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Based on clinical record review, surveillance video review, policy review and staff interview, it was determined, the hospital failed to adopt and enforce a policy to ensure compliance with the EMTALA requirements at 42 CFR 489.20 and 489.24, as evidenced by failure to provide an appropriate Medical Screening Exam (MSE) to determine the extent of an emergency medical condition, and to provide care and treatment to relieve or eliminate such condition. This failure affected 1 of 21 sampled patients (Patient #21).

The findings included:

Based on clinical record review, surveillance video review and interviews conducted on 04/14/25 and 04/15/25, the hospital failed to provide written evidence that a patient, who presented to the Emergency Department (ED) seeking medical care, was registered in the ED central log and received a medical screening exam and stabilization treatment. These failures affected Patient #21 as detailed in citation A 2406.

Based on record review, video surveillance review, policy review and interview, it was determined the facility failed to ensure the central log included all individuals who presented to the Emergency Department (ED) seeking treatment. This failure affected one (1) of 21 sample patients (Patient #21).

The findings included:

Review of the facility policy, titled, EMTALA (Emergency Medical Treatment and Labor Act), last revised 08/03/22, documents:
"CENTRAL LOG POLICY
Central Log Procedure.
a. Hospital will maintain a Central Log either in an electronic format in Cerner (Cerner ED Activity Log) or on paper. The report is reconciled on a regular basis.
b. All ancillary logs maintained by all Hospital Departments, including the DED (Dedicated Emergency Department) are incorporated by reference and become part of Hospital's EMTALA Central Log.
c. The Central Log must contain at a minimum, the name of the individual, the date, time and means of the individual's arrival, the individual's age, the individual's sex, the individual's record number, the nature of the individual's complaint, the individual's disposition, the individual's time of departure, and whether the individual:
refused treatment, was refused treatment,
was transferred,
was admitted and treated,
was stabilized and transferred,
was stabilized and discharged; or
expired.
d. A log entry for all individuals protected under EMTALA should be made by the appropriate individual. Further, in non-DED departments of the hospital where an individual may present with an EMC, the department will provide the necessary information from the point of contact to the DED for logging purposes.
e. The Central Log of individuals protected by EMTALA will be available within a reasonable amount of time for surveyor review and must be retained for a minimum of five years or as delineated by State regulation from the date of disposition of the individual."

Review of the surveillance video conducted on 04/14/25 at approximately 12 noon while accompanied by the Director of the ED, (Emergency Department), the ED Medical Director and the Director of Women Services revealed on 03/11/25 at 1:01 AM, a female carrying a baby in a car seat, entering the ED. The female interacted with the ED staff (Identified as Staff C, a nurse extern). The Staff C and the female went out the door with a wheelchair. A few seconds later, a female in a wheelchair (identified as Patient #21), a male (identified as Patient #21' significant other) and the female carrying the baby (identified as Patient #21's sister) entered the ED and interacted with Staff C and the security guard. The patient's significant other and sister presented identification and received a visitor pass. During the video Staff C is seen contacting someone over the phone. Staff B, the Triage Nurse, is also seen interacting with the patient and family members and contacting someone over the phone. The video shows multiple interactions between the staff and the patient. Patient #21 left the facility without being seen or examined on 03/11/25 at 1:27 AM.

Review of the facility Emergency Department Central Logs dated 03/11/25 revealed the hospital staff failed to maintain a record of every patient presenting to the emergency department. There was no record of Patient #21 in the Central Log. There is no record of any patient refusing care.

A phone interview with Staff B, the Triage Nurse, was conducted on 04/15/25 at 8:38 AM while accompanied by the ED Director, revealed his recollection of events. Patient #21 came in with two family members, and said she was here for obstetrics services (OB ED). Staff B recalled the patient had birthed the baby and was saying something about needing sutures and a procedure and that she was not here to check in for the emergency room. The family explained Patient #21's midwife wanted the patient to be seen by the OB doctor. Staff B contacted the OB ED and was told that the patient had to go through the regular ED. The interview continued and then ED Director kept asking Staff B if he tried to register the patient and Staff B, stated yes, but the patient did not want to be registered, the family members kept saying the patient was here for OB care. Staff B stated the family called the patient's midwife and they were told to leave and go to another hospital. Staff B stated the interaction was not escalated, because the midwife told the patient to leave and go to another hospital. Staff B confirmed Patient #21, who presented at the emergency department seeking care after giving birth and requesting obstetric services, was not registered on the hospital ED central logs.

