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Based on interview, record review, and policy review, the facility failed to comply with the conditions of participation outlined in §489.24: (refer to Appendix V). The facility failed to provide a MSE (medical screening examination) by a QMP (qualified medical provider) within the capability of the hospital's ED (emergency department), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists for 1 (#15); failed to provide stabilizing treatment; and the facility failed to provide an appropriate transfer for 1 (#15) of 20 sampled patients who presented to the ED for emergency care.

Findings include:

Review of a facility policy, "Emergency Medical Treatment and Active Labor Act, with a revision date of 1/2024, showed:

" ...Medical Screening Examination
1. When an individual comes to the hospital Campus requesting examination or treatment for an EMC, or who appears to a reasonable observer to need medical treatment, an MSE will be performed by an individual qualified to perform such an examination, to determine whether an EMC exists, or, with respect to a pregnant woman having contractions, whether the woman is in labor. ..."

" ...2. A transfer will be an appropriate transfer if:
...B. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment;
...Additional Transfer-Related Situations
...4. Transfers for High Risk Deliveries. A hospital that is not capable of handling the delivery of a high-risk woman in labor must still provide an MSE and any necessary stabilizing treatment as well as meet the requirements of an appropriate transfer even if a transfer agreement is in place. In addition, a provider certification that the benefits of transfer outweigh the risks of transfer is required for the transfer of a woman in labor.

-Patient #15 presented to the OB department with premature rupture of membranes at 34 weeks gestation. The patient was not provided a MSE by a QMP. [See A-2406]

-Patient #15 was sent to another hospital for a higher level of care. The facility failed to notify the receiving hospital of the transfer and ensure the hospital had qualified personnel and space available to provide care for the patient. [See A-2409]

Based on observation, interview and policy review, the facility failed to post signs specifying the rights of individuals to receive an examination and treatment for emergency medical conditions, and the rights of women in labor, in a conspicuous area to be noticed by all individuals entering and receiving care in the ED (emergency department) and the OB (obstetrics department).

Findings include:

During an observation and interview on 6/17/25 at 7:48 a.m., the ED waiting room was inspected. A single sign was posted with information on patient EMTALA rights. The sign was written in English and lacked information regarding filing a complaint with CMS. Observations within the ED hallways and examination rooms showed the areas lacked EMTALA signage. Staff member G stated the facility had placed an order to replace the existing signage. Staff member G stated the new signage would be available in English and in Spanish and would conform to the facility signage policy. Staff member G stated she was not aware of the requirement for the EMTALA signage to be posted in patient treatment areas.

During an observation and interview on 6/17/25 at 8:04 a.m., the obstetric waiting area was observed. The waiting area did not have any posted signage regarding patient EMTALA rights. Observations of the obstetric department, including labor/delivery rooms, triage room, and hallways, revealed the areas did not have signage regarding patient EMTALA rights. Staff member F stated EMTALA signs were posted at each of the hospital entries; on the wall in the vestibule, and between the two sliding glass entry doors. Staff member F said patients entering the facility for OB care and treatment would register at the registration desk at the entry of the OB department and would wait in the OB waiting room or enter the OB department for treatment. Staff member F said she was not aware EMTALA signage was required to be posted in patient waiting areas and patient treatment areas.

Review of a facility policy, "Emergency Medical Treatment and Active Labor Act, with a revision date of 1/2024, showed:
" ...Medical Screening Examination
3. Signs are posted in [facility name] Eds specifying the rights of individuals with an EMC and women in labor who come to a [facility name] ED for health care services, and the signs indicate that the hospital participates in the Medicaid and Medicare programs. ..."

Based on interview, record review and policy review, the facility failed to provide a MSE (medical screening examination) by a QMP (qualified medical provider) within the capability of the hospital's ED (emergency department), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists for 1 (#15) of 20 sampled patients.

Findings include:

Review of patient #15's electronic medical record, dated 4/26/25, showed:
- 00:22 a.m., patient #15 arrived at the facility with a complaint of premature rupture of membranes at 34 weeks 2 days
- 00:30 a.m., patient #15 was assessed by staff member E. Testing for ruptured fetal membranes (ROM), a vaginal examination with results of 2cm diameter dilation and 90% effacement (determines readiness for labor and delivery), soft cervix, no vaginal bleeding.
- 00:37 a.m., staff member E notified the provider (staff member H) of examination findings. Communication comments showed: "[Staff member H] stated if patient is stable with no threat of labor, she can be given the option to be discharged and drive herself to [hospital B] or go via ambulance."
- 00:50 a.m., Communication comments showed: "Called provider back, I asked her to come in and evaluate patient to deem her stable to ride via car. [Staff member H] stated that if patient is 2cm/90% with reactive NST (measures baby's heart rate response to movement) and no threat of labor she is considered stable and would not need to come in and evaluate her in person.
- 1:07 a.m., patient #15 discharged with instructions to head to [hospital B] immediately.

