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Based on record review, staff interviews and review of facility policies and procedures the facility failed to ensure staff followed the policies and procedures for EMTALA for 1 of the 21 (Patient # 21) patients selected from the emergency department log during January to July 2012. The facility staff failed to provide patient #21 a Medical Screening Examination (MSE) and failed to enter the patient in the central log. Findings are:

A. Review of the facility' s report sent to the State Agency on 6/26/12 revealed Patient # 21, who was 38 weeks pregnant and complaining of lower right side discomfort told the ED nurse she " might be in labor. " The report specified the ED nurse failed to register the patient in the central log and failed to notify the on call provider or provide the patient with a MSE.

B. In an interview on 6/29/12 at 2:45 PM, Registered Nurse (RN) A stated that Patient # 21 came to the ED around 6 or 6:15 PM on 6/21/12. The RN stated the patient stated "I want to see a Doctor, have a pain" and pointed to the right side of her stomach. RN A stated the patient was "obviously very pregnant." RN A said she asked the patient if she might be in labor and the patient responded "Yeah I could be." RN A told the patient "We will be glad to have you checked out here, but if you are in labor we don't normally deliver babies here, only in an emergency." RN A said she then told the patient "If you think you're in labor then you should go to [Name of Hospital A or B]." The patient told the nurse she was going to Hospital A. RN A stated she "did not do any exam at all or call [Name of hospital A] and she did not get the patient's name.

C. Review of the facility' s policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" effective date 12/09 states under the section titled "MSE": "For any individual arriving at the ED or other areas of the hospital providing unscheduled care and on whose behalf a request for examination or treatment for a medical condition is made or a prudent lay person observer would conclude from the individual's appearance or behavior a need for examination or treatment of a medical condition, an appropriate MSE will be provided within the capabilities of the department, and ancillary services routinely available to the department, to determine whether or not an EMC [Emergency Medical Condition] exists." The policy further states "All ED patients will be seen by an RN who will conduct an assessment." The policy then states "The Qualified Medical Personnel (QMP) will review the initial nursing information and will complete the MSE for existence of an EMC." The policy defines the QMP as a Medical Doctor, Doctor of Osteopathy, Physician Assistant, Nurse Practitioner or an RN with additional training and competency in obstetrical services or behavioral health services.

Review of the policy under the section titled "Emergency Department/Obstetrical Service Logs" states "A list of all patients presenting to the ED or Obstetrical Services will be maintained. At a minimum, this list will contain the patient's name, chief complaint and disposition. Review of log entries for 6/21/12 failed to include an entry related to Patient # 21's visit to the ED.

Based on record review, staff interview and review of facility policies, the facility failed to ensure 1 of 21 patients (Patient # 21) sampled from January to July 2012, were entered in the emegerncy department Central Log. Findings are:

A. Review of facility self report of an EMTALA violation sent to the State Agency on 6/26/12 describes an incident in which Patient 21 presented to the Emergency Department (ED), 38 weeks pregnant with lower right side discomfort and told the nurse she "might be in labor." The nurse failed to perform a MSE, register the patient in the central log, or notify a provider of the patient's presentation to the ED.

B. In an interview on 6/29/12 at 2:45 PM, Registered Nurse (RN) A stated Patient # 21 came to the ED around 6 or 6:15 PM on 6/21/12. The RN stated the patient stated "I want to see a Doctor, have a pain" and pointed to the right side of her stomach. RN A stated the patient was "obviously very pregnant." RN A asked the patient if she might be in labor and the patient responded "Yeah I could be." RN A told the patient "We will be glad to have you checked out here, but if you are in labor we don't normally deliver babies here, only in an emergency." RN A then told the patient "If you think your in labor then you should go to [Name of Hospital A and B]." The patient told the nurse they were going to hospital A about a 20 minute drive away. RN A stated she "did not do any exam at all or call [Name of hospital A] and did not get the patient's name. The patient's name was later obtained during the facility's internal investigation.

C. Review of the policy under the section titled "Emergency Department/Obstetrical Service Logs" states "A list of all patients presenting to the ED or Obstetrical Services will be maintained. At a minimum, this list will contain the patient's name, chief complaint and disposition. Review of log entries for 6/21/12 failed to include any entry related to Patient # 21's visit to the ED.

