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Based on observation, interview, and document review, the hospital failed to ensure compliance with requirements of 42 CFR 489.24 as evidenced by the deficient practice cited at 42 CFR 489.24(a) and (c).

Based on observation, interview, and document review, the hospital failed to post sufficient signage in the Emergency Department (ED) that specified the rights of patients with emergency medical conditions and women in labor.

Findings include:

Observations of the hospital's ED on 01/19/16 at 9:50 a.m. established that the ED is comprised of a patient waiting area, three patient exam rooms with one bed each, and a trauma bay with two beds. Only one EMTALA sign was posted in the ED, which was located on a wall facing the ED entrance where all patients arrive, including patients who arrive by ambulance or police escort. The ED waiting area was a separate room from where the EMTALA sign was posted on the wall. Patients in the waiting area would not notice the sign and could not see the sign from the waiting area. There was no signage on any wall in the waiting area. There was no signage for either bed in the trauma bay. There was no signage in Exam Room #1, which is set up for common patient needs, such as sutures. There was no signage in Exam Room #2, which is set up for patients with Orthopedic needs. There was no signage in Exam Room #3, which is set up for patients with Obstetric needs.

RN/B was interviewed on 01/19/16 at 10:00 a.m. RN/B stated that the ED's average patient census is less than eight patients per 24 hours. The waiting area is rarely utilized as patients are usually roomed immediately upon arrival. The majority of patient waiting occurs in exam rooms.

The hospital's EMTALA policy, dated 12/05/11, indicated that "EMTALA signage is required: Each department that provides Emergency services shall post a sign (English and Spanish) in a place or places likely to be noticed by all individuals entering the department that includes: A statement that Swift County Benson Hospital participates in Medicaid; The rights of patients with emergency conditions and women in labor. The sign shall state: If you have an emergency: You have the right to receive, within the capabilities of this hospital's staff and facilities: An appropriate medical screening examination, necessary stabilizing treatment (including treatment of an unborn child), an appropriate transfer to another facility, even if you cannot pay or do not have medical insurance or you are not entitled to Medicare or Medicaid."The hospital's EMTALA policy did not address the need for EMTALA signage in patient waiting areas, such as the patient waiting room and exam rooms.

Based on interview and document review, the hospital failed to maintain a central Emergency Department (ED) log that accurately tracked the care of all patients who presented to the ED seeking assistance with an emergency medical condition (EMC), for 1 of 23 patients reviewed (P1), who presented to the ED on 01/11/16 for evaluation of preterm labor. The ED log did not include any data about P1's ED visit on 01/11/16.

Findings include:

RN/B was interviewed on 01/19/16 at 10:00 a.m. RN/B stated that the hospital maintains an ED log that tracks the care of each individual who comes to the ED seeking evaluation of an EMC. P1 presented to the ED on 01/11/16, around 7:00 a.m., at shift change. P1 needed to be evaluated for vaginal bleeding during pregnancy. RN/F was the assigned ED nurse when P1 presented on 01/11/16. RN/F did not include any information on the ED log about P1's ED visit, which is in violation of the hospital's routine practice when patients seek emergency care.


RN/F was interviewed on 01/20/16 at 9:00 a.m. RN/F stated she is an experienced ED nurse and worked the night shift of 01/10/16 - 01/11/16 from 7:00 p.m. to 7:30 a.m. During RN/F's 12-hour shift on 01/10/16 - 01/11/16, two patients presented to the ED seeking care for an EMC, P20 and P1. P20 presented at 6:30 a.m. with complaints of flank pain. RN/F entered data about P20 on the ED log. P1 then presented to the ED around 7:00 a.m. with complaints of vaginal bleeding. P1 was 30 weeks pregnant. P1 denied pain but was concerned about the bleeding. RN/F did not enter any data about P1 on the ED log. P1 was in the ED for just a few minutes before P1 went to Hospital #2 for evaluation of the obstetric problem. RN/F's normal practice is to include data on the ED log that pertains to every patient who seeks emergency care. RN/F did not know why she failed to include information on the ED log about P1's ED visit on 01/11/16.

