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Based on document review, policy review, medical record review, video review and interview, the hospital failed to ensure all patients presenting to the hospital's Labor and Delivery [L&D]/Obstetrical [OB] Emergency Department [ED] were provided an appropriate medical screening examination (MSE) within the hospital's capabilities, in order to determine whether an emergency medical condition existed for 1 of 20 (Patient #1) sampled patients.

The findings included:

Patient #1 was a 16 year old female who presented to Hospital #1's L&D/OB ED on 11/20/2022 at 6:33 PM, after being assessed at a local community health clinic, for concerns with ectopic pregnancy. Patient #1 was registered and seated in the L&D/OB ED waiting room. Patient #1 was not triaged by the Maternal Fetal Triage Index nurse. On 11/20/2022 at 6:59 PM Physician #1 approached Patient #1 in the L&D/OB ED waiting room and discussed with her the plan of care from the community medical clinic to seek care at Hospital #2's ED. Patient #1 left Hospital #1's L&D/OB ED at 7:05 PM. Patient #1 was not offered a medical screening exam by Physician #1. Patient #1 received no care for her ectopic pregnancy and vaginal bleeding at Hospital #1. Patient #1 arrived at Hospital #2's ED on 11/20/2022 at 8:10 PM seeking care for her ectopic pregnancy when a medical screening exam was performed and treatment and counseling was provided.

Refer to 2406

Based on document review, policy review, medical record review, video review, emergency department log, and interview, the hospital failed to ensure all patients presenting to the hospital's Labor and Delivery [L&D]/Obstetrical [OB] Emergency Department [ED] seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening exam (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's Medical staff Rules and Regulations approved 1/26/2021 revealed, "...2.12 On Call Coverage...Definitions...Emergency Condition-An emergency condition is a medical condition manifesting acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in impairment of bodily functions...Medical Screening Examination- When an individual presents to the emergency department requesting examination or treatment of a medical condition, the medical screening examination is based on the individual's presenting complaint and is typically provided by a physician or a Nurse Practitioner or Certified Physician Assistant under the direct supervision of the emergency department physician. EMTALA defines medical screening as a process, not an event....For isolated pregnancy related complaints, in pregnancies greater than 20 weeks, the medical screening examination may be initiated by the labor and delivery registered nurse who communicates those findings to a physician by telephone and , the physician determines if the woman has a emergency medical condition or can be discharged..."

2. Review of the hospitals "Obstetric Triage Assessment Guidelines" policy dated 2/2022 revealed, "PURPOSE: To provide a standardized approach to the Obstetric Triage Assessment for the pregnant woman presenting to the L&D [Labor and Deliver]/OB [Obstetric] ED to determine priority for full evaluation and medical screening exam. The Maternal Fetal Triage Index (MFTI) process provides a brief, thorough, and systematic maternal fetal assessment to a pregnant woman presenting for care in the obstetrical unit. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) Maternal-Fetal Triage Index is a process for determining a pregnant woman's urgency for evaluation and treatment. PROCEDURE: All pregnant women will receive an assessment following presentation, leading to appropriate prioritization and care, utilizing the Maternal- Fetal Triage Index acuity system, with the following exceptions: 1) Pregnant women < [less than] 20 weeks gestation (only in facilities with an Emergency Dept.) 2) Pregnant women scheduled for induction of labor, Caesarian birth, external cephalic version, or an outpatient procedure (i.e. outpatient testing, blood patch 3) Pregnant women with orders for a direct admission to the obstetric or antepartum units 4) Pregnant women that give birth on the way to the hospital 5) Hospital to hospital transfers 6) Pregnant women who present with an imminent birth. If there is an extended wait time associated with the above, a MFTI assessment will be completed. The following information will be included as part of the MFTI assessment: 1)Presenting complaint 2) Gestational age/multiple gestation 3) Signs and symptoms of labor 4) Presence of fetal movement 5) Status of amniotic membranes 6) Presence of vaginal bleeding 7) Mental Status 8) Maternal vital signs (BP [blood pressure], HR [heart rate], RR [respiratory rate], temperature and SpO2 [oxygen saturation]) 9) Fetal Heart Rate 10) Pain assessment for non-labor or coping with labor 11) Uterine activity. The pregnant patient will be assigned one of the following levels based on the MFTI assessment: 1) MFTI Priority One (STAT)- Need for immediate lifesaving intervention, vital signs which require immediate attention, or imminent birth. The patient is transferred to the Triage/Assessment/ OB ED immediately (examples: Obstetric Hemorrhage, Prolapsed umbilical cord). 2) MFTI Priority Two (URGENT)-Need for a higher level of care, the identification of a high-risk situation, severe pain unrelated to contractions, or vital signs that require urgent attention (examples: Severe pain, decreased fetal movement). 3) MFTI Priority Three (PROMPT)- Need for prompt attention (examples: active labor, early labor or SROM [spontaneous rupture of membranes] at late preterm gestation, labor with plan for repeat CS [cesarean section], or not coping with labor) , or vital signs that require prompt attention. 4)MFTI Priority Four (NON-URGENT)- Need for non-urgent attention (example: term pregnancy with signs of early labor and/or SROM). 5) MFTI Priority Five (SCHEDULED/NO COMPLAINT)- Request for services without a complaint (outpatient service, prescription, schedule procedure). If a patient is asked to return to the waiting room, she is reassessed every hour or as clinically indicated until such time as a medical screening exam can be performed. Patients in the waiting room will be admitted to Triage based on MFTI score acuity and clinical status."