Based on record review, staff interviews, and tour of the Emergency Department (ED) and Labor and Delivery Room (LDR) the facility failed to ensure 1 of 21 patients (Patient 21) selected from the emergency department log January to July 2012, received a Medical Screening Examination within the hospital's capabilities to determine whether or not an Emergency Medical Condition (EMC) existed. Findings are:

A. Review of the facility' s report sent to the State Agency on 6/26/12 describes an incident in which Patient 21 presented to the Emergency Department (ED), 38 weeks pregnant with lower right side discomfort and told the nurse she "might be in labor." The report specified the ED nurse failed to perform a MSE, register the patient in the central log, or notify the on call provider.

B. In an interview on 6/29/12 at 2:45 PM, Registered Nurse (RN) A stated that Patient 21 came to the ED around 6 or 6:15 PM on 6/21/12. RN A stated the patient said "I want to see a Doctor, have a pain" and pointed to the right side of her stomach. RN A stated the patient was "obviously very pregnant." RN A said she asked the patient if she might be in labor and the patient responded "Yeah I could be." RN A told the patient "We will be glad to have you checked out here, but if you are in labor we don't normally deliver babies here, only in an emergency." RN A said she then told the patient "If you think you're in labor then you should go to [Name of Hospital A or B]." The patient told the nurse she was going to Hospital A. RN A stated she "did not do any exam or call [Name of hospital A]. RN A stated that she has experience with obstetrical patients and in delivering babies and that one time in an emergency, she delivered a baby without a physician present. RN A stated the hospital stopped providing inpatient Obstetrical services in November of 2011. RN A stated that "truly I panicked, it has been over a year since I did a delivery." RN A stated that she is Neonatal Resuscitation Program (NPR) certified. NRP training ensures nurses are able to respond to the resuscitation needs of a newborn infant. RN A stated that if the situation occurred again she "would put the patient in a room, get information, call the physician, assess the patient and put on a fetal monitor." RN A confirmed she "can always get help from the floor if we need it to speed up the assessment."

C. In an interview on 7/5/2 at 10:40 AM the Acute Care Coordinator confirmed the hospital had not provided any retraining or evaluation of staff who cover the ED related to examining obstetrical patients. The Coordinator stated the hospital planned to go over details like checking fetal heart tones or applying a monitor to assess for labor at the next nursing staff meeting in August. The Coordinator stated that RN A knew she needed to examine Patient # 21, that RN A was afraid the patient would deliver here, and told us she (RN A) panicked and knew it was wrong.

D. Observations made during tour of the ED and LDR room on 7/5/12 from 2:30 PM until 2:50 PM with the ED Nursing Manager, RN B, revealed the ED has a fetal heart/maternal contraction monitor in the department and the necessary equipment to perform an emergency delivery. In addition the facility still maintains a separate LDR room down the hall from the ED set up with an infant warmer and another fetal monitor. Interview with RN B during the tour revealed the on call schedule includes either an RN and Licensed Practical Nurse or 2 RN's on call at all times. Staff are to come in within 30 minutes of being called. In addition to the RN in house for ED, the call schedule includes either a mid level practitioner (Physician Assistant, Nurse Practitioner, Advanced Nurse Practitioner) with a Medical Doctor (MD) as backup or a MD as first call. A Certified Registered Nurse Anesthetist is also on call 24/7 to respond to emergencies. RN B stated that all the nursing staff have had Obstetrical training. RN B stated the expectation is that when an Obstetrical patient comes in, staff are to assess the patient, listen for fetal heart tones, check vital signs, check for contractions using the fetal monitor, and then call the provider on call. The provider, either a midlevel practitioner or MD comes in and finishes the MSE usually performing a vaginal exam to determine if delivery is imminent (an EMC). " If delivery is imminent but not precipitous we would move the patient to the LDR room and deliver there. "

E. Review of facility policy titled "Obstetrical Care in the Emergency Department" effective date 8/06 states the assessment of the patient would include the "EDC (Estimated Date of Confinement), name, date and time of last visit to physician, physician's name, Fetal heart tones, vitals, symptoms of possible problem/complications or absence of such and if necessary and indicated, perform vaginal examination to determine effacement and dilation if in apparent labor." An ED record "will be generated and the aforementioned information charted." The policy goes on to state that "if the patient's physician is from the Alegent Health staff, he should be notified. If he is not available , notify the 'on call ' physician." The policy was not updated to reflect that this hospital no longer provided inpatient non emergency deliveries.