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Based on interview and document review, the hospital failed to post in places likely to be noticed by all individuals a sign specifying the rights of individuals under section 1867 treatment for individuals for examination and treatment for emergency medical conditions and women in labor (EMTALA).

Findings include:

During a tour of the hospital on 8/11/21, at 11:00 a.m. it was observed that one EMTALA sign was posted in the waiting area for the emergency department (ED). No signage was observed in the ED, in the triage area, or the ambulance entrance. Physician assistant (PA)-D, assistant director of the ED, confirmed the lack of signs. PA-D stated there was construction going on, and the signs must have been removed.

The policy EMTALA undated, lacked direction for posting of signs.

Based on interview and document review, the hospital failed to ensure an accurate central log of all individuals who presented to the emergency department (ED) for 2 of 25 patients (P1) and her newborn baby (P2), when P1 delivered a live preterm baby in an ambulance in the hospital parking lot. Although hospital ED staff assisted in the delivery and provided some treatment for P1, this was not documented. No hospital record could be found for P1 or P2. P2 died in route to another hospital.

Findings include:

There was no medical record for P1 or P2 to be reviewed from the sending hospital (H)-A.

P1 and P2 were not listed on the hospital's (H)-A central ED log.

The Ambulance Run record dated 7/8/21, revealed the ambulance was called to a nearby gas station at 7:33 p.m. The ambulance crew found an 18 year-old patient (P1) at 23 weeks gestation, in preterm labor. The ambulance called for air ambulance and left to meet them at H-A's helipad. At 7:43 p.m., P2 was born in the ambulance assisted by hospital staff in H-A's parking lot.

During interview on 8/11/21, at 11:35 a.m. PA-D stated she was working in the ED on 7/8/21. PA-D stated she heard a call for help from the ambulance that was in the hospital parking lot waiting for the air ambulance. The ambulance had a patient who was pregnant more that 20 weeks who had vaginal bleeding, and they needed help. PA-D stated certified registered nurse anesthetist (CRNA)-E was already out at the ambulance and had delivered the preterm baby. PA-D stated CRNA-E was providing life sustaining treatment, as the baby was born alive, was moving, and making respiratory effort. PA-D stated she started helping with P1 because she looked very pale. The plan was to bring both P1 and P2 into the hospital for treatment, and staff inside the hospital were gearing up for treating them, getting equipment and staff ready. PA-D stated she was just about to assess the baby including checking for breathing and heart sounds when physician (MD)-F arrived into the ambulance and ordered her to stop treating the baby. PA-D and CRNA-E both told MD-F they were going to keep treating the baby and provide life sustaining treatment, when MD-F ordered them to stop life sustaining treatment on the baby, so that the grandma could go into the ambulance and be with the baby and mom. PA-D stated she recalled P1 ask if there was anything that could be done for baby and MD-F said no that the baby was not viable. PA-D stated she left the ambulance. No documentation of this incident occurred.

During an interview on 8/11/21, at 10:15 a.m. the director of nursing (DON) stated that there was no documentation of any kind, except an ambulance report for P1 or P2.

The facility policy EMTALA undated, directed under Procedure 11. A patient log will be maintained to record patient information with respect to the individual presenting to the hospital requesting evaluation or treatment of a medical condition.

Based on interview and document review, the hospital failed to provide a medical screening examination for 2 of 25 patients reviewed (P1) and her newborn baby (P2), when P1 delivered a live preterm baby in an ambulance in the hospital parking lot, but staff did not provide a medical screening examination for P2. Additionally, although hospital emergency department (ED) staff assisted in the delivery, and provided some treatment for P1, this was not documented. P2 died in route to another hospital.

Findings include:

There was no medical record for P1 or P2 to be reviewed from the sending hospital (H)-A.

The Ambulance Run record dated 7/8/21, revealed the ambulance was called to a nearby gas station at 7:33 p.m. The ambulance crew found an 18-year-old patient (P1) at 23 weeks gestation, in preterm labor. The ambulance called for air ambulance and left to meet them at H-A's helipad. At 7:43 p.m. P2 was born in the ambulance assisted by hospital staff in H-A's parking lot.

