HospitalInspections.org

Based on observation, policy review, medical record review, RCA review, and staff interviews, it was determined the facility failed to meet emergency needs, and ensure Emergency Room Providers treated presenting symptoms, provided diagnostic testing, and provide appropriate MSEs within the capability of the hospital for 4 of 20 emergency Patients (Patients #5, #6, #8 and #12) whose records were reviewed. This had the potential to put all patients presenting to the hospital in labor and/or with an EMC at risk of injury, harm, impairment, or death due to the ED not providing comprehensive medical screening exams to determine if an EMC exists. Findings include:

The facility underwent a recertification survey completed on 12/02/23. During the course of that survey the facility was cited an immediate jeopardy at A 1100. One of the citations that led to the immediate jeopardy was:

"There was no documentation of stabilizing treatment, diagnostic testing, or assessment by a physician prior to transfer in 9 of 11 patients ... whose ED records were reviewed." The facility was cited during a complaint investigation for similar issues as follows:

1. There was no documentation of treatment of presenting symptoms prior to transfer for 2 of 20 patients (Patients #5 and #6) whose ED records were reviewed.

a. Patient #5 was an 80 year old female with Medicare insurance who presented to the ED on 2/26/23 at 3:27 PM with a chief complaint of shortness of breath and dizziness.

Patient #5's medical record included "Emergency Documentation" completed by the RN over the course of Patient #5's stay in the ED. The documentation included Patient #5 had a pain score of 3 on a scale of 1 to 10 with 10 being the worst pain. The documentation included the patient "reports dizziness and lightheadedness. Pt reports nausea." The documentation included a narrative note by the RN on 2/26/23 at 4:00 PM, which included, "Provider aware of pain decided to transfer before treatment, EKG done before transfer and shown to provider upon arrival."

Patient #5's medical record included a note by the ED Provider on 2/26/23 at 3:41 PM. It included "80-year-old female who presents to the Mountain View emergency department by private automobile with shortness of breath and chest discomfort. Symptoms started earlier this morning. She denies any significant chest pain at this time but does feel fatigued and shortness of breath."

The section "medical decision making" included, "Patient was rapidly evaluated in the emergency department. EKG was available as soon as I walked into the patient's room with changes concerning for possible subendocardial injury. I advised the patient that we do not have cardiology specialist on call at this facility and she will need to be transferred to Idaho falls community hospital emergency department immediately. Patient was placed in a wheelchair immediately and taken to Idaho falls can[sic] hospital emergency department."

Staff I, an RN, was interviewed on 9/13/23 beginning at 10:00 AM and Patient #5's record was reviewed in her presence. When asked what stabilizing treatment was done for Patient #5's presenting symptoms she stated an EKG was performed. When asked if the patient was transferred with a cardiac monitor, she stated there was no documentation Patient #5 was placed on a monitor. When asked if Patient #5 had an IV line started in the MVH ED she stated there was no documentation an IV line was placed. When asked if there was any stabilizing treatment for Patient #5's presenting symptoms of shortness of breath and dizziness, she stated, "not that I can see."

Staff K, a PA, was interviewed on 9/13/23 beginning at 2:50 PM. When asked what stabilizing treatment was provided for Patient #5, he stated an IV was ordered but was not placed. He stated an EKG was performed. When asked if Patient #5 was placed on oxygen he stated she was not hypoxic, so her condition did not warrant oxygen. He stated she was transferred to IFCH and fortunately the other ED is "down the hall" so additional diagnostics or treatments were not done.

Patient #5 was not provided stabilizing treatment for presenting symptoms prior to transfer to a different hospital.

b. Patient #6 was a 42 year old female with Medicaid insurance. She presented to the MVH ED on 3/02/23 at 3:50 AM with a chief complaint of body aches, leg pain, chills, headache, nausea, and upper abdominal pain. Patient #6 was approximately 10 days post op for a Panniculectomy (abdominal surgery to remove excess skin). The surgery was performed by a physician who had surgical and admitting privileges at MVH.

