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Based on interview and record review, Facility A failed to implement and maintain its Emergency Medical Treatment and Active Labor Act (EMTALA), policy and procedures (P&Ps), for six of 31 sampled patients (Patient 4,6,10,11,13, and Patient 15) when:

1. One of 31 sampled patients (Patient 6) presented to Facility A seeking emergency medical care after water breakage/ruptured membrane (a process which happens before labor/childbirth) and was not logged. (Refer to Tag A- 2405).

2. The L&D EMTALA log was incomplete and did not include the reason for visit for four of 31 sampled patients (Patient 10,11,13,15). (Refer to Tag A-2405).

3. One of 31 sampled patients (Patient 6) was not triaged (the process of sorting patient into groups based on their need for care) by nursing or medical screening exam (MSE- an examination performed by a qualified medical provider to determine if a patient has and emergency condition) received. (Refer to Tag A-2406).

4. One of 31 sampled patients (Patient 4) was not triaged or assigned a Maternal Fetal Triage Index (MFTI - the process of sorting pregnant patients into groups based on their need for care) level of urgency was not done. (Refer to Tag A-2406).

The cumulative effects of these failures resulted in six of 31 sampled patients who came to L&D unit for emergency medical care was not triaged or received MSE, which could delay treatment for critical medical conditions and potentially cause harm to the patient and fetus.

Based on interview and record review, Facility A failed to maintain a centralized log for the Labor and Delivery (L&D) unit per it's Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedure (P&P) for five of 31 sampled patients (Patient 6,10, 11, 13, and 15) when:

1. Patient 6, who was 36 weeks pregnant, presented to Facility A seeking emergency medical care after water breakage/ruptured membrane (a process which happens before labor/childbirth) and was not logged.

This failure resulted in emotional distress due to Patient 6's uncertainty about the priority of care for her and her baby, and which could jeopardize the health and safety of the patient and her unborn baby.

2. The L&D EMTALA log was not completed and did not include the reason for visit for four of 31 sampled patients (Patient 10,11,13,15).

This failure resulted in an inappropriate evaluation of the patients who presented to L&D unit which will delay the care and cause high risk for the patients and their unborn babies.

Findings:

1.An unannounced visit was conducted on April 1, 2025, through April 3, 2025, to investigate a possible EMTALA violation. There was no documented evidence to indicate Patient 6 was registered on Facility A's Emergency Department (ED) or obstetric (OB- specialty for pregnancy and childbirth) logs, nor was there documentation indicating Patient 6 received a medical screening examination (MSE- an examination performed by a qualified medical provider to determine if a patient has and emergency condition), to rule out if an emergency medical condition existed or that the patient was medically stabilized.

During a review of Patient 6's documents from Facility B, "face sheet" (demographic data), indicated Patient 6 was a 40-year female presented to Facility B with the diagnosis of pregnancy of 36 weeks and 5 days.

During a review of Patient 6's documents from Facility B "Progress Note", dated March 15, 2025, at 12:42 PM, by Physician 1 (P1), the "Progress Note" indicated, Patient 6 had grossly ruptured membrane since 6:00 AM on March 15, 2025.

During a telephone interview with Patient 6, on April 1, 2025, at 8:50 AM, Patient 6 stated she was presented to Facility A, on March 15, 2025, after her water was broken at 6:00 AM. Patient 6 stated, she was checked in at Facility A's ED with the front desk and they redirected her to the L&D unit. Patient 6 stated a nurse came out and provided with a form to fill out and told her that the facility was in full capacity and had to wait for a long time. Patient 6 further stated she was wearing a black shirt, peach sweater and pants.