Review of the hospital's "Evaluation and Transfer of Patient with an Emergency Medical Condition Including Pregnancy with Contractions" revised January 2016 revealed, "Objectives- to establish a method for the screening and , if indicated, transfer of persons presenting at the Emergency Department [ED] or Labor and Delivery [L&D] with emergency medical conditions, including pregnancy with contractions, to establish a method for the screening and, if indicated, transfer of hospital inpatients that have unstable emergency medical conditions better managed elsewhere, to provide quality patient care without regard to a patient ' s age, sex, race, color, religion, national origin, handicap, disability, or financial status, to comply with local, state and federal law...Emergency Medical Condition- Medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance/ and or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in 1) Placing health of individual (or with respect to pregnant women, health of woman or unborn child) in serious jeopardy, 2) Serous impairment to bodily functions, or 3)Serious dysfunction of any bodily organ or part...Medical Screening A. [named hospital] complies with federal statutes and regulations regarding screening and transfer of patients with emergency medical conditions including pregnancy with contractions present B. [named hospital] does not discriminate based on race, religion, handicap, disability, national origin, or financial status C. Persons requesting examination or treatment for medical conditions are provided an appropriate medical screening examination to determine whether or not they have emergency medical conditions...E The initial medical screening and stabilizing treatment includes the use of necessary ancillary services routinely available at [named hospital] emergency department or L&D...Scope of Responsibility A. If patient is determined to have an emergency medical condition as defined above, further medical examination and treatment may be needed to stabilize the patient. The patient is provided, within capabilities of the staff and facilities available at hospital, further medical examination and treatment as required to stabilize the medical condition or transfer the patient..."

3. Review of Hospital #1's ED logs dated 11/20/2022 revealed Patient #1 was 16 year old female who presented seeking treatment for an ectopic pregnancy via private car at 6:33 PM.

Medical record review revealed Patient #1 was registered in the L&D/ OB ED but had no nursing assessment/triage to determine the priority of care needed.

Progress notes by RN #1 dated 11/20/2022 at 7:00 PM revealed, "[Named Physician #1] in MFTI room to speak with pt. [patient]. MD discussed POC [plan of care] with pt. Home from MFTI room. Pt left without further instructions from RN."

A progress note by Physician #1 dated 1/20/2022 at 10:57 PM revealed, "Nurse reports that I have seen patient sent from the office [community medical clinic] with suspected ectopic. Since no report received from PCP [primary care physician] in office, I went to assess the patient after review of her chart to discuss management plan. Patient seen sitting in a chair on her phone in waiting room not yet registered or triaged, not in any pain or visible distress. Patient is accompanied by her father. Patient condition appears stable. After further discussion of the care, the Patient expressed her views that she wants to go to [named Hospital #2] since the plan was already discussed by the provider of our clinic [community medical clinic] to go to [named Hospital #2], due to financial issues. Patient asked for directions to [named Hospital #2] since per patient, she has never been to [named Hospital #2]. I gave her complete information. My contact information given to patient and asked patient to inform me on her arrival to the hospital [Hospital #2] to ensure she made it safely. Patient left from the waiting room to go to [named Hospital #2] without further assessment. Patient informed me of her safe arrival to [named Hospital #2] and plans to be assessed there..."

