 were assigned medical record numbers; however, no medical records were created for these patients as they were never admitted to the neonatal intensive care Unit (NICU). Patient #17's medical record was reviewed with Staff Q and Staff P. Staff Q identified what he/she believed was the medical screening exams performed on Patient #18 and #19. Staff Q revealed resident physician's delivery remarks for Patient #19 that stated, "resuscitation is unable to be performed given baby's extremely early gestational age" was the medical screening exam. Similar to Patient #19, Staff Q identified the medical screening of Patient #18 as the resident physician's delivery note that stated, "non-viable morphologically normal male infant delivered. Infant with weak cry." Staff Q was asked to provide documentation a resident physician was approved by the governing board to perform medical screenings.

The facility policy titled Compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA), (Number: OH.POL.P-100.055), issued 08/15/10, was reviewed on 02/04/2020 at 1:30 PM. Review of the policy revealed medical screening is to be conducted to the extent necessary by physicians and/or other qualified medical personnel to determine whether an emergency medical condition exists. A qualified medical person or personnel is defined as a licensed physician or other individual who is licensed or certified in the following professional categories, Advanced Practice Provider, which have been approved by the hospital's governing board as qualified to administer a medical screening examination, and who have demonstrated current competence in the performance of medical screening examinations to determine whether or not an emergency medical condition exists.

Staff J was interviewed on 02/05/2020 at 4:15 PM. He/She revealed residents were not permitted to perform medical screening exams as they were considered learners and were not privileged physicians. It was also confirmed that neither delivery note was co-signed by an attending physician who was privileged to perform medical screening exams.

This substantiates Substantial Allegation OH00109348.


B. Based on record review and staff interview, the facility failed to ensure qualified medical personnel were approved by the hospital's governing board as qualified to administer a medical screening examination. This had the potential to affect all patients requiring a medical screening.

Findings include:

The facility policy titled Compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA), (Number: OH.POL.P-100.055), issued 08/15/10, was reviewed on 02/04/2020 at 1:30 PM. Review of the policy revealed medical screening is to be conducted to the extent necessary by physicians and/or other qualified medical personnel to determine whether an emergency medical condition exists. A qualified medical person or personnel is defined as a licensed physician or other individual who is licensed or certified in the following professional categories, Advanced Practice Provider, which have been approved by the hospital's governing board as qualified to administer a medical screening examination, and who have demonstrated current competence in the performance of medical screening examinations to determine whether or not an emergency medical condition exists.

The Medical Staff Bylaws, approved by the Governing Body on 12/21/11, were reviewed on 02/05/2020 at 3:00 PM. The bylaws did not state who is approved to perform medical screenings as a qualified medical person. This finding was confirmed with Staff J in an interview on 02/06/2020 at 12:11 PM.

Based on medical record review and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer for two of five medical records of transferred patients reviewed (Patient #12 and #14). A total of 22 medical records were reviewed.

Findings include:

1. Review of the medical record for Patient #12 revealed an arrival date of 11/12/19 at 6:23 AM to the emergency department. The medical record contained documentation the patient was suicidal and an order for a medical hold (involuntary admission) was dated 11/12/19 at 6:30 AM. The medical record revealed the patient was transferred to a psychiatric facility on 11/14/19 at 9:34 AM. The medical record lacked documentation of a transfer document that listed the risks and benefits of the transfer signed by the physician.

2. Review of the medical record for Patient #14 revealed an arrival date of 11/07/19 at 9:11 AM to the emergency department. The medical record contained documentation the patient was suicidal and an order for a medical hold (involuntary admission) was dated 11/07/19 at 9:30 AM. The medical record revealed the patient was transferred to a psychiatric facility on 11/07/19 at 10:59 PM. The medical record lacked documentation of a transfer document that listed the risks and benefits of the transfer signed by the physician.

On 02/06/2020 at 3:23 PM, Staff L verified the transfer documents were not in the medical records for Patient #12 and #14.