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Based on document review, record review, policy review and interview the hospital failed to ensure the Emergency Medical Treatment and Labor Act (EMTALA) requirements were met by failing to: 1. provide an appropriate medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed for patients who presented to the obstetrics department seeking medical care; 2. provide stabilizing treatment for patients who presented to the emergency department seeking medical care; and 3. appropriately transfer patients who presented to the emergency department seeking emergency medical care for an emergency medical condition (EMC). Failure to perform an appropriate MSE, provide stabilizing treatment and appropriately transfer patients places patients at risk for unidentified emergency medical conditions and deterioration of their condition resulting harm and injury up to an including death.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) situation. (Refer tag 2406)

On 05/01/25 at 8:13 AM, surveyors notified Staff C1, Administrator, that an immediate jeopardy (IJ) existed related to A2406 §489.24(a); §489.24(c), Appropriate Medical Screening Examination.

The hospital submitted a plan of removal (POR) on 05/01/25 at 8:55 AM. On 05/01/25 at 12:50 PM the hospital was notified the written POR was accepted.

The POR included but was not limited to the following:

May 1, 2025

Re: Immediate Jeopardy Removal Plan - EMTALA Medical Screening Exam [Above Named Hospital] has taken the following actions to remove the Immediate Jeopardy, effective immediately:

Contacted the OB Medical Director, via phone, to notify him of the change in practice regarding OB-privileged providers providing on-site medical screening exams for OB patients presenting for emergent care.

Notified OB-privileged providers of the need to provide an on-site assessment of OB patients presenting for emergent care.

Educated OB nursing staff to the need to call the on-call OB-privileged provider to come in for an on-site assessment if an OB patient presents for emergent care.

Clarification notification to OB nursing staff they are to continue their assessment processes. The change in practice is contacting the OB-privileged provider to come on-site to conduct a medical screening exam.

The hospital's plan of removal validated prior to survey exit on 05/01/25 at 12:52 PM.

Findings Include:

The hospital failed to provide an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 3 of 20 patients (Patient's 1, 11 and 12) who presented to the hospital seeking medical care. (Refer to tag A2406)

The hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking medical care. (Refer to tag A2407)

The hospital failed to ensure an appropriate transfer of 6 of 6 patients (Patient's 4, 5, 6, 13, 14 and 16) who transferred with an emergent medical condition (EMC). (Refer to A2409)

Based on record review, policy review, document review and interview the hospital failed to provide an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 3 of 20 patients (Patient's 1, 11 and 12) who presented to the hospital seeking medical care. The hospital's failure to provide an appropriate MSE has the potential for patients to be discharged with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition, including harm and death.

Findings Include:

Review of hospital policy titled "Emergency Medical Treatment and Active Labor Act Compliance (EMTALA)," last revised 04/2025, showed, " ...Qualified Medical Personnel (QMP): A physician, physician assistant, an Advance Practice Registered Nurse in the Emergency Department or a Certified Nurse Midwife in Obstetric Unit with demonstrated competency acting within the scope of his or her license under a medically approved protocol ..."

Review of hospital document titled "Hypertension in pregnancy patient care," dated 11/17/24 showed, " ... Hypertension in pregnancy is defined as systolic blood pressure greater than or equal to 140 mm Hg, diastolic blood pressure greater than or equal to 90 mm Hg .... Notify the practitioner of a systolic reading of 140 mm Hg or greater, a diastolic reading of 90 mm Hg or greater, or for both for two measurements taken within 15 minutes as directed by your facility or the practitioner's order. Patient with hypertension should be reassessed within 15 minutes. If the patient remains hypertensive, evaluation by a practitioner is needed ... continue to monitor the patient's blood pressure at an interval determined by the practitioner's order and the patient's condition ... Obtain blood samples for diagnostic tests ..."