4. Review of video dated 11/20/2022, provided by Hospital #1's Security Department, revealed the following:
6:28:07 PM- Patient #1 and a male companion [identified as her father] can be seen exiting the elevator on the 2nd floor at the L&D/OB ED.
6:28:19 PM- Patient #1 can be seen approaching the L&D/OB ED registration desk.
6:28:56 PM- Patient #1 can be seen taking a seat in the L&D/OB ED waiting room to complete paperwork.
6:31:43 PM- Patient #1 can be seen approaching the L&D/OB ED registration desk to return completed paperwork/clipboard.
6:32:20 PM- Patient #1 can be seen taking a seat in the L&D/OB ED waiting room beside her father.
6:59:00 PM Physician #1 can be seen walking into the L&D/OB ED waiting room and approaching Patient #1 and her father. Physician #1 can be seen kneeling down in front of Patient #1 and appears to be talking with Patient #1.
7:01:40 PM- Physician #1 can be seen continuing her conversation with Patient #1.
7:04:55 PM- Physician #1 can be seen walking away from Patient #1.
7:05:00 PM- Patient #1 can be seen walking to the L&D/OB ED registration desk [to retrieve driver's license].
7:05:16 PM- Patient #1 and her father can be seen getting on the elevator to leave the L&D/OB ED.
Patient #1 remained in the L&D/OB ED waiting room from 6:32 PM through 7:05 PM- Patient #1 was not assessed by a nurse to determine her MFTI level. Patient #1 did not receive a MSE.

5. In an interview on 1/9/2023 at 9:30 AM the Director of Quality stated the Chief Executive Officer reported the potential EMTALA violation after Hospital #2 called the L&D/OB unit and reported to the nursing staff Patient #1 reported she was directed to leave Hospital #1 and seek care at Hospital #2.

In an interview on 1/10/2023 at 8:12 AM, the Director of Quality was asked if all credentialed L&D/OB Physicians were expected to adhere to EMTALA requirements. The Director of Quality stated, "Most definitely."

In a telephone interview on 1/10/2023 at 8:23 AM, RN #1 verified she was working the evening shift in the L&D/OB ED on 11/20/2022, when Patient #1 presented. When asked what she recalled about Patient #1 she stated, "I never laid eyes on her [Patient #1]." RN #1 stated Physician #1 came to the triage room and told RN #1 "I just saw patient and she thinks she has an ectopic pregnancy. She got some misinformation and I sent her home." RN #1 stated she did not know who contacted Physician #1 to inform her Patient #1 was in the ED.

In a telephone interview on 1/10/2023 at 12:27 PM, Physician #1 verified she was a Physician affiliated with the community medical clinic where Patient #1 received care on 11/20/2022 prior to coming to Hospital #1's ED. Physician #1 stated she was not on the hospital premises when Patient #1 presented on 11/20/2022, but she was on call for the medical clinic at Hospital #1 for L&D/OB services. Physician #1 stated she received a telephone call on 11/20/2022 from one of the nurses in the L&D/OB ED that reported Patient #1 was in Hospital #1's ED with complaints of possible ectopic pregnancy, but the community clinic had not called or sent any information about Patient #1. Physician #1 stated she came to Hospital #1's L&D/OB ED and went into the ED waiting room to speak with Patient #1. Physician #1 stated she was surprised Patient #1 was still in the ED waiting room and had not been triaged. Physician #1 stated, "Usually a doctor from the [community clinic] will let me know when they are sending a patient to the hospital." Physician #1 stated after she was notified by the OB nursing staff, she called the community clinic and was informed Patient #1 had just been seen in the clinic and was instructed to go to Hospital #2. Physician #1 verified she then approached Patient #1 in the ED L&D/OB waiting room at Hospital #1 on 11/20/2022 and the patient reported she was seeking care for an ectopic pregnancy. Physician #1 stated she discussed with Patient #1 that the plan the clinic physician had recommended was for Patient #1 to seek care at Hospital #2's ED. Physician #1 stated Patient #1 reported she did not know where Hospital #2 was located, so she came to Hospital #1. Physician #1 stated Patient #1 was in no distress and agreed to leave Hospital #1 and seek care at Hospital #2. Physician #1 stated she provided the directions to Hospital #2 for Patient #1. When Physician #1 was asked if she performed a MSE for Patient #1, she stated, "From all knowledge I had, her labs from clinic records, I knew she was stable...not an emergency." Physician #1 did not perform a MSE. Physician #1 stated, "You're right I probably should have put information in medical record...." Physician #1 verified she did not take Patient #1 to the MFTI room and she only spoke with Patient #1 in the ED waiting room area.