No documentation was found in the EMR for staff member H. Patient #15 arrived at [hospital b] at 1:36 a.m.

During an interview on 6/23/25 at 12:34 p.m., patient #15 said on 4/26/25 her water had broken, and she called her physician's office. Patient #15 said she had spoken to the physician on call, and she was instructed to go to the ED to be evaluated. Patient #15 stated she was concerned because she knew the facility could not care for a baby delivered at 34 weeks and she would have to be transferred to another facility. Patient #15 said when she arrived at the ED, the OB nurse checked and confirmed her water had broken. She stated she was not seen by a provider. Patient #15 stated the OB nurse discharged her and instructed her and her husband to go directly to [hospital B], which was 12 miles away.

During an interview on 6/18/25 at 7:47 a.m., staff member E said patient #15 arrived at the ED for a complaint of ruptured membranes. Staff member E said the standard practice for a possible rupture of membranes was to do a ROM+ test (Rupture of Membranes test to check for amniotic fluid) for verification of membrane rupture, and to perform a NST (prenatal test that monitors a baby's heart rate and how it reacts to movement during pregnancy) to determine fetal wellbeing and if the patient was having contractions. Staff member E stated a nurse would then notify the physician of the findings. Staff member E stated she performed a ROM+ test and determined patient #15 was positive for ruptured membranes. Staff member E stated she performed an NST, which was reactive, and performed a vaginal examination. Staff member E stated she did not believe patient #15 was having contractions. Staff member E stated she informed staff member H of her findings and staff member H made the determination to send patient #15 to [hospital B] via her personal vehicle for a higher level of care. Staff member E stated she consulted another staff member and staff member D, the house coordinator, and then made a second phone call to staff member H. Staff member E stated she asked staff member H to come in and evaluate patient #15 to determine if she was stable enough to go to [hospital B] via personal vehicle. Staff member E stated staff member H stated if all the information she was reporting was correct, patient #15 was not in active labor and was stable enough she could be discharged and go to [hospital B] via private vehicle. Staff member E said she discharged patient #15 via private vehicle to go directly to [hospital B].

During an interview on 6/18/25 at 9:05 a.m., staff member D said she told staff member E the doctor should come in and evaluate the patient to determine if she is stable or unstable and able to go to another facility via private vehicle.

During an interview on 6/25/25 at 8:42 a.m., staff member H said she had received a phone call from patient #15 stating she thought she had "broke her water", and she was 34 weeks gestation. Staff member H stated she instructed patient #15 to go to [hospital B] for evaluation. Staff member H stated she explained to patient #15 that [facility name] was not equipped to care for a 34-week infant. Staff member H said she then received a call from the OB nurse stating patient #15 had arrived at the ED and she was proven ruptured, and she was on the monitor (device to measure contractions and fetal heart rate) and not contracting. Staff member H said patient #15 was stable and could go via private vehicle to [hospital B]. Staff member H stated she did not remember staff member E asking her to come and evaluate patient #15 to determine if she was stable. Staff member H stated she was not aware the nurses at the ED were not trained or able to do a MSE. Staff member H said she was not provided with education before or after the incident on the EMTALA requirements for the facility.

During an interview on 6/25/25 at 12:33 p.m., staff member I said she was the Medical Director for the Birth Center at the facility. Staff member I stated that any patient coming to the facility in preterm labor requires a provider to come in and do an evaluation at the bedside and initiate the transfer to another facility through the call center.

During an interview on 6/25/25 at 11:24 a.m., staff member F stated if a patient was to arrive at the ED with a rupture of membranes, earlier than 34 weeks and not in labor, the provider would come in to evaluate the patient's stability and arrange for transport to another facility for a higher acuity of care. Staff member F said nursing staff were currently not designated as QMP's and unable to perform a MSE.

During an interview on 6/26/25 at 10:33 a.m., staff member A said the facility did not have a policy that contains the educational requirements for a nurse to be trained to perform an MSE within the OB setting.

