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Based on interview and record review, the facility failed to ensure that emergency medical services were provided in accordance with 42 CFR §489.24, the regulations for the Emergency Medical Treatment and Active Labor Act (EMTALA), when a medical screening exam was not provided for one of 21 sample patients (Patient 1). (Refer to C 2406)

Based on interview and record review, the facility failed to provide a medical screening exam (MSE) for one of 21 sampled patients (Patient 1). Patient 1, who was 34 weeks pregnant with twins, came to the hospital seeking care after her water broke (spontaneous rupture of membranes with release of amniotic fluid) and was told by nursing staff to go to another facility. This failure had the potential to place Patient 1 and her twin babies at risk for life-threatening medical complications.

Findings:

A facility policy, titled, "Refusal of Service or Leaving Against Medical Advice (Emergency Medical Treatment and Active Labor Act - EMTALA)," approved 7/1/23, was reviewed. The policy indicated its purpose was to provide appropriate medical screening to all patients presenting for emergency services. Under EMTALA, Medicare-participating hospitals must provide an appropriate medical screening examination to each patient presented for emergency services and any necessary stabilizing treatment.

A facility policy, titled, "Labor Admission Evaluation," approved 8/1/24, was reviewed. The policy described the process of assessing a pregnant patient to determine if she was in active labor and needed to be admitted. A list of tasks to be completed by the nursing staff included having the patient change into a gown, applying an external fetal monitor (a device placed on the mother's abdomen to record the baby's heartbeat), obtaining the patient's vital signs (temperature, pulse, respiration rate and blood pressure measurements), and assessing contraction frequency (how often), duration (length), and palpated (felt by the hands) strength. If the patient suspected spontaneous rupture of membranes, nursing was to have performed an Amnisure test (a swab to check for the presence of amniotic fluid).

Review of Patient 1's clinical record indicated they were admitted to the facility (Facility A) on 8/8/24 with diagnoses that included dichorionic diamniotic twin pregnancy (each twin had its own placenta and amniotic sac), preterm (before 37 weeks of pregnancy) premature rupture of membranes, and anemia (low red blood cells). Patient 1 had had five children prior to this pregnancy, making these her sixth and seventh children. Patient 1 was transferred to a higher level of care via ambulance on 8/8/24 at approximately 7 am.

During a telephone interview on 8/22/24, at 9:18 am, Patient 1 described events that occurred on the morning of 8/8/24. Patient 1 stated that her water broke at approximately 3 am and she called Facility A to find out if she should come in or wait at home since she was six weeks early. Two female nurses met her at the main entrance and asked if she was sure her water broke. She recognized one nurse as Registered Nurse (RN) 6, an obstetrics (OB) nurse whom she knew from prior visits to the hospital. Patient 1 stated that she went to the hospital knowing that she would be admitted into Labor & Delivery. She felt that her water broke and she was having contractions, so she knew she was in labor. Patient 1 stated that the nurses told her she would be better off driving up to another facility (Facility B) in Medford, Oregon in her own vehicle to be seen there. (Facility B was a one-hour drive from Facility A). It would be faster. While on the freeway, Patient 1 phoned Facility B to let them know she was on her way, and they advised her to turn around and go back to Facility A, which was closest. They told her things could progress quickly and they didn't want her to deliver on the side of the road with just her husband.

During a concurrent observation and interview, on 8/23/24, at 8:20 am, the Security Manager (SM) accessed surveillance video from the morning of 8/8/24. In the video, Patient 1 and her husband entered Facility A's parking lot in a private vehicle at 3:57 am. At 3:58 am they were met at the main entrance glass doors by RN 3 and RN 6. They stood and talked, and Patient 1 didn't step into the lobby. At 4:02 am, they walked to their car and left the parking lot at 4:11 am. At 4:23 am Patient 1 and her husband return to Facility A and walked to the OB department at 4:25 am.

During a telephone interview on 8/22/24, at 3:52 pm, Medical Doctor (MD) 1 described the care of Patient 1 on 8/8/24. MD 1 stated that Facility A did not have a neonatal intensive care unit (NICU). MD 1 stated the OB nurses phoned her at 3:40 am to tell her about Patient 1, and she asked them to call Patient 1 back and direct her to drive directly to Facility B in Medford, Oregon that did have a NICU. MD 1 thought Patient 1 was still at home. MD 1 stated Patient 1 had asked the nurses, "Should I wait until I'm contracting?" so she felt like Patient 1 was not currently laboring. MD 1 stated she rode with Patient 1 in the ambulance up to Facility B later that morning.

During a telephone interview on 8/23/24, at 12:41 pm, RN 6 described her interaction with Patient 1 on 8/8/24. RN 6 stated that she talked with Patient 1 when she came to the lobby door. Patient 1 stated she was not hurting, not having contractions and her back didn't hurt. RN 6 stated she told Patient 1 that MD 1 felt it would be in her best interest to go directly to Facility B so she wouldn't be separated from her babies.

During a telephone interview on 8/23/24, at 3:57 pm, RN 3 described her interactions with Patient 1 on 8/8/24. RN 3 stated that she was the House Supervisor and the nurses in OB told her they had received a call from a patient who had premature rupture of her membranes, was 34 weeks pregnant with twins, which were babies six and seven. The OB nurses notified MD 1 about Patient 1 and that Facility A was not equipped to deliver babies less than 36 weeks old, especially twins. RN 3 stated since she knew Patient 1 would be having premature twins her first instinct was to send the Patient 1 to where she could get help for her babies.

A facility document, titled, "Obstetrical Unit - RN Orientation Checklist," undated, was reviewed. Among the items on the checklist was a section on Nursing Accountability. Nurses were expected to have an awareness of the, "COBRA (Consolidated Omnibus Budget Reconciliation Act) regulations/EMTALA."

During an interview on 8/22/24, at 4:20 pm, RN 2 stated that Emergency Department staff received annual training that included EMTALA. RN 2 stated that if a patient was on hospital grounds, they would be seen and evaluated by Emergency staff.

During an interview on 8/22/24, at 10:47 am, the Patient Safety/Risk Management RN (RM) stated that they discovered the incident with Patient 1 and reported it to the California Department of Public Health. RM stated she and the Assistant Administrator of Patient Care Services were working on the investigation and putting together more material on EMTALA issues to further educate the staff.