During a concurrent interview and record review on April 1,2025, at 3:00 PM, with Labor and delivery Manager (L&DM), Facility A's document "Labor and delivery Emergency department Log (L&D ED Log)", for March 2025, was reviewed. The "L&D ED Log" indicated, Patient 6 was not logged and only 2 patients were logged on March 15,2025. The L&DM verified and confirmed Patient 6 was neither logged nor MSE done. L&DM further stated it was expected that patients who comes to L&D unit should be logged and MSE completed to ensure they are evaluated, treated and stabilized the patient prior to be transferred to another facility.

During an interview on April 2, 2025, at 2:15 PM, with Registered Nurse 1 (RN 1), RN 1 stated, she recalls Patient 6, and she gave the form to Patient 6 to fill the demographic information. RN 1 further stated that she was unable to recall any other conversation with Patient 6.

During a concurrent interview and record review on April 3,2025, at 8:35 AM, with RN 2, "video recording" on March 15, 2025, at 7:47 AM was reviewed. RN 2 stated, she recalls Patient 6 as a patient with 36 weeks gestation and having labor symptoms but not remembering what the exact problem was. RN 2 further stated, she called the L&D unit and gave a brief report about Patient 6 that was send to L&D ED unit with EDT.

During a concurrent interview and review of Facility A's recorded video surveillance (video recording) on April 3,2025, at 8:58 AM, with Emergency Department Technician (EDT), video recording dated March 15, 2025, 7:47 AM to 8:00 AM was reviewed. The video recording indicated, the following:

AT 7:47 AM, Patient 6 came by herself to the ED front desk and was talking to the person at the front desk.
At 7:48 AM, Emergency department Technician (EDT) offered a wheelchair to Patient 6 to go to L&D unit and Patient 6 refused and was walking with EDT to L&D unit.
At 7:51 AM, Patient 6 came to L&D unit waiting area with the EDT.
AT 8:00 AM, Patient 6 left the L&D unit.

The EDT stated, she recalls Patient 6 and she was walking with Patient 6 to L&D unit with the red bag( a bag used for L&D patients if they have an emergency delivery through the route to L&D unit, which also called as Baby on arrival bag).EDT further stated, she remembers that she gave a brief report about Patient 6 to RN 1.

During a concurrent interview and review of Facility A's recorded video surveillance on April 3, 2025, at 9:22 AM, with the Labor and Delivery Manger (L&DM), video recording, dated March 15, 2025, from 7:47 AM to 8 :00 AM was reviewed and indicated, the following:

AT 7:47 AM, Patient 6 came by herself to the Emergency Department front desk and was talking to the person at the front desk.
At 7:48 AM, Emergency department Technician (EDT) offered a wheelchair to Patient 6 to go to L&D unit and Patient 6 refused and was walking with EDT to L&D unit.
At 7:51 AM, Patient 6 came to L&D unit waiting area with the EDT.
AT 8:00 AM, Patient 6 left the L&D unit.
The L&D M verified and confirmed Patient 6 was presented to the L&D unit waiting area on March 15,2025 and she left the unit.

During a concurrent interview and record review on April 3,2025, at 9:50 AM, with L&DM, the facility's P&P titled, "Screening, stabilization and transfer of individuals with emergency medical condition", dated June 2023, and "OB Emergency department Scope of Service", dated May 2023, were reviewed. The P&P for "Screening, stabilization and transfer of individuals with emergency medical condition" indicated, " ...Central Log-refers to the log maintained by hospital that documents each patient that comes to ED seeking assistance and documents such patient's disposition ...I. Central log data will be entered by department designee on each patient presenting for emergency for emergency treatment. The central log must indicate whether the individual refused treatment or transfer, was refused treatment, or was transferred prior to stabilization, admitted and treated, stabilized and transferred, or discharged..." The P&P for "OB Emergency department Scope of Service" indicated, " ...B. The OB ED delivers care to pregnant patients of all ages, 20 weeks gestation or greater, who are expecting uncomplicated emergency and/or remedial problems associated with pregnancy .... D.1.Assessment, evaluation, management and treatment, that is appropriate and timely, to patients with obstetric conditions without delay to inquire about payment status ..." The L&D M stated these policies were not followed as the Patient 6 was not logged or received MSE.

