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Based on record review, staff interview, RCA report review, and review of L&D walk-in logs, it was determined the facility failed to record a laboring patient who presented to the L&D department for emergency services on the L&D log for 1 of 1 laboring patient (Patient #12) who was turned away from the hospital and whose record was reviewed. This caused a lack of documentation of Patient #12's presentation to the hospital. Findings include:

The hospital's risk management department self-reported a potential EMTALA violation to the SA on 8/31/23 and provided information about Patient #12. Patient #12's medical record was requested from the hospital.

Provided for Patient #12 was a "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer," which was signed by Patient #12 and Staff B at 4:30 AM on 8/25/23. The form showed Patient #12 presented to the hospital for emergency treatment.

L&D walk in logs for the month of August 2023 were reviewed and did not include Patient #12 as a walk in.

Staff A, from risk management, was interviewed on 9/12/23 at 9:40 AM. When asked how she became aware of Patient #12's presentation to L&D, she stated the hospital Patient #12 went to after presenting to MVH called and told her. When asked if Patient #12 was listed in the L&D walk in logs, she stated, "not that I could find."

The facility failed to ensure all patients presenting to the hospital for emergency services were reflected in the L&D log.

Based on medical record review, RCA review, policy review, medical staff credentialing files review, and staff interview, it was determined the facility failed to provide an appropriate MSE to 3 of 20 patients (Patients #6, #8, and #12) whose record was reviewed, including one laboring patient (Patient #12) who was turned away from the hospital. Additionally, the hospital failed to ensure patients presenting with similar signs and symptoms (Patients #6 and #8) were provided the same level of MSE as (Patients #9 and #19) within the capability of the hospital. Failure to provide an MSE within the capability of the hospital to all patients presenting for emergency medical care put patients at risk of a serious negative outcome and had the ability to affect all patients presenting to the facility with an EMC. Findings include:

1. Patients were not provided an appropriate MSE.

a. A facility policy titled, "L&D - EMTALA Medical Screening Protocol," approved 5/2022 stated, "Any patient who comes to the Labor and Delivery unit requesting examination or treatment must be provided with 'an appropriate medical screening examination' (MSE) immediately upon arrival to the unit ... The MSE begins with the collection of patient history, including chief complaint. A complete physical assessment (including vital signs) and OB assessment (including a Sterile Vaginal Exam and fetal monitoring) will be done if applicable." This policy was not followed. An example includes:

The hospital's risk management department self-reported a potential EMTALA violation to the SA on 8/31/23 and provided information about Patient #12. Patient #12's medical record was requested from the hospital during the survey.

Provided for Patient #12 was a "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer," which was signed by Patient #12 and Staff B at 4:30 AM on 8/25/23. The form stated the following:

"Benefits of Services
I (the patient or parent/legal guardian of the listed patient) understand that the hospital has a duty to provide and has offered to:
- Perform a medical screening exam to determine if an emergency medical condition exists.
- Provide necessary medical treatment to stabilize any emergency medical condition.
- If necessary, transfer to another facility that can provide treatment not available at this facility.
- Other (none, if not checked)

Risks of Refusal
I have been informed of an understand the risks that may be associated with my refusal, including, but not limited to:
- The medical condition may worsen and result in permanent disability or even death.
- Delaying care at this time may result in increased cost of care at a later time.
- Other (none if not checked)

Patient (or parent/legal guardian) Acknowledgement of Understanding:
I understand that by refusing the services offered, I am doing so against the medical advice of the physician and hospital. I also understand that the availability of medical services, including examination and stabilizing treatment, is not based on my ability to pay for these services. I have been given the opportunity to ask questions about the above information and all my questions have been answered to my satisfaction. I assume the risks and consequences involved and release the physician, facility, and staff from any liability.

I completely understand the possible consequences of my refusal."

The form was signed by Patient #12 on 8/25/23 at 4:30 AM.

