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Based on a review of policy and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that one Patient (P) #1 of 21 sampled patients received an appropriate medical screening examination. Specifically, a review of the facility's Inpatient Log and Emergency Department (ED) transfers from 7/1/22 to 9/30/22 failed to reveal P#1's information on the logs. A review of P#1's ED records only revealed an Admission/Registration Agreement form signed by P#1 on 8/22/22 at 10:02 p.m. No other documentation was found on the ED records.

Cross Refer to A-2406 as it relates to the facility's failure to provide an appropriate medical screening examination to P#1.

Based on review of facility policy and procedures and facility logs it was determined that the facility failed to enter one (P#1) of 12 sampled patients with a pregnancy related complaint into the emergency department (ED) log when she arrived at the facility on 8/22/22 seeking medical treatment.

Findings included:

A review of the facility's policy titled '[Emergency Medical Treatment and Labor Act] EMTALA - Medical Screening, Treatment and Related Issues', last reviewed 10/20/16 revealed: "Emergency Department Log, Signage, On-Call Roster

1. All individuals who come to the Emergency Department for whom a request is made for examination and treatment should be entered into the Emergency Department electronic log and have a medical record generated, regardless of eventual disposition. The purpose of the electronic log is to track the care provided to each individual who comes to the Emergency Department seeking care for an Emergency Medical Condition.

A review of the facility's Inpatient Log and Emergency Department (ED) transfers from 7/1/22 to 9/30/22 failed to reveal P#1's information on the log.

Based on the review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) for one patient (P#1) of 12 sampled patients with a pregnancy related complaint, a 37-week pregnant patient who presented to the facility's ED with complaints of abdominal pain. P#1 waited an undetermined amount of time in the facility's ED waiting room before being moved to the labor and delivery waiting room. P#1 then waited an undetermined amount of time in the labor and delivery waiting room without being seen. P#1 left without being seen after she had a change in her status, vaginal bleeding. P#1 was taken by private vehicle to Facility B, where it was determined that she had intrauterine fetal demise.

Findings included:

A review of the facility's "[Emergency Medical Treatment and Labor Act] EMTALA - Medical Screening, Treatment, and Related Issues", effective date 10/20/2016 stated that "Any individual who comes to the Emergency Department or Labor & Delivery requesting care should be offered an appropriate Medical Screening Examination to determine if the individual has an Emergency Medical Condition. If an Emergency Medical Condition exists, the Hospital should provide treatment to stabilize the condition or an appropriate transfer in accordance with the Hospital Policy on Transfers.

PROCEDURE: An appropriate Medical Screening Examination should be provided to any individual who comes to the Emergency Department (and/or on Hospital Property) and:
(1) the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or
(2) it is apparent that the person needed an examination or treatment of a medical condition based on the individual's appearance or behavior."

A review of the facility's "OB Assessment Area, Care of the Patient policy", effective date 7/20/2021 stated that an "RN [Registered Nurse] will conduct a basic screening assessment on all patients who present to the OB Assessment Area. The basic screening re-assessments are to be communicated as indicated by the patient's condition. The results of the assessment would be documented on the triage flow sheet within the GE Centricity Perinatal (CPN) system. A basic screening assessment will include (but is not limited to):

1. Maternal vital signs
2. Documentation of fetal well-being (fetal heart rate, variability, presents of accels/decels) via a Non-Stress Trest (NST) on an electronic fetal monitor.
3. Frequency and duration of uterine contractions (if present) via NST
4. Vaginal examination: cervical dilation, effacement, fetal presentation and station of presenting part (unless otherwise contraindicated-frank bleeding, placenta previa, preterm PROM)
5. Status of membranes (date, time and color if ROM is reported)
6. Date and time of patient's arrival and notification of provider

I. Obstetrical findings, present or suspected, that require immediate provider notification are:
"3. frank bleeding (vaginal bleeding greater than bloody show)"

II. Obstetrical findings, present or suspected, that require prompt (within 60 minutes provider notification are:
"1. vaginal bleeding"

A review of Patient (P)#1's Emergency Department (ED) records revealed that P#1 signed the Admission/Registration Agreement form on 8/22/22 at 10:02 p.m. There was no other medical record documentation available.

During the electronic medical record review at the facility on 9/4/24 at 10:30 a.m., CD OO stated that P#1 had no ambulance trip reports and there was no video recording since P#1's visit was in 2022, and the facility only kept video recordings for 30 days.

During a facility tour of the Labor and Delivery (L&D) area on 9/3/24 at 10:40 a.m., Unit Director (UD) CC stated when the Emergency Department (ED) gets an OB patient who is more than 20 weeks pregnant, the ED staff would bring the patient directly to the OB floor where the patient would be triaged and given an available bed for further treatment.