Review of hospital document titled, "Rules & Regulations [Above Named Hospital]," dated 05/2022, showed, " ... the Hospital shall provide for an appropriate medical screening examination within the capability of the hospital's emergency department for any individual who comes to the hospital's emergency department on whose behalf the request is made for examination or treatment for a medical condition as required by the Emergency Medical Treatment and Active Labor Act... A "medical screening examination" is the process required to determine, within a reasonable clinical competence, whether the patient has an emergency medical condition as defined under EMTALA and applicable hospital policies ... All medical screening examinations shall be performed by a qualified medical personnel in a manner consistent with Hospital policies. As determined by the Governing Body, "qualified medical personnel" shall include (i) members of the medical staff acting within the scope of their Privileges, and (ii) Advanced Practice Providers who have been approved to practice at the hospital's acting within their scope of their approval ...


Review of hospital document titled, "Obstetric triage of patients," last reviewed on 02/23/25, showed " ...Clinical Alert: If the patient's systolic blood pressure exceeds 140 mm Hg or the diastolic blood pressure exceeds 90 mm Hg, notify the practitioner because these signs may indicate gestational hypertension [high blood pressure that develops after 20 weeks of pregnancy in woman with normal blood pressure]. Gestational hypertension is a blood pressure that exceeds these values on two separate occasions at least 4 hours apart after 20 weeks' gestation ..."


Review of Obstetrics Log (OB) [Obstetrics is medicine focused on the care of women during pregnancy] from 11/28/24 to 04/29/25 showed that 59 out of 82 patients were assessed by a registered nurse (RN) who according to interview and hospital policy are not a QMPs.


Review of email dated 04/30/25 at 3:45 PM, showed that there are currently 10 RN's working on obstetrical unit.


During an interview on 04/30/25 at 3:38 PM, Staff E, Accreditation and Regulatory Compliance Manager, stated that no RNs in OB are QMPs to provide appropriate MSEs.


During a review of the personnel files on 05/01/25 at 09:10 AM, Staff E, Accreditation and Regulatory Compliance Manager, stated that the following nursing staff employed on the OB unit; Staff U, RN, Staff V, RN, Staff W, RN, Staff H, RN, Staff Y, RN, Staff Z, RN, Staff T, RN, Staff X, RN, Staff A1, RN and Staff B1, RN, are not QMPs.


Patient 1

Review of Patient 1's medical record showed a 23-year-old female, who was approximately 31 weeks pregnant, presented to the OB Unit on 04/21/25 at 12:45 AM with complaint of " ...Pain Itching; Location of Pain Hand radiating to other body parts, arms, legs, back, neck, and abd. [Abdomen] ..."

Review of "Vital Signs" dated 04/21/25 at 1:01 AM, showed, " ...Order comments: Notify provider and increase the frequency of vitals to q15 minutes for the parameter below: HR>120, SBP<80 or >140, DBP<50 or >90, RR >20, SpO2 <95% and temp >38 Celsius (recheck hourly) ..."

Review of "Vitals," dated 04/21/25 showed Patient 1's blood pressure (BP) was 148/86 at 1:09 AM and 159/99 at 2:19 AM, prior to discharge. Her lowest BP was 141/82 at 1:31 AM.

Review of "PT [Patient] Reported Data," dated 04/21/25 at 1:15 AM, showed, " ...Pregnancy induced hypertension - Preeclamptic Risk [pregnancy complication characterized by new onset of high blood pressure] - Headache; Hypertension..."

Review of "Progress Notes" dated 04/21/25 showed, by Staff H, RN, " ...0130 [1:30 AM] Notifiy (sic)[Staff G, MD], lab results, symptoms per patient, current fetal HR [heart rate] status, and ctx [contraction] status. Order received. 0145 [1:45 AM] Medication given per [Staff G, MD], provided water, ice packs, and fan for comfort ..."

Patient 1's medical record showed, " ...Discharge Date and Time: 4/21/25 2:45 AM ..."

