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Based on record review, policy review and staff interview the facility failed to ensure staff complied with EMTALA (Emergency Medical Treatment and Labor Act) for failure to provide a Medical Screening Examination (MSE) for 1 of 20 sampled patients (Patient 1) and also failed to include Patient 1 in the Central Log. Findings are:

A. Review of facility policy titled "Emtala Compliance Plan" effective date 5/1/87 under section titled "Procedures" states "'Upon presentation on LRHC [Lexington Regional Health Center] property, an individual who is not otherwise a patient of LRHC shall be provided an appropriate medical screening examination or treatment for a medical condition." The policy also states that a "central log shall be maintained on each individual who comes to the Emergency Department seeking assistance, recording whether he or she refused treatment, was refused treatment, was transferred, was admitted or treated, was stabilized and transferred or was discharged."

B. Review of Patient 1's 11/25/18 medical record showed the patient presented for care at 8:15 AM. Documentation by obstetrical (OB) nurse B at 12:17 PM, approximately 4 hours after patient # 1 left the ED showed that patient # 1 called staff at Lexington Regional Health Center prior to arrival at 8:15 AM stating that she was planning to present to be checked out because she had been having contractions through the night. Further documentation showed that the patient arrived and stated she was 33 weeks pregnant. RN B documented the patient stated she had been having contractions all night. Further documentation by OB RN B indicated she told patient # 1 they would put her on the monitor and evaluate her. Obstetrical (OB) Medical Doctor (MD) "B" was on call and would be seeing her. The patient said she did not want to be seen by MD B. OB RN B informed the patient that if in labor she would deliver at Lexington Regional and that if the baby had any problems, the baby would be transferred for specialized care. Further concerns were voiced by the parents regarding ability to transfer due to weather (snowing on 11/25/18). OB RN B documented the patient/spouse decided to go to Kearney for special care. The nursing notes indicated the patient decided to "leave without being seen."

RN A witnessed the patient arriving at the hospital and leaving the hospital approximately 5 minutes later but was not present when RN B interacted with patient # 1 and her husband. RN A and RN B documented on facility form titled "Refusal of Exam/Treatment Form" that the patient "refused to be placed on fetal monitor, refused to see [name of MD B]" and "refused all cares." The nurses documented the patient left without being seen prior to signing the Against Medical Advice form.

C. In an interview on 12/4/18 at 11:45 AM, RN A, Emergency Department Director confirmed she talked with Patient 1 prior to arrival. The patient was a patient of MD C, was 33 weeks and was having contractions all night. RN A stated she told Patient 1 that she needed to be seen. RN A stated she recalled telling the patient "we will have a bed for you." RN A recalled seeing the patient walking down the hall with RN B to the OB room. RN A said she then saw RN B, the patient and her husband come out of the room. The entire interaction was about 5 minutes.

D. Interview with OB RN B 12/4/18 at 9:50 AM. RN B stated the OB RN's have special training on conducting a MSE on OB patients The MSE includes putting the patient on the monitor, head to toe assessment, assess fetal heart tones, evaluate monitor strip and notify the OB on call.

On 11/25/18 OB RN B was the OB RN for the day. She recalled RN A reported a 33 week pregnant high risk (for complications) patient was coming in. RN B walked with them to the OB patient room. I asked if she doctored here and she said yes (MD C). She recalled telling the patient that MD B was on call not MD C. The patient said "I do not see [name of MD B]."

RN B recalled having a conversation with the patient telling her that at 33 weeks they needed to make sure she was safe and needed to stay here. I "explained state law that you are here in our facility and we have to check her out." The patient replied she was 33 weeks and was told she would deliver here and stabilize and move to other facility. If not in labor they could send her by air or ground ambulance with fetal heart monitor and OB nurse. The patient again stated "I don't see [name of MD B]". Her husband then came in the room and asked his wife "do you want to go to Kearney?" The patient said "yes" and they left. RN B recalled telling them "you need to stay to check that you are not in labor". They left the hospital and did not sign consent to treat or Against Medical Advice paperwork.

RN B stated we did not enter the patient in the Central Log because we did not do a medical screening examination (MSE).

