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Based on observation, interview and document review, the hospital failed to ensure compliance with requirements of 42 CFR 489.24, as evidenced by the deficient practice cited at 489.24(a) and (c) and 489.24(e)(1-2).

Based on observation, interview, and document review, the hospital failed to provide a medical screening examination (MSE) for 1 of 6 patients (P1), who presented to the emergency department (ED) for evaluation of an obstetric emergency medical condition (EMC):
Findings include:Observations of the hospital's ED on 08/19/14 at 8:55 a.m. indicated that the ED is comprised of five patient examination rooms. Room #5 is set up for patients who present with obstetric problems. Room #5 has an obstetric cart with obstetric examination supplies, a Doppler, an infant warmer, and neonatal resuscitation equipment. One RN and one Physician Assistant (PA) were present in the ED at the time it was toured. Nurse (B)/RN was interviewed on 08/19/14 at 8:07 a.m. Nurse (B) stated that the ED is staffed 24/7 with one RN and one mid-level medical provider, which is usually a Physician Assistant (PA). The mid-level provider is located onsite at the hospital while on duty, including periods when the ED's census is zero. The hospital does not have an Obstetric Department.

The hospital's ED log indicated that P1 presented to the ED on 07/29/14 at 6:53 a.m. for evaluation of an "OB problem." The ED log indicated that PA/(H) was the medical provider for P1. The ED log indicated that P1 was "discharged to home or self care" at 7:00 a.m. P1's total time in the ED was seven minutes. P1 was the only patient in the ED during this time.
A review of P1's ED record indicated that PA/(H) saw P1 on 07/29/14, immediately upon P1's arrival in the ED at 6:53 a.m. P1 was in Room #5. P1 presented with possible labor. P1 was full-term. P1 told PA/(H) that she was having contractions every 5 - 8 minutes. P1 told PA/(H) that she had some pink vaginal discharge earlier that day. PA/(H) did not evaluate the regularity or duration of P1's contractions, fetal position or station, fetal heart tones, cervical dilation, or status of P1's membranes. PA/(H)'s physical examination of P1 entailed listening to P1's heart and lungs. PA/(H) informed P1 that the hospital did not do deliveries or C-sections and that P1 should go straight to the hospital in Mankato. PA/(H) then discharged P1 from the ED, without a medical screening examination of P1's labor.
PA/(H) was interviewed on 08/19/14 at 3:05 p.m. PA/(H) stated she was the ED's medical provider on 07/29/14. Due to P1's language barrier, PA/(H) interacted with P1 and several family members to ascertain P1's recent history and onset of possible labor. PA/(H) did not evaluate the regularity or duration of P1's possible labor contractions. PA/(H) listened to P1's heart and lungs. PA/(H) looked at P1's vital signs, which were taken by the nurse. PA/(H) did not obtain fetal heart tones. PA/(H) did not conduct a pelvic examination because PA/(H) thought it might precipitate an obstetric complication, since P1 was 40 weeks gestation. PA/(H) determined that P1's condition was stable and that P1 should go to the Mankato hospital for further evaluation of possible labor.

Interpreter (J) was interviewed on 08/20/14 at 8:45 a.m. Interpreter (J) stated she is P1's family member and designated representative for communication because English is not P1's primary language. Interpreter (J) was with P1 on 07/29/14 when P1 presented to the ED for evaluation of labor. P1 was not examined by the medical provider on 07/29/14, even though P1 was crying in pain and wanting to push. The medical provider "brushed off" P1's complaints of labor pains and told P1 that P1 needed to go to the Mankato hospital because the Waseca Hospital did not deliver babies. P1 was in the ED approximately five minutes, was directed to go to another hospital, and was discharged.
The recipient hospital's medical record, dated 07/29/14, indicated that P1 was admitted directly to the obstetric unit upon arrival at 7:19 a.m. P1's initial physical assessment at 7:45 a.m. indicated that P1 was dilated to 4 cm with 80% cervical effacement. The baby's head was at -1 station. P1's contractions were every 2 -3 minutes, lasting 60 - 70 seconds. P1 had complete cervical dilation by 12:52 p.m. followed by an uncomplicated spontaneous vaginal delivery at 12:56 p.m.

The hospital's policy on EMTALA, revised 07/18/14, indicated that the "medical screening examination will be performed by a qualified medical provider...the emergency department staff use any necessary ancillary services routinely available to the Emergency Department, as appropriate, to conduct the medical screening examination...the medical screening examination is an evaluation designed to determine whether an individual has an emergency medical condition...a medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist."