Review of Patient 1's [Hospital 2] medical record dated 04/21/25 at 12:42 PM, showed, " ...here for c/o [complaint of] itching on hands, feet, abdomen and back. Informed dr [doctor] that pt [patient] also with elevated bp [blood pressure] on arrival 168/88 ...takes 100 mg labetalol [medication to treat high blood pressure] BID [twice a day] last took this morning ...dr [doctor] ...will send ursodol [Ursodeoxycholic acid is prescribed to pregnant women to treat intrahepatic cholestasis of pregnancy] to home pharmacy ...to increase labetalol to TID [three times a day] as well ..."

During an interview on 04/29/25 at 10:30 AM, Patient 1 stated that on that same day of 04/21/25 after being dismissed from [Above Named Hospital], she sought care at another hospital where she received lab work and medications for the itching and blood pressure.

During an interview on 04/30/25 at 1:04 PM, Staff H, RN, stated that Patient 1's blood pressure was elevated at 159/99. She was already taking medication for high blood pressure.

During an interview on 04/30/25 at 8:13 AM, Staff G, Obstetrician Gynecologist (OBGYN), MD, stated that she was unaware of the patient's blood pressure of 159/99 and was reporting symptoms of headache. Given these findings, the patient should have been admitted for additional care. Since itching is sign of intrahepatic cholestasis [a liver condition that affects bile flow during pregnancy] the patient would require additional labs and medication.

During an interview 04/30/25 at 9:24 AM, Staff T, OB RN, stated that we have always called it triage, but I guess it is like a Medical Screening Exam (MSE). The physician is called within an hour or earlier if there are contractions, bleeding or premature rupture of membranes and provide them with the triage information, such as telling them if vital signs are stable.

During a review of the personnel files for Staff H, OB RN on 04/30/25 at 1:50 PM, revealed that Staff H was a traveling nurse, and was not a QMP as defined in the hospitals Rules & Regulations.

During an interview on 04/30/25 at 1:50 PM, Staff C, DON, stated that Staff H, OB RN does not have any competencies to provide an MSE as a QMP.


Patient 11

Review of Patient 11's medical record showed a 31-year-old female, who was in her first trimester (1-13 weeks pregnant) of pregnancy presented to the OB Unit on 12/10/24. An MSE was provided by Staff V, RN, with a complaint " ...comes in for not feeling infant move and headache and swelling ..."and a visit diagnosis of " ...Supervision of normal intrauterine pregnancy in multigravida [a female who has been pregnant at least a second time], first trimester ..."

During an interview on 05/01/25 at 9:10 AM, Staff E, Accreditation and Regulatory Compliance Manager, stated that Staff V, RN, does not have any competencies to provide an MSE as a QMP.

Review of Patient 11's medical record failed to show evidence that an MSE was provided by a QMP.


Patient 12

Review of Patient 12's medical record showed a 29-year-old female, who was approximately 35 weeks pregnant, presented to the OB Unit on 04/20/25. An MSE was provided by Staff X, RN, on 04/20/25 at 2:45 PM with a chief complaint of " ...Rupture of Membrane [Leaking or bursting of the sac that protects the baby or fetus] ..."

During an interview on 05/01/25 at 9:10 AM, Staff E, Accreditation and Regulatory Compliance Manager, stated that Staff X, RN, does not have any competencies to provide an MSE as a QMP.

Review of Patient 12's medical record failed to show evidence that an MSE was provided by a QMP.

Based on record review, policy review, document review and interview the hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death.

Findings Include:

Review of hospital policy titled "Emergency Medical Treatment and Active Labor Act Compliance (EMTALA)," Last Revised 04/2025, showed, " ... Stabilize: with respect to an emergency medical condition as defined above, to provide treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration is likely to result from (or occur during) the transfer of an individual ...Stable for discharge: QMP has determined, within reasonable clinical confidence, that the patient has reached a point where his/her continued care, including diagnostic work-up and/ or treatment, could be reasonably performed as an outpatient or later as an inpatient with no material deterioration in condition, provided the patient has given a plan for appropriate follow up care with discharge instructions ..."