Patient #6's medical record included a physician note documented by the ED physician on 3/02/23 at 4:33 AM. The note included Patient #6 was being seen at wound care for dressing changes and wound care stated to Patient #6 if she had worsening abdominal pain that she would require further evaluation. It included, "she notes that this morning she started having body aches chills nausea as well as worsening abdominal pain which prompted her to come to the emergency department."

The ED physician note included, "Patient with abdominal discomfort, chills, body aches. There is a concern for intra abdominal infection post surgery. IV started, blood cultures obtained. Lactate ordered. I do feel that this patient requires a higher level of care. I did speak with the CT scan at the neighboring facility who states that there will be a slight delay. Unfortunately, patient quires[sic] high level of care and will be transferred to out of falls[sic] community hospital."

The ED provider did not indicate what higher level of care was needed and the expected benefits of such care. Additionally, the provider did not indicate what care could not be provided by MVH ED in a hospital (MVH) that performed surgery, provided post surgical care, and had a CT scanner with 24/7 availability.

There was no documentation in Patient #6's medical record she was treated for presenting fever, chills, and pain.

Staff I, an RN, was interviewed on 9/13/23 beginning at 10:00 AM. When asked what treatment was provided for Patient #6's presenting symptoms, she stated labs and blood cultures were drawn. When asked if antibiotics were given she stated "yes." She confirmed no radiology diagnostics were performed. Additionally, she confirmed there was no documentation Patient #6 was given any medications for her pain and fever.

Patient #6's medical record included an ED Nursing Note 3/02/23 at 5:12 AM. The note included, "Ordered antibiotic treatment was unavailable in Omnicell [medication cabinet]. Pt was wheeled down to IFCH ED. IFCH ED staff was notified of situation they reported that they did have medication needed on hand and would immediately begin to administer antibiotic treatment upon completion of pt assessment and triage into their system."

Staff L, an RN, was interviewed on 9/13/23 beginning at 3:00 PM and Patient #6's medical record was reviewed in his presence. When asked if the hospital had Pharmacy services 24/7 he stated "yes." When asked if the hospital had other Omnicells to retrieve the ordered Rocephin from he stated that there were multiple Omnicells throughout the hospital. Staff L agreed that Rocephin is a commonly available antibiotic and was likely in another Omnicell in the hospital. He confirmed no antibiotic treatment was given to Patient #6 prior to her transfer to IFCH ED.

Staff G, the DO who cared for Patient #6, was interviewed by phone 9/13/23 beginning at 2:00 PM and Patient #6's medical record was reviewed in his presence. Staff G was asked if he contacted Patient #6's physician who performed her surgery. He stated he attempted but was unable to contact him. When asked why CT was not performed at MVH he stated it would be delayed with radiology staff coming to MVH from IFCH and IFCH can perform "rapid CT." When asked if CT was available at the hospital 24/7, he stated yes but would have to call in staff members. When asked why Patient #6 was transferred to IFCH he stated she looked like an "acute abdomen" needed a "Higher level of care," possibly requiring admission or surgery. He confirmed there was no documentation Patient #6 was treated for pain or fever.

MVH hospital provides surgical services and has a medical surgical unit. Patient #6's provider's, who performed her surgery, credentialing file was reviewed. It contained current surgical and admitting privileges at MVH. There was no indication in Patient #6's record if any on call surgeon or hospitalist was contacted to see if patient #6's condition warranted admission and/or surgery.

Clevelandclinic.org, (https://my.clevelandclinic.org/health/diseases/25064-acute-abdomen), defines acute abdomen as, "Acute abdomen refers to sudden, severe abdominal pain. Many times, it's a sign of a medical emergency that requires immediate surgery. Inflammation, infections, hemorrhaging, blood flow blockages, obstructions and perforations can all cause acute abdomen."