Based on interview and document review, the hospital failed to stabilize an EMC prior to transferring a patient in labor to another hospital 28 miles away for delivery and failed to utilize qualified personnel and transportation equipment for 1 of 8 patients transferred (P1), who was transferred to another hospital by private vehicle after presenting to the ED in labor.
Findings include:

The hospital's ED log indicated that P1 presented to the ED on 07/29/14 at 6:53 a.m. for evaluation of an "OB problem." The ED log indicated that PA/(H) was the medical provider for P1. The ED log indicated that P1 was "discharged to home or self care" at 7:00 a.m. P1's total time in the ED was seven minutes. P1 was the only patient in the ED during this time.
A review of P1's ED record indicated that PA/(H) saw P1 on 07/29/14, immediately upon P1's arrival in the ED at 6:53 a.m. P1 presented with possible labor. P1 was full-term and was having labor contractions. PA/(H) did not conduct a medical screening examination of P1's labor. PA/(H) informed P1 that the hospital did not do deliveries or C-sections and that P1 should go straight to the hospital in Mankato. PA/(H) then discharged P1 from the ED, by private vehicle, without conducting a medical screening examination of P1's labor to ensure that P1's condition was stable for transfer to another hospital. The ED record did not contain a certification form that PA/(H) discussed with P1 the benefits, risks, or recommended mode of P1's transfer to the recipient hospital. There was no evidence that PA/(H) communicated with anyone at the recipient hospital regarding P1's status and pending arrival.

PA/(H) was interviewed on 08/19/14 at 3:05 p.m. PA/(H) stated she was the ED's medical provider on 07/29/14. Due to P1's language barrier, PA/(H) interacted with P1 and several family members to ascertain P1's recent history and onset of possible labor. PA/(H)'s evaluation of P1's labor included listening to P1's heart and lungs and looking at P1's vital signs which were obtained by the nurse. PA/(H) did not evaluate the regularity or duration of P1's possible labor contractions. PA/(H) did not obtain fetal heart tones. PA/(H) did not conduct a pelvic examination because PA/(H) thought it might precipitate an obstetric complication, since P1 was 40 weeks gestation. PA/(H) determined that P1's condition was stable and that P1 should go to the Mankato hospital for further evaluation of possible labor. PA/(H) recommended that P1 should transfer to the Mankato hospital by ambulance, but P1 wanted to go by private vehicle. PA/(H) did not complete the benefit/risk certification form for transfer or a refusal form that P1 had declined to transfer by ambulance. After P1 opted to transfer by private vehicle, PA/(H) then determined that it was safe for P1 to go to the Mankato hospital by private car. PA/(H) told the ED RN to call the Mankato hospital to inform them that P1 was on her way there by private car.
Interpreter (J) was interviewed on 08/20/14 at 8:45 a.m. Interpreter (J) stated she is P1's family member and designated representative for communication because English is not P1's primary language. Interpreter (J) was with P1 on 07/29/14 when P1 presented to the ED for evaluation of labor. P1 was not examined by the medical provider on 07/29/14, even though P1 was crying in pain and wanting to push. The medical provider "brushed off" P1's complaints of labor pains and told P1 that P1 needed to go to the Mankato hospital because the Waseca Hospital did not deliver babies. The ED did not offer to transfer P1 by ambulance to the Mankato hospital. Interpreter (J) drove P1 to the Mankato hospital by private car. It took approximately one half hour to get to the hospital in Mankato. No complications were encountered during transit. When they arrived at the hospital in Mankato, hospital staff awaited them at the door and immediately escorted P1 to the room on the Obstetrics unit where P1 later delivered her baby.
The recipient hospital's medical record, dated 07/29/14, indicated that P1 was admitted directly to the obstetric unit upon arrival at 7:19 a.m. P1 was accompanied by family member/(I) and Interpreter/(J). The OB Admission/History Assessment indicated that P1's expected date of confinement was 07/27/14. P1 was gravida 1 para 0. The Labor & Delivery Chronology record indicated that P1's onset of spontaneous labor had commenced at 3:00 a.m., with rupture of membranes at 4:00 a.m. P1's initial physical assessment at 7:45 a.m. indicated that P1 was dilated to 4 cm with 80% cervical effacement. The baby's head was at -1 station. P1's contractions were every 2 -3 minutes, lasting 60 - 70 seconds. P1 had complete cervical dilation by 12:52 p.m. followed by a normal spontaneous vaginal delivery at 12:56 p.m. Neither P1 nor the baby experienced any complications. The baby's apgars were 9 and 9.
The hospital's policy on EMTALA, revised 07/18/14, indicated "When a patient has an emergency medical condition that has not been stabilized and transfer to another hospital is appropriate, the physician (or his/her designee): Explain to the patient, or the patient's representative, the hospital's obligation under EMTALA as well as the risks and benefits of being transferred to another facility, and has the patient, or the patient's representative, sign the Patient Consent for/or Option to Refuse Transfer form. Arrange transfer to a receiving facility that he or she reasonably believes has the capacity to manage the patient's medical condition and any reasonably foreseeable complication of that condition. Provide medical treatment, within the hospital's capacity and capabilities, that minimizes the risks to the patient's health and, in the case of a woman in labor, the health of the unborn child. Contact the receiving facility prior to arranging for transfer to discuss the patient's condition and verifies the receiving facility's capacity and willingness to accept the patient; documents the date and time of the transfer request and the name of the physician accepting the transfer...Arrange for a mode of transportation matching the patient's clinical needs (including consideration of transport personnel qualifications and transportation equipment). Certify, in writing on the Patient Consent for/or Option to Refuse Transfer form, that based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment available at another facility outweigh the increased risks to the patient (or unborn child) from the transfer. The certification contains a summary of the risks and benefits upon which this decision is based and must signed by the physician."