Review of hospital document titled, "Hypertension in pregnancy patient care," dated, 11/17/24 showed, " ... Hypertension [high blood pressure] in pregnancy is defined as systolic blood pressure greater than or equal to 140mm Hg, diastolic blood pressure greater than or equal to 90mm Hg .... Notify the practitioner of a systolic reading of 140mm Hg or greater, a diastolic reading of 90mm Hg or greater, or for both for two measurements taken within 15 minutes as directed by your facility or the practitioner's order. Patient with hypertension should be reassessed within 15 minutes. If the patient remains hypertensive, evaluation by a practitioner is needed ... continue to monitor the patient's blood pressure at an interval determined by the practitioner's order and the patient's condition ... Obtain blood samples for diagnostic tests ..."

Review of hospital document titled, "Obstetric triage of patients[Obstetrics is medicine focused on the care of women during pregnancy]," last reviewed on 02/23/25, showed " ...Clinical Alert: If the patient's systolic blood pressure exceeds 140 mm Hg or the diastolic blood pressure exceeds 90 mm Hg, notify the practitioner because these signs may indicate gestational hypertension [high blood pressure that develops after 20 weeks of pregnancy in woman with normal blood pressure]. Gestational hypertension is a blood pressure that exceeds these values on two separate occasions at least 4 hours apart after 20 weeks' gestation ..."


Patient 1

Review of Patient 1's medical record showed a 23-year-old female, who was approximately 31 weeks pregnant, presented to the Obstetric Unit (OB) on 04/21/25 at 12:45 AM with complaint of " ...Pain Itching; Location of Pain Hand radiating to other body parts, arms, legs, back, neck, and abd. [Abdomen] ..."

Review of "Vital Signs" dated 04/21/25 at 1:01 AM, showed, " ...Order comments: Notify provider and increase the frequency of vitals to q15 minutes for the parameter below: HR>120, SBP<80 or >140, DBP<50 or >90, RR >20, SpO2 <95% and temp >38 Celsius (recheck hourly) ..."

Review of "Vitals," dated 04/21/25 showed Patient 1's blood pressure (BP)was 148/86 at 1:09 AM and 159/99 at 2:19 AM, prior to discharge. Her lowest BP was 141/82 at 1:31 AM.

Review of "PT [Patient] Reported Data," dated 04/21/25 at 1:15 AM, showed, " ...Pregnancy induced hypertension - Preeclamptic Risk [pregnancy complication characterized by new onset of high blood pressure] - Headache; Hypertension."

Review of "Progress Notes" dated 04/21/25 showed, by Staff H, RN, " ...0130 [1:30 AM] Notifiy (sic)[Staff G, MD], lab results, symptoms per patient, current fetal HR [heart rate] status, and ctx [contraction] status. Order received. 0145 [1:45 AM] Medication [Benadryl 50mg oral] given per [Staff G, MD], provided water, ice packs, and fan for comfort.

Patient 1's medical record showed, " ...Discharge Date and Time: 04/21/25 2:45 AM ..."

Review of Patient 1's [Hospital 2] medical record dated 04/21/25 at 12:42 PM, showed, " ...here for c/o [complaint of] itching on hands, feet, abdomen and back. Informed dr [doctor] that pt [patient] also with elevated bp on arrival 168/88 ...takes 100mg labetalol [medication to treat high blood pressure] BID [twice a day] last took this morning ...dr [doctor] ...will send ursodol [Ursodeoxycholic acid is prescribed to pregnant women to treat intrahepatic cholestasis of pregnancy] to home pharmacy ...to increase labetalol to TID [three times a day] as well ..."

During an interview on 04/29/25 at 10:30AM, Patient 1 stated that on that same day of 04/21/25 after being dismissed from [Above Named Hospital], she sought care at another hospital where she received lab work and medications for the itching and blood pressure.