Review of a facility policy, "Emergency Medical Treatment and Active Labor Act, with a revision date of 1/2024, showed:
" ...Medical Screening Examination
1. When an individual comes to the hospital Campus requesting examination or treatment for an EMC, or who appears to a reasonable observer to need medical treatment, an MSE will be performed by an individual qualified to perform such an examination, to determine whether an EMC exists, or, with respect to a pregnant woman having contractions, whether the woman is in labor.
...Definitions
...7. "Qualified Medical Person (QMP)" may include licensed or certified clinical social workers, registered nurses, physician assistants, psychologists, and other professionals delineated as such in governing by-laws of the scope of the EMC is within the individual's scope of practice. ..."

Review of a the facility "Critical Access Hospitals Medical Staff Credentials Policy," with a revision date of 1/2025, showed:
"...Qualified Medical Personnel (QMP) is a Physicaian or Advanced Practice Professional who is qualified to perform a Medical Screening Examination ("MSE") to determine if a patient has an Emergency Medical Condition ("EMC") as defined in the Emergency Medical Treatment and Active Labor Act ("EMTALA"). ..."

Based on interview and record review, the facility failed to provide stabilizing treatment to a patient who presented with signs of premature rupture of membranes for 1(#15) of 20 sampled patients.

Findings include:

Review of patient #15's electronic medical record, dated 4/26/25, showed:

- 00:22 a.m., patient #15 arrived at the facility with a complaint of premature rupture of membranes at 34 weeks 2 days
- 00:30 a.m., patient #15 was assessed by staff member E. Premature ruptured of membranes (PROM) was confirmed.
- 00:37 a.m., staff member E notified the provider (staff member H) of examination findings. Communication comments showed: "[Staff member H] stated if patient is stable with no threat of labor, she can be given the option to be discharged and drive herself to [hospital B] or go via ambulance."
- 00:50 a.m., Communication comments showed: "Called provider back, I asked her to come in and evaluate patient to deem her stable to ride via car. [Staff member H] stated that if patient is 2cm/90% with reactive NST and no threat of labor she is considered stable and would not need to come in and evaluate her in person."
- 1:01 a.m., Communication comments showed: "patient given option to be discharged and drive via private car to [hospital B] or take an ambulance, ...Discharge orders placed."
- 1:07 a.m., patient #15 discharged with instructions to head to [hospital B] immediately.

During an interview on 6/23/25 at 12:34 p.m., patient #15 said on 4/26/25 her water had broken, and she called her physician's office. Patient #15 said she had spoken to the physician on call, and she was instructed to go to the ED to be evaluated. Patient #15 said when she arrived at the ED, the OB nurse checked and confirmed her water had broken. Patient #15 said the facility did not start an IV or give her any medication. She stated she was not seen by a provider. Patient #15 stated the OB nurse discharged her and instructed her and her husband to go directly to [hospital B], which was 12 miles away. Patient #15 stated she was having some cramping following her vaginal examination.

During an interview on 6/18/25 at 7:47 a.m., staff member E said patient #15 arrived at the ED for a complaint of ruptured membranes. Staff member E stated she performed a ROM+ test and determined patient #15 was positive for ruptured membranes. Staff member E stated she performed an NST (prenatal test that monitors a baby's heart rate and how it reacts to movement during pregnancy), which was reactive, and performed a vaginal examination. Staff member E stated she did not believe patient #15 was having contractions. Staff member E stated she informed staff member H of her findings and staff member H made the determination to send patient #15 to [hospital B] via her personal vehicle for a higher level of care. Staff member E stated she made a second phone call to staff member H. Staff member E stated she asked staff member H to come in and evaluate patient #15 to determine if she was stable enough to go to [hospital B] via personal vehicle. Staff member E stated staff member H stated if all the information she was reporting was correct, patient #15 was not in active labor and was stable enough she could be discharged and go to [hospital B] via private vehicle. Staff member E said she discharged patient #15 via private vehicle to go directly to [hospital B].

During an interview on 6/18/25 at 9:05 a.m., staff member D said she told staff member E the doctor should come in and evaluate the patient to determine if she is stable or unstable and able to go to another facility via private vehicle.

During an interview on 6/25/25 at 8:42 a.m., staff member H said she had received a phone call from patient #15 stating she thought she had "broke her water", and she was 34 weeks gestation. Staff member H stated she instructed patient #15 to go to [hospital B] for evaluation. Staff member H said she then received a call from the OB nurse stating patient #15 had arrived at the ED and she was proven ruptured, and she was on the monitor (device to measure contractions and fetal heart rate and not contracting. Staff member H said patient #15 was stable and could go via private vehicle to [hospital B].