During an interview on April 3, 2025, at 1:17 PM, with Physician (Phys 2), Phys 2 stated, pre-rupture of membrane (PROM- a condition in which the membrane is ruptured before the delivery of the baby) is a condition which needs to be evaluated.

During an interview on April 3, 2025, at 1:50 PM, with the Director of Quality Management (DQM), the DQM stated, Patient 6 should have been logged and received MSE.



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2a. During a review of the facility's document titled "OB Events Log" dated November 2024, the "OB Events Log" indicated, Patient 10 arrived to the labor and delivery department (L&D) on November 2, 2024, at 2:17 PM and her disposition was entered as AMA [left Against Medical Advice of the medical provider: doctor and was educated on risks]/Eloped [left the department]. The "OB Events Log" did not include reason for Patient 10's visit or the time Patient 10 left AMA.

During a concurrent interview and record review on April 2, 2025, at 2:55 PM, with the L&D Nursing Supervisor (NS), Patient 10's "Physician [doctor] OB Triage Notes Addendum [a change or clarification made to an existing document]" dated November 2, 2024, was reviewed. The "Physician OB Triage Notes Addendum" indicated, Patient 11 arrived with complaints of bilateral lower extremity edema (swelling to both legs) for one week and elevated blood pressure and after consulting the doctor decided to leave AMA. The NS stated, either nursing or registration staff will register a patient to the department and this information flows to the log. The registration should include the reason the patient has presented to L&D.

2b. During a review of facility's document titled "OB Events Log" dated October 2024, the "OB Events Log" indicated, Patient 11 arrived to the labor and delivery department (L&D) on October 15, 024 at 7:42 PM, and her disposition was entered as LBWS (left without being seen by a medical provider, such as a doctor or nurse midwife). The "OB Events Log" did not include reason for Patient 10's visit or the time Patient 11, LWBS.

During a concurrent interview and record review on April 2, 2025, at 2:40 PM, with the L&D Nursing Supervisor (NS), Patient 11's visit from October 15, 2024, was reviewed. The visit indicated, Patient 11 arrived to the unit at 7:42 PM and LWBS at 8:25 PM, there was no documented reason for visit or notes regarding Patient 11's this visit. The NS stated, there should be a chief complaint listed when a patient is registered to the department and more notes as to calling for patient in the waiting room.

2c. During a review of the facility's document titled "OB Events Log" dated November 2024, the "OB Events Log" indicated, Patient 13 arrived at L&D on November 24, 2024, at 8:28 PM and her disposition was entered as LWBS. The "OB Events Log" did not include reason for Patient 13's visit or the time Patient 13 LWBS.

During a concurrent interview and record review on April 2, 2025, at 3:25 PM, with the NS, Patient 13's "Visit" from, November 24, 2024, was reviewed. The "Visit" indicated, Patient 13 arrived to the unit at 8:28 PM and LWBS at 8:35 PM, there was no documented reason for visit or notes regarding patient during this visit. The NS stated, there should be a chief complaint listed when a patient is registered to the department and a reason as to why the patient LWBS.

2d. During a review of the facility document titled "OB Events Log" dated February 2025, the "OB Events Log" indicated, Patient 15 arrived at L&D on February 15, 2025, at 1:01 PM and her disposition was entered as LWBS. The "OB Events Log" did not include reason for Patient 15's visit.

During a concurrent interview and record review on April 2, 2025, at 3:40 PM, with the NS, Patient 15's "Visit" from February 15, 2025, was reviewed. The "Visit" indicated, Patient 13 arrived to the unit at 1:01 PM and LWBS at 1:30 PM, there was no documented reason for visit or notes regarding patient during this visit. The NS stated, there should be a chief complaint listed when a patient is registered to the department and a reason as to why the patient LWBS. Additionally, Patient 15's, "Triage Consent/ED Sign in Sheet" dated February 15, 2025, was reviewed. The "Triage Consent/ED Sign In Sheet" indicated, Patient 15's reason for visit was feeling lightheaded and fainted. The NS stated, the reason for visit should have been added when patient registered to the unit as Patient 15 filled out the triage form.

