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Based on a tour of the ED and staff interview conducted on September 29, 2014, it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1866 of the Act with respect to examination and treatment of emergency medical conditions and women in labor or information indicating whether or not the hospital participates in the Medicaid program.

Findings include:


1. The following observations of the ED where made on 9/29/14.

a. The entrance to the ED revealed no signage posted.

(i) One EMTALA sign, 8 x 11 inches, was inconspicuously placed in the hallway between the ED and the ED admission area.

b. The ambulance entrance to the ED revealed no signage posted.

c. The ED triage rooms revealed no signage posted.

d. The ED treatment rooms revealed no signage posted.


2. The above findings were confirmed by Staff #1 and Staff #2.

3. The following observation of the Labor and Delivery Unit was made on 9/29/14.

a. The entrance area revealed no signage posted.

b. The Labor and Delivery treatment rooms revealed no signage posted.

4. The main hospital entrance revealed no signage posted.

5. The above findings were confirmed by Staff #1 and Staff #2.

Based on review of medical records, review of the Emergency Department Activity Log, and staff interview, it was determined that the facility failed to ensure that all entries in the log are accurate.

Findings include:

1. Documentation on the face sheet of Medical Record #1 indicated Patient #1 arrived at the facility on 5/26/14 at 0148.

a. The ED Central Log did not have Patient #1 listed on the log.

2. Upon interview with Staff #8 and Staff #9, it was confirmed that time of night, the only way into the facility is through the ED.

3. Documentation in Medical Record #9 indicated Patient #9 left against medical advice.

a. The ED Central Log indicated Patient #9 eloped.

4. Documentation in Medical Record #12 indicated Patient #12 left against medical advice.

a. The ED Central indicated Patient #12 eloped.

5. Documentation in Medical Record #24 indicated Patient #24 was admitted through the ED.

a. The ED Central Log did not have Patient #24 listed on the log.

6. Documentation in Medical Record #25 indicated Patient #25 was admitted through the ED.

a. The ED Central Log did not have Patient #25 listed on the log.

7. These findings were confirmed by Staff #1.

Based on medical record review, staff interviews and review of policy and procedure, it was determined that the facility failed to ensure that emergency medical conditions are resolved for all patients prior to discharge.

Reference #1: Administrative Policy, 'EMTALA (Emergency Medical Treatment Care & Labor Act)' states, " Purpose: To provide guidelines concerning the appropriate stabilization and transfer of the individuals presenting to Hackettstown Regional Medical Center (HRMC) with an emergency medical condition ... " To Stabilize " ... I. A patient is deemed stabilized if the treating physician attending to the patient in the emergency department/hospital has determined that, within reasonably medical probability, that no deterioration of the condition is likely to result from or occur during the transfer of the individual or (in the case of a woman in labor) the woman has delivered the child and the placenta. "


1. The Labor and Delivery (L&D) Log indicates that Patient #1 was admitted to the L&D Unit on 5/26/14 at 0150 and discharged on 5/26/14 at 0320.

a. Reason for Admission/Comments indicates: #39 wk [weeks gestation] SROM pt [patient] of (name of clinic).

b. Disposition of patient indicates: Discharge to (name of hospital clinic), R c/s [ Repeat cesarean section for 5/27/14], p.o.v. [per own vehicle].

2. Review of Medical Record #1 indicates the following:

a. The L&D Flow Chart indicates Patient #1 was triaged on 5/26/14 at 0211.

b. Pain level was documented as 8 out of 10.

c. Membrane Status: Ruptured

d. Membranes Ruptured Method: Spontaneous

e. Amniotic Fluid Color: Meconium

f. Pattern: Normal <= [less than or equal to] 5 contractions in 10 minutes

g. At 0246, Teaching: Verbal; Patient instructed; ...Via Interpreter: Verbalized understanding

h. Plan of Care: Plan of Care was discussed

i. Additional Teaching: pts [patients] husband to take pt [patient] to (name of hospital) via car, pt [patient] goes to (name of hospital clinic) and will deliver there by repeat cesarean section, ...leaking small amount thin meconium fluid, reinforced need to go directly to (name of hospital) by the RN and the language line, interpreter (name of interpreter), tolerating irregular contractions, ... bought to car via wheelchair, discharged by Staff #15, on-call OB.

j. The Fetal Strip dated 5/26/14, 0206, indicated a deceleration in fetal heart rate.