The hospital had no documentation to reflect P1's ED visit.

The hospital's EMTALA policy, dated 12/05/11, indicated that the "Emergency Medical Care Log is a record maintained for all individuals who come to a department seeking emergency care. The log shall be kept for five years and shall contain specific patient information including: Date admitted, Time admitted, Patient's name, Patient's address, Age, Sex, Admitting nurse, Doctor caring for patient, Nature of Injury, Services rendered, Discharge time, Disposition of Care: Treated and release, Admitted, Stabilized and transferred, Discharged or, Refusal of treatment. The purpose of the log is to track the care provided to each individual who comes to Swift County Benson Hospital seeking emergency medical care. Patients who present in labor will be screened in the Emergency Room."

Based on observation, interview, and document review, the hospital failed to provide a medical screening examination (MSE) for 1 of 6 patients (P1), who presented to the Emergency Department (ED) for evaluation of an obstetric emergency medical condition (EMC).

Findings include:

Observations of the hospital's ED on 01/19/16 at 9:50 a.m. established that the ED is comprised of three patient exam rooms with one bed each and a trauma bay with two beds. Exam room #3 is set up for patients who present with obstetric problems. Exam room #3 has obstetric examination supplies, a Doptone, neonatal emergency supplies, and an infant warmer. One RN was present in the ED at the time it was toured.
RN/B was interviewed on 01/19/16 at 10:00 a.m. RN/B stated that the ED is staffed 24/7 with one RN. A mid-level provider is onsite in the ED, Monday through Friday from 8:00 a.m. to 5:00 p.m. After 5:00 p.m. weekdays, weekends, or holidays, the ED is staffed by on-call medical providers. A weekend is defined as beginning at 5:00 p.m. on Friday and extending through 8:00 a.m. on Monday. During weekends, the medical provider on-call is located onsite in an apartment that is attached to the hospital. The hospital does not have an Obstetric Department.P1 was interviewed on 01/25/16 at 12:54 p.m. P1 stated she woke up on 01/11/16 around 6:50 a.m. and had a considerable amount of vaginal bleeding. P1 also had a low backache. P1 was scared because she knew these were abnormal signs for a 30-week pregnancy. P1 took a picture of the bleeding and went to the nearest hospital, which was Swift County Benson Hospital (SCBH). P1 arrived at the SCBH ED around 7:00 a.m. A nurse greeted P1 at the ED door and had P1 sit in a chair in an exam room. The nurse offered to call P1's Obstetrician about P1's bleeding. The Nurse didn't examine P1 or look at the picture P1 had taken of the bleeding. The nurse left P1 in the exam room alone for about 5 minutes and then came back and told P1 to go to Hospital #2, which is where P1 had pre-planned to deliver her baby per her primary Obstetrician. P1 left the ED at SCBH and drove herself to Hospital #2, which is about a half hour away from SCBH. When P1 got to Hospital #2, a physician examined her. P1 was dilated to 4 or 5 cm and was in active labor. The physician at Hospital #2 told P1 she needed to go to Hospital #3 where there is a NICU for premature infants. Hospital #2 then sent P1 by ambulance to Hospital #3, which is over an hour from Hospital #2. When P1 got to Hospital #3, P1 was immediately admitted to the inpatient Obstetric Department. P1 received medication for two days in attempt to stop the premature labor. On the second day at Hospital #3, P1's water broke and the baby flipped to a breech position. P1 had a C-section on 01/13/16. P1's baby was born at 31 weeks and weighed 3 pounds, 15 ounces. P1's baby was taken to the NICU. P1 was discharged from Hospital #3 on 01/15/16. P1's baby remains in the NICU at Hospital #3 on ventilatory support.

