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Based on interview and record review, Facility A failed to implement and maintain it's Emergency Medical Treatment and Active Labor Act (EMTALA), policy and procedures (P&Ps), when:

1. One of 29 sampled patients (Patient 29), who was 34 weeks pregnant, presented to Facility A seeking emergency medical care after sustaining a fall and was not logged or registered to the labor and delivery (L&D) unit. (Refer to Tag A- 2405)

2. Three of 29 sampled patients (Patients 20, 24 and 29) presented to the L&D unit with an emergency medical condition and were not provided a timely triage or Medical Screening Exam (MSE). (Refer to Tag A-2406)

The cumulative effects of these failures resulted in three of 29 sampled patients, to leave without being seen (LBWS) after arriving to the L&D unit for emergency medical care which could delay treatment for critical medical conditions and potentially cause harm to the patient and fetus.

Based on interview and record review, Facility A failed to maintain a centralized log for the Labor and Delivery (L&D) unit per it's Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedure (P&P) for one of 29 sampled patients (Patient 29) when, Patient 29, who was 34 weeks pregnant, presented to Facility A seeking emergency medical care after sustaining a fall and was not logged.

This failure resulted in emotional distress due to Patient 29's uncertainty about the priority of care for her , and which could jeopardize the health and safety of the patient and her unborn baby.

Findings:

An unannounced visit was conducted on February 24, 2025, through February 26, 2025, to investigate a possible EMTALA violation.

During a review of Facility A's Emergency Deaprtment (ED) and obstetric (OB- specialty for pregnancy and childbirth) logs indicated, there was no documented evidence to indicate Patient 29 was registered on Facility A's ED or OB logs, nor was there documentation indicating Patient 29 received a medical screening examination to rule out if an emergency medical condition existed or that the patient was medically stabilized.

During an audio/ visual call (Microsoft TEAMS) on February 24, 2025, at 5:30 PM, with Facility B's Accrediting, Licensing and Regulatory Specialist (ALR 1), Facility B's "Telephone Encounter OB Advice Call" dated November 5, 2024, at 10:03 PM, was reviewed. The" Telephone Encounter OB Advice Call" indicated, Patient 29 was 34 weeks pregnant and reported a fall, Patient 29 was directed to go to Facility A's L&D department for evaluation because it was closer to her home. ALR 1 stated, Patient 29 was instructed to follow-up at Facility A because it was closer to her home. ALR 1 further stated, these documents were accessible by Facility A and could be provided to surveyor by them.

On February 25, 2025, at 9:16 AM, Patient 29's documents dated November 5, 2024, by Facility B were reviewed with Facility A's Maternal Child Educator (MCE), and received the documents as requested.

During an interview on February 25, 2025, at 9:32 AM, with Facility A's Accrediting, Licensing and Regulatory Specialist (ALR 2), ALR 2 taken away the documents from the surveyor and stated, Facility A could not provide Facility B's documents, even though they belong to same company and are accessible because they are not Facility A's property.

During an interview on February 25, 2025, at 11:08 AM, with Unit Secretary 1 (US1), US1 stated she was able to recall Patient 29. US1 stated, Patient 29 presented to the L&D waiting room and rang the doorbell for the department. US1 stated, Patient 29 had her child with her and US1 inquired if there was another adult with hem to sit with her child, which Patient 29 answered she did not. US 1 Stated, she then informed the triage nurses, who followed the chain of command and called the charge nurse. US1 stated, the charge nurse spoke with Patient 29 in the waiting room. US1 further stated, she was told by the charge nurse there was no need to register Patient 29 to the L&D unit because she had left.

During an interview on February 25, 2025, at 3:00 PM, with Charge Nurse 1 (CN1), CN 1 stated she recalled Patient 29 presenting to the L&D Department. CN1 stated, one of the triage nurses informed her that Patient 29 was in the waiting room with a child. CN1 stated, Patient 29 was not originally brought into the department because she had a child. CN1 stated, she inquired if Patient 29 had someone to take care of her child in the event she had an emergency and needed to stay, but Patient 29 stated she did not have anybody. CN 1 sated, during this conversation in the waiting room, Patient 29 decided she was going to leave and go home. CN1 further stated, she did not know if Patient 29 was registered or logged to the unit.