A phone interview was conducted with Staff C, the Nurse Extern (NE), who greeted Patient # 21, on 04/15/25 10:05 AM. Staff C explained Patient #21 presented with a friend, saying she just delivered a baby a few hours ago and she needed to have her vaginal tear repaired. Staff C called the OB ED and the charge nurse told her the patient needed to be seen in the ED first and when she told the patient's sister, she got upset and said the midwife from the birth center told her to leave and go to another hospital. The patient did not speak very much, the sister and significant other were doing the talking, and the patient did not want to be registered and left. Staff C confirmed Patient #21, who presented at the emergency department seeking care after giving birth and requesting obstetric services, was not registered on the hospital central ED logs.

Based on policy review, record review, surveillance video review and interview, it was determined the hospital failed to substantiate the provision of emergency services for one (1) of 21 sampled patients (Patient #21) as evidenced by lack of a medical screening exam (MSE) to determine if a medical condition existed and if so to provide care and treatment to relieve or eliminate the condition.

The findings included:

Facility policy, titled, EMTALA (Emergency Medical Treatment and Labor Act), last revised 08/03/22 documents:
Review of the "Emergency Medical Condition ("EMC") means:
l . A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part; or
3. With respect to a pregnant woman who is having contractions:
a. that there is inadequate time to effect a safe transfer to another hospital before delivery; or
b. that transfer may pose a threat to the health or safety of the woman or the unborn child; or

N. Medical Screening Examination ("MSE") is the process (which begins with the initial collection of an individual's vital signs and other medical data collection) required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists, or a woman is in labor. Screening is to be conducted to the extent necessary, by physicians and/or other QMP to determine whether an EMC exists. With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric screening.

Procedure:
A. When a Medical Screening Examination is Required
An individual MUST receive an MSE, within the capabilities of Hospital's DED, including ancillary services routinely available, to determine whether or not an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor, and whether or not the treatment requested is explicitly for an emergency condition if:
l . The individual comes to Hospital's DED, including by transfer from another hospital, and a request is made on his or her behalf for examination or treatment for a medical condition.
2. The individual arrives on the Hospital Property other than a DED and a request is made on the individual's behalf for examination or treatment for an EMC.
3. The individual arrives on the Hospital Property, either in the DED or Hospital Property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a Prudent Layperson Observer to believe that the individual needed such examination or treatment and that the individual would request that examination or treatment if he or she were able to do so."

Review of the surveillance video conducted on 04/14/25 at approximately 12 noon while accompanied by the Director of the ED (Emergency Director), the ED Medical Director and the Director of Women Services revealed on 03/11/25 at 1:01 AM, a female carrying a baby in a car seat, entering the ED, the female interacted with the ED staff (Identified as Staff C, a nurse extern). Staff C and the female went out the door with a wheelchair. A few seconds later, a female in a wheelchair (identified as Patient #21), a male (identified as Patient #21' significant other) and the female carrying the baby (identified as Patient #21's sister) entered the ED and interacted with the Staff C and the security guard. The patient's significant other and sister presented identification and received a visitor pass. During the video, Staff C is seeing contacting someone over the phone. Staff B, the Triage Nurse, is also seen interacting with the patient and family members and contacting someone over the phone. The video shows multiple interactions between the staff and the patient. Patient #21 left the facility without being seen for a MSE on 03/11/25 at 1:27 AM.

A phone interview with Staff A, OBED (obstetrics emergency department) Charge Nurse was conducted on 04/14/25 at 12:23 PM, while accompanied by the Director of Women Services. Staff A explained she was on duty on 03/11/25 and recalled the ED calling the unit regarding Patient #21, and the physician intercepted the call. Staff A overheard the conversation, and the physician told the ED that she was not seeing the patient, that is was illegal for the midwife to send a patient with a 3rd degree laceration and asked where was the midwife's back-up doctor for the birth center. At the same time, the midwife from the birth center called the unit, then the physician spoke to the midwife and stated that she was going to report her for sending the patient in this condition. The charge nurse stated the patient was not seen. The ED told them that the patient was signing out AMA and was going to another hospital. The patient never came to the OB ED and when asked, the charge nurse stated she did not report the event to her leadership, she thought the ED staff was going to do it and she is aware that all patients seeking care, have to be seen, but again the physician said she would not see the patient and there was nothing else she could do.