During an interview on 04/30/25 at 1:04 PM, Staff H, RN, stated that Patient 1's stated that the patient presented with non-obstetric concern of itching, which is not considered a pregnancy related symptom. Her blood pressure was elevated at 159/99. She was already taking medication for high blood pressure.

During an interview on 04/30/25 at 8:13 AM, Staff G, Obstetrician Gynecologist (OBGYN), MD, stated that she was unaware of the patient's blood pressure of 159/99 and that the patient was reporting symptoms of headache. Given these findings, the patient should have been admitted for additional care. Since itching is sign of intrahepatic cholestasis [a liver condition that affects bile flow during pregnancy] the patient would require additional labs and started on a medication called Ursodeoxycholic acid.

During an interview 04/30/25 at 9:24 AM, Staff T, OB RN, stated that that itching in pregnant woman could be a sign of intrahepatic cholestasis. That would need additional lab test and sign of possible early delivery. If pregnant patient has a headache and blood pressure of 159/99 it would need to be reported to the doctor.

Review of the medical record showed the hospital failed to provided Patient 1 stabilizing treatment for signs and symptoms of intrahepatic cholestasis and gestational hypertension.

Based on record review, policy review, document review and interview the hospital failed to ensure appropriate transfer of patients with an emergency medical condition (EMC) for 6 of 6 patients (Patients 4, 5, 6, 13, 14 and 16) reviewed for transfer. Failure to ensure an appropriate transfer place patients at risk for an unsafe transfer and deterioration person's condition, including harm and death.

Findings Include:

Review of a hospital policy titled "Emergency Medical Treatment and Active Labor Act Compliance (EMTALA)," last reviewed 04/2025, showed, " ...If physician not physically present at the time of transfer, a designated QMP [Qualified Medical Professional] may sign the certificate. The determination to transfer the patient will be made by the physician in consultation with the signing QMP, and the physician will co-sign the certification within 24 hours of the transfer ..."


Patient 4

Review of Patient 4's medical record showed a 77-year-old the patient who presented to emergency department (ED) on 04/21/25 at 10:28 AM by private vehicle. Patient 4 was triage at 10:41 AM. Her chief complaint was chest pain. Patient 4 was seen and evaluated by Staff K, Advanced Practice Registered Nurse (APRN).

Review of Patient 4's medical record dated 04/21/25 at 3:10 PM showed Patient 4 was transferred by ALS (Advanced Life Support) air ambulance for diagnosis of non-ST elevation MI [Myocardial Infarction] (NSTEMI) (a type of heart attack).

During an interview on 04/30/25 at 10:37 AM, Staff A, Emergency Department Manager, stated that there is no co-signature on Patient's 4 medical record.

Review of Patient 4's certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital "Emergency Medical Treatment and Active Labor Act Compliance (EMTALA)," policy.


Patient 5

Review of Patient 5's medical record showed a 47-year-old the patient who presented to ED on 01/16/25 at 11:34 AM by private vehicle. Patient 5 was triage at 11:40 AM. Her chief complaint was rapid heart rate. Patient 5 was senn and evaluated by Staff M, APRN.

Review of Patient 5's medical record dated 01/16/25 at 6:30 PM showed Patient 5 was transferred by ALS (Advanced Life Support) ground ambulance for diagnosis of Atrial fibrillation with RVR (heart rhythm disorder where the atria beat irregularly and the ventricles beat too fast), Hyperthyroidism (overproduction of hormone by the gland in of the neck (thyroid), Hypomagnesemia (low magnesium levels in the blood).

Review of Patient 5's certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital "Emergency Medical Treatment and Active Labor Act Compliance (EMTALA)," policy.


Patient 6

Review of Patient 6's medical record showed a 22-year-old the patient who presented to ED on 03/23/25 at 4:11 PM by ambulance. Patient 6 was triage at 4:11 PM. His chief complaint was gunshot wound to head. Patient 6 was seen and evaluated by Staff M, APRN.

Review of Patient 6's medical record dated 03/23/25 at 4:42 PM showed Patient 6 was transferred by ALS (Advanced Life Support) air ambulance for diagnosis of gunshot wound of head.

