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Based on record review, interview with staff, and review of policy and procedures, the facility failed to ensure compliance with EMTALA Regulations 489.20 and 489.24 in that the facility failed to provide a medical screening exam for 1 of 20 patients whose record was reviewed.

See findings:

The Hospital failed to provide a medical screening exam. See A2406.

Based on review of 20 medical records, and three of three staff interviews (A,B,C), the hospital failed to provide a medical screening exam to 1 of the 20 patients who presented in labor having contractions.

Findings include:

Per review of patient #1's clinical record on 9/27/11, the patient presented to the hospital's OB unit (through the emergency room) on the morning of 09/18/2011 complaining of cramping. Initial comments by the RN A in the clinical record at 12:57 AM state; "pt. rode scooter to ER, lower abdominal pain for last 2 days, got worse this evening. History of pre-term labor on bedrest now. Denies RBOW (rupture of bags of water) or vaginal bleeding. She was evaluated by OB nursing staff who contacted the OB physician on-call by telephone. Documentation by RN A in the patient's record timed 1:15 AM states; "Report to Dr. (B), order received to transfer to Aurora".

A review of the patient's record revealed that her vital signs were stable. Fetal strips indicated that the fetus was also stable. The patient's record did not contain a narrative note; instead information was presented in the form of flowsheets tracking the patient's condition.

The patient was transferred by ambulance to the receiving hospital at 1:40 AM according to the transfer form. As mentioned in the hospital's report of the incident, the "Physician Certificate of Transfer form" had not been completed by a physician or qualified personnel. The patient was not provided an appropriate medical screening exam as she had not been examined by qualified personnel.

According to the hospital's policy on transfer of patients to another facility the physician must complete and sign the transfer form which indicates the patient is stabilized for transfer, risks and benefits have been discussed with the patient, and the accepting physician has been consulted and has agreed to accept the transfer.

Per interview (by phone on 09/28/2011 at 2:05 PM) physician B, on-call the evening of the incident, said she misunderstood the nurse's report. She was led to believe that the patient was stable and therefore could be discharged.

RN A was interviewed by phone on 09/30/2011 at 8:15 AM. She stated that the patient #1 had made her way to the hospital by scooter and couldn't get to her doctor. When the nurse called the on-call physician, the nurse understood she was to send the patient to the other hospital. Before the transfer she called nursing staff at the receiving hospital and filled out the physician certificate of transfer form. Then the nurse called an ambulance and accompanied the patient to the receiving hospital.

Based on the preceding information the EMTALA complaint was substantiated, and therefore an EMTALA deficiency is being cited.

Based on record review, interview with staff, and review of policy and procedures, the facility failed to ensure compliance with EMTALA Regulations 489.20 and 489.24 in that the facility failed to provide a medical screening exam for 1 of 20 patients whose record was reviewed.

See findings:

The Hospital failed to provide a medical screening exam. See A2406.

Based on review of 20 medical records, and three of three staff interviews (A,B,C), the hospital failed to provide a medical screening exam to 1 of the 20 patients who presented in labor having contractions.

Findings include:

Per review of patient #1's clinical record on 9/27/11, the patient presented to the hospital's OB unit (through the emergency room) on the morning of 09/18/2011 complaining of cramping. Initial comments by the RN A in the clinical record at 12:57 AM state; "pt. rode scooter to ER, lower abdominal pain for last 2 days, got worse this evening. History of pre-term labor on bedrest now. Denies RBOW (rupture of bags of water) or vaginal bleeding. She was evaluated by OB nursing staff who contacted the OB physician on-call by telephone. Documentation by RN A in the patient's record timed 1:15 AM states; "Report to Dr. (B), order received to transfer to Aurora".

A review of the patient's record revealed that her vital signs were stable. Fetal strips indicated that the fetus was also stable. The patient's record did not contain a narrative note; instead information was presented in the form of flowsheets tracking the patient's condition.

The patient was transferred by ambulance to the receiving hospital at 1:40 AM according to the transfer form. As mentioned in the hospital's report of the incident, the "Physician Certificate of Transfer form" had not been completed by a physician or qualified personnel. The patient was not provided an appropriate medical screening exam as she had not been examined by qualified personnel.

According to the hospital's policy on transfer of patients to another facility the physician must complete and sign the transfer form which indicates the patient is stabilized for transfer, risks and benefits have been discussed with the patient, and the accepting physician has been consulted and has agreed to accept the transfer.

Per interview (by phone on 09/28/2011 at 2:05 PM) physician B, on-call the evening of the incident, said she misunderstood the nurse's report. She was led to believe that the patient was stable and therefore could be discharged.

RN A was interviewed by phone on 09/30/2011 at 8:15 AM. She stated that the patient #1 had made her way to the hospital by scooter and couldn't get to her doctor. When the nurse called the on-call physician, the nurse understood she was to send the patient to the other hospital. Before the transfer she called nursing staff at the receiving hospital and filled out the physician certificate of transfer form. Then the nurse called an ambulance and accompanied the patient to the receiving hospital.

Based on the preceding information the EMTALA complaint was substantiated, and therefore an EMTALA deficiency is being cited.