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Based on review of facility documentation, recipient/second hospital medical record (MR) review, and staff interview (EMP), it was determined the facility failed to comply with 489.24 related to Medical Screening Examination.

Findings include:

The review of facility documentation, recipient hospital medical record (MR) review, and staff interviews (EMP) revealed the facility failed to ensure an appropriate medical screening examination (MSE) to a patient who was on hospital property was completed in one of 22 medical records reviewed. (MR21)

Cross reference with:
489.24(a) and 489.24(c) - Medical Screening Exam
489.20 (r) (3) Emergency room log

Based on review of facility policy, facility documents, and staff interview (EMP), it was determined the facility failed to maintain a central log for one patient (Patient1) presenting to the ED.

Findings include:

Review on July 27, 2023, of the updated facility policy, "EMTALA System Policy," last reviewed, July 7, 2023, revealed "... Purpose ... To comply with the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations ... Definitions ... Emergency Medical Care Log is in the Geisinger ' s electronic health record which is maintained on all individuals who present to the emergency department seeking medical care. The log shall be kept for five years and contain specific patient information including: Patient identification, Medical record and encounter number, Patient type, Presentation time, Provider evaluation note, Discharge time, Disposition categorized as treatment and released, admitted, discharged, transferred, elopement, left without being seen, or refusal of treatment (AMA). Emergency Medical Treatment and Labor Act EMTALA refers to Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. and 1395dd, which obligates hospitals to provide medical screening, treatment and transfer of individuals with emergency medical conditions or women in labor. It is also referred to as the ' anti-dumping ' statute and COBRA (Consolidated, Omnibus Budget and Reconciliation Act). ... PROCEDURE ... Routine Business Registration: The medical screening of a patient seeking emergency care cannot be delayed for financial inquiry including managed care authorization. However, routine registration may take place to facilitate the patient flow through the department. Guidelines to observe when registering a patient: Do not interfere with the timeliness of the medical screening. Do not call the managed care organization to obtain permission to do a medical screening. Do not say or imply anything that may discourage the patient from seeking the medical screening. Do not give the patient any information about advanced beneficiary notice prior to the medical screening. Patients who decide to leave prior to a disposition: If a patient decides to leave prior to a medical screening, the following steps should be taken if at all possible: Explain to the patient it is important to have the medical screening to rule out whether or not there is a medical condition that needs treatment. Inform the patient of the risks of not having a medical screening. Ask the patient to sign the AMA form acknowledging understanding the risks of leaving. It is recognized that at times the patient may refuse to sign this form. ... Document on the medical record the above information including refusal to sign AMA documentation ..."
Interview with EMP12 on July 27, 2023, at 1023 confirmed Patient1 presented to the hospital's emergency department (ED) on July 9, 2023, and EMP12 did not register Patient1 on ED registration log.

Review on July 27, 2023, of the Central Log for the Emergency Department (ED) for July 9, 2023, revealed no documentation Patient1 presented to the facility's ED.

Cross reference with:
489.24(a) and 489.24(c) - Medical Screening Exam

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure labor and delivery patients received medical screening in the Emergency Department for two of two medical records reviewed (MR1 and MR2) and failed to ensure each patient presenting to the Emergency Department was provided with an appropriate medical screening examination for one of 22 medical records reviewed (MR21).

Findings include:

1. Review on July 10, 2023, of the facility policy, "EMTALA System Policy," last reviewed, August 12, 2022, revealed "... Purpose To identify guidelines for providing the appropriate setting for conduction medical screening examinations To identify providers eligible to perform emergency medical screening examinations To comply with the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations ... Policy Any person who comes to a facility requesting assistance for a potential emergency medical condition/emergency service will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists Persons with emergency conditions will be treated and their condition stabilized without regard to ability to pay for services. ... Definitions ... Emergency Medical Condition (which is determined by a qualified medical provider after conducting a medical screening examination) is defined as a medial condition manifesting itself by acute symptoms or sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of medical attention could reasonably be expected to result in: Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part; or With respect to a pregnant woman who is having contractions: There is inadequate time to provide a safe transfer to another hospital before delivery; or The transfer may pose a threat to the health or safety of the woman or the unborn child. ... Procedure A hospital must provide for an appropriate medical screening examination within the capability of the hospital emergency department to any individual who comes to the emergency department and requests examination or treatment. The purpose of this screening examination is to 'determine whether or not an emergency medical condition exists.' If an emergency medical condition exists, then further medical treatment must be provided to stabilize the patient or the patient must be transferred to another facility in accordance with the policy. Requirements of a medical screening: The medical screening consists of an assessment and any ancillary testing or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an emergency medical condition. This may be a brief history and physical examination or may require complex ancillary studies and procedures such as, but not limited to, lab tests, fetal monitoring, EKG tracing or radiology exam. The medical screening is the process a provider must use to reach with reasonable clinical confidence whether a medical emergency does or does not exist. The medical screening must provide evaluation and stabilizing treatment within the scope of the hospital or facility's abilities and not consider a patient's ability to pay for services. The medical record will reflect the findings of the medical screening including results of any test performed and analysis. Disposition of the patient will be documented with any education provided and a follow-up plan of care if the disposition of discharge is appropriate. ... "