Patient #6's medical record included an abdominal assessment by Staff G. It included, "Surgical wound on abdomen, dressing in place. Dressing is saturated with blood. Mild abdominal tenderness to palpation throughout her abdomen without guarding or rebound. Dressing is taken down, surgical wound over the umbilicus has a small area of separation, no active bleeding noted, old blood in some oozing noted." Patient #6's medical record had no indication of an acute abdomen. There was no documentation as to why Patient #6 could not wait for the CT technician to come to MVH. There was no indication it would be a lengthy delay as the above provider note stated it would be a slight delay - especially since it was the same CT tech who would perform the CT.

Staff H, from the quality department, was interviewed on 9/13/23 beginning at 3:00 PM. When asked what the disposition of Patient #6 was from IFCH, she stated the patient was discharged home after receiving a CT. She said the discharge diagnosis was febrile illness.

Patient #6's discharge record was requested from IFCH. It showed that a CT abdomen and pelvis was ordered at 5:45 AM on 3/2/23. The discharge instructions showed Patient #6 was discharged with a diagnosis of "febrile illness" at 7:24 AM.

Patient #6 was not provided stabilizing treatment for presenting symptoms prior to transfer to a different hospital. Additionally, it was unclear how an ED to ED transfer for a CT and or surgical admission, when CT and surgical admission was available at MVH, was a transfer to a "higher level of care."

2. Individuals coming to the ED were not provided an MSE appropriate to the individuals' presenting signs and symptoms, as well as the capability and capacity of the hospital.

a. Patient #12 was a 23 year old female who presented to the L&D unit, with contractions, seeking care. Her medical record was requested, and she had no documented medical record outlining the care she received.

The hospital's risk management department self-reported a potential EMTALA violation to the SA on 8/31/23 and provided information about Patient #12. Patient #12's medical record was requested from the hospital during the survey.

Provided for Patient #12 was a "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer," which was signed by Patient #12 and an RN at 4:30 AM on 8/25/23. The form stated the following:

Benefits of Services

I (the patient or parent/legal guardian of the listed patient) understand that the hospital has a duty to provide and has offered to:
- Perform a medical screening exam to determine if an emergency medical condition exists.
- Provide necessary medical treatment to stabilize any emergency medical condition.
- If necessary, transfer to another facility that can provide treatment not available at this facility.
- Other (none, if not checked)

Risks of Refusal

I have been informed of an understand the risks that may be associated with my refusal, including, but not limited to:
- The medical condition may worsen and result in permanent disability or even death.
- Delaying care at this time may result in increased cost of care at a later time.
- Other (none if not checked)

Patient (or parent/legal guardian) Acknowledgement of Understanding:

I understand that by refusing the services offered, I am doing so against the medical advice of the physician and hospital. I also understand that the availability of medical services, including examination and stabilizing treatment, is not based on my ability to pay for these services. I have been given the opportunity to ask questions about the above information and all my questions have been answered to my satisfaction. I assume the risks and consequences involved and release the physician, facility, and staff from any liability.
I completely understand the possible consequences of my refusal."

Surveyors requested the investigation into the incident.

The RCA related to Patient #12's course of treatment was requested. It was dated 8/31/23. It stated, "Patient presented to L&D with contractions. CNA roomed patient and had her change into a gown since the charge nurse was busy with other tasks. RN then presented to patient room and informed her that we were on 'divert' and that she could not deliver at MVH and would need to go to [Hospital A, another local hospital]. Staff told patient that if they checked her cervix and she was dilated to >6 [centimeters], she would have to go by EMS. Patient signed refusal and drove by private vehicle to [Hospital A] L&D." The RCA also stated, "Spoke with all staff involved with event. Thursday to Friday morning was very busy. Staff went onto 'divert' at L&D manager's direction ... The charge RN did not see this patient present to L&D because she was busy with other tasks. CNA roomed patient so she was not waiting at the nurses' station and instructed pt to change into a gown. There was an open bed but there was not sufficient staffing to care for a walk-in. This was discussed with the patient by the RN and the patient signed a refusal and willingly left to [Hospital A.]"