The RCA related to Patient #12's course of treatment was requested. It was dated 8/31/23. It stated, "Patient presented to L&D with contractions. CNA roomed patient and had her change into a gown since the charge nurse was busy with other tasks. RN then presented to patient room and informed her that we were on "divert" and that she could not deliver at MVH and would need to go to [Hospital A, another local hospital]. Staff told patient that if they checked her cervix and she was dilated to >6 [centimeters], she would have to go by EMS. Patient signed refusal and drove by private vehicle to [Hospital A] L&D." The RCA also stated, "Spoke with all staff involved with event. Thursday to Friday morning was very busy. Staff went onto 'divert' at L&D manager's direction ... The charge RN did not see this patient present to L&D because she was busy with other tasks. CNA roomed patient so she was not waiting at the nurses' station and instructed pt [patient] to change into a gown. There was an open bed but there was not sufficient staffing to care for a walk-in. This was discussed with the patient by the RN and the patient signed a refusal and willingly left to [Hospital A.]"

Staff B, an RN, was interviewed on 9/13/23 at 12:54 PM. She stated at midnight on 8/25/23, they were told to go on divert by the L&D manager. She stated Patient #12 presented to the L&D department while the unit was still on divert and Patient #12 signed the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer" form. She stated Patient #12 was upset. She stated she had been educated to use the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer" form in staff meetings as well as in orientation. When asked if Patient #12 refused services, Staff B stated, "I don't believe she necessarily refused."

Staff D, an RN, was interviewed on 9/12/23 at 4:36 PM. When asked about Patient #12 signing the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer," she stated, "this has been happening for years." She stated if they were declared on divert due to staffing or "drowning" then they were trained to send L&D patients elsewhere and have them sign the refusal form. She stated, "we tell them they can go across the street and get better care at [Hospital A] and no ambulance." She also stated, "they can refuse to sign the form - in that case we can see them." When asked if she agreed that Patient #12 did not actually refuse services and instead was turned away due to inadequate staffing she stated, "yes."

Staff C, the L&D Manager, was interviewed on 9/14/23 at 8:45 AM and the RCA was reviewed with her. She stated she did not tell anyone to go on divert. When shown the RCA which stated the divert was at her direction, she stated, "I was not in on this conversation." When asked if she said anything that could have been interpreted as her telling staff to put the unit on divert, she said "no."

Additional L&D nurses were interviewed on the L&D floor on 9/13/23 beginning at 2:35 PM regarding the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer," form. The form was shown to them, and the nurses were asked how they were instructed to use it. Staff E stated the NICU had expanded to be able to care for infants as young as 20 weeks gestational age. Staff E stated before the NICU expansion, they would use the form if a laboring patient less than 35 weeks along came in. She stated once they had a woman come in who was 22 weeks along, and they told her they would triage her, but she would have to get shipped to Hospital A, or she could drive herself since it was cheaper. She stated the woman refused treatment and went to hospital A. Another RN, Staff F, was shown the form and stated it was used if a woman came in to get triaged and refused triage to choose to go to another hospital. She stated if all the rooms were full, they might tell a laboring patient there was the potential the patient might deliver in the triage room or postpartum room.

Staff A, from risk management, was interviewed on 9/12/23 at 9:15 AM and the RCA about Patient #12 was reviewed. Surveyors and Staff A reviewed the documentation that Patient #12 was told to go to a different hospital by MVH staff. Surveyors asked Staff A why Patient #12 signed a refusal form she said, "I wouldn't say that it fits for a refusal." Staff A agreed Patient #12 did not refuse services at the facility. Staff A agreed the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer" form was not used appropriately. When asked if there was an MSE done for Patient #12 she stated, "there was not - no."

Patient #12 was not provided an MSE.

b. Patient #6 was a 42 year old female with Medicaid insurance. She presented to the MVH ED on 3/02/23 at 3:50 AM with a chief complaint of body aches, leg pain, chills, headache, nausea, and upper abdominal pain. Patient #6 was approximately 10 days post op for a Panniculectomy (abdominal surgery to remove excess skin). The surgery was performed by a physician who had surgical and admitting privileges at MVH.

Patient #6's medical record included a physician note documented by Staff G on 3/02/23 at 4:33 AM. The note included Patient #6 was being seen at wound care for dressing changes and wound care stated to Patient #6 if she has worsening abdominal pain that she would require further evaluation. It included, "she notes that this morning she started having body aches chills nausea as well as worsening abdominal pain which prompted her to come to the emergency department."