RN/F was interviewed on 01/20/16 at 9:00 a.m. RN/F stated she is an experienced ED nurse and worked the night shift of 01/10/16 - 01/11/16 from 7:00 p.m. to 7:30 a.m. During RN/F's 12-hour shift on 01/10/16 - 01/11/16, two patients presented to the ED seeking care for an EMC, P20 and P1. P20 presented at 6:30 a.m. with complaints of flank pain. RN/F escorted P20 to Exam Room #2, assessed P20, and notified the on-call medical provider of P20's arrival and need for a MSE. The on-call medical provider, MD/E, was onsite at the hospital and conducted P20's MSE about ten minutes later. MD/E then left the ED while results from P20's labs and U/A were pending. P1 then presented to the ED around 7:00 a.m. with complaints of vaginal bleeding. P1 was 30 weeks pregnant. P1 denied pain but was concerned about the bleeding. RN/F escorted P1 to Exam room #1. RN/F did not know why she did not room P1 in Exam room #3 which is set up for obstetric patients. RN/F did not assess P1. RN/F did not obtain P1's vital signs, check the amount or color of P1's vaginal bleeding, palpate P1's abdomen for possible uterine contractions, or check fetal heart tones. RN/F did not notify MD/E of P1's arrival and need for a MSE. Rather, RN/F asked P1 if P1 had notified her Obstetrician of the present problem with vaginal bleeding. P1 had not contacted her Obstetrician so RN/F offered to contact P1's Obstetrician, who was not the medical provider on-call and is not a medical provider on staff at the hospital. P1's Obstetrician is a medical provider on staff at Hospital #2. P1's Obstetrician directed RN/F to send P1 to Hospital #2 for evaluation. P1 left the hospital and went to Hospital #2, by private vehicle. Hospital #2 is approximately 32 miles away. After P1 left the hospital, RN/F went to the nurse's desk to check on the status of P20's labs. A nurse (unidentified) from Hospital #2 called and asked many questions about the condition and transfer status of P1, as Hospital #2 had been alerted by P1's Obstetrician that P1 was on her way there with an obstetric problem. It was then that RN/F realized she her error regarding the care of P1 and P1's unborn fetus. RN/F did not know why she failed to assess P1 or notify the on-call medical provider of P1's need for an obstetric MSE. RN/F's normal practice is to thoroughly assess a patient based on the patient's presenting symptoms. RN/F's normal practice is to notify the medical provider on-call of all patients presenting to the ED with EMCs.

MD/E was interviewed on 01/20/16 at 9:30 a.m. MD/E stated he was located onsite at the hospital from 5:00 p.m. on 01/08/16 to 8:00 a.m. on 01/11/16 as he was the medical provider on-call. Typically when patients present to the ED, the ED nurse gets the patient's vital signs, conducts a patient assessment based on symptoms, obtains a brief history, and then notifies him of the patient's arrival and need for the MSE. Typically all of the nurse's patient assessment data is available to him when he arrives to conduct the MSE. It is his role to determine the patient's treatment plan, whether to consult another medical service, or whether to notify the patient's Obstetrician. It is his role to determine the patient's disposition from the ED, including whether or not the patient needs to be transferred to another hospital for a higher level of care. On 01/11/16, MD/E was not notified by the ED RN that P1 had presented to the ED for evaluation of an EMC. As a result, P1 did not receive a MSE to evaluate her obstetric EMC.

MD/D was interviewed on 01/20/16 at 8:00 a.m. MD/D stated that the hospital's policy is for ED nurses to notify the medical provider on-call whenever any patient presents to the ED for emergency care. Although the hospital does not have Obstetric services, the ED still evaluates any woman who presents to the ED with an obstetric problem. If a pregnant woman is bleeding, the ED RN should immediately notify the on-call medical provider. It is never appropriate for ED nurses to notify a medical provider who is not on staff at the hospital or who is not the designated on-call medical provider. One of the medical provider's roles is to determine whether the patient's condition necessitates consultation by any other medical services, including the patient's primary medical provider or Obstetrician. On 01/11/16 when P1 presented with bleeding during pregnancy, the ED RN failed to make decisions that were in the best interest of P1. P1's EMC wasn't evaluated by a medical provider on 01/11/16 because the ED RN failed to notify the hospital's on-call medical provider that P1 had presented to the ED with an obstetric EMC.