Staff B, an RN, was interviewed on 9/13/23 at 12:54 PM. She stated at midnight on 8/25/23, they were told to go on divert by the L&D manager. She stated Patient #12 presented to the L&D department while the unit was still on divert and Patient #12 signed the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer" form. She stated Patient #12 was upset. She stated she had been educated to use the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer" form in staff meetings as well as in orientation. When asked if Patient #12 refused services, Staff B stated, "I don't believe she necessarily refused."

Staff D, an RN, was interviewed on 9/12/23 at 4:36 PM. When asked about Patient #12 signing the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer," she stated, "this has been happening for years." She stated if they were declared on divert due to staffing or "drowning" then they were trained to send L&D patients elsewhere and have them sign the refusal form. She stated, "we tell them they can go across the street and get better care at [Hospital A] and no ambulance." She also stated, "they can refuse to sign the form - in that case we can see them." When asked if she agreed that Patient #12 did not actually refuse services and instead was turned away due to inadequate staffing she stated, "yes."

Staff C, the L&D Manager, was interviewed on 9/14/23 at 8:45 AM and the RCA was reviewed with her. She stated she did not tell anyone to go on divert. When shown the RCA which stated the divert was at her direction, she stated, "I was not in on this conversation." When asked if she said anything that could have been interpreted as her telling staff to put the unit on divert, she said "no."

Additional L&D nurses were interviewed on the L&D floor on 9/13/23 beginning at 2:35 PM regarding the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer," form. The form was shown to them, and the nurses were asked how they were instructed to use it. Staff E stated the NICU had expanded to be able to care for infants as young as 20 weeks gestational age. Staff E stated before the NICU expansion, they would use the form if a laboring patient less than 35 weeks along came in. She stated once they had a woman come in who was 22 weeks along, and they told her they would triage her, but she would have to get shipped to Hospital A, or she could drive herself since it was cheaper. She stated the woman refused treatment and went to Hospital A. Another RN, Staff F, was shown the form and stated it was used if a woman came in to get triaged and refused triage to choose to go to another hospital. She stated if all the rooms were full, they might tell a laboring patient there was the potential the patient might deliver in the triage room or postpartum room.

Staff A, from risk management, was interviewed on 9/12/23 at 9:15 AM and the RCA about Patient #12 was reviewed. Surveyors and Staff A reviewed the documentation that Patient #12 was told to go to a different hospital by MVH staff. Surveyors asked Staff A why Patient #12 signed a refusal form she said, "I wouldn't say that it fits for a refusal." Staff A agreed Patient #12 did not refuse services at the facility. Staff A agreed the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer" form was not used appropriately. When asked if there was an MSE done for Patient #12 she stated, "there was not - no."

There was no documentation Patient #12 was provided an MSE within the capability of the hospital to determine if the patient was in active labor and an EMC existed.

b. Patient #6 was a 42 year old female with Medicaid insurance. She presented to the MVH ED on 3/02/23 at 3:50 AM with a chief complaint of body aches, leg pain, chills, headache, nausea, and upper abdominal pain. Patient #6 was approximately 10 days post op for a Panniculectomy (abdominal surgery to remove excess skin). The surgery was performed by a physician who had surgical and admitting privileges at MVH.

Patient #6's medical record included a physician note documented by Staff G on 3/02/23 at 4:33 AM. The note included Patient #6 was being seen at wound care for dressing changes and wound care stated to Patient #6 if she has worsening abdominal pain that she would require further evaluation. It included "she notes that this morning she started having body aches chills nausea as well as worsening abdominal pain which prompted her to come to the emergency department."

The ED physician note included, "Patient with abdominal discomfort, chills, body aches. There is a concern for intra abdominal infection post surgery. IV started, blood cultures obtained. Lactate ordered. I do feel that this patient requires a higher level of care. I did speak with the CT scan at the neighboring facility who states that there will be a slight delay. Unfortunately, patient quires[sic] high level of care and will be transferred to out of falls[sic] community hospital."

The ED provider did not indicate what higher level of care included and the expected benefits of such care. Additionally, the provider did not indicate what care could not be provided by MVH ED in a hospital (MVH) that performed surgery, provided post surgical care, and had a CT scanner with 24/7 availability.