During an interview on February 26, 2025, at 10:05 AM, with the Director of the Maternal Child Department (DMC), the DMC stated, she was aware that Patient 29 had been to the unit to request medical care. The DMC stated she did not know why the normal workflow was not followed for Patient 29. The DMC stated, Patient 29 should have been invited into the hall and registered to the L&D unit per the normal workflow. The DMC further stated, Patient 29 should have not been left to stay in the waiting room and should have been registered before escalating to the charge nurse. The DMC stated, there was no policy against unaccompanied minors to be present during the initial assessment and a patient presenting with a child should not delay registration to the unit and medical evaluation.

During an interview on February 26, 2025, at 10:35 AM, with Medical Doctor 1 (MD 1), MD 1 stated, when a patient presents with a minor and no other adult, initial patient work-up including registration, triage and a medical screening exam should occur in the same manner as patients presenting without a minor.

During a review of the facility's policy and procedure ( P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer" dated January 9, 2023, the P&P indicated, "It is the policy of [Name of Facility] to comply with the Emergency Medical Treatment and Labor ACT (EMTALA) obligations ...The hospital prohibits actions that would discourage an individual from seeking emergency medical services ...Central EMTALA Log ...Logs will be maintained by the emergency and labor and delivery departments on each person who comes to the hospital seeking medical care ...The log shall be maintained and shall contain at least information about whether the individual refused treatment, and individual's disposition (e.g., admit, discharge, transfer, LWBS elopement, and leaving against advice) ...".

During a review a review of the facility's document titled, "Job Description" (JD), dated November 1, 2021, the "JD" indicated, " ...Domain: RN [Registered Nurse] ...Specialty: Hospital-Labor & Delivery ...Essential Responsibilities ...Leadership: Upholds [Name of Hospital] Policies and Procedures, Principles of Responsibilities, and applicable state, federal and local laws. Serves as a leader of the health care team; delegates tasks appropriately, and demonstrate appropriate accountability ...Demonstrates professional, supportive behavior ...Utilizes communication strategies including chain of command and issue escalation, which result in intended outcomes ...Participates in problem identification and resolution ...Documentation reflects nursing process and interventions and evaluations taken ...".

Based on interview and record review, the facility failed to ensure the policy and procedures (P&P's) pertaining to the Emergency Medical Treatment and Labor Act (EMTALA) for a timely medical screening examination (MSE) to determine if an emergency medical condition existed and were implemented for three of 29 sampled patients (Patients 20, 24 and 29) when:

1. Patient 20 was registered to the labor and delivery unit (L&D), but there was no triage (the process of sorting patient into groups based on their need for care) by nursing or medical screening exam (MSE- an examination preformed by a qualified medical provider to determine if a patient has and emergency condition) provided prior to Patient 20 leaving without being seen (LWBS - leaving before patient was seen by the provider).

2. Patient 24 was registered to L&D, but there was no triage by nursing or MSE provided prior to Patient 24 leaving without being seen .

3. Patient 29 presented to the L&D unit for medical emergency and was not provided a triage, or MSE.

These failures resulted in Patients 20, 24, and 29 not being provided an appropriate triage or MSE to address if these patients had an existing emergency medical condition and had the potential to severely impact the health and welfare of these patients and their fetus (unborn baby).

Findings:

1. During a review of the "[Regional Hospital] L&D Admissions EMTALA" (L&D log) dated for January 2025, the (L&D log) indicated, Patient 20 was admitted to L&D on January 23, 2025, at 4:50 PM, for labor symptoms and LWBS on January 23, 2025, at 10:58 PM.

During a concurrent interview and record review on February 24, 2025, at 3:10 PM with the Maternal Child Educator (MCE ), Patient 20's "Encounter" for January 23, 2025, was reviewed. There was no other documentation noted in the Patient 20's chart for this visit during the six hours Patient 20 was registered to the L&D unit. The MCE stated, there was no documented evidence of a nurse triage, a medical screening exam or the situation leading to Patient 20's LWBS. The MCE further stated every patient is expected to be triaged by a nurse and the physician to be contacted regarding patient presentation.

2. During a review of the "[Regional Hospital] L&D Admissions EMTALA" (L&D log) dated for February 2025, the L&D log indicated, Patient 24 was admitted to L&D on February 10, 2025, at 3:44 PM, for labor symptoms and LWBS on February 10, 2025, at 7:00 PM.

