HospitalInspections.org

Based on staff interview, EMTALA log review, medical record review, and review of policy and procedure, it was determined the facility failed to ensure 1.) all obstetric [OB] patients presenting to the hospital with an emergency medical condition are included on their central log; 2.) a discharge disposition is included for all patients on the Emergency Department [ED] and OB EMTALA logs.

Findings include:

1.) Facility policy "EMTALA," (reviewed 4/17/23) states, "...13. Log a. Maintenance of a Log for ED patients An electronic log is maintained for each individual arriving in the ED for medical assistance. The log contains the following information: ...vi. Disposition (AMA, transfer, admitted, left without treatment or left before being seen, discharged). ..."

On 10/10/23 at 12:00 PM, during a tour of the Labor and Delivery (L&D) Unit, Staff (S)30 (Nurse Clinical Leader of Maternity) stated that patients may arrive directly to labor and delivery through the front of the hospital (main lobby entrance), or they may arrive through the ED. S30 stated that the unit maintains an electronic log book of patient arrivals.

At 2:10 PM, during a review of the OB EMTALA log, S30 stated the log includes all patients registered as triage patients, but that if a patient arrives and is admitted right away, the patient may not be included on the log.

On 10/11/23, a review of Patient (P)1's medical record revealed that on 8/12/23 at 3:20 AM, on the way to the main lobby entrance, P1 had given birth in a taxi. The patient was brought inside and treated by labor and delivery staff, with the baby brought to the NICU (neonatal intensive care unit) for assessment and monitoring. Review of the OB EMTALA log for the dates of 8/6/23 - 8/12/23 revealed that P1 was not included on the log. This finding was confirmed with S30.

On 10/11/23 at approximately 10:30 AM, S30 provided a copy of the "Maternity Activity Log" which he/she stated includes all patients who arrive at the L&D unit. Review of the Maternity Activity Report revealed the following:
On 6/1/23 at 19:55 [7:55 PM], P17 arrived at the L&D unit with a "Reason for Visit/Diagnosis" of "Preterm premature rupture of membranes Pregnant..."
On 7/6/23 at 13:48 [1:48 PM]. P18 arrived at the L&D unit with a "Reason for Visit/Diagnosis" of "Delivery Pregnant..."
Upon review, P17 and P18 were not documented on the OB EMTALA Log or the ED EMTALA Log.

2.) On 10/10/23 at 2:10 PM, a review of the OB EMTALA log revealed that the disposition of the patients arriving with an emergency medical condition to the labor and delivery unit was not included on the log. S5 (Director of Corporate Compliance) confirmed this finding.

A review of the ED EMTALA log for July revealed that the Discharge Disposition was not completed for the following patients who arrived to the ED: P21 - arrived on 7/1/23; P22 - arrived on 7/1/23; P23 - arrived on 7/2/23; P24 - arrived on 7/7/23; P25 - arrived on 7/9/23; P26 - arrived on 7/10/23; P27 - arrived on 7/16/23; P28 - arrived on 7/18/23; P29 - arrived on 7/20/23; P30 - arrived on 7/30/23; P31 - arrived on 7/31/23. These findings were discussed at exit the conference on 10/12/23 at 3:30 PM.

Based on review of the medical record for patient #1 (P1), staff interviews, review of facility surveillance video and review of facility documents, it was determined the facility failed to ensure that patients presenting to the Emergency Department (ED) receive an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition (EMC) exists.

Findings include:

Reference: Facility policy titled, "EMTALA " (last reviewed 3/20/23) states, " ... POLICY: ...PROCESS1. Medical Screening Exam (MSE). The hospital must provide a MSE within the capability of its ED[Emergency Department], including ancillary services routinely available at the hospital, to determine whether an EMC exists, to all of the following persons: ...b) Each individual who presents on Hospital property (as defined above) other than a dedicated emergency department, including the parking lot, sidewalk and driveway, and requests, or a request is made on such person's behalf, for examination or treatment for what may be and EMC, or if a prudent layperson observer, based on the individual's appearance or behavior, would believe that the individual needs emergency examination or treatment. ... ."

On 10/11/23 a review of Patient (P)1's medical record was conducted. The History and Physical from 8/12/23 at 3:59 AM stated, " ... CC [Chief Complaint]: s/p [status post] delivery of fetus, placenta in situ (placenta retained in the uterus) HPI [History of Present Illness]: We were called from hospital lobby that patient presented s/p delivery of fetus in taxi in transport to hospital. ..."

On 10/11/23 at 12:06 PM an interview was conducted with S7 (Director of ED). S7 explained that he/she was aware of the patient arriving to the facilities ED and being re-directed to the main entrance. S7 indicated that the video surveillance of the incident was reviewed, and the staff involved were interviewed. S7 explained that the video showed the taxi pulling up to the ED entrance and the taxi driver exiting the taxi and walking into the ED. In the ED the taxi driver walks up to the registrar and motions "a pregnant stomach" and "wheelchair", before walking over to a security guard who points the taxi driver in a direction after which the taxi driver exits the ED, returns to the taxi and drives off.

Review of the surveillance video from the ED entrance revealed that on 8/12/23 at 3:20 AM the following occurred:

In the ED lobby S39 (Security Guard) is standing, S41 (Patient Access Representative/Registrar) is sitting at the front desk and S42 (Pivot Nurse) is sitting at a computer around the corner at the nursing station.

3:20:24 Taxi pulls up to ED entrance and Taxi Driver (TD) gets out and walks around car and opens door. At the same time inside the ED S39 is observed sitting down in a chair at his/her station and pulling out his/her cell phone and looking at the cell phone.

3:21:25 TD walked into ED entrance and past the security officer (the first point of contact into the ED), who was on his/her phone and did not look up, greet, or interact with TD. TD walks up to the registration desk, interacts with S41 and gestures "pregnant belly" and "wheelchair".

3:21:57 TD walks over to S39, who is still on his/her cell phone. TD is seen talking to security guard and security guard points in a direction. TD exits the ED, gets into taxi and drives away.

On 10/12/23 at 10:23 AM a telephone interview was conducted with S39. S39 explained that he/she saw the man (taxi driver) come in and speak to the registrar, but he/she was unaware of what was said. S39 explained that the man then came to him/her and asked where the main lobby was located, to which S39 gave directions and the man left. When asked if he/she "qualified" (ask who the person is, why they are in the ED) the man or asked any additional questions, S39 explained that he did not. S39 also explained that he/she was not aware that the main lobby was closed when he/she sent the man to the main lobby.

At 11:12 AM a telephone interview was conducted with S41 (Patient Access Representative/Registrar). S41 explained that the taxi driver came into the ED and stated, "I have a labor and delivery". S41 explained that he/she did not see a woman with the man when he came in and when asked if he/she inquired as to where the patient was, S41 indicated that he/she did not.

The facility failed to ensure that a MSE was complete on a patient presenting with an emergency medical condition.