There was no documentation in Patient #6's medical record she was treated for presenting fever, chills, and pain.

Staff I, an RN, was interviewed on 9/13/23 beginning at 10:00 AM. When asked was treatment was provided for Patient #6's presenting symptoms she stated labs and blood cultures were drawn. When asked if antibiotics were given she stated, "yes." She confirmed no radiology diagnostics were performed. Additionally, she confirmed there was no documentation Patient #6 was given any medications for her pain and fever.

Patient #6's medical record included an ED nursing note completed by the RN on 3/02/23 at 5:12 AM. The note included, "Ordered antibiotic treatment was unavailable in Omnicell [medication cabinet]. Pt was wheeled down to IFCH ED. IFCH ED staff was notified of situation they reported that they did have medication needed on hand and would immediately begin to administer antibiotic treatment upon completion of pt assessment and triage into their system."

Staff L, an RN, was interviewed on 9/13/23 beginning at 3:00 PM and Patient #6's medical record was reviewed in his presence. When asked if the hospital had Pharmacy services 24/7 he stated, "yes." When asked if the hospital had other Omnicells to retrieve the ordered Rocephin from, he stated that there were multiple Omnicells throughout the hospital. The ED director agreed that Rocephin is a commonly available antibiotic and was likely in another Omnicell in the hospital. He confirmed no antibiotic treatment was given to Patient #6 prior to her transfer to IFCH ED.

Staff G, a DO, who cared for Patient #6 was interviewed by phone 9/13/23 beginning at 2:00 PM and Patient #6's medical record was reviewed in his presence. Staff was asked if he contacted Patient #6's physician who performed her surgery. He stated he attempted but was unable to contact him. When asked why CT was not performed at MVH he stated it would be delayed with radiology staff coming to MVH from IFCH and IFCH can perform "rapid CT." When asked if CT was available at the hospital 24/7 he stated yes but would have to call in staff members. When asked why Patient #6 was transferred to IFCH he stated she looked like an "acute abdomen" needed a "Higher level of care," possibly requiring admission or surgery. He confirmed there was no documentation Patient #2 was treated for pain or fever.

MVH hospital provides surgical services and has a medical surgical unit. Patient #6's provider's, who performed her surgery, credentialing file was reviewed. It contained current surgical and admitting privileges at MVH. There was no indication in Patient #6's record if any on call surgeon or hospitalist was contacted to see if patient #6's condition warranted admission and/or surgery.

Clevelandclinic.org, (https://my.clevelandclinic.org/health/diseases/25064-acute-abdomen), defines acute abdomen as, "Acute abdomen refers to sudden, severe abdominal pain. Many times, it's a sign of a medical emergency that requires immediate surgery. Inflammation, infections, hemorrhaging, blood flow blockages, obstructions and perforations can all cause acute abdomen."

Patient #6's medical record included an abdominal assessment by the ED provider. It included, "Surgical wound on abdomen, dressing in place. Dressing is saturated with blood. Mild abdominal tenderness to palpation throughout her abdomen without guarding or rebound. Dressing is taken down, surgical wound over the umbilicus has a small area of separation, no active bleeding noted, old blood in some oozing noted." Patient #6's medical record had no indication of an acute abdomen. There was no documentation as to why the patient could not wait for the CT tech to come over to MVH. There was no indication it would be a lengthy delay as the above provider note stated it would be a slight delay.

Staff H, from the quality department, was interviewed on 9/13/23 beginning at 3:00 PM. When asked what the disposition of Patient #6 was from IFCH, she stated the patient was discharged home after receiving a CT. She said the discharge diagnosis was febrile illness.

Patient #6's discharge record was requested from IFCH. It showed that a CT abdomen and pelvis was ordered at 5:45 AM on 3/2/23. The discharge instructions showed Patient #6 was discharged with a diagnosis of "febrile illness" at 7:24 AM.

Patient #6 was not provided stabilizing treatment for presenting symptoms prior to transfer to a different hospital. Additionally, it was unclear how an ED to ED transfer for a CT and or surgical admission, when CT and surgical admission was available at MVH, was a transfer to a "higher level of care."

