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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in ?489.20 and ?489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag A2405 - Central Log
Based on interviews and document review, the facility failed to document, in a central log, a patient who presented to the Obstetrics Department of the facility seeking care.

Tag A2406 - Medical Screening Examination
Based on interviews and document review, the facility failed to provide a Medical Screening Examination (MSE) to a patient who presented to the Obstetrics Department of the facility seeking care.

Based on interviews and document review, the facility failed to ensure a patient (Patient #5) who presented to the Obstetrics Department seeking care was documented on the Department's Central log.

This failure created a situation in which the identity of a patient seeking medical care remained unknown to the facility, and subsequently the patient's medical status remained unknown.

FINDINGS:

POLICY

According to facility policy, WIS: Medical Screening Examination in the Obstetrical Department and Process for RN Validation as Qualified Medical Personnel, an obstetrical log will be maintained reflecting all patients that seek emergency medical services including evaluation of labor status and disposition including admit, transfer and or transport, patient refusal of treatment or patient discharge.

1. Obstetrics Department staff did not obtain and document in the Central Log, basic patient information for Patient #5, who presented to the Department seeking medical care.

a) On 08/05/14 at 10:23 a.m., an interview was conducted with the Nurse Manager of the Obstetrics Department to review the Central Log for the department. The Manager stated s/he was made aware of a possible Emergency Medical Treatment and Labor Act (EMTALA) violation that occurred in the Obstetrics Department on 07/20/14. The Manager stated s/he learned from a Charge Nurse working on 07/20/14 that a patient presented to the Obstetrics Department sometime during the morning, was met in the waiting room by Registered Nurse (RN) #1, and was not documented on the Central Log used in the triage area to capture patients who presented for care. The Manager stated no information was documented on the Log for this patient by RN #1 who was working the triage area, specifically, no name, date of birth, chief complaint, etc., in order to begin the patient's registration process and to provide tracking for the patient's care which would become part of the patient's medical record.

The Manager explained the process RNs in the Obstetrics Department used when patients presented to the Department and stated RNs first asked for the patient's name and date of birth, chief complaint or reason the patient was in the Department, then asked the name of the patient's physician. The Manager stated triage of the patient would then be provided by the RN, followed by a Medical Screening Examination, and the provision of needed care. The Manager stated RN#1 had received EMTALA training initially upon hire and at least annually since that time.

b) On 08/05/14, review of the Obstetrics Department's electronic medical record system revealed Patient #5 was last documented as seen in the Department on 03/14/13. The patient's visit to the Obstetrical Department on 07/20/14 was not present in the patient's medical record as the patient did not become part of the Central Log and was not further registered in the electronic system. No documentation could be provided by the facility showing that Patient #5 had entered the Obstetrics Department seeking care.

c) On 08/06/14 at 10:58 a.m., an interview was conducted with RN #1 who stated s/he was the nurse who met Patient #5 in the Obstetrics Department waiting room on 07/20/14. RN#1 stated the patient was pregnant and complained of abdominal cramping. RN#1 stated s/he spent approximately 7 minutes with the patient and asked who her physician was. RN#1 stated she did not ask the patient for her name, date of birth, or any other questions to document on the Central Log and did not call the registration department to inform this staff there was a patient in the Obstetrics Department requesting care, which s/he stated was the Department's process. RN#1 informed the patient that her physician no longer "delivered babies" at the facility but instead delivered at another hospital. RN#1 stated Patient #5 then said maybe she would go to the other hospital.

RN#1 stated she did not ask the patient for her name, did not initiate registration of the patient's visit by documenting basic information on the Central Log, did not call registration to inform staff there was a patient in the Department requesting care, did not initiate nursing triage of the patient or a Medical Screening Examination, and did not request the patient sign a "Refusal of Treatment" form before s/he left the Department.

RN#1 stated s/he had received EMTALA training initially upon hire and at least annually since that time.

Based on interviews and document review, the facility failed to ensure a patient (Patient #5)who presented to the Obstetrics Department seeking care received a Medical Screening Examination.

This failure created a situation in which a pregnant patient who stated a medical concern was allowed to leave the facility and go to another facility to receive care without nursing staff obtaining any pertinent information about the patient's health/medical status.

FINDINGS:

POLICY

According to facility policy, EMTALA - Medical Screening Examination and Stabilizing Treatment, if an individual has refused a Medical Screening Examination/treatment, the Refusal of Treatment or Transfer form is signed, indicating what aspects of care are refused, the risks of refusal and the reasons for the refusal. If the individual refuses to sign, documentation relative to the above is noted in the medical record along with the steps taken to try to secure the informed refusal.

1. Obstetrics Department nursing staff did not provide a Medical Screening Examination to Patient #5 and did not request the patient sign a "Refusal of Treatment" form.

a) On 08/05/14 at 10:23 a.m., an interview was conducted with the Nurse Manager of the Obstetrics Department to review how patients who presented to the Department received triage and Medical Screening Examinations. The Manager stated s/he was made aware of a possible Emergency Medical Treatment and Labor Act (EMTALA) violation that occurred in the Obstetrics Department on 07/20/14. The Manager stated s/he learned from a Charge Nurse working on 07/20/14 that a patient presented to the Obstetrics Department sometime during the morning, was met in the waiting room by Registered Nurse (RN) #1, was not documented on the Central Log by RN#1, and did not receive nursing triage or a Medical Screening Examination by RN#1.

The Manager stated RN#1 instead informed the patient that her physician no longer "delivered babies" at the facility and allowed the patient to leave the Department, even though the patient stated she was experiencing abdominal cramping. The Manager stated RN#1 did not request assistance or advice from other nursing staff, including the Charge Nurse, in order to encourage Patient #5 to stay for examination. The Manager stated RN#1 informed the Charge Nurse of the event after Patient #5 left the Department.

b) On 08/06/14 at 10:58 a.m., an interview was conducted with RN #1 who stated s/he was the nurse who met Patient #5 in the Obstetrics Department waiting room on 07/20/14. RN#1 stated the patient was pregnant and complained of abdominal cramping. RN#1 stated s/he spent approximately 7 minutes with the patient and asked the name of her physician. RN#1 stated s/he informed the patient that her physician no longer "delivered babies" at the facility and did not begin triage of the patient and a Medical Screening Examination. RN#1 stated when the patient said maybe she would go to the hospital where her physician practiced, s/he did not ask the patient to sign a "Refusal of Treatment" form to document the patient was leaving the Department without being assessed by nursing staff, which s/he stated was the Department's process. RN#1 stated the patient looked "fine" but could not state any knowledge of the patient's actual clinical status. RN#1 stated s/he did not ask the patient for her name and date of birth, but instead asked the patient the name of her physician.

RN#1 stated s/he had received EMTALA training initially upon hire and at least annually since that time.