During a concurrent interview and record review on April 3, 2025, at 11:45 AM, with the Labor and Delivery Manager (L&DM), the facility's "OB Events Log" for the past six months, October 2024 through March 2025, was reviewed. The "OB Events Log" was missing multiple entries for reason for visit and disposition times. The L&DM stated, the data that has been input into the log was inconsistent and incomplete. The L&DM further stated the reason for visit and disposition time should be entered for each encounter for trending and reference purposes and the log should be consistent with that information. The LD&M stated, the log data entry is the responsibility of either the registration clerk or the nurses on the L&D unit and agreed there is a trend of incomplete data entry on patients with dispositions of LWBS and AMA.

During a review of the facility's policy and procedure (P&P) titled, "Screening, Stabilization and Transfer of Individuals with Emergency Medical Condition", dated June 2023, the P&P indicated, " ...Central Log-refers to the log maintained by hospital that documents each patient that comes to ED seeking assistance and documents such patient's disposition ...I. Central log data will be entered by department designee on each patient presenting for emergency for emergency treatment. The central log must indicate whether the individual refused treatment or transfer, was refused treatment, or was transferred prior to stabilization, admitted and treated, stabilized and transferred, or discharged...".

Based on interview and record review, the facility failed to ensure its policy and procedures (P&P's) for an appropriate Medical Screening Examination (MSE-an examination performed by a qualified medical provider to determine if a patient has and emergency condition), within the capability of Facility A's Emergency Department (ED) and Labor &Delivery (L&D) unit was conducted to determine if an emergency medical condition (EMC) existed and were implemented for two of 31 sampled patients (Patient 6 and Patient 4) when :

1. Patient 6, who was 36 weeks pregnant presented to Facility A's labor and delivery (L&D) unit and was not triaged (the process of sorting patient into groups based on their need for care) by nursing or a qualified MSE was received.

This failure resulted in Patient 6 not being appropriately triaged or received MSE to determine Patient 6 had an EMC, as a result Patient 6 sought treatment at Facility B and underwent C- section (cesarian section-a surgical procedure done for child birth) for an EMC which had the potential to severely impact the health and welfare of both patient and fetus (unborn baby) .

2. Patient 4 was not triaged or assigned a Maternal Fetal Triage Index (MFTI - the process of sorting pregnant patients into groups based on their need for care) level of urgency.

This failure had the potential to severely impact the health and welfare of the patients (Patient 4) and their fetus (unborn baby).

Findings:

1.An unannounced visit was conducted on April 1, 2025, through April 3, 2025, to investigate a possible EMTALA violation. There was no documented evidence to indicate Patient 6 was registered on Facility A's Emergency Department (ED) or obstetric (OB- specialty for pregnancy and childbirth) logs, nor was there documentation indicating Patient 6 received a medical screening examination (MSE) to rule out if an emergency medical condition existed or that the patient was medically stabilized.

During a review of Patient 6's documents obtained from Facility B "face sheet" (demographic data), indicated Patient 6 was a 40-year female presented to Facility B with the diagnosis of pregnancy of 36 weeks and 5 days.

During a review of Patient 6's document from Facility B, titled "Progress Note", dated March 15, 2025, at 12:42 PM, by Physician 1 (P1), the "Progress Note" indicated, Patient 6 had grossly ruptured membrane since 6:00 AM on March 15, 2025.