The ED physician note included, "Patient with abdominal discomfort, chills, body aches. There is a concern for intra abdominal infection post surgery. IV started, blood cultures obtained. Lactate ordered. I do feel that this patient requires a higher level of care. I did speak with the CT scan at the neighboring facility who states that there will be a slight delay. Unfortunately, patient quires[sic] high level of care and will be transferred to out of falls[sic] community hospital."

Staff I was interviewed. On 9/13/23 beginning at 10:00 AM. She confirmed no radiology diagnostics were performed.

The ED director, Staff L, was interviewed on 9/13/23 beginning at 3:00 PM and Patient #6's medical record was reviewed in his presence. When asked if CT services were provided at MVH he stated "yes." He stated they are on call after 5:00 PM but can be called to come in to perform CT and other radiology services.

The ED physician who cared for Patient #6, Staff G, was interviewed by phone 9/13/23 beginning at 2:00 PM and Patient #6's medical record was reviewed in his presence. The ED Physician was asked if he contacted Patient #6's physician who performed her surgery. He stated he attempted but was unable to contact him. When asked why CT was not performed at MVH he stated it would be delayed with radiology staff coming to MVH from IFCH and IFCH can perform "rapid CT." When asked if CT was available at the hospital 24/7 he stated yes but they would have to call in staff members. When asked why she was transferred to IFCH he stated she needed a "Higher level of care," possibly requiring admission or surgery. He confirmed there was no documentation Patient #2 was treated for pain or fever.

Staff H, from the quality department, was interviewed on 9/13/23 beginning at 3:00 PM. When asked what the disposition of Patient #6 was from IFCH, she stated the patient was discharged home after receiving a CT at IFCH. She said the discharge diagnosis was febrile illness.

Patient #6's discharge record was requested from IFCH. It showed that a CT abdomen and pelvis was ordered at 5:45 AM on 3/2/23. The discharge instructions showed Patient #6 was discharged with a diagnosis of "Febrile illness" at 7:24 AM.

There was no documentation Patient #6 was provided an MSE within the capability of the hospital to determine if an EMC existed.

c. Patient #8 was a 17 year old female with Medicaid insurance. She presented to the ED on 5/06/23 at 9:26 AM with a chief complaint of left lower quadrant abdominal pain.

Patient #8's medical record included "Emergency Documentation" which was completed by Patient #8's nurse throughout her stay in the ED. Patient #8 was given pain medication and anti-emetic medications.

Patient #8's medical record included an "ED Note Physician" completed by Patient #8's PA, Staff M. The note included a narrative by the PA. It stated, "On exam she is pleasant and awake. Vital signs are stable. She does have some left LLQ and CVA tenderness. She was given IV fluids, Toradol, antiemetics, and Rocephin. Her white blood cell count is 1800 with a left shift and urinalysis does show some signs of infection. With her symptoms we discussed need for transport to higher level of care as she may have pyelonephritis, and infected renal stone versus tubo-ovarian abscess versus pelvic inflammatory disease versus ovarian torsion or ovarian hemorrhagic cyst requiring specialty consultation. Less likely would be acute appendicitis as she does not have mcburneys point tenderness. [IFCH provider name] excepts[sic] transfer to Idaho Falls Community Hospital."

Patient #8's medical record included a transfer form that included, "Patients diagnosis and/or reason for transfer: Left flank pain, needs higher level of care."

Staff I, an RN, was interviewed on 9/13/23 beginning at 10:00 AM. She confirmed no diagnostic radiology was performed for Patient #8

On 9/13/23 at 10:45, surveyor requested to speak with Staff M who cared for Patient #8. The ED provider was not available for an interview

The Director of Quality, Staff J, was interviewed on 9/13/23, beginning at 3:00 PM. He stated it was within the provider's medical decision making to determine if CT would be ordered and performed. He confirmed CT was available at the hospital.

There was no documentation Patient #6 was provided an MSE within the capability of the hospital to determine if an EMC existed.

