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Based on interview and record review the facility failed to:

1. Obtain or attempt to obtain an informed refusal of examination (medical screening exam-MSE) form for Patient 100 and failed to inform Patient 100 of the risks of refusing treatment.

2. Obtain or attempt to obtain a leaving against medical advice (AMA) form for Patient 100 and failed to inform Patient 100 of the risks of leaving AMA.

3. Ensure there was documentation that 2 out of 22 sampled patients (Patient 103 and Patient 101) had been informed of the risks of leaving AMA.

These failures had the potential to violate the patient's right to know about the medical risks of leaving AMA and refusing treatment.

Findings:

1. During a review of the facility's EMTALA (Emergency Medical Treatment and Labor Act) and MSE/ Labor and Delivery Competency 2020, indicated in part ... "Medicare-participating hospitals that offer emergency services to provide a Medical Screening Exam (MSE) when a request is made for examination for an emergency medical condition (EMC), including active labor, regardless an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMC's ...Medical Screening Exam (MSE): An MSE must be done on all patients that arrive seeking an examination for an emergency medical condition. We are required to determine if a women is in active labor or not "after a reasonable amount of observation ..." REFUSAL OF SERVICE: If a patient chooses to decline an examination or desires to leave the hospital prior to the completion of the MSE, the RN must inform the patient that there may be an "unfavorable outcome to either the mother or the baby (fetus) as we have not been able to complete out examination ..." The patient must be asked to sign the WAIVER OF RIGHT TO REFUSE A MEDICAL SCREENING EXAM ...If she signs it, it must be retained in the medical record ...If she refuses to sign it, document that you have informed her of the possibility of an unfavorable outcome by not following through with the MSE and document that she was asked to sign the waiver and refused ..."

During an interview on 10/20/23, 3:40 p.m., with the director of perinatal services (DOPS), DOPS was asked about a medical screening exam. When asked what the medical screening exam consists of in labor and delivery, DOPS verbalized the MSE consists of a physical assessment, asking about medical history, chief complaint, putting the patient on the fetal monitor, determine if contracting, and a vaginal exam.

During a review of the facility's policy and procedure (P&P) titled, "Medical Screening Exam of Patients Presenting to the labor and delivery Department" dated 11/2022, indicated in part ... "Medical Screening Examination Procedure ...2. Procedure ...a. patient presents to labor and delivery and is admitted for observation ...b. patient is given a gown to change into and instructed to provide a urine sample for urinalysis dipstick purposes ...c. place patient in bed, place external tocodynameter (a machine that reads uterine contractions) and ultrasound monitor (used to record the baby's heartbeat) on abdomen ...d. Perform assessment: complete observation history/assessment including admission vital signs ...obtain prenatal records, if available ...obtain fetal monitor strip and evaluate fetal wellbeing ....perform vaginal exam if indicated include dilation, baby presentation, and status of membranes (bag of water) ...assess uterine activity ...perform nursing assessment ....complete medical screening exam scoring form to determine requirement of MD's presence ...consult with physician ...receiving orders ...receive, document, and carry out orders: if patient is admitted ...if patient is discharged ...if patient is to be transferred ..."

During a review of Patient 100's "L&D Labor Notes" dated 10/3/23, at 10:20 p.m., the notes indicated Patient 100 refused the sterile vaginal exam. The midwife and the father of the baby stated that Patient 100 is refusing an exam and demanded to be admitted. At 10:30 p.m. the notes indicated MD 1 was at the bedside assessing Patient 100. Patient 100 refused to be assessed by MD 1. Further review of Patient 100's medical record had no documentation about the risks of refusing an MSE and no documentation that an MSE refusal form was completed.

During an interview on 10/20/23, at 5:36 p.m., with licensed nurse (RN 2), RN 2 was asked about Patient 100 on the night of 10/3/23. RN 2 verbalized Patient 100 arrived at labor and delivery with a midwife (CP 1) and her husband. Patient 100 was in labor and having painful contractions. RN 2 verbalized walking into Patient 100's room to help the other nurse (RN 1) with the admission. RN 2 verbalized that RN 1 indicated she needed to do a quick assessment first to check to see how far Patient 100 was dilated. RN 2 verbalized the midwife said they are refusing the vaginal exam. RN 2 then verbalized MD 1 walked in the room to do a vaginal exam. RN 2 verbalized the midwife, and the husband were rude and refused the exam. RN 2 verbalized MD 1 stepped out of the room and went to the nurse's station. RN 2 verbalized Patient 100 did not want to be checked against her will. When asked how long this conversation was, RN 2 verbalized 5-10 minutes. RN 2 verbalized leaving the room and going back to the nurse station. When asked about MSE refusal and filling out a refusal form, RN 2 verbalized there was no signing of any form.