In a telephone interview on 1/10/2023 at 2:21 PM, RN #2 verified she was the assigned MFTI nurse on 11/20/2022 when Patient #1 presented to the hospital with complaints of ectopic pregnancy. When asked what her duties were as MFTI nurse, RN #2 stated, "...like a triage nurse, get vital signs...ask what they came in for..." When asked if Patient #1 received the Obstetric triage assessment, RN #2 stated "She did not." When asked if it was a common occurrence for patients to wait in the waiting room without a triage assessment for an extended period of time, RN #2 stated, "Right now it is typical...we are very busy...goal is to be seen with in 30 minutes of presentation..." RN #2 stated she contacted Physician #1 because Physician #1 was the on call physician for the community clinic Patient #1 presented from. RN #2 stated she was unsure of the time she contacted Physician #1. RN #2 verified Patient #1 received no care while she was at the L&D/OB ED on 11/20/2022.

In an interview during the L&D/OB ED tour on 1/11/2023 at 9:20 AM,with the Director of Quality and the L&D/OB Nursing Manager, the L&D/OB Manager verified Patient #1 was not assessed by the MFTI nurse after being registered. The OB Nursing Manager stated, "RN #2 called Physician #1 to see what Patient #1 was here for..." The OB Nursing Manager stated, "For ectopic we do one of three things...surgery, administer medications and discharge the patient or admit for observation..." The L&D/OB Nursing Manager stated the clinic who sent Patient #1 did not call the charge nurse, so RN #1 reached out to the clinic on call physician (Physician #1). The surveyor asked if the ED was full/at capacity on 11/20/2022 when Patient #1 presented, the L&D/OB Nursing Manger stated, "No it was not." The surveyor asked why the MFTI nurse did not complete an assessment. The L&D/OB Nursing Manger stated RN #2 called the physician. When asked if it was acceptable to seat a patient in the waiting room and not perform a MFTI assessment, the OB Nursing Manager stated, "I don't want to say yes or no... we are not an ED." The surveyor explained the L&D/OB ED had to meet EMTALA requirements. The Director of Quality stated, "I would say she [MFTI nurse] should have assessed [Patient #1]."

6. Medical record review from Hospital #2 revealed Patient #1 presented via private car on 11/20/2022 at 8:10 PM [after leaving Hospital #1 at 7:05 PM] with the chief complaint of vaginal bleeding ectopic pregnancy and was assigned an acuity level 3. The physician who performed the MSE documented, "16 year old...presented with concern for ectopic pregnancy. She was seen in [named community medical clinic]...US [ultrasound] showed concern for a L [left] ectopic pregnancy...Patient went to [named Hospital #1] OB triage tonight and was told by MD prior to exam or vitals that since she did not have insurance she would need to leave and present to [named Hospital #2]. Currently patient reports mild LLQ [left lower quadrant] pain as well as vaginal bleeding on and off for the past 3 weeks..." Patient #1 had lab work and an ultrasound completed Patient #1 was determined to have an ectopic pregnancy that was not well visualized. The Physician further documented, "...Patient and her father were extensively counseled on medical versus surgical management of the ectopic pregnancy and elected for medical management.