During an interview on 6/25/25 at 11:24 a.m., staff member F, Director of the Birth Center, stated if a patient was to arrive with a rupture of membranes, earlier than 34 weeks and not in labor, the provider would come in to evaluate the patient's stability and arrange for transport to another facility for a higher acuity of care.

Review of patient #15's EMR showed there was no documentation of an evaluation for stability for transfer or documentation of stabilizing treatment provided.

Review of a facility policy, "Emergency Medical Treatment and Active Labor Act, with a revision date of 1/2024, showed:

"...4. Transfers for High Risk Deliveries. A hospital that is not capable of handling the delivery of a high-risk woman in labor must still provide an MSE and any necessary stabilizing treatment as well as meet the requirements of an appropriate transfer even if a transfer agreement is in place. ..."

Based on interviews, record review and policy review, the facility failed to provide an appropriate transfer for 1 (#15) of 20 sampled patients who presented to the ED for emergency care.

Findings include:

Review of patient #15's electronic medical record, dated 4/26/25, showed:

- 00:22 a.m., patient #15 arrived at the facility with a complaint of premature rupture of membranes at 34 weeks 2 days
- 00:30 a.m., patient #15 was assessed by staff member E. Testing for ruptured fetal membranes (ROM), a vaginal examination with results of 2cm diameter dilation and 90% effacement, soft cervix, no vaginal bleeding.
- 00:37 a.m., staff member E notified the provider (staff member H) of examination findings. Communication comments showed: "[Staff member H] stated if patient is stable with no threat of labor, she can be given the option to be discharged and drive herself to [hospital B] or go via ambulance."
- 00:50 a.m., Communication comments showed: "Called provider back, I asked her to come in and evaluate patient to deem her stable to ride via car. [Staff member H] stated that if patient is 2cm/90% with reactive NST and no threat of labor she is considered stable and would not need to come in and evaluate her in person. She said the patient could speak to her on the phone if she had any questions."
- 1:01 a.m., Communication comments showed: "Patient given option to be discharged and drive via private care to [hospital B] or take an ambulance, ...Discharge orders placed."
- 1:07 a.m., patient #15 discharged with instructions to head to [hospital B] immediately.

Review of patient #15's EMR showed there was no documentation of an evaluation for stability for transfer, no documentation of transfer paperwork provided, no documentation to indicate [hospital B] was contacted for verification of qualified personnel to care for the mother and baby, or verification space was available within the NICU to provide care for a 34-week gestation baby.

Review of patient #15's electronic medical record for [hospital B], dated 4/26/25, showed:

- 1:30 a.m., patient #15 arrived in Labor & Delivery Unit (L&D)
- History of present illness, showed: " ...[Patient #15] presented to [hospital A] where she was evaluated with a positive ROM+ test and cervix was noted to be 2cm and 90% effaced. She was not thought to be in labor at [hospital A]. She was then discharged ...and instructed to come to [hospital B] via private vehicle for management of PPROM. She is having intermittent cramping that seems like contractions, but not regular; ctx more significant after cervical exam. ..."
- OB delivery note showed: At 9:35 a.m. a baby was delivered and required transfer to a NICU at [hospital C] as the NICU at [hospital B] was on diversion.

During an interview on 6/23/25 at 12:34 p.m., patient #15 said on 4/26/25 her water had broken, and she called her physician's office. Patient #15 said she had spoken to the physician on call, and she was to go to the ED to be evaluated. She said she was concerned because she knew the facility could not care for a baby delivered at 34 weeks and they would have to be transferred to a NICU somewhere. Patient #15 said she was discharged from the ED and instructed to go to [hospital B] immediately. Patient #15 said she and her husband were informed when they arrived at [hospital B] the NICU was full and on divert and they would not be able to keep the baby at the facility. Patient #15 said she elected to stay at [hospital B] and see if labor could be stalled. Once the baby was delivered, patient #15 stated the baby was flown to [hospital C] for NICU care for respiratory distress.