During an concurrent interview and record review of Patient 100's medical record on 11/13/23, at 10:47 a.m., with the OB physician (MD 1), MD 1 was asked about Patient 100 and the refusal of the medical screening exam (MSE). MD 1 verbalized the MSE consists of doing a physical "head to toe" assessment, listening to the baby, and a vaginal exam. MD 1 verbalized if a patient refuses an exam, would try to find out what was the reason for refusal. MD 1 verbalized the midwife and husband were cursing at MD 1, MD 1 stepped out because she was concerned for her safety. MD 1 verbalized going back to the nurse's station. When asked about informing Patient 100 about the risks of refusing the MSE, MD 1 verbalized not at that time. MD 1 stated security personnel was at the nurses station, but did not take security personnel to Patient 100's room, to discuss risk of MSE refusal. Review of Patient 100's medical record indicated Patient 100 was on the unit for 55 minutes, however MD 1 stated "Did not have time to discuss MSE refusal."

During a review of the facility's policy and procedure (P&P) titled, "Scope of Service Labor & Delivery" dated 7/2021, indicated in part ... "Governing Rules of The Unit ... "f. The nursing staff may alter these visiting regulations at their discretion, as warranted by the patient's condition and the activity within the unit. Security personnel are available to help control visitors ..."

2. During a review of the facility's policy and procedure (P&P) titled, "AMA: Leaving Against Medical Advice" dated 3/19, indicated in part ... "When a competent patient wishes to leave the hospital without a discharge order from the attending physician, the clinical hospital staff should facilitate communication to address any underlying quality of care issues, and the pertinent medical staff should make diligent efforts to inform the patient of possible implications of leaving against medical advice ...The clinical hospital staff is responsible for complete documentation of the incident in the patient's medical records. A diligent effort should be made to have the patient read and sign the "Leaving Hospital Against Medical Advice" form."

During a review of Patient 100's "L&D Labor Notes" dated 10/3/23, at 10:50 p.m., the notes indicated Patient 100 left against medical advice (AMA) with the midwife. Patient 100 took off the monitors and had midwife put her in a wheelchair and left. Further review of Patient 100's medical record had no documentation about the risks of leaving AMA and no documentation that an AMA form was completed.

During an interview on 10/27/23, at 3:06 p.m., with licensed nurse (RN 1), RN 1 was asked about Patient 100 on the night of 10/3/23. RN 1 verbalized MD 1 came out of Patient 100's room, back to the nurse's station, indicating they (midwife and husband) refused the vaginal exam and were verbally abusive. MD 1 called security and the house supervisor. RN 1 verbalized the midwife comes out to the nurse's station and stated out loud, "I need Patient 100's medical records back, we want to leave." RN 1 verbalized giving the records back to the midwife. RN 1 verbalized seeing the husband and midwife pushing Patient 100 out of the unit in a wheelchair. When asked if anyone had Patient 100 sign the leaving against medical advice (AMA) form and explain the risks of leaving to the patient, RN 1 verbalized printing out the form, but MD 1 said, "Don't even bother, do not approach them, and do not ask for a signature." RN 1 stated, "We all heard he midwife say we are going to leave." RN 1 acknowledged the risks of leaving AMA were not explained to the patient and the AMA form was not filled out.

During an interview on 11/13/23, at 10:47 a.m., with the OB physician (MD 1), MD 1 was asked about Patient 100 leaving AMA. MD 1 verbalized not knowing Patient 100 was leaving AMA. MD 1 was informed, staff verbalized you told them not to approach Patient 100, and do not have them sign the AMA form. MD 1 stated, "I was not physically going to go and have them sign the form because they were being hostile towards me." MD 1 acknowledged security personnel was at the nurse's station.

3. Review of Patient 103's medical record indicated Patient 103 was seen by the emergency room doctor (EDMD 1), on 7/10/23, at 9:24 p.m. with the diagnosis of chest pain and palpitations. Patient 103 left AMA (against medical advice) on 7/10/23, at 9:40 p.m. Further review of the medical record for Patient 103, did not reveal any documentation of risks and consequences of leaving the hospital against medical advice. Patient 103 had signed the AMA form however was not signed by the physician.

During a concurrent interview and Patient 103's medical record review on 11/14/23, at 10:12 a.m., with emergency department director (EDD), EDD acknowledged there was no documentation of the risks of leaving AMA in the physician's narrative note and the AMA form was not signed by the physician and further acknowledged the form should have been signed.

Review of Patient 101's medical record indicated Patient 101 was seen by the emergency room doctor (EDMD 2), on 8/10/23, at 9:11 p.m. with the diagnosis of chest pain. The medical record further indicated Patient 101 did not want to wait for the workup, observation, and treatment; and her UBER ride was there to pick her up. Patient 101 left AMA (against medical advice) and eloped from the emergency room lobby on 8/10/23, at 10:10 p.m. Further review of the medical record for Patient 101, did not reveal any documentation of risks and consequences of leaving the hospital against medical advice (AMA). Patient 101 had eloped and there was no AMA Form in the medical record.