Medical record from the receiving hospital (H)-B (P1's ED record dated 7/8/21) indicated P1 was admitted to their emergency room on 7/8/21, at 9:17 p.m. P1's diagnoses included anemia secondary to blood loss, fetal demise, preterm labor/ruptured membranes, vaginal delivery. A note from the admitting ED physician dated 7/8/21, indicated H-A made no attempts to save the baby (P2). P2 was sent to H-B because they "don't do deliveries" at H-A. The baby was born alive at H-A, but died in route to H-B. He was cyanotic and colorless upon presentation to H-B.

During interview on 8/11/21, at 11:35 a.m. PA-D stated she was working in the ED on 7/8/21. PA-D stated she heard a call for help from the ambulance that was in the hospital parking lot waiting for the air ambulance. The ambulance had a patient who was pregnant more that 20 weeks who had vaginal bleeding, and they needed help. PA-D stated certified registered nurse anesthetist (CRNA)-E was already out at the ambulance and had delivered the preterm baby. PA-D stated CRNA-E was providing life sustaining treatment, as the baby was born alive, was moving, and making respiratory effort. PA-D stated she started helping with P1 because she looked very pale. The plan was to bring both P1 and P2 into the hospital for treatment, and staff inside the hospital were gearing up for treating them, getting equipment and staff ready. PA-D stated she was just about to assess the baby including checking for breathing and heart sounds when physician (MD)-F arrived into the ambulance and ordered her to stop treating the baby. PA-D and CRNA-E both told MD-F they were going to keep treating the baby and provide life sustaining treatment, when MD-F ordered them to stop life sustaining treatment on the baby, so that the grandma could go into the ambulance and be with the baby and mom. PA-D stated she recalled P1 ask if there was anything that could be done for baby and MD-F said no that the baby was not viable. PA-D stated she left the ambulance.

During an interview on 8/11/21, at 12:30 p.m. CRNA-E stated he got called in for the premature delivery of a baby who was more than 20 weeks gestation. CRNA-E stated he followed the ambulance to the hospital on 7/8/21. CRNA-E stated he entered the ambulance and saw that P1 was crowning. CRNA-E stated he delivered P2, and started resuscitation efforts on P2 who was born alive, moving, and making respiratory effort. CRNA-E stated during this process MD-F stuck his head into the ambulance and told them to stop what they were doing. CRNA-E stated he told MD-F no, they would keep providing resuscitative efforts and kept stimulating P2, suctioning him, and providing oxygen. CRNA-E's plan was to move both P1 and P2 into the ED. CRNA-E stated MD-F again ordered them to stop their efforts, telling them P2 was not viable and the family needed to be with the baby. CRNA-E stated MD-F never assessed P2 before giving this order, nor did he present P1 with any options related to P2's treatment. CRNA-E stated he realized P1 was looking pale, so ran into the ED to get ready to bring her in, and PA-D started giving orders for blood draws. CRNA-E stated suddenly, P1 and P2 were being sent by ground ambulance to H-B. CRNA-E stated he fully disagreed with this treatment plan. "I remember (P1) asking why can't I stay here?"

During an interview on 8/11/21 at 12:00 p.m. MD-G, the ED Medical Director, stated he was at the hospital for a meeting on 7/8/21. MD-G stated he went to the ED and MD-F told him that P2 was deceased, and P1 and grandma were in the ambulance with P2. MD-G stated he was trying to determine next steps in their treatment when the ambulance left. MD-G stated he found out that the ambulance left with P1 and P2, and P2 was alive. MD-G stated P1 and P2 should have come into the ED for medical screening and stabilizing treatment.

