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Based on interview and record review, the hospital failed to comply with the requirements of 42 CFR 489.24 by failing to provide a written description of a refused examination and treatment including risk and benefits of the examination and treatment (refer to data tag A-2407).

Based on interview and record review, the hospital failed to provide evidence all reasonable steps were taken to secure a patient's written informed refusal. The hospital further failed to provide a written description of the examination and treatment including risk and benefits of the examination and treatment for one of 32 sampled patients (1). Findings:

Patient 1, a 33 year old pregnant female, was seen in the Emergency Department (ED) on 6/25/13 with complaints of abdominal pain.

On 7/15/13 at 9:30 a.m. a review of Patient 1's ED record was conducted. Nursing notes dated 6/25/13 at 1:31 a.m. indicated Patient 1 arrived to the ED and was triaged (prioritizing incoming patients to determine appropriate wait time to be seen by a physician). Patient 1 was complaining of "lower abdominal discomfort since 6 p.m., worse over the past hour, 31 weeks pregnant, her doctor is at [Hospital B]". Further review of nursing notes dated 6/25/13 at 1:41 a.m. indicated Patient 1 was seen by Physician A (MD A) in the triage area. After being seen by MD A, Patient 1 was planning to leave and go to Hospital B "where she is being treated by her OBGYN (obstetrician gynecologist), patient instructed to follow up with her OBGYN by MD A after discharge from ER [emergency room]".

On 7/15/13 at 9:35 a.m. review of MD A's documentation dated 6/25/13 indicated Patient 1 was 33 weeks pregnant and was complaining of abdominal pain. MD A documented Patient 1 did not have any "obvious contractions...abdomen was soft...still feel the baby moving at this time". Further review of MD A's notes indicated Patient 1 had "decided that she really did not want to be checked here, wanted be followed up with her physician up at [Hospital B]." The plan for Patient 1 was that she "declines being seen here and will pursue her primary care physician or OB physician at [Hospital B]".

On 7/15/13 at 9:40 a.m. a complete record review of Patient 1's 6/25/13 ED visit was conducted in the presence of the ED manager. The record had no indication Patient 1 had signed a refusal of service form. The record had no indication Patient 1 had been informed of a description of the refused examination and treatment including risk and benefits of the examination and treatment for her current condition (pregnant with complaints of abdominal pain).

On 7/16/13 at 8 a.m. during an interview with MD A, he explained it was the hospital's policy to have the ED physician called to the triage area when a pregnant female arrived to the ED department. MD A further explained if the pregnant female was greater than 16 weeks pregnant and presenting with pregnancy related complaints she needed to be further evaluated in the labor and delivery unit.

On 6/25/13 on Patient 1's arrival to the ED, MD A stated he was called to the triage area to assess Patient 1. MD A stated Patient 1 and her husband were sitting in the triage area. He asked Patient 1 if she was having any pain or vaginal bleeding at that time. Patient 1 stated no but did state she was having possible contractions four to six hours prior. MD A stated he asked Patient 1 information regarding her primary OBGYN (routine practice to inquire the name of the primary OBGYN). MD A stated he did not recognize the OBGYN as being a member of the hospital staff. MD A stated he proceeded with his assessment and informed Patient 1 and her husband that he suspected Patient 1 was in preterm labor and needed to have a "rapid evaluation". MD A stated he explained to Patient 1 and her husband that the hospital's on call OBGYN provider could perform a rapid evaluation to rule out labor. MD A stated Patient 1 and her husband had an open conversation and determined they would drive to hospital B because Patient 1 "really wanted" to be seen by her OBGYN. MD A stated he reiterated to Patient 1 and her husband that the hospital could take care of her, but Patient 1 and her husband refused the service offered and left the hospital.

MD A stated that although the risk and benefits of the examination and treatment were not documented in the medical record they were verbalized to Patient 1 and her husband. MD A further stated he was not aware that Patient 1 had not signed a refusal of service form.

On 7/16/13 at 10:05 a.m. during a telephone interview with the triage nurse (RN A), she stated Patient 1 was approximately 31 weeks pregnant with complaints of abdominal pain. On Patient 1's arrival to the ED, RN A stated Patient 1 was pain free. RN A called MD A to the triage area to perform a rapid exam. MD A and Patient 1 had a conversation. RN A stated MD A palpated Patient 1's abdomen. After the examination RN A stated MD A reassured Patient 1 and her husband, that Patient 1 had a non-emergent condition, her vital signs were stable, and she had no vaginal bleeding, and it was okay for Patient 1 to either stay at the hospital or go. RN A further stated Patient 1 appeared uncertain on what to do, but recalled Patient 1 did not want to be seen at the hospital. RN A stated she did not obtain a refusal of service form from Patient 1 because she believed MD A had discharged the patient.

On 7/16/13 at 11 a.m. review of the hospital's "Refusal of Treatment" policy and procedure dated 3/12 indicated physicians should document "the initial refusal and the outcome of the discussion between the patient and the physician..the note should specifically document that the physician gave the patient or legal representative all relevant information, including potential consequences of declining to follow the recommended course of action ...a refusal of permit medical treatment" form should be completed.

On 7/16/13 at 11:15 a.m. review of the hospital's "Emergency Medical Treatment and Active Labor Act (EMTALA)" policy and procedure dated 3/12 indicated "a hospital's EMTALA stabilization obligation is complete when the....physician must inform the patient and surrogate of the risks and benefits of performing the examination and stabilizing treatment and document a statement to this affect in the patient's medical record" and, "take all reasonable steps to secure the patient's or surrogate's written informed consent to refuse examination and treatment".

On 7/18/13 at 10 a.m. review of Hospital B's medical record for Patient 1 indicated the patient arrived to the hospital on 6/25/13 at 2:10 a.m. Admission diagnoses included preterm labor and "was having contractions" on arrival. Patient 1 was stabilized and was transferred later that day (6/25/13) to Hospital C for a higher level of care.

On 7/22/13 at 9:30 a.m. review of Hospital C's medical record for Patient 1 indicated the patient was admitted on 6/25/13 (time unknown). Patient 1 had unstoppable preterm labor and delivered a baby boy on 6/25/13 at 8:51 p.m.. Baby boy was admitted to the neonatal intensive care unit. Patient 1 was discharged from Hospital C on 6/27/13.