There was no documentation Patient #6 was provided an MSE, including diagnostic testing, within the capability of the hospital to determine if an EMC existed.

c. Patient #8 was a 17 year old female with Medicaid insurance. She presented to the ED on 5/6/23 at 9:26 AM with a chief complaint of left lower quadrant abdominal pain.

Patient #8's medical record included "Emergency Documentation" which was completed by Patient #8's nurse throughout her stay in the ED. Patient #8 was given pain medication and anti-emetic medications.

Patient #8's medical record included an "ED Note Physician" completed by Staff M, a PA. The note included a narrative by the PA. It stated, "On exam she is pleasant and awake. Vital signs are stable. She does have some left LLQ and CVA tenderness. She was given IV fluids, Toradol, antiemetics, and Rocephin. Her white blood cell count is 1800 with a left shift and urinalysis does show some signs of infection. With her symptoms we discussed need for transport to higher level of care as she may have pyelonephritis, an infected renal stone versus tubo-ovarian abscess versus pelvic inflammatory disease versus ovarian torsion or ovarian hemorrhagic cyst requiring specialty consultation. Less likely would be acute appendicitis as she does not have mcburneys point tenderness. [IFCH MD] excepts[sic] transfer to Idaho Falls Community Hospital."

Patient #8's medical record included a transfer form that included "Patients diagnosis and/or reason for transfer: Left flank pain, needs higher level of care."

Staff I, an RN, was interviewed on 9/13/23 beginning at 10:00 AM. She confirmed no diagnostic radiology was performed for Patient #8.

On 9/13/23 at 10:45, surveyor requested to speak with Patient #8's ED provide, Staff M. The ED provider was not available for an interview

Staff J, the Quality Director, was interviewed on 9/13/23, beginning at 3:00 PM. He stated it was within the Provider medical decision making to determine if CT would be ordered and performed. He confirmed CT was available at the hospital.

There was no documentation Patient #8 was provided an MSE, including diagnostic testing, within the capability of the hospital to determine if an EMC existed.

3. Refer to A1111 as it relates to the hospital's failure to ensure emergency services of the hospital was supervised by a member of the medical staff who was onsite and immediately available.

4. Refer to A1112 as it relates to the hospitals failure to ensure staffing was adequate to provide care for patients presenting to the hospital seeking care for EMCs.

The cumulative effects of these negative systemic practices seriously impeded the ability of the hospital to meet the needs of emergency patients.



42316

Based on staffing schedule review and staff interview, it was determined the facility failed to ensure immediate supervision of Emergency Services by a qualified member of the medical staff. This caused overlap in coverage between the MVH ED and IFCH's ED, another separate hospital which shared the same building as MVH. This put patients presenting to the ED at risk of delay in treatment due to ED providers working in a different hospital at the same time as providing coverage to MVH. Findings include:

Appendix A of the hospital Conditions of Participation 482.55(b)(1) elaborates of the meaning of supervision as: "In this context, "supervision" implies a more immediate form of oversight by a qualified member of the medical staff during all times the hospital makes emergency services available. A supervisor may be briefly absent from the emergency department, but is expected to be in the hospital and immediately available to provide direction and/or direct care during the operating hours of the emergency department."

Staffing schedules for ED providers were requested from June 2023 to current. The schedules included time frames and names of providers and was titled, "Multiple Group Schedule." For each day there were 7 time slots. Of the 7 time slots, 1 time slot was labeled as "MV on call 2a." Three of the time slots were for IFCH providers, and 3 of the time slots were for Hospital A providers.

The Quality Director for MVH, Staff J, and Staff L were interviewed 9/13/23 beginning at 3:10 PM and the schedules were reviewed in their presence. When asked how provider coverage for the MVH ED is scheduled, he stated the provider covers both MVH and IFCH. He stated IFCH has multiple providers on per day and one is assigned for MVH response. When asked if the MVH provider is in the MVH ED at all times he stated "no." He stated they would respond from IFCH if a patient comes into the MVH ED. Staff L stated the "MV on call 2a" section was an on call provider from 2am to 6am that was in the sleep room at IFCH and would respond to the MVH ED as needed. He stated the IFCH providers covered the MVH ED the rest of the time and would go to the MVH ED when there was a patient.