The facility policy EMTALA undated, directed it is policy that person's needing transfer to other facilities for acute conditions that are not within the capability of (the hospital) will meet the EMTALA Guidelines for Medical Screening Examination, Stabilizing the patient, appropriate mode of transfer, informed consent, and appropriate documentation. Under definitions: Emergency Medical Condition: A condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the person in serious jeopardy (or with respect to a pregnant woman, the health or the woman or the unborn child.) Under definitions, a medical screening examination (MSE) is the process of examination and treatment necessary to determine whether an emergency medical condition exists. The hospital must provide an appropriate MSE within the hospital's capabilities...to any individual who comes to the hospital and requests examination or treatment for a medical condition.

Based on interview and document review, the hospital failed to provide stabilizing treatment for 2 of 25 patients (P1, P2) when they presented to the hospital via ambulance, P1 delivered a baby (P2) in the ambulance located in the hospital parking lot, and hospital staff sent them to another hospital before first providing necessary, life saving treatment, and P2 died on route to the second hospital.

Findings include:

There was no medical record for P1 or P2 to be reviewed from the sending hospital (H)-A.

The Ambulance Run record dated 7/8/21, revealed the ambulance was called to a nearby gas station at 7:33 p.m. The ambulance crew found an 18-year-old patient (P1) at 23 weeks gestation, in preterm labor. The ambulance called for air ambulance and left to meet them at H-A's helipad. At 7:43 p.m. P2 was born in the ambulance assisted by hospital staff in H-A's parking lot.

Medical record from the receiving hospital (H)-B (P1's ED record dated 7/8/21) indicated P1 was admitted to their emergency room on 7/8/21, at 9:17 p.m. P1's diagnoses included anemia secondary to blood loss, fetal demise, preterm labor/ruptured membranes, vaginal delivery. A note from the admitting ED physician dated 7/8/21, indicated H-A made no attempts to save the baby (P2). P2 was sent to H-B because they "don't do deliveries" at H-A. The baby was born alive at H-A, but died in route to H-B. He was cyanotic and colorless upon presentation to H-B.

During interview on 8/11/21, at 11:35 a.m. PA-D stated she was working in the ED on 7/8/21. PA-D stated she heard a call for help from the ambulance that was in the hospital parking lot waiting for the air ambulance. The ambulance had a patient who was pregnant more that 20 weeks who had vaginal bleeding, and they needed help. PA-D stated certified registered nurse anesthetist (CRNA)-E was already out at the ambulance and had delivered the preterm baby. PA-D stated CRNA-E was providing life sustaining treatment, as the baby was born alive, was moving, and making respiratory effort. PA-D stated she started helping with P1 because she looked very pale. The plan was to bring both P1 and P2 into the hospital for treatment, and staff inside the hospital were gearing up for treating them, getting equipment and staff ready. PA-D stated she was just about to assess the baby including checking for breathing and heart sounds when physician (MD)-F arrived into the ambulance and ordered her to stop treating the baby. PA-D and CRNA-E both told MD-F they were going to keep treating the baby and provide life sustaining treatment, when MD-F ordered them to stop life sustaining treatment on the baby, so that the grandma could go into the ambulance and be with the baby and mom. PA-D stated she recalled P1 ask if there was anything that could be done for baby and MD-F said no that the baby was not viable. PA-D stated she left the ambulance.

During an interview on 8/11/21, at 12:30 p.m. CRNA-E stated he got called in for the premature delivery of a baby who was more than 20 weeks gestation. CRNA-E stated he followed the ambulance to the hospital on 7/8/21. CRNA-E stated he entered the ambulance and saw that P1 was crowning. CRNA-E stated he delivered P2, and started resuscitation efforts on P2 who was born alive, moving, and making respiratory effort. CRNA-E stated during this process MD-F stuck his head into the ambulance and told them to stop what they were doing. CRNA-E stated he told MD-F no, they would keep providing resuscitative efforts and kept stimulating P2, suctioning him, and providing oxygen. CRNA-E's plan was to move both P1 and P2 into the ED. CRNA-E stated MD-F again ordered them to stop their efforts, telling them P2 was not viable and the family needed to be with the baby. CRNA-E stated MD-F never assessed P2 before giving this order, nor did he present P1 with any options related to P2's treatment. CRNA-E stated he realized P1 was looking pale, so ran into the ED to get ready to bring her in, and PA-D started giving orders for blood draws. CRNA-E stated suddenly, P1 and P2 were being sent by ground ambulance to H-B. CRNA-E stated he fully disagreed with this treatment plan. "I remember (P1) asking why can't I stay here?"