The hospital failed to ensure MSEs were provided to all patients.

2. The MSE provided was not the same between patients presenting with similar signs and symptoms for Abdominal Pain.

A hospital policy titled, "MVH Emergency Department: Scope of Service and Fundamental Standards of Care" included, "If the patient belongs to a non-contracted health plan, he or she will be evaluated to exclude any emergency condition before calling for authorization to treat. If authorization is denied, the patient will be referred to an appropriate physician or facility." The policy also stated, "MVH emergency Department scope of service will include emergency severity index (ESI level 5 and /or/ level 4 on a case by case basis as directed by a provider ... note: Any ESI level 1-3 patient will be promptly transferred to an appropriate care setting under Emergency medical Treatment and Labor Act (EMTALA) guidelines."

The policy explains the ESI level to include:

"Urgent (level 3) treatment and reassessment should occur in 15-45 minutes:

a. Abdominal Pain ..."

Indicating that a patient presenting with abdominal pain will be classified as an ESI level of 3, thus exceeding the treatment capabilities of the MVH ED.

It was unclear why patients presenting to the MVH ED were provided different services for similar presenting symptoms. Examples include:

a. Patient #19 was a 35 year old male with VA / Triwest health insurance. He presented to the ED on 8/08/23 at 1:05 PM. His presenting symptoms were right lower quadrant abdominal pain. Per hospital policy he would be classified as an ESI level of 3 and would warrant a transfer to an appropriate care setting.

Patient #19's medical record included that Patient #19 was provided lab work, pain medication, iv antibiotics, and a CT.

The CT showed that Patient #19 had an acute appendicitis and was admitted to MVH for surgery.

b. Patient #9 was a 19 year old female, with Blue Cross Blue Shield private insurance, who presented to the MVH ED with abdominal pain, with burning and aching that radiated to her lower back.

Her presenting symptoms were right lower quadrant abdominal pain. Per hospital policy she would be classified as an ESI level of 3 and would warrant a transfer to an appropriate care setting.

Patient #9's medical record included a note from the ED provider on 5/10/23 at 7:05 AM. The note included that Patient #9 had recurrent urinary tract infections and has been treated with multiple rounds of antibiotics. The MVH ED provider ordered a CT of her abdomen pelvis. The CT was unremarkable, and Patient #9 was discharged home.

c. Patient #6 was a 42 year old female with Medicaid insurance. She presented to the MVH ED on 3/02/23 at 3:50 AM with a chief complaint of body aches leg pain chills headache nausea and upper abdominal pain. Patient #6 was approximately 10 days post op for a Panniculectomy (abdominal surgery to remove excess skin). The surgery was performed by a physician who had surgical and admitting privileges at MVH.

The ED physician note included. "Patient with abdominal discomfort, chills, body aches. There is a concern for intra abdominal infection post surgery. IV started, blood cultures obtained. Lactate ordered. I do feel that this patient requires a higher level of care. I did speak with the CT scan at the neighboring facility who states that there will be a slight delay. Unfortunately, patient quires[sic] high level of care and will be transferred to out of falls[sic] community hospital."

The ED provider did not indicate what higher level of care included and the expected benefits of such care. Additionally, The provider did not indicate what care could not be provided by MVH ED in a hospital (MVH) that performed surgery, provided post surgical care, and had a CT scanner with 24/7 capability.

There was no documentation in Patient #6's medical record she was treated for presenting fever, chills, and pain.

Staff I, an RN was interviewed on 9/13/23 beginning at 10:00 AM. When asked what treatment was provided for Patient #6's presenting symptoms, she stated labs were drawn and blood cultures. She confirmed no radiology diagnostics were performed. Additionally, she confirmed there was no documentation Patient #6 was given any medications for her pain and fever.

Patient #6's medical record included an ED Nursing Note completed by the RN on 3/02/23 at 5:12 AM. The note included, "Ordered antibiotic treatment was unavailable in Omnicell [medication cabinet]. Pt was wheeled down to IFCH ED . IFCH ed staff was notified of situation they reported that they did have medication needed on hand and would immediately begin to administer antibiotic treatment upon completion of pt assessment and triage into their system."

