HospitalInspections.org

Based on the facility self report; interviews of nursing staff, a physician, and a paramedic; and review of the hospital's documentation, policies and procedures; the facility failed to comply with the agreement of the special responsibilities in emergency cases for 1 of 31 sampled emergency patients [Patient 31] by failing to provide Patient 31 with a medical screening examination [MSE]. The hospital had come back into compliance with EMTALA requirements at the time of the investigation.

Findings are:

A. Review of Medical Staff Bylaws, and Rules and Regulations confirmed the hospital did have the EMTALA requirements for Medicare Hospitals included. The hospital Policy and Procedure titled "Medical Screening Examination & Stabilization" [MSE] was last revised and approved 11/2014 by the Medical Staff and the Governing Body. The policy directs that an MSE obligation is triggered when:
1. "The individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition or
2. A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition."
The policy continues to define that the MSE (the determination of an emergency medical condition) is to be determined by a physician or qualified medical practitioner. The policy defines who may perform an MSE to include: a qualified physician with appropriate privileges ... a physician's assistant, or an advanced practice registered nurse who has been credentialed and is a member of the medical staff approved by the governing board [with the appropriate privileges and within their scope of practice].
The policy includes the definition of an MSE for a pregnant woman which should include at a minimum: ongoing evaluation of fetal heart tones, regularity and duration of contractions, fetal position and station, cervical dilation, and status of membranes (ruptured, leaking or intact).
B. The Administrator [CEO], Chief Operating Officer [COO], and the Manager of ED learned of the incident from an email from the Registered Nurse that diverted Patient 31 from the ambulance bay of the hospital on 1/11/2015 [RN-A]. The CEO and COO met with the Director of Nursing, the Manager of ED and other administrative staff on 1/12/2015. They knew this was a violation of EMTALA and decided they must report it. The CEO called and then emailed the self-report on 1/14/2015.
C. The facility had pursued corrective action to achieve compliance with the EMTALA requirements prior to the investigation. The initial step taken was to counsel RN-A and the physician who had directed the ambulance be diverted [MD-B], which was accomplished on 1/12/2015. Verification was found in interviews with RN-A and MD-B, as well as review of facility documentation. The facility revised its policies and procedures related to transfers to ensure they were more clear regarding EMTALA requirements. The training was provided to all Medical Staff including all mid-level practioners on the Medical Staff. The training was also provided to all nursing staff. The training included improvement of communication between nursing staff and physicians or mid level providers. These meetings were completed on 1/15/2015, prior to the survey start of 1/16/2015. This training was verified by review of the materials presented and sign in sheets. The staff had to complete competencies that were confirmed by review of the copies of the certificates for all medical staff and all nursing staff. Three (3) nursing staff that had not attended the meetings will not be able to work until they have had the training according to the Director of Nursing. The facility has scheduled training (by another hospital who provides labor and obstetric services) for management of imminent delivery and neonatal care on 2/5/2015 for their staff. The facility has also contracted with a hospital to provide annual training on care of patient in labor and newborns.