RN/J from Recipient Hospital #2 was interviewed on 01/15/16 at 1:00 p.m. RN/J stated that P1 came to Hospital #2's ED, by private car, on 01/11/16 at 7:50 a.m. P1 said she had just been at the ED at SCBH, who directed her to seek evaluation of her obstetric emergency at Hospital #2. P1 had no paperwork from SCBH nor was Hospital #2 called by SCBH about P1's transfer. On arrival, P1 was emotionally distressed as P1 was having labor contractions. P1 was examined by a physician. P1 was dilated to 4 cm. P1 had a bulging bag of water and was bleeding. The physician determined that P1 was in active labor and required a higher level of care than what Hospital #2 could provide, as Hospital #2 does not have a NICU and does not perform deliveries before 36 weeks gestation. At 8:30 a.m. on 01/11/16, P1 was transferred by ambulance from Hospital #2 to Hospital #3, which is 60 miles away.

Hospital #2's medical record, dated 01/11/16, indicated that P1 arrived in the ED (time not indicated) with complaints of vaginal bleeding and period-like cramps. P1 said she went to SCBH to be checked and was directed to go to Hospital #2, where her Obstetrician is on staff. P1 was examined by the ED physician. Speculum examination revealed that P1 was dilated to 4 cm and had bulging membranes. P1 was having labor contractions about every 6 minutes. P1 was in active labor and needed a higher level of care for preterm labor. The ED physician contacted Hospital #3, who accepted P1 in transfer. Terbutaline and Betamethasone were administered prior to P1's transfer to Hospital #3 at 8:38 a.m., by ambulance. The ED physician and ED nurse accompanied P1 in the ambulance enroute to Hospital #3.

Recipient Hospital #3's medical record, dated 01/11/16, indicated that on arrival to Hospital #3, P1 was in active labor with vaginal bleeding and lower abdominal pain radiating to her back. P1 was dilated to 4 cm. and had a bulging bag of water. P1 was admitted to Labor and Delivery for antepartum care. The antepartum progress notes, dated 01/11/16 - 01/13/16, indicated that P1 continued to have irregular contractions and medications given to arrest preterm labor were not successful. The obstetric progress notes, dated 01/13/16, indicated that P1's membranes ruptured and the fetus flipped to a breech position. The obstetric procedural notes, dated 01/13/16 at 4:34 p.m., indicated that P1 underwent a C-section for preterm labor. P1's baby weighed 3 pounds, 15 ounces and was transferred to the NICU for care. The hospital discharge summary indicated that P1 had no post-operative complications and was discharged to home on 01/15/16.
SCBH's EMTALA policy, dated 12/05/11, indicated "any person who comes to Swift County Benson Hospital (SCBH) requesting assistance for a medical condition/emergency services will receive a medical screening by a qualified provider to determine whether an emergency medical condition exists...a qualified provider to perform a medical screen at SCBH includes a Doctor of Medicine or Osteopathy or a Certified Nurse Practitioner...the medical screen consists of an assessment and any ancillary tests or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an emergency medical condition...the medical screening examination is the process of determining, with reasonable clinical confidence, whether or not an emergency medical condition exists or a woman is in labor...a woman is in true labor unless a physician or qualified medical personnel certifies that, after a reasonable time of observation, the woman is in false labor."

The hospital's policy Admission to the ED, dated June 2010, indicated "all patients entering the Swift County Benson Hospital ED will have T/P/R/BP/O2 Sats...Patient's assessment will initially be done by the ED RN...RN will inform on call Dr of patient status and information."

The hospital's policy for Evaluation of OB Patients in ER, dated 12/05/11, indicated "a patient presenting to the ER with suspected or known labor must receive a medical screening examination (MSE). A minimal MSE/OB triage assessment includes the following: maternal vital signs, fetal heart tones, uterine contractions...for pregnant patients in labor, the purpose of the MSE is to determine whether there is sufficient time to transfer the patient before delivery, or whether the transfer would pose a threat to the patient or her baby. A physician must make this determination...serious conditions in pregnant women to be considered are:...placenta previa with painless vaginal bleeding."