During a concurrent interview and record review on February 24, 2025, at 3:40 PM, with the MCE, Patient 24's "Encounter" for February 10, 2025, was reviewed. Patient 24's "Encounter" indicated, "3:51 PM ...Contractions .... RN: ABD [abdominal] Pain/Dizziness ...". There was no other documentation noted in the Patient 24's chart for this visit during the three hours Patient 24 was registered to the L&D unit. The MCE stated, the note entered was a "Quick Assessment" by the RN. There was no other documented evidence of a nurse triage, a medical screening exam or the situation leading to Patient 24's LWBS. The MCE stated, there was no specific requirements regarding charting of a "Quick look" assessment or triage. The MCE further stated, facility had a tirage color system to classify patients that need to be medically screened by the provider immediately and patients that can wait, but there was no charting regarding this triage model in Patient 24's chart.

3. During a review of Facility A's Emergency Department (ED) or obstetric (OB- specialty for pregnancy and childbirth) logs indicated,there was no documented evidence to indicate Patient 29 was registered on Facility A's ED or OB logs, nor was there documentation indicating Patient 29 received a medical screening examination to rule out if an emergency medical condition existed or that the patient was medically stabilized.

During an interview on February 26, 2025, at 9:00 AM, with the Director of the Maternal Child Department (DMC), the DMC stated, she was aware Patient 29 had been to the unit to request medical care. The DMC stated she did not know why the normal workflow was not followed for Patient 29. The DMC stated, Patient 29 should have been invited into the hall and registered to the L&D unit per the normal workflow. The DMC further stated, Patient 29 should have not been left to stay in the waiting room and should have been registered before escalating to the charge nurse.

During a concurrent interview and record review, on February 26, 2025, at 10:05 AM, with the Maternal Child Manager (MCM), the facility's P&P titled "Labor and Delivery Triage" dated December 2023, was reviewed. The P&P indicated, " ...It is the policy of [Name of Hospital] to maintain patient safety by providing consistent and timely care to women who present to Labor and Deliver[y] for triage ...Register patient as an outpatient in [name of electronic chart] ...For all patients presenting to Labor and Delivery Triage ...Initial interview and assessment will be done by an L&D RN ...The nurse shall perform a patient assessment including subjective and objective information to determine the appropriateness for initiating the Standing Orders prior to provider evaluation ...". The MCMC stated, patients presenting to L&D are registered by the unit secretary and then a nurse will see the patient before they are sent to a waiting room. The MCM stated, the nurse asks for a chief complaint (reason for patient to present to the L&D unit) and any other signs or symptoms and will determine acuity of the patient and decide how quickly the patient needs to be seen. The MCM stated a Quick assessment is gathering information from the patient by asking questions and this depends on what the patient's chief complaint. The MCM further stated, there was no policy on what is actually included in a triage assessment or "Quicklook" assessment, documentation of these assessments with priority to be seen or a timeline in which these assessments need to be completed.

During an interview on February 26, 2025, at 10:32 AM, with Medical Doctor 1 (MD1), M D1 stated, the L&D unit was responsible for registering and triage of any maternal patient that steps foot in the hospital, seeking a medical examination and the L&D obligation does not end until all care is provided until the patient is stable or is appropriately transferred. MD 1 stated, an L&D triage includes mother's vital signs (measure the basic functions of the body: temperature, heart rate, blood pressure, respiratory rate), fetal doppler (measuring of an unborn baby's heartbeat), and interview questions tailored to the patient complaints. MD 1 stated, once the triage evaluation is done by the nurse then report is to be given to the provider. MD 1 further stated, if a patient is planning to leave, whether or not they have been evaluated by the provider, the goal is to address any of the patient's issues before they leave.

During a review of the facility's policy and procedure ( P&P) titled, "Emergency Medical Screening Examination, Treatment, and Transfer" dated January 9, 2023, the P&P indicated, " ...It is the policy of [Name of Facility] to comply with the Emergency Medical Treatment and Labor ACT (EMTALA) obligations ...The hospital prohibits actions that would discourage an individual from seeking emergency medical services ...The hospital will provide a MSE by a QMP [Qualified Medical Professional - doctor, nurse practitioner, midwife] to any individual who comes to the hospital seeking emergency medical treatment ...to determine if the individual seeking care has an EMC {Emergency Medical Condition] ... The hospital prohibits actions that would discourage an individual from seeking emergency medical services ...Triage ...As soon as practical after arrival, all individuals who come to the emergency department or labor and delivery department for medical treatment will be triaged to determine the order in which they will receive an MSE ...All reasonable efforts should be made to conduct a MSE before the individual leaves, with documentation of the discussions and efforts made to prevent the individual from leaving ...Staff will attempt to obtain the individual's signature on the form documenting the individual refused an MSE ...If the individual refuses to sign the form, a notation to such should be made by the [staff] ...