An interview was conducted in the facility's Labor and Delivery (L&D) conference room on 9/4/24 at 10:15 a.m. with Patient Access Manager (PAM) MM who stated that whenever a patient in the Emergency Department (ED) waiting room complained of pain, the process would be to call the nurse's desk and ask the unit clerk to let the nurses know that a patient was in pain. If the patient had not been seen after five to eight minutes, they would call the clinical staff in triage and let them know that the patient was in pain. If the patient had still not been seen, they would escalate the issue to the charge nurse and the unit director. PAM MM further stated that she was informed that P#1 got on the elevator and left.

An interview was conducted in the conference room on 9/4/24 at 3:40 p.m. with Patient Account Representative (PAR) KK who stated that P#1 came from the facility's main Emergency Department (ED) to Labor and Delivery (L&D) in a wheelchair with her partner. P#1 was bent over and appeared to be in pain, but she (P#1) did not complain of bleeding. PAR KK recalled that on that night, there were several patients in the labor and delivery waiting room complaining of abdominal pain and the L&D was very busy with no available beds. PAR KK recalled that she (PAR KK) called the nurse's desk every 10 to 15 minutes and received the same answer; all nurses were with other patients and there were no available beds; and that the charge nurse was working to get beds. PAR KK also stated that when P#1 went to the bathroom, her (P#1) partner came to the desk and said "She (P#1) was bleeding in the bathroom". PAR KK stated that her (PAR KK) shift was done so she (PAR KK) gave report to the oncoming staff. She (PAR KK) observed that P#1's partner was leaving with P#1 in the elevator.

An interview was conducted in the conference room on 9/4/24 at 3:55 p.m. with Patient Access Supervisor (PAS) LL who stated that on the day of P#1's incident, the Labor and Delivery (L&D) was very busy and there were no rooms available. PAS LL stated that there were several patients in the waiting room with complaints of abdominal pain, including P#1. PAS LL also stated that she (PAS LL) remembered P#1 being in a wheelchair and quiet. PAS LL further stated that multiple calls were made to the charge nurse in L&D, but she was told that "there were no beds and that the L&D nurses were trying to get beds".

A telephone interview took place in the conference room on 9/5/24 at 1:10 p.m. with Medical Doctor (MD) NN who stated that he saw P#1 at the clinic in the morning on 8/22/22, and P#1 had no complaints. MD NN stated that P#1 had no bleeding, and to the best of his (MD NN) knowledge, there were no medical concerns during the course of P#1's pregnancy.

An interview was conducted in the conference room on 9/5/24 at 2:02 p.m., with Clinical Nurse Specialist (CNS) DD who stated that if the ED received a patient who was more than 20 weeks pregnant, the ED staff would bring the patient directly to the Obstetrics Emergency Department (OB ED), where the patient would be triaged. CNS DD stated that if L&D had no beds, they would utilize any available main operating rooms and also medical-surgical Registered Nurses (RN) to help with antepartum (before birth) patients, so the L&D nurses could focus on the women in labor.

A telephone interview was conducted offsite on 9/5/24 at 6:30 p.m., with Registered Nurse (RN) QQ who was the Labor and Delivery nurse at Facility B. RN QQ stated that she received P#1 in a wheelchair and observed she (P#1) was visibly bleeding, and P#1 and her partner appeared very anxious and worried. RN QQ then called the on-call Medical Doctor (MD) PP, who came immediately and did an Ultrasound for Fetal Heart Tones and confirmed that there were no Fetal Heart Tones. RN QQ also stated that P#1 was urgently admitted for further treatment.

A telephone interview was conducted offsite on 9/6/24 at 10:00 a.m., with Medical Doctor (MD) PP who stated that he was on call at Facility B on 8/22/2022 and was informed by the nurses about P#1. MD PP stated that when he (MD PP) came to the Labor and Delivery (L&D) triage area, he (MD PP) noted that P#1 was visibly bleeding, and the Ultrasound machine was ready for him. MD PP further stated that when he (MD PP) did the ultrasound for Fetal heart tones (Baby's heart rate and rhythm), there was no fetal heart rate and no fetal cardiac activity. MD PP also stated that P#1 and her partner were appropriately anxious and flabbergasted. MD PP further stated that he (MD PP) ordered the radiology Ultrasound to confirm his diagnosis of Intrauterine Fetal Demise (fetus dies in the womb) and urgently admitted P#1 for labor induction (a medical procedure that stimulates labor and delivery).

During an offsite telephone interview on 9/9/24 at 3:10 p.m., Medical Doctor (MD) RR explained that she had been on call for labor and delivery at Facility A on 8/22/22. She further explained that she was not notified of P#1 being in the ED or the Labor and Delivery ED at Facility A. MD RR further stated that she (MD RR) received a phone call from the Chief Resident at Facility A who told her (MD RR) that P#1 was seen at Facility B because when P#1 was at Facility A's ED, she (P#1) was never seen by anyone.