Review on July 10, 2023, of the facility policy, "Obstetric Patient Presents to the Emergency Department," last reviewed February 13, 2023, revealed "... Purpose To direct the nursing care of an obstetric patient with obstetric complaints or symptoms who presents to the emergency department for care. ... Policy The policy is to ensure proper communication, safety, and medical care of the obstetric patient presenting to the emergency department. Procedure Area of Responsibility: Emergency Department (ED) Process for communication to inpatient obstetrics Obstetric patient arrives to ED for care Ed nurse triages or screens patient's symptoms per hospital specific guidelines in content links. Follow guideline for communicating to inpatient obstetrics in necessary Call inpatient obstetric extension per guideline Speak with charge registered or obstetric exam room registered nurse (RN) Escort to obstetrics if agreed and appropriate If obstetric registered nurse in [sic] unavailable and the request is urgent, ED staff member to call back as soon as possible or request return phone call from obstetric registered nurse as soon as possible. If obstetric registered nurse in [sic] unavailable and the request is emergent, ED attending to contact Obstetric physician on call. At the discretion of the ED staff, obstetric emergency response team can be called overhead per guidelines. If patient remain in ED for treatment, consult obstetric nursing and provider staff as needed ..."

Review on July 10, 2023, of MR1 revealed the patient presented to the ED on May 26, 2023, approximately 10 minutes after delivery of an infant in the car. The patient had not delivered the placenta and was in a wheelchair with the infant in lap with the umbilical cord intact. The patient was transported to the NICU via a wheelchair. There was documentation the patient was transported to a labor room and was assessed. The patient had delivered at approximately 36 weeks and two days gestation. There was documentation the placenta was delivered and the patient was in stable condition. There was no documentation the patient was screened or examined in the ED.

Interview on July 10, 2023, at approximately 1330 with EMP4 confirmed the findings noted above for MR1.

Review on July 10, 2023, of MR2 revealed the patient was a 36-week-two-day gestation infant delivered by spontaneous vaginal delivery on May 26, 2023. There was documentation the delivery was spontaneous and precipitous. The patient was transported to the NICU and required positive pressure ventilation briefly, was transitioned to high flow nasal canal, and was titrated as needed. The patient was weaned to room air on May 27, 2023. There was no documentation the patient was screened or examined in the Emergency Department upon presentation to the ED on May 26, 2023.

Interview on July 10, 2023, at approximately 1335 with EMP4 confirmed the findings noted above for MR2.

2. Review on July 27, 2023, of the updated facility policy, "EMTALA System Policy," last reviewed, July 7, 2023, revealed "... Purpose To identify guidelines for providing the appropriate setting for conduction (sic) medical screening examinations ... To comply with the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations ... Policy Any person who comes to a facility requesting assistance for a potential emergency medical condition/emergency service will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists Persons with emergency conditions will be treated and their condition stabilized without regard to ability to pay for services. ... Procedure A hospital must provide for an appropriate medical screening examination within the capability of the hospital emergency department to any individual who comes to the emergency department and requests examination or treatment. The purpose of this screening examination is to ' determine whether or not an emergency medical condition exists.' If an emergency medical condition exist, then further medical treatment must be provided to stabilize the patient or the patient must be transferred to another facility in accordance with the policy. Requirements of a medical screening: The medical screening consists of an assessment and any ancillary testing or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an emergency medical condition. This may be a brief history and physical examination or may require complex ancillary studies and procedures such as, but not limited to, lab tests, fetal monitoring, EKG tracing or radiology exam. The medical screening is the process a provider must use to reach with reasonable clinical confidence whether a medical emergency does or does not exist. The medical screening must provide evaluation and stabilizing treatment within the scope of the hospital or facility's abilities and not consider a patient's ability to pay for services. The medical record will reflect the findings of the medical screening including results of any test performed and analysis. Disposition of the patient will be documented with any education provided and a follow-up plan of care if the disposition of discharge is appropriate. ... Patients who decide to leave prior to a disposition: If a patient decides to leave prior to a medical screening, the following steps should be taken if at all possible: Explain to the patient it is important to have the medical screening to rule out whether or not there is a medical condition that needs treatment. Inform the patient of the risks of not having a medical screening. Ask the patient to sign the AMA form acknowledging understanding the risks of leaving. It is recognized that at times the patient may refuse to sign this form. ... Document on the medical record the above information including refusal to sign AMA documentation ..."

Review on July 27, 2023, of the medical record from the secondary receiving hospital revealed Patient1 (MR21) presented for a chief complaint of eye pain on July 9, 2023. The patient was treated and discharged to home with discharge instructions on July 9, 2023, at 1353.

Interview with EMP20 on July 27, 2023, at 1150 revealed EMP20 was the triage nurse at the secondary receiving hospital on July 9, 2023, when Patient1 arrived in their Emergency Department. Patient1 noted they had presented to Geisinger Medical Center's Emergency Department. Patient1 noted the registration clerk provided Patient1 with the number of patients waiting services in the Emergency Department at the secondary receiving hospital.

Staff interview with EMP23 on July 27, 2023, at 1000, confirmed there was no medical record for this patient at Geisinger Medical Center (Patient1), only at the secondary receiving Hospital (MR21).
Staff interview with EMP12 on July 27, 2023, at 1023, confirmed there was no medical screening exam for Patient1 at Geisinger Medical Center.