During an interview on 6/18/25 at 7:47 a.m., staff member E said patient #15 came into the facility for a complaint of ruptured membranes. Staff member E stated she performed a ROM+ test and determined patient #15 was positive for ruptured membranes. Staff member E performed a NST, which was reactive, and performed a vaginal examination. Staff member E stated she reported the findings to staff member H. Staff member E stated she did not believe patient #15 was having contractions. Staff member E stated staff member H made the determination to send patient #15 to [hospital B] via personal vehicle for a higher level of care. Staff member E stated she informed staff member H she was not comfortable with discharging the patient to drive via personal vehicle. Staff member E stated she consulted another staff member and the staff member D, the house coordinator. She stated she informed staff member D, patient #15 had a preterm rupture of membranes but was not in labor and she did not think it was appropriate to discharge the patient to drive to [hospital B] via private vehicle. Staff member E stated staff member D told her that if the physician (staff member H) felt the patient was stable enough to be discharged and transported via private vehicle, it would be fine. Staff member E said she made a second phone call to staff member H and asked her to come in and evaluate patient #15 to determine if she was stable enough to go to [hospital B] via personal vehicle. Staff member E said she felt staff member H should have come to the ED and "lay hands" on patient #15. Staff member E stated staff member H told her that if all the information she was reporting was correct, patient #15 was not in active labor and was stable enough she could be discharged and go to [hospital B] via private vehicle. Staff member E said she discharged patient #15 via private vehicle to go directly to [hospital B].

During an interview on 6/18/25 at 9:05 a.m., staff member D said she told staff member E that the doctor should come in and evaluate the patient to determine if she is stable or unstable and able to go to another facility via private vehicle.

During an interview on 6/25/25 at 11:24 a.m., staff member F, Director of the Birth Center, stated if a patient was to arrive with a rupture of membranes, earlier than 34 weeks and not in labor, the provider would come in to evaluate the patient's stability and arrange for transport to another facility for a higher acuity of care.

During an interview on 6/25/25 at 12:33 p.m., staff member I stated that any patient presenting to the ED in preterm labor requires a provider to come in and do an evaluation at the bedside and initiate the transfer to another facility through the call center.

During an interview on 6/25/25 at 8:42 a.m., staff member H stated she was a provider at the facility. Staff member H said she received a call from staff member E informing her patient #15 had arrived at the ED and she was proven ruptured, was on the monitor and was not contracting. Staff member H said patient #15 was stable and could go via private vehicle to [hospital B], and there was no need for her to be transported by ambulance. Staff member H said she would have followed the facility protocol for transfer if she knew the facility protocol.

During an interview on 6/18/25 at 9:38 a.m., NF1 said she was the provider on call for [hospital B] when patient #15 arrived. She stated she had not received a call or any contact from [hospital A] or staff member H prior to patient #15's arrival. NF1 said she was contacted by the charge nurse on L&D (Labor & Delivery) around 2:00 a.m. informing her patient #15 had arrived at the facility. NF1 stated on arrival, patient #15's examination showed she was dilated to 2.0 cm and 90% effaced, and this would be her first baby. NF1 said a preterm rupture of membranes was an emergency, as the patient could go into labor at any time. NF1 said if the transfer of patient #15 had been made through the correct process, she would not have accepted patient #15 because she knew the baby would require NICU services and the NICU was on diversion. NF1 stated they delivered the infant at [hospital B], then had to transfer the infant to the nearest hospital with a NICU bed available [hospital C].

Review of a facility policy, "Emergency Medical Treatment and Active Labor Act, with a revision date of 1/2024, showed:

" ...2. A transfer will be an appropriate transfer if:
...B. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment; ...
...Additional Transfer-Related Situations
...4. Transfers for High Risk Deliveries. A hospital that is not capable of handling the delivery of a high-risk woman in labor must still provide an MSE and any necessary stabilizing treatment as well as meet the requirements of an appropriate transfer even if a transfer agreement is in place. In addition, a provider certification that the benefits of transfer outweigh the risks of transfer is required for the transfer of a woman in labor. ..."

Review of a facility policy, "Maternal Transport Policy," with a revision date of 11/23, showed:

" ...1. Initial Screening
...b. Transport is indicated when, after assessment, it is determined that the patient requires advanced resources and skilled personnel at a higher level facility, or if it is expected that newborn will require higher level of neonatal care.
...Care prior to transport-stabilization of patient
...b. Prior to transport, consent is required from the mother regarding the transfer and documented on the transfer request form.
...3. Disposition of transfer
a. All obstetrical transports are arranged following the Patient Transport Algorithm. ..."

Review of a facility document, "Patient Transport Algorithm", not dated, showed:

-Physician or nurse calls [medical center name] Transfer Center to initiate transport of mother or infant ...
-The Transfer Center will have a conference call with [Facility name] provider and [Medical Center Name] provider.
-[Medical Center Name] provider accepts the patient transfer. The Transfer Center confirms bed availability for the patient. ..."