During an interview on 8/11/21 at 12:00 p.m. MD-G, the ED Medical Director, stated he was at the hospital for a meeting on 7/8/21. MD-G stated he went to the ED and MD-F told him that P2 was deceased, and P1 and grandma were in the ambulance with P2. MD-G stated he was trying to determine next steps in their treatment when the ambulance left. MD-G stated he found out that the ambulance left with P1 and P2, and P2 was alive. MD-G stated P1 and P2 should have come into the ED for medical screening and stabilizing treatment.

The facility policy EMTALA undated, directed it is policy that person's needing transfer to other facilities for acute conditions that are not within the capability of (the hospital) will meet the EMTALA Guidelines for Medical Screening Examination, Stabilizing the patient, appropriate mode of transfer, informed consent, and appropriate documentation. Under definitions: Emergency Medical Condition: A condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the person in serious jeopardy (or with respect to a pregnant woman, the health or the woman or the unborn child.) Stabilized: A patient will be deemed stable if the attending provider in the emergency department has determined with reasonable clinical confidence, the the EMC no longer poses an imminent threat to life.

Based on interview and document review, the hospital failed to ensure an appropriate transfer of a patient that had not been stabilized for 2 of 25 patients (P1, P2) when P1 presented by ambulance in preterm labor, and the baby (P2) was born in the ambulance in the hospital parking lot. P1 and P2 were sent to another hospital for treatment before they were treated and stabilized, and P2 died on the way to the other hospital.

Findings include:

There was no medical record for P1 or P2 to be reviewed from the sending hospital (H)-A.

The Ambulance Run record dated 7/8/21, revealed the ambulance was called to a nearby gas station at 7:33 p.m. The ambulance crew found an 18-year-old patient (P1) at 23 weeks gestation, in preterm labor. The ambulance called for air ambulance and left to meet them at H-A's helipad. At 7:43 p.m. P2 was born in the ambulance assisted by hospital staff in H-A's parking lot.

Medical record from the receiving hospital (H)-B (P1's ED record dated 7/8/21) indicated P1 was admitted to their emergency room on 7/8/21, at 9:17 p.m. P1's diagnoses included anemia secondary to blood loss, fetal demise, preterm labor/ruptured membranes, vaginal delivery. A note from the admitting ED physician dated 7/8/21, indicated H-A made no attempts to save the baby (P2). P2 was sent to H-B because they "don't do deliveries" at H-A. The baby was born alive at H-A, but died in route to H-B. He was cyanotic and colorless upon presentation to H-B.

During an interview on 8/11/21 at 12:00 p.m. MD-G, the ED Medical Director, stated he was at the hospital for a meeting on 7/8/21. MD-G stated he went to the ED and MD-F told him that P2 was deceased, and P1 and grandma were in the ambulance with P2. MD-G stated he was trying to determine next steps in their treatment when the ambulance left. MD-G stated he found out that the ambulance left with P1 and P2, and P2 was alive. MD-G stated P1 and P2 should have come into the ED for medical screening and stabilizing treatment. This treatment was not provided according to hospital policies. MD-G stated additionally, MD-F never contacted H-B to get acceptance of the patients and did not transfer them according to policy.

The policy EMTALA undated, directed it is policy that person's needing transfer to other facilities for acute conditions that are not within the capability of (the hospital) will meet the EMTALA Guidelines for Medical Screening Examination, Stabilizing the patient, appropriate mode of transfer, informed consent, and appropriate documentation. Under definitions: Emergency Medical Condition: A condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the person in serious jeopardy (or with respect to a pregnant woman, the health or the woman or the unborn child.)