During a concurrent interview and record review on April 1,2025, at 3:00 PM, with Labor and Delivery Manager (L&DM), Facility A's document "Labor and delivery Emergency department Log (L&D ED Log)", for March 2025, was reviewed. The "L&D ED Log" indicated, Patient 6 was not logged and only 2 patients were logged on March 15,2025. The L&DM verified and confirmed Patient 6 was neither logged nor MSE done. L&DM further stated that it was expected that patients who comes to L&D unit should be logged and MSE completed to ensure they are evaluated and treated and stabilized the patient prior to be transferred to another facility.

During an interview on April 2, 2025, at 2:15 PM, with Registered Nurse 1 (RN 1), RN 1 stated, she recalls Patient 6, and gave the form to Patient 6 to fill the demographic information.RN1 further stated, Patient 6 was not registered so she has not received MSE and it is expected that all patients who come to L&D should be registered and received MSE.

During a concurrent interview and record review on April 3,2025, at 9:50 AM, with L&DM, the facility's policy and procedure (P&P) titled, "Screening, stabilization and transfer of individuals with emergency medical condition", dated June 2023, and "OB Emergency department Scope of Service", dated May 2023, were reviewed. The P&P for "Screening, stabilization and transfer of individuals with emergency medical condition" indicated, " ...Medical screening Exam (MSE): the screening process performed by a physician, or another Qualified Medical Person (QMP) required to determine with reasonable clinical confidence whether an Emergency Medical Condition (EMC) does or does not exist. The MSE should be performed to the extent necessary to determine whether an EMC exist, and it represents a spectrum. It can range from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as laboratory tests, x rays, and /or other diagnostic tests and procedures.B..1. Delay the provision of a MSE, stabilizing treatment, or appropriate transfer in order to inquire about individual's method of payment or insurance status;or ...B. 1. A MSE must be performed for: a. Every individual described above. b. An individual who present anywhere on hospital property that is not a Dedicated Emergency Department as defined above and seek treatment for a potential EMC ...2. MSE process: a. Within the capability of the DED, the MSE should be performed to the extent sufficient to determine within reasonable medical probability whether an EMC exists". The P&P for "OB Emergency department Scope of Service" indicated, " ...B. The OB ED delivers care to pregnant patients of all ages, 20 weeks gestation or greater, who are expecting uncomplicated emergency and/or remedial problems associated with pregnancy .... D.1.Assessment, evaluation, management and treatment, that is appropriate and timely, to patients with obstetric conditions without delay to inquire about payment status ...3. Provision of care that begins in the pre -hospital settings (provided by Emergency Medical Services-EMS), continues in the OB ED and concludes with the patient being admitted, transferred per EMTALA regulations or discharged ....1. Patients entering the OB ED shall be assessed by an RN." The L&D M stated these policies were not followed as the Patient 6 was not logged or received MSE.

2. During a review of Patient 4's "Admission Note" (AN), dated March 21,2025, the "AN", indicated, Patient 4 was a 31 year old female with 38 weeks of gestational age (common term used during pregnancy to describe how far along the pregnancy is).

During a concurrent interview and record review on April 2,2025, at 1:20 PM, with Labor and Delivery Manager (L&DM), Patient 4's "Flow Sheet" dated March 21,2025 was reviewed. The "Flow sheet" indicated, Patient 4's MFTI was not documented upon admission to L&D unit. The L&DM stated, it is expected to do the triaging which is necessary that the patient is evaluated and triaged right, so the physician can check the patient fast.

During a concurrent interview and record review on April 3,2025, at 9:50 AM, with L&DM, the facility's policy and procedure (P&P) titled, "OB Emergency department Scope of Service", dated May 2023, were reviewed. The P&P indicated, " ...Patient Assessment.4. Patients will be classified according to the Maternal Fetal Triage Index (MFTI)." The L&DM stated, Policy was not followed as patient records were missing MFTI.

During an interview on April 3,2025, at 1:50 PM, with the Director of Quality Management (DQM), the DQM stated, MFTI was not completed, and it is expected to be completed when the patients arrive at the ED.