The ER director was interviewed on 9/13/23 beginning at 3:00 PM and Patient #6's medical record was reviewed in his presence. When asked if the hospital had Pharmacy services 24/7 he stated "yes." When asked if the hospital had other Omnicells to retrieve the ordered Rocephin from he stated that there were multiple Omnicells through out the hospital. The ER director agreed that Rocephin is a commonly available antibiotic and was likely in another omnicell in the hospital. He confirmed no antibiotic treatment was given to Patient #6 prior to her transfer to IFCH ED.

The ED physician who cared for Patient #6 was interviewed by phone 9/13/23 beginning at 2 PM and Patient #6's medical record was reviewed in his presence. The ED Physician was asked if he contacted Patient #6's physician who performed her surgery. He stated he attempted but was unable to contact him. When asked why CT was not performed at MVH he stated it would be delay with radiology staff coming to MVH from IFCH and IFCH can perform "rapid CT". When asked if CT is available at the hospital 24/7 he stated yes but would have to call in staff members. When asked why she was transferred to IFCH he stated she looked like an "acute abdomen" needed a "Higher level of care," possibly requiring admission or surgery. He confirmed there was no documentation Patient #2 was treated for pain or fever.

MVH hospital provides surgical services and has a medical surgical unit. Patient #6's provider's, who performed her surgery, credentialing file was reviewed. It contained current surgical and admitting privileges at MVH. There was no indication in Patient #6's record if any on call surgeon or hospitalist was contacted to see if patient #6's condition warranted admission and/or surgery.

Clevelandclinic.org, (https://my.clevelandclinic.org/health/diseases/25064-acute-abdomen), defines acute abdomen as "Acute abdomen refers to sudden, severe abdominal pain. Many times, it's a sign of a medical emergency that requires immediate surgery. Inflammation, infections, hemorrhaging, blood flow blockages, obstructions and perforations can all cause acute abdomen."

Patient #6's medical record included an abdominal assessment by the ED provider. It included: "Surgical wound on abdomen, dressing in place. Dressing is saturated with blood. Mild abdominal tenderness to palpation throughout her abdomen without guarding or rebound. Dressing is taken down, surgical wound over the umbilicus has a small area of separation, no active bleeding noted , old blood in some oozing noted." Patient #6's medical record had no indication of an acute abdomen. There was no documentation as to why the patient could not wait for the CT tech to come over to MVH. There was no indication it would be a lengthy delay as the above provider note stated it would be a slight delay.

Staff H, from the quality department, was interviewed on 9/13/23 beginning at 3:00 PM. When asked what the disposition of Patient #6 was from IFCH, she stated the patient was discharged home after receiving a CT. She said the discharge diagnosis was febrile Illness.

Patient #6's discharge record was requested from IFCH. It showed that a CT abdomen and pelvis was ordered at 5:45 AM on 3/2/23. The discharge instructions showed she was discharged with a diagnosis of "febrile illness" at 7:24 AM.

d. Patient #8 was a 17 year old female with Medicaid insurance. She presented to the ED on 5/6/23 at 9:26 AM with a chief complaint of left lower quadrant abdominal pain.

Patient #8's medical record included "Emergency Documentation" which was completed by Patient #8's nurse throughout her stay in the ED. Patient #8 was given pain medication and anti-emetic medications.

Patient #8's medical record included a "ED Note Physician" completed by the ED Provider Staff M, a PA. The note included a narrative by the PA. It stated, "On exam she is pleasant and awake. Vital signs are stable. She does have some left LLQ and CVA tenderness. She was given IV fluids, Toradol, antiemetics, and Rocephin. Her white blood cell count is 1800 with a left shift and urinalysis does show some signs of infection. Whit her symptoms we discussed need for transport to higher level of care as she may have pyelonephritis, and infected renal stone versus tubo-ovarian abscess versus pelvic inflammatory disease versus ovarian torsion or ovarian hemorrhagic cyst requiring specialty consultation. Less likely would be acute appendicitis as she does not have mcburneys point tenderness. [IFCH MD] excepts[sic] transfer to Idaho Falls Community Hospital."