A phone interview with Staff B, the Triage Nurse, was conducted on 04/15/25 at 8:38 AM while accompanied by the ED Director, that revealed his recollection of events: Patient #21 came in with two family members, and said she was here for obstetrics care (OB ED). Staff B recalled the patient had birthed the baby and was saying something about needing sutures and a procedure and that she was not here to check in for the emergency room. The family explained that Patient #21's midwife wanted the patient to be seen by the OB doctor. Staff B contacted the OB ED and was told that the patient had to go through the regular ED. The family members kept saying the patient was here for OB care and then the family called the patient's midwife and were told to leave and go to another hospital.

A phone interview was conducted with OBGYN (obstetrics and gynecology physician) on 04/15/25 at 9:14 AM, while accompanied by the ED Medical Director revealed, the OBGYN was on duty on 03/11/25. It was night shift, very busy night, she can't recall all the details but somehow there was a call, an issue with a patient from a birth center and the midwife did not know what to do after she sustained a laceration after the baby's birth. At some point, the midwife called the unit, she spoke to her and told her that she was abandoning her patient, she was floored how they can run such an unqualified institution, that she needed to call her supervising provider to handle the situation. The OBGYN asked for the midwife's name and license and the midwife gave her name but would not give her license, "she did not want to be used for something that is obviously wrong". The OBGYN added that the midwife called the patient and asked the patient to sign herself out AMA (against medical advice) from the hospital and to go to Hospital A. The OBGYN was asked if she had spoken to the ED nurse and confirmed she did. She told Staff B, "she did not want to see this patient, she did not want to deal with it". The OBGYN was asked if she knew where the patient was at the time of the conversation with Staff B and stated she did not know. The ED Medical Director, then intervened and asked the OBGYN if she refused the patient and replied with a no, adding she told the ED nurse the patient needed to go through the ED.

Interview with the Nurse Midwife was conducted on 04/16/25 at 1:02 PM that revealed Patient #21 was her patient at the birth center. After delivery, the patient sustained a laceration, based on her training and scope of practice, she was not able to repair it, and the patient was discharged with instructions to go to the hospital to repair the tear. The patient chose Wellington Regional Medical Center (WRMC). The Midwife called the hospital (WRMC) and spoke to the nurse, she gave her the name of the patient, what had happened and what she needed, and the nurse stated it was okay to send her just to make sure she had paperwork. Then she received a call from the patient and family members stating the hospital would not see her and they are denying her care. The midwife then called the OBGYN physician, and was told she was not touching her patient, that she was unethical, and the midwife tried to explain to the OBGYN her scope of practice, but the physician was not interested in seeing her patient. After the conversation, she then called Hospital A and asked them to see her patient. Hospital A agreed, and she proceeded to call her patient back and advised them that if WRMC wouldn't treat her, she should go to Hospital A to seek the care that she required.

The investigation determined Patient #21 presented to the ED seeking emergency care after complications of birth, vaginal laceration, and the hospital failed to provide a medical screening exam.

Review of Hospital A records documented Patient #21 presented to the ED on 03/11/25 at 03:11 AM. The medical screening exam documents Patient #21, "a 31-year-old female, first pregnancy and delivery. Postpartum day #0 after spontaneous vaginal delivery at a birth center. Presents for evaluation of perineum and repair of vaginal laceration. Patient reports that she was in labor for less than twenty-four hours and delivered at 9:30 PM today. She was told by her midwife that the vaginal tear was beyond her expertise and sent to Wellington Regional Hospital for evaluation and repair. Patient presented to Wellington Regional Hospital ED and was told that the OB there refused to see her, that they could not treat her and told her to leave. They went back to the birth center, now with a significant delay of care. The patient was then sent to this hospital, ED by her midwife. The patient underwent a laceration repair at 4:44 AM."