3. Staff #8 and Staff #9 confirmed the deceleration in the fetal monitor strip.

k. The Patient Care Provider Orders dated 5/26/14 indicate a telephone order at 0200 by Staff #15, the on-call OB, taken by Staff #16, an L&D nurse, which was read back and verified; ... "4. Evaluate for presence of amniotic fluid or if presence of amniotic fluid is grossly obvious notify the patients primary care provider ... 6. Sterile Vaginal Exam"

(i) There was no evidence documented in the L&D Flow sheet that the RN notified the the OB physician that the membranes were ruptured.

(ii) There was no evidence documented on the L&D Flow sheet that the OB was notified of meconium in the amniotic fluid.

l. The Patient Care Provider Orders dated 5/26/14 indicate a telephone order at 0315 by Staff #15, the on-call OB, taken by Staff #16, an L&D nurse, which was read back and verified; "Patient Discharged."

4. Upon interview and review of Medical Record #1, on 9/30/14, with Staff #8 and Staff #9, both L&D nurses, it was confirmed that Patient #1 was not considered stabile at the time of discharge and should not have been discharged, to self-transport to another hospital.

5. Upon telephone interview with Staff #15 the on-call OB physician, on 10/1/14, he/she stated that he/she did not examine the patient. He/she reviewed the fetal heartrate strip. His/her decision to discharge Patient #1, was based on the nurse's report.

6. Patient #1 and her husband were instructed to self-transport to another hospital, approximately 45 minutes away.

(i) There was no documentation in the medical record explaining the risks and/or benefits of self-transporting to another hospital.

7. There was no evidence that Patient #1 was deemed stabile by the treating physician, nor was it determined that no deterioration of the condition was likely to result from instructing the patient/husband to self-transport to another hospital.

8. As per facility policy, in the case of a woman in labor, the patient is deemed stabilized when she has delivered the child and the placenta. Patient #1, a woman in the early stages of labor with ruptured membranes and meconium stained amniotic fluid, was scheduled to have a repeat cesarean section 5/27/14 and did not deliver the child and the placenta at the facility.

9. The Face Sheet from (name of hospital) indicated that Patient #1 was admitted on 5/26/14 at 0503 with the diagnosis of Cesarean Delivery.

10. Patient #1's Discharge Summary from (name of hospital) indicated the following:

a. Chief Complaint: rupture of membranes since 5/25/10 at 2200.

b. Operations and Procedures: ...Cesarean Section.

c. Neonate Information: Infant female

d. Apgar: 9/8

Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure all transfers are conducted appropriately.

Findings include:

Reference: Facility Policy Titled: EMTALA, section V. A. Written Request by Individual or Responsible Party states, "...The request must be in writing and indicate the reason for the request and that the individual is aware of the risks and the benefits of the transfer..."

1. Documentation in Medical Record #2 in the Nursing Notes dated 7/31/14 at 6:41 AM states, "family watned [SIC] pt to go to MMH Dr. (name) is his surgeon but volunteer squad brought him here. FAmily [SIC] wants tpt [SIC] transferred expalined [SIC] needs to e [SIC] seen and if there [SIC] PMD watns [SIC] to accept him then he can be transferred."

2. Documentation in Medical Record #2 failed to have the "Patient Initiated Transfer Request" completed. The areas that were not completed include:

a. Request transfer to

b. Reason for transfer

c. Patient signature and witness signature

d. Date and time

3. Documentation on the transfer form indicated that an RN was needed for transport and the patient was to be transferred by ambulance.

4. There was no documentation in Medical Record #2 indicating the patient was transferred via ambulance with an RN.

5. The above was confirmed by Staff #1.