Staff K, and ED provider who worked in both IFCH and MV ED was interviewed on 9/13/23 beginning at 2:50 PM. When asked if he covers MVH he stated yes. He stated he covers both MVH and IFCH at the same time. He stated he works at IFCH and if a patient comes into MVH, he carries a phone and will get a call and text. He stated if he is in a patient room at IFCH he will ask one of the other IFCH providers to take over and he will walk down to MVH and the provider will let MVH staff know he may be delayed.

It was unclear how the ED was supervised by a qualified member of the medical staff, during all hours when the hospital provided emergency services, when there was not an ED provider in the hospital emergency department at all times.



42316

The hospital failed to ensure their L&D unit was staffed with appropriate numbers of professional staff to meet the needs anticipated by the facility

SOM appendix V defines an ED as:

(3) The hospital department during the preceding calendar year, (i.e., the year immediately preceding the calendar year in which a determination under this section is being made), based on a representative sample of patient visits that occurred during the calendar year, provided at least one-third of all of its visits for the treatment of EMCs on an urgent basis without requiring a previously scheduled appointment. This includes individuals who may present as unscheduled ambulatory patients to units (such as labor and delivery or psychiatric intake or assessment units of hospitals) where patients are routinely evaluated and treated for emergency medical conditions.

The number of patient encounters for the hospitals L&D unit was requested and provided. It showed since May of 2023, the L&D unit had been seeing approximately two times as many walk ins as scheduled patients. The numbers were as follows:

May - Walk-ins 120 patients. Scheduled patients 61
June - Walk-ins 133 patients. Scheduled patients 77
July - Walk-ins 131 Patients. Scheduled Patients 73
August - Walk-ins 104 patients. Scheduled Patients 82
September - Walk-ins 51 Patients. Scheduled Patients 30

The Hospitals L&D unit was not appropriately staffed to handle walk in emergencies and deliveries. An example includes:

The hospital's risk management department self-reported a potential EMTALA violation to the SA on 8/31/23 and provided information about Patient #12. Patient #12's medical record was requested from the hospital during the survey. Patient #12 did not have a medical record. Patient #12 was a patient who presented to the hospital L&D unit and was not provided an MSE to determine if she was in active labor.

The RCA related to Patient #12's course of treatment was requested. It was dated 8/31/23. It stated, "Patient presented to L&D with contractions. CNA roomed patient and had her change into a gown since the charge nurse was busy with other tasks. RN then presented to patient room and informed her that we were on "divert" and that she could not deliver at MVH and would need to go to [Hospital A, another local hospital]. Staff told patient that if they checked her cervix and she was dilated to >6 [centimeters], she would have to go by EMS. Patient signed refusal and drove by private vehicle to [Hospital A] L&D." The RCA also stated, "Spoke with all staff involved with event. Thursday to Friday morning was very busy. Staff went onto 'divert' at L&D manager's direction ... The charge RN did not see this patient present to L&D because she was busy with other tasks. CNA roomed patient so she was not waiting at the nurses' station and instructed pt [patient] to change into a gown. There was an open bed but there was not sufficient staffing to care for a walk-in. This was discussed with the patient by the RN and the patient signed a refusal and willingly left to [Hospital A.]"

Staff D, an RN, was interviewed on 9/12/23 at 4:36 PM. When asked about Patient #12 signing the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer," she stated, "this has been happening for years." She stated if they were declared on divert due to staffing or "drowning" then they were trained to send L&D patients elsewhere and have them sign the refusal form. She stated, "we tell them they can go across the street and get better care at [Hospital A] and no ambulance." She also stated, "they can refuse to sign the form - in that case we can see them." When asked if she agreed that Patient #12 did not actually refuse services and instead was turned away due to inadequate staffing she stated, "yes."