Patient #8's medical record included a transfer form that included "Patients diagnosis and/or reason for transfer: Left flank pain, needs higher level of care."

Staff I, an RN, was interviewed on 9/13/23 beginning at 10:00 AM. She confirmed no diagnostic radiology was performed for Patient #8

On 9/13/23 at 10:45, surveyor requested to speak with Staff M. The ED provider was not available for an interview

The Director of Quality, Staff J, was interviewed on 9/13/23, beginning at 3:00 PM. He stated it was within the Provider's medical decision making to determine if CT would be ordered and performed. He confirmed CT was available at the hospital.

There was no documentation Patient #8 was provided an MSE within the capability of the hospital to determine if an EMC existed.

It was unclear why patients presenting with similar symptoms were provided or not provided diagnostic radiological services. Additionally, it was unclear why the MSE provided for patients with similar presenting symptoms was not consistent.

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Based on policy review, medical record review, RCA review, and staff interview, it was determined the facility failed to provide stabilizing treatment for 1 of 1 laboring patient (Patient #12) who was turned away from the hospital and whose record was reviewed. This failure put Patient #12 at risk of a negative outcome due to declining to provide services to a laboring patient. Findings include:

A facility policy titled, "L&D - EMTALA Medical Screening Protocol," revised 5/2022 stated, "If the patient is unstable or in active labor, treatment must be provided until the patient is stable, delivered, or appropriately transferred to another medical facility." This policy was not followed. An example includes:

The hospital's risk management department self-reported a potential EMTALA violation to the SA on 8/31/23 and provided information about Patient #12. Patient #12's medical record was requested from the hospital during the survey.

Provided for Patient #12 was a "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer," which was signed by Patient #12 and Staff B at 4:30 AM on 8/25/23. The form stated Patient #12 refused treatment at the facility, and was signed by Patient #12 and Staff B.

An RCA for the incident with Patient #12 was provided and stated, "Patient presented to L&D with contractions. CNA roomed patient and had her change into a gown since the charge nurse was busy with other tasks. RN then presented to patient room and informed her that we were on "divert" and that she could not deliver at MVH and would need to go to [Hospital A, another local hospital]."

Staff A, from risk management, was interviewed on 9/12/23 at 9:15 AM and the RCA about Patient #12 was reviewed. Staff A agreed Patient #12 did not refuse services at the facility. Staff A agreed the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer" form was not used appropriately. When asked if there was an MSE done for Patient #12 she stated, "there was not - no."

The hospital failed to assess for an EMC for Patient #12 and therefore failed to provide stabilizing treatment for Patient #12.

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Based on medical record review, policy review, RCA review, and staff interview, it was determined the facility failed to ensure transfer of a laboring patient was appropriate and safe for 1 of 1 laboring patient (Patient #12) who was turned away from the hospital and whose record was reviewed. This put Patient #12 at risk of a serious negative outcome due to lack of assessment of Patient #12 and her unborn child and subsequent lack of communication with the receiving hospital. Additionally, the facility failed to ensure an appropriate transfer for 1 of 2 patients (Patient #5) presenting to the hospital with chest pain and whose record was reviewed. This placed Patient #5 at risk due to being transferred without appropriate transportation equipment, including necessary and medically appropriate life support measures during the transfer. Findings include:

1. A facility policy titled, "L&D - EMTALA Medical Screening Protocol," revised 5/2022 stated the following:

"A registered nurse may not discharge or transfer a patient until:
1. Patient has had a medical screening exam.
2. Nurse has consulted with a provider who has authorized the discharge or transfer of the patient.
3. If transferring a patient, complete and get signatures on the appropriate EMTALA transfer form.
4. Documented the MSE, any interventions, provider orders, disposition of the patient, and applicable discharge instructions.
5. Met discharge criteria as stated in this EMTALA policy"

This policy was not followed. An example includes:

The hospital's risk management department self-reported a potential EMTALA violation to the SA on 8/31/23 and provided information about Patient #12. Patient #12's medical record was requested from the hospital during the survey.

