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Based on medical record review, review of the hospital's policies and procedures and staff interview it was determined that the hospital failed to follow their policies in regard to EMTALA requirements. This deficient practice was found in 1 of 4 patients who presented with complaint of pregnancy complications in a sample of 20 medical records, Patient 4. The hospital saw 7,045 patients in the Emergency Department in the month of January 2011.

Findings include:

The hospital failed to follow their policy as evidenced by the lack of written documentation that Patient 4 was notified of the risks of leaving without an examination by the physician and no documentation that Patient 4 was asked to sign the patient refusal form as required by their EMTALA policy.

Please refer to 42 CFR 489.24(d); A2407, Stabilizing Treatment for Emergency Medical Conditions.

This substantiates complaint number OH00059488.

Based on review of medical records, staff interview and review of the hospital's policy and procedures, it was determined that the hospital failed to ensure that a patient who presented to the emergency department for stabilizing treatment was explained the risks and benefits prior to leaving against medical advice as required per hospital policy. This deficient practice was found in 1 of 4 patients who presented with complaint of pregnancy complications in a sample of 20 medical records, Patient 4. The facility saw 7,045 patients in the Emergency Department in the month of January 2011.

Findings include:

The medical record for the Patient 4 was reviewed on 02/07/11. The patient presented to the Emergency Department on 02/03/11 at 5:58 PM with a chief complaint of pregnancy complications. According to the medical record Patient 4 was placed in a triage room at 6:00 PM and the medical record documents that the patient had vaginal bleeding which started 30 minutes prior to her arrival, with light cramping and no clots. Patient 4 stated she was 12 weeks pregnant. The documentation showed that at 6:11 PM Patient 4 was escorted to the waiting room to await an available treatment room.

At 6:59 PM nursing documentation revealed that Patient 4 informed the staff she intended to leave the hospital without receiving medical treatment. Further review of nursing documentation revealed the nurse "encouraged" the patient to stay. There was no documentation in the medical record that Patient 4 had been counseled in regard to the risks of leaving without being seen and treated by the physician; nor was there documentation that the patient was asked to sign a release before leaving against medical advice.

An interview with Staff 5 was conducted on 02/09/11 at 1:29 PM. When asked about the hospital's leave against medical advice policy Staff 5 stated there are no policies in place in regard to patients who leave prior to being seen by a physician.

The hospital's policy titled "Emergency Medical and Treatment and Active Labor Act (EMTALA)" was reviewed on 02/07/11. The policy stated that "If an individual refuses treatment against medical advice, qualified medical personnel must explain all risks and benefits of treatment and have the individual sign the "Patient Refusal to Accept Examination and Treatment Against Medical Advice Form". If the individual refuses to sign the form, document the risks and benefits explained to the individual and the effort taken to have the individual sign the form and the individual's refusal".