During a concurrent interview and Patient 101's medical record review on 11/14/23, at 10:35 a.m., with emergency department director (EDD), EDD acknowledged there was no documentation of the risks of leaving AMA in Patient 101's medical record. EDD verbalized the physician needed to document more and at least attempted to have a conversation with Patient 101, before leaving (eloping) from the emergency room.

During a review of the facility's policy and procedure (P&P) titled, "AMA: Leaving Against Medical Advice" dated 3/19, indicated in part ... "When a competent patient wishes to leave the hospital without a discharge order from the attending physician, the clinical hospital staff should facilitate communication to address any underlying quality of care issues, and the pertinent medical staff should make diligent efforts to inform the patient of possible implications of leaving against medical advice ...The clinical hospital staff is responsible for complete documentation of the incident in the patient's medical records. A diligent effort should be made to have the patient read and sign the "Leaving Hospital Against Medical Advice" form."

Based on observation, interview and record review, the hospital failed to post signs visible to all in the Emergency Department (ED) entrance, waiting room and treatment areas, as well as the main entrance which specified the rights of individuals under the Emergency Medical Treatment and Active Labor Act (EMTALA), regarding examination and treatment for emergency medical conditions and women in labor (ready to give birth).

This failure had the potential for patients and families to be unaware of their rights under EMTALA.

Findings:

During a concurrent observation and interview on 10/25/23 at 12:20 p.m. with the emergency department director (EDD), no signs were posted that specify the rights of individuals to examination and treatment for emergency medical conditions (EMC) and women in labor at the emergency room entrance, inside waiting room, treatment rooms, or in the main lobby, confirmed by EDD.

During an interview on 10/25/23, at 1:06 p.m. with regulatory manager (RM), RM confirmed, there is no EMTALA sign in the main lobby.

During a review of the facility's policy and procedure (P&P) titled, "EMTALA - Signage Policy," dated 10/2022, the P&P indicated, "signage must be conspicuously posted in any place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than the traditional emergency department (e.g., entrance, admitting area, waiting room, labor and delivery, and other treatment areas located on hospital property): signage must be readable from anywhere in the area."

Based on interview and record review, the facility failed to ensure that MSE were conducted by an individual(s) who was determined qualified by medical staff bylaws or rules and regulations and who met the requirements of the facility's policies and procedures concerning emergency services personnel and direction.

This failure resulted in individuals performing MSE without competency requirements and facility approval as required under EMTALA.

Findings:

During an interview on 10/25/23, at 1:15 p.m. with manager of regulatory (MOR), MOR stated that she was not aware that a list of Labor and Delivery nurses who have been approved to perform a MSE should be kept in the office of the Vice President (Patient Care Services) and didn't know who's office that would be.

During an interview on 10/27/23, at 2:50 p.m. with director of perinatal services (DOPS), DOPS the last required annual competency for Labor and Delivery nurses to perform a MSE was done in 2021. DOPS acknowledged the facility policy is not being followed.

During an interview on 11/13/23, at 3:06 p.m. with chief medical officer (CMO), CMO stated that who is determined as qualified to perform a MSE is not in the medical staff bylaws or rules and regulations it is only in the facility's EMTALA Medical Screening Examination and Stabilization policy.

During a review of the facility's policy and procedure (P&P) titled, "EMTALA - Medical Screening Examination and Stabilization Policy," dated 3/2014, the P&P indicated, "Purpose: To establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment ... as required by EMTALA ... Who May Perform the MSE: Only the following individuals may perform an MSE: A qualified physician with appropriate privileges; other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges; or A qualified staff member who: is qualified to conduct such an examination through appropriate privileging and demonstrated competencies; is functioning within the scope of his or her license and in compliance with state law and applicable practice acts; is performing the screening examination based on medical staff approved guidelines, protocols or algorithms; and is approved by the facility's governing board as set forth in a document such as the hospital bylaws or medical staff rules and regulations, which document has been approved by the facility's governing body and medical staff."

During a review of the facility's policy and procedure (P&P) titled, "Medical Screening Exam of Patients Presenting to the Labor and Delivery Department," dated 11/2022, the P&P indicated, "Scope: Authorized Registered Nurses who have one year experience in Labor and Delivery, have attended mandatory annual competency classes ... have met expectations in competency testing will perform MSE ... Yearly Competency Requirements: 1. Meet expectation in mandatory competency for the Labor and Delivery Registered Nurse annually. 2. Participate in mandatory annual competency classes. 3. Attend Fetal Monitoring Class every two years, minimal Fetal Monitoring- Intermediate. 4. Yearly validation of competency related to performing this standardized procedure to a MD or RN preceptor. Record of Authorized Nurses: A written record of all Labor and Delivery nurses who have been approved to perform the procedure will be reviewed annually and will be maintained by the Director of Women's and Children's Services and in the office of the Vice President, Patient Care Services."