During an interview on 04/30/25 at 10:37 AM, Staff A, Emergency Department Manager, stated that there is no co-signature on Patient's 6 medical record.

Review of Patient 6's certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital "Emergency Medical Treatment and Active Labor Act Compliance (EMTALA)," policy.


Patient 13

Review of Patient 13's medical record showed a 44-year-old male who presented to the ED on 03/10/25 at 11:07 AM by private vehicle. Patient 13 was triaged at 11:17 AM. His chief complaint was paranoid delusions with a diagnosis of psychosis. (state of mind that results in magical thinking, delusions, and/or hallucination. The inability to process stimuli properly.) Patient 13 was seen and evaluated by Staff Q, APRN.

Review of Patient 13's medical record dated 03/10/25 at 11:32 PM showed Patient 13 was accepted for transfer to a behavioral health hospital and transported via secured vehicle.

During an interview on 04/29/25 at 3:15 PM, Staff Q, Advanced Practice Registered Nurse (APRN), stated that Patient 13 did not have a co-signature from a physician on the EMTALA plus transfer form.

Review of Patient 13's certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital "Emergency Medical Treatment and Active Labor Act Compliance (EMTALA)," policy.

Patient 14

Review of Patient 14's medical record showed a 67-year- old male who presented to the ED on 02/25/25 at 2:25 PM by private vehicle. Patient 14 was triaged at 2:27 PM. His chief complaint of chest pain resulted in diagnosis of Myocardial Infarction (often called a heart attack, in which blood cannot reach the organ of the heart properly, usually due to blood clots). Patient 14 was seen and evaluated by Staff Q, APRN.

Review of Patient 14's medical record dated 02/25/25 at 2:56 AM showed Patient 14 was transferred to an acute care hospital via air ambulance.

During an interview on 04/29/25 at 3:15 PM, Staff Q, Advanced Practice Registered Nurse (APRN), stated that Patient 14 did not have a co-signature from a physician on the EMTALA plus transfer form.

Review of Patient 14's certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital "Emergency Medical Treatment and Active Labor Act Compliance (EMTALA)," policy.

Patient 16

Review of Patient 16's record showed a 44-year-old male who presented to the ED on 04/04/25 at 7:29 PM by private vehicle. Patient 14 was triaged at 7:34 PM. His chief complaint was of right sided extremity weakness that led to the diagnosis of an Acute Ischemic Stroke (Blockage of blood to the brain, usually resulting from a blood clot. Leads to the gradual death of brain tissues). Patient 16 was seen and evaluated by Staff I, Physician Assistant-Certified (PA-C).

Review of Patient 16's medical record dated 04/04/25 at 9:10 PM, showed Patient 16 was transferred to an acute care hospital by fixed wing transport ambulance.

During an interview on 04/29/25 at 2:28 PM, Staff M, Advanced Practice Registered Nurse (APRN), stated that Patient 16 did not have a co-signature from a physician on the EMTALA plus transfer form.

Review of Patient 16's certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital "Emergency Medical Treatment and Active Labor Act Compliance (EMTALA)," policy.

During an interview on 04/29/25 at 2:51 PM, Staff I, Physician Assistant (PA), stated that the physician co-signature is signed after the patient has been transferred.

During an interview on 04/29/25 at 3:05 PM, Staff Q, Advance Practice Registered Nurse (APRN), stated that a physician signature is required on the EMTALA Plus forms, not sure of the exact steps involved.

During an interview on 04/29/25 at 4:11, PM, Staff K, Advance Practice Registered Nurse (APRN), stated that when a patient is transferred, the receiving facility's physician is the cosigner and signs the EMTALA form.

During an interview on 04/30/25 at 10:00 AM, Staff D1, Doctor of Osteopathic Medicine (DO), Emergency Department Director, stated that as the only physician, he personally has never co-signed the EMTALA Plus Transfer form.