E. Review of receiving Hospital "D" history and physical dated 11/25/18 indicated that patient # 1 "presents with complaints of contractions at 33 weeks gestational age. Further documentation showed that the patient sees [Name of MD C] in Lexington for her pregnancy. Documentation in the medical record indicated the patient stated she presented to the hospital (in Lexington) this morning and spoke to a nurse with complaints of contractions. She was not checked or hooked up to a monitor and was told to drive by a private car to Kearney due to concern for possible preterm delivery and them not having adequate care for preterm infants. Upon presentation here the patient reported she is feeling contractions approximately every 3 minutes. She was diagnosed with preterm labor and admitted. Review of the operative report 11/25/18 noted that shortly after admission patient # 1's membranes ruptured with a large amount of blood loss. Fetal heart rate dropped and a emergency C-section (surgical opening of the abdomen/uterus to deliver the infant) was needed. The preterm infant was taken to the Neonatal Intensive Care Unit ( NICU).

F. Telephone interview with Patient 1 on 12/11/18 at 12:00 PM revealed the patient was told by the OB nurse who took her to a room on OB, that "just so you know, we are not equipped to handle a 34 week baby and if you deliver we would have to call a helicopter and can't guarantee they can fly today", referring to the weather/snow. Patient # 1 stated the nurse said that [ MD B] was on call. Patient # 1 stated she wanted her doctor [MD C ] called and the nurse told her she could not. Patient 1 also recalled the OB nurse telling her that "if it was my baby I would go to [Name of Hospital D]." The nurse told her that if I admit you I need to examine you and if you're in active labor we must keep you. Patient 1 said she was having contractions and "did not refuse service." The RN told her they did not need to call [name of Hospital D] but to go straight to the Emergency Room. Patient # 1 stated she arrived at Hospital D 45 minutes to 1 hour later. Patient # 1 stated her contractions were 3 minutes apart and that 30 minutes after she arrived, her water broke.

Staff interview, review of facility policy and review of the Central Log for the Emergency Department and Obstetrical Department for November 2018 failed to contain and entry for 1 of 20 sampled patients (Patient 1) who presented for unscheduled examination/treatment.Findings are:

A. Record review of facility policy titled "Emtala Compliance Plan" effective date 5/1/87 under section titled "Procedures" states that a " central log shall be maintained on each individual who comes to the Emergency Department seeking assistance, recording whether he or she refused treatment, was refused treatment, was transferred, was admitted or treated, was stabilized and transferred or was discharged."

B. Record review of Patient 1's medical record dated 11/25/18 notes the patient arrived and requested examnation for labor. Patient was 33 weeks and told staff she had been having contractions all night.

C. Interview with OB RN B 12/4/18 at 9:50 AM. RN B was assigned to do the MSE for Patient 1. The patient per hosptal records left without being seen. RN B stated we did not enter the patient in the Central Log because they did not do a MSE.

Based on record review, receiving hospital record review, EMTALA policy review and staff interview the facility failed to provide 1 of 20 sampled Patients (Patient 1) a Medical Screening Examination. Patient 1 was pregnant at 33 weeks with contractions and presented to the hospital for examination and treatment. Failure to perform a medical screening examination (MSE) has the potential to cause serious harm and or death from an untreated Emergency Medical Condition. Findings are:

A. Review of facility policy titled "Emtala Compliance Plan" effective date 5/1/87 under section titled "Procedures" states "'Upon presentation on LRHC [Lexington Regional Health Center] property, an individual who is not otherwise a patient of LRHC shall be provided an appropriate medical screening examination or treatment for a medical condition."

B. Review of the 11/25/18 medical record showed that at 12:17 PM, approximately 4 hours after Patient # 1 left the hospital, registered nurse B (RN B) documented that patient # 1 arrived at the hospital at 8:15 AM. Further documentation by RN B showed that patient # 1 called the hospital prior to her apprival and talked with RN A stating she was "going to present to hospital to get checked out because she had been having some contractions through the night." Upon patient # 1's arrival to the hospital, RN B documented she asked patient # 1 "do you dr here at lexington?" RN B's documentation continued as follows: "This nurse states 'ok' Dr. [name] is not on call but Dr. [name] is and she will be the one seeing you." "Patient states no, I don't see Dr. [name] and everyone here should know that." "It should be all over my chart." "I had an issue with dr [name] and it was a big deal and the hospital staff was involved with it and I don't want to see her." "Conversation with patient continued to her (sic) being 33 weeks gestation and stated that she had been having ctx (contractions) all night and has been drinking water and put her feet up with no relief." "Patient instructed that we would put her on the monitor and evaluate and (sic) if she is in labor." "In which case if patient is in active labor she would have to stay here and deliver baby due to state laws of (sic) not transferring patients in active labor." "Conversation continues about premature delivery and if baby would have any problems it would have to be transferred to specialty care." "Concerns were voiced by parents ability (sic) to transfer baby due to weather conditions." "Patient and spouse make decision to leave and go to kearney for specialty care." "At this time pt decides to leave without being seen."