Staff B was interviewed on 9/13/23 beginning at 12:54. When asked about Patient #12, she stated she did not feel the L&D unit was staffed appropriately that night, and that night shift is short staffed in general. She stated it is difficult to call in staff in the middle of the night. She stated that 2 of the nurses were above the max acuity and at a level of "12," that night and management did not reach out. She stated she has had to reach out for extra staffing on occasion and staffing issues have been brought to the attention of management on night shifts. She stated staff were frequently told by management that they are adequately staffed. She stated staff have brought up the use of traveler nurses to management to supplement the staffing and have been told an adamant "no." She stated she had several examples of problems due to short staffing, missing 15 min vital signs, missing fundal checks.

Staff A, from risk management, was interviewed on 9/12/23 beginning at 9:40 AM. When asked about the above incident, she stated staffing and overtime have been an ongoing issue with L&D. She provided the as worked overtime hours for the L&D unit. The data she provided included:

- For 2019 there were 768 hours of overtime.
- For 2021 there were 794 hours of overtime.
- For 2023 from January to the end of August 2023 there had already been 1321 hour of clocked over time. Almost twice as much as 2019 and 2021.

She confirmed the L&D unit was seeing more patients and her recommendation was more staffing to help with the education of new nurses. Additionally, she stated there was a change to start accepting babies at an earlier gestational age of 20 weeks. She stated additional staff was brought on since the change.

Staffing schedules for the L&D unit and the staffing acuity matrix was reviewed. The staffing acuity matrix included:
- An acuity of 12 means a mother that is critically ill/ hemodynamically unstable. An acuity of 12 for an infant would mean the infant is unstable. This would require 1 nurse for the mother and 1 nurse for the infant.
- An acuity of 6 could include a woman in active labor, or a triage patient until deemed stable. All infants for the first 2 hours of life would be categorized as 6 acuity.

The L&D manager, Staff C, was interviewed on 9/13/23 beginning at 2:35 PM. When asked about staffing she stated ideally the staffing acuity should be a 6-9 acuity per nurse based on their staffing acuity matrix.

Staffing matrixes for acuity levels were reviewed. The schedule included acuity checks every 2 hours, with each time slot listing each nurses' acuity assignment. However, it was unclear how it would be handled if a walk in patient, or a deteriorating patient put the unit nurses over their allotted acuity levels.

The L&D manager was interviewed a second time on 9/14/23 at 9:20 AM. When asked if the L&D unit had staff onsite for walk in emergency's and delivery's she stated "yes." She stated the charge nurse and triage nurse would take any walk ins because they started their shifts with no patients but could take patients. When asked when staff are at maximum acuity (9), including the triage and charge nurse, if a nurse would be called in prior to a patient presenting to handle any potential emergencies and walk in deliveries is she stated "yes and no." She stated "you have to staff for what is here and not what is going to come in."

One example includes: On the night of 8/24/23 the charge nurse was assigned an acuity of 12 at 8:00PM. The charge nurse and a second nurse were then assigned an acuity of 12 again at midnight. The charge nurse maintained her acuity of 12 until 6:00 AM. The census of the unit that was documented at midnight on 8/24/23 indicated that there were 6 mothers and 1 baby on the unit. There were 5 nurses present at midnight with 2 of those nurses with an acuity of 12, above the maximum ideal staffing acuity. From Midnight on 8/24/23 until the end of the schedule at 6:00 AM every nurse had an acuity of 6 or greater. If a triage patient walked in, she would be classified as an acuity of 6, the nurses would not be able to maintain their desired acuity level of 6-9. If an unstable critically ill patient walked in staff would not be able to maintain an appropriate acuity level. There was no indication or documentation staff members were called in after midnight, or that the hospital supervisor was aware of the short staffing.

The short staffing of the L&D unit resulted in Patient #12 seeking emergency care to be turned away from the unit.

The L&D unit were not staffed adequately to handle walk in emergencies and mothers in active labor.



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