Based on the facility self-report; and interviews with nursing staff, a physician, and a paramedic; the facility failed to provide a medical screening examination to 1 of 31 sampled emergency patients [Patient 31]. The hospital has not had any prior EMTALA violations during the past 6 months or since the reported violation that occurred on 1/11/2015. The hospital was in compliance at the time of the onsite investigation.
Findings are:
A. An interview with the Paramedic attending Patient 31 on the date of the incident [1/11/2015] was conducted on 1/20/2015 at 10:35 AM. He revealed the rescue squad was a volunteer department. He received the call on 1/11/2015 at 8:34 AM. The Paramedic, upon arrival at the location, determined that the patient was 37 weeks gestation with irregular contractions about 3 minutes apart lasting 45 to 60 seconds. The patient was not crowning and there was no leaking or bleeding present. The patient was in good spirits. The EMS protocol is to go to the closest hospital. He was aware this hospital did not have Obstetric services, but had delivered babies there when birth was imminent or precipitous. The closest hospital was this facility which had a dedicated emergency department [ED]. They called the facility and informed the nurse they were bringing in a woman in labor and gave the information noted above. According to the Paramedic, it takes 4 to 5 minutes to reach the ED from anywhere in the town. When they arrived in the ED ambulance bay a nurse ran out to the ambulance and as they opened the door, she told them the physician had requested they divert to a hospital with OB services, such as Omaha or Fremont. The Paramedic asked if the doctor was present, and the nurse said "No, he's on his way." The Paramedic repeated to verify, "Dr. [name of physician] would like us to divert?" And the nurse said "Yes". The patient was never taken out of the ambulance and the nurse did not talk to the patient nor examine/touch the patient. The Paramedic said they closed the doors and went to a hospital in Omaha where the patient had told them she was scheduled for a cesarean section. The Paramedic said if he had been concerned about getting the patient safely to another hospital he would have told the nurse they were coming in regardless.
B. An interview with the Registered Nurse [RN-A] that had directed the squad to divert was completed on 1/20/2015 at 3:30 PM. RN-A revealed that she had been employed at this facility for 5 months and this was her first position after graduating from nursing school. She confirmed she had been working the day shift on 1/11/2015. She said she was working on the nursing unit when a call was given to her from the local EMS squad. She was told about Patient 31 being 37 weeks, and having 3 minute contractions lasting 45 to 60 seconds, the patient was not crowning nor leaking any fluid. She called the physician on call and informed him of the call. He requested she tell the squad to divert to a hospital with OB services and said he was on his way. RN-A said she then ran to the ED and saw the squad pulling in. She ran out and when they opened the doors she told them the physician wanted them to divert to a hospital in Omaha or Fremont. She said they responded with OK and left. She went back inside and stated that she didn't know what else she should do. Another nurse told her they don't send ambulances away like that and was surprised the physician directed the diversion. RN-A said she was trying to do what was best for the patient. She confirmed she did not talk to the patient or look at the patient while the squad was in the ambulance bay. She said she had received some EMTALA information in orientation, but she did not recall the requirement for MSE. She said she had received some additional training on 1/15/2015 and had discussed the incident at length with the Manager of the ED the day after the event. She confirmed she would never let this happen again and she did not believe anyone else working at the facility would make this mistake.
C. An interview with the physician on call on 1/11/2015, [MD-B], was completed on 1/21/2015 at 1:05 PM. MD-B revealed he was the facility's Chief of Medical Staff and the Medical Director of the Emergency Department. He said when he received the call from RN-A on 1/11/2015, he was not aware the patient was already in route to the hospital. Because they do not have obstetrics he felt it was in the best interest of the patient to go to a hospital that did have those services and the neonatal services too. He said since the patient was having contractions 3 minutes apart and not crowning that he thought she could safely be transported to a hospital that could meet the needs of the patient immediately. MD-B stated he arrived at the ED about 10 minutes later to see if the patient had been brought in to their ED, but there wasn't any patient there. He did not refuse to see the patient and would never refuse to see any patient. The CEO had talked to him about the incident on 1/12/2015, he had some updated training and he also did some research on EMTALA himself. He said in retrospect Patient 31 should have been seen in the ED and then whatever arrangements needed could have been completed.
D. The Administrator [CEO], Chief Operating Officer [COO], and the Manager of EDlearned of the incident from an email from RN-A. The CEO and COO met with the Director of Nursing, the Manager of ED and other administrative staff on 1/12/2015. They knew this was a violation of EMTALA and decided they must report it. The CEO called and then emailed the self-report on 1/14/2015.
E. The facility had pursued corrective action to achieve compliance with the EMTALA requirements prior to the investigation. The initial step taken was to counsel RN-A and MD-B, which was accomplished on 1/12/2015. Verification was found in interviews with RN-A and MD-B, as well as review of facility documentation. The facility revised its policies and procedures related to transfers to ensure they were more clear regarding EMTALA requirements. The training was provided to all Medical Staff including all mid-level practioners on staff. The training was also provided to all nursing staff. The training included improved communication between the nursing staff and the physician. The hospital provided their staff with a handout title "Skillful Physician Communication." These meetings were completed on 1/15/2015, prior to the survey start of 1/16/2015. This training was verified by review of the materials presented and sign in sheets. The staff had to complete competencies that were confirmed by review of the copies of the certificates for all medical staff and all nursing staff. Three (3) nursing staff that had not attended the meetings will not be able to work until they have had the training according to the Director of Nursing. The facility has scheduled training (by another hospital who provides labor and obstetric services) for management of imminent delivery and neonatal care 2/5/2015 for their staff. The facility has also contracted with a hospital to provide annual training on care of patient in labor and newborns.