The medical record contained a "Refusal of Exam/Treatment Form" that was not signed by patient # 1. RN B documented on the form that "pt refused to be placed on fetal monitor, refused to see Dr. [name] pt refused all cares." RN B documented the reason for patient # 1's refusal was "I do not see Dr. [name]." RN B also documented that "pt left without being seen prior to signing AMA (against medical advice) form." The Emergency Department Director, RN A co-signed the form but acknowledged during an interview on 12/4/18 at 11:45 AM that she was not present during RN B's interaction with patient # 1 and her husband.

RN B documented her "conversation" with patient # 1 which included state law requirements for women in labor, the potential for premature delivery, and the possible need for transfer, but the medical record did not contain evidence that she attempted to contact the OB physician on-call, or the ED physician, or develop a plan to get patient # 1 safely to another hospital for examination.

C. In an interview on 12/4/18 at 11:45 AM, RN A, Emergency Department Director, confirmed talking with Patient 1 prior to her arrival. RN A stated that patient # 1 was a patient of MD C, was 33 weeks pregnant and was having contractions all night. RN A stated she told Patient 1 that she needed to be seen. RN A recalled telling the patient "we will have a bed for you." RN A recalled seeing the patient walking down the hall with RN B to the OB room. RN A said she then saw RN B, the patient and her husband come out of the room. RN A stated the entire interaction lasted about 5 minutes.

D. In an interview on 12/4/18 at 9:50 AM, obstetrical (OB) nurse RN B stated that OB nurses have special training on conducting a MSE on OB patients. RN B stated the MSE includes putting the patient on the monitor, head to toe assessment of the pregnant woman, assessment of fetal heart tones, evaluation of the monitoring strips and then OB physician notification. OB RN B stated she was the obstetrical nurse on duty on 11/25/18. She recalled RN A reported that a 33 week pregnant high risk (for complications) patient was coming in. RN B stated that when patient # 1 arrived she walked with her and her husband to the OB patient room. RN B stated she asked patient # 1 if she doctored here and she said yes. RN B stated she recalled telling the patient that MD B was on call, not MD C. The patient said "I do not see [name of MD B]." RN B stated that patient # 1's husband
came in the room and asked his wife "do you want to go to Kearney?" The patient said "yes" and they left. RN B recalled telling them "you need to stay to check that you are not in labor." They left the hospital and did not sign consent to treat or Against Medical Advice paperwork.

E. In a telephone interview on 12/11/18 at 12:00 PM, patient # 1 stated she was told by the OB nurse who took her to a room that "just so you know, we are not equipped to handle a 34 week baby and if you deliver we would have to call a helicopter and can't guarantee they can fly today", referring to the weather/snow. Patient # 1 stated the nurse told her that [ MD B] was on call. Patient # 1 stated she wanted her doctor [MD C ] called and the nurse told her she could not. Patient # 1 stated she also recalled the OB nurse telling her that "if it was my baby I would go to [Name of Hospital D]." Patient # 1 stated that the nurse told her that "if I admit you I need to examine you and if you are in active labor we must keep you." Patient 1 said she was having contractions and "did not refuse service." Patient # 1 stated that the OB nurse told her "we do not need to call [name of Hospital D], go straight to the Emergency Room." Patient # 1 stated that she arrived at Hospital D 45 minutes to 1 hour later, that her contractions were 3 minutes apart and that 30 minutes later, her water broke.

F. Review of receiving Hospital "D" history and physical dated 11/25/18 indicated that patient # 1 "presented at 33 weeks 6 days gestational age with complaints of contractions." "Of note, the patient sees [Name of MD C] in Lexington for her pregnancy." "The patient states that she presented to (Lexington Regional Health Center) this morning and spoke to a nurse about her contractions." "She was not checked or hooked up to a monitor and was told to drive by a private car to Kearney due to concern for possible preterm delivery and them not having adequate care for preterm infants." Further documentation showed that patient # 1 was 4 cm dilated and experienced a rupture of her membranes shortly after arrival with a large amount of blood loss. Patient # 1 was diagnosed with preterm labor, admitted and taken to the operating room for an emergency cesarean section (C-section) after the baby's heart rate dropped. After delivery, the premature infant was taken to the Neonatal Intensive Care Unit.