Provided for Patient #12 was a "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer," which was signed by Patient #12 and Staff B at 4:30 AM on 8/25/23. The form stated Patient #12 refused treatment at the facility, and was signed by Patient #12 and Staff B.

An RCA for the incident with Patient #12 was provided and stated, "Patient presented to L&D with contractions. CNA roomed patient and had her change into a gown since the charge nurse was busy with other tasks. RN then presented to patient room and informed her that we were on "divert" and that she could not deliver at MVH and would need to go to [Hospital A, another local hospital]."

There was no documentation of communication with Hospital A, where Patient #12 was told to go to. There was no documentation Patient #12 requested the transfer to Hospital A.

Staff A, from risk management, was interviewed on 9/12/23 at 9:15 AM and the RCA about Patient #12 was reviewed. Surveyors and Staff A reviewed the documentation that Patient #12 was told to go to a different hospital by MVH staff. Surveyors asked Staff A why Patient #12 signed a refusal form she said, "I wouldn't say that it fits for a refusal." Staff A agreed Patient #12 did not refuse services at the facility. Staff A agreed the "Mountain View Hospital Refusal of Screening Exam, Treatment, &/or Transfer" form was not used appropriately. When asked if there was an MSE done for Patient #12 she stated, "there was not - no."

Patient #12 did not request the transfer to Hospital A and was not provided an MSE where the physician or QMP signed off on the transfer and agreed the benefits of the transfer outweighed the risk of Patient #12 staying at the facility. Additionally, the facility did not provide medical treatment within its capacity to minimize the risks to the Patient #12's health and the health of her unborn child prior to the transfer.

The facility failed to ensure transfers were safe and appropriate.

2. Patient #5 was an 80 year old female with Medicare insurance, who presented to the ED on 2/26/23 at 3:27 PM with a chief complaint of chest discomfort, shortness of breath, and dizziness.

Patient #5's medical record included "Emergency Documentation" completed by the RN over the course of Patient #5's stay in the ED. The documentation included Patient #5 had a pain score of 3 on a scale of 1 to 10 with 10 being the worst pain. The documentation included the patient "reports dizziness and lightheadedness. Pt reports nausea." The documentation included a narrative note by the RN on 2/26/23 at 4:00 PM, which included, "Provider aware of pain decided to transfer before treatment, EKG done before transfer and shown to provider upon arrival."

Patient #5's medical record included a note by the ED Provider on 2/26/23 at 3:41 PM. It included "80-year-old female who presents to the Mountain View emergency department by private automobile with shortness of breath and chest discomfort. Symptoms stated earlier this morning. She denies any significant chest pain at this time but does feel fatigued and shortness of breath."

The section "medical decision making" included, "Patient was rapidly evaluated in the emergency department. EKG was available as soon as I walked into the patient's room with changes concerning for possible subendocardial injury. I advised the patient that we do not have cardiology specialist on call at this facility and she will need to be transferred to Idaho falls community hospital emergency department immediately. Patient was placed in a wheelchair immediately and taken to Idaho falls can[sic] hospital emergency department."

Staff I, an RN, was interviewed on 9/13/23 beginning at 10:00 AM and Patient #5's record was reviewed in her presence. When asked what stabilizing treatment was done for Patient #5's presenting symptoms she stated an EKG was performed. When asked if the Patient #5 was transferred with a cardiac monitor she stated there was no documentation Patient #5 was placed on a monitor. When asked if Patient #5 had an IV line started in the MVH ED she stated there was no documentation an IV line was placed. When asked if there was any stabilizing treatment for Patient #5's presenting symptoms of shortness of breath and dizziness, she stated, "not that I can see."

Staff K, a PA, was interviewed on 9/13/23 beginning at 2:50 PM. When asked what stabilizing treatment was provided for Patient #5, he stated an IV line was ordered but was not placed. He stated an EKG was performed. When asked if Patient #5 was placed on oxygen he stated she was not hypoxic, so her condition did not warrant oxygen. He stated she was transferred to IFCH and fortunately the other ED is "down the hall" so additional diagnostics or treatments were not done.

The facility failed to ensure transfers were safe and appropriate.