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Based on interview, Maternal/Childbirth event report, Labor and Delivery sign-in-sheet review, and policy and procedures, the hospital failed to ensure that Patient #1 (of 14 sampled patients with pregnancy related conditions) who presented at the hospital's emergency department (ED) received an appropriate medical screening examination that made use of the hospital's capabilities (including but not limited to the ancillary obstetrical services routinely available to the emergency department) to determine whether an emergency medical condition existed. On January 18, 2025, Patient #1, presented to the hospital at 3:30 PM with intense abdominal pain, was unable to use the urinate {sic}, and gestational age of under 30 weeks per interview with Patient #1. The hospital had the capability and capacity in the emergency department to conduct a medical screening examination to determine if an emergency medical condition existed, however, the patient refused examination and/or treatment. The facility failed to explain the risks and benefits of examination and/or treatment to Patient #1, and the facility failed to secure her informed refusal to consent to examination and/or treatment.


Refer to findings in Tag A-2406

Based on interviews, labor and delivery log review, and policy and procedure review, the facility failed to maintain a central log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for one (1) of 20 patients, Patient #1, who presented to the obstetric triage with complaints of acute abdominal pain.

Findings include:

The facility's policy titled, "TGH-N-Brooksville and Spring Hill Hospital Policy and Procedure", Original issue date: 12/1/1996, Last Revision Date 2/5/2021. The Policy revealed in part, GENERAL EMTALA REQUIREMENTS; CENTRAL LOG ... 2. Central Log: The hospital shall maintain a Central Log on each individual who comes to the Emergency Department seeking assistance ... Content of Central Log: The Central Log must contain the name of the individual seeking assistance, and the disposition of the patient. Permitted dispositions include: 1) left without treatment, 2) patient refused treatment, 3) patient was transferred, 4) patient was admitted and treated, 5.) patient was stabilized and transferred, 6) patient presented for outpatient or treatment only, or 7) patient was discharged."


Review of the Labor and Delivery Log dated 01/18/2025 for the time on and about 15:30 PM did not document Patient #1 presenting to the OB [obstetrics]/ED [emergency department] for a medical screening exam. This was Patient #1's second presentation to the hospital on 01/18/2025.


During an Interview on 3/19/2025 at 3:10 PM, Staff A, Registered Nurse (RN) stated, "We do act as an emergency room, we treat anyone who comes in, once they are registered, we log them. The secretary does the registration. We put all patients into the triage rooms when they come in with any problem. But anyone can walk in with a problem. I don't do the log, but we should have logged her into the Central Log. All patients with complaints need to be logged, I don't think we have done that all the time. I don't usually do that, usually the Unit Secretary does that."


During an interview on 03/20/2025 at 8:48 AM, Staff B, RN stated, "Traditionally, if a patient were coming in, the secretary would register them in the computer and fill out the log sheet. Looking back, she [Patient #1] should have been entered onto the log sheet. We don't register the patients or complete the logs. We do have a triage that acts as a stand-alone ER [Emergency Room]."

During an interview on 3/20/2025 at 10:45 AM, the Director of OB/GYN (obstetrics/gynecology) stated, "I was notified of this, I think the next day I was working. I was told that she [Patient #1] signed out AMA [against medical advice] and came back later that day but didn't want to stay, wanted to go to another hospital. I spoke with each nurse and the Unit Secretary that was on. We do serve as an emergency room for OB patients. We do register all patients; we keep a log of all patients. She [Patient 1] is not on the log; she should be on the log; we should have placed her on the log. I guess because we are a unique place, we do inpatient, outpatient and emergencies, I guess we just didn't think [about placing Patient #1 on the log]."

During an interview on 3/20/2025 at 1:11 PM, MD #1 (Medical Doctor) stated, "She [Patient #1] did present to us with a problem, so we should keep an accurate log related to who comes in with an emergency medical condition. I think education is warranted so the staff will know to log all of the people that come in."

The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to maintain a central log for Patient #1 on 1/18/2025, who came to the ED seeking medical assistance.

Based on interview, Maternal/Childbirth event report, Labor and Delivery sign-in-sheet review, and policy and procedures, the hospital failed to ensure that Patient #1 (of 14 sampled patients with pregnancy related conditions) who presented at the hospital's emergency department (ED) received an appropriate medical screening examination that made use of the hospital's capabilities (including but not limited to the ancillary obstetrical services routinely available to the emergency department) to determine whether an emergency medical condition existed. On January 18, 2025, Patient #1, presented to the hospital at 3:30 PM with intense abdominal pain, was unable to use the urinate {sic}, and gestational age of under 30 weeks per interview with Patient #1. The hospital had the capability and capacity in the emergency department to conduct a medical screening examination to determine if an emergency medical condition existed, however, the patient refused examination and/or treatment. The facility failed to explain the risks and benefits of examination and/or treatment to Patient #1, and the facility failed to secure her informed refusal to consent to examination and/or treatment.


Findings included:


Patient #1 and her significant other presented to the hospital's labor and delivery department on 01/18/2025, around 1530 [3:30 PM]. This was Patient #1's second presentation on 01/18/2025, where she was seeking medical treatment. A facility document titled, "Maternal/Child Event Report" documented, "This writer was tending to another triage at the time [when Patient #1 presented] and did not directly speak with them through the check in window. It is noted by our secretary that the patient's significant other states that they went home and she was able to nap for a little while but woke up with intense abdominal pain again. Patient reported the pain was 10/10 [a pain rating scale used to measure pain. A 10 indicates [the worst pain possible] and was unable to use the urinate [sic]. Floor RN [Staff A's name] presented to the window to speak with patient. Significant other asked what level NICU [neonatal intensive care unit] we have at this hospital, floor RN [Staff A's name] reported that we were a level 2 NICU and if newborn was delivered here it would have to be transferred out because we only deliver 30 weeks and up. Floor RN [Staff A's name] informed patient and significant other that [name of a different local area hospital] was a Level 3 NICU. Significant other stated they did not want to be separated from their baby as this had happened to them in the past. Significant other was asking the opinion of the nurse, in which she responded she could not tell them what to do. At this time patient and significant other stated they would go to [name of local area hospital] in order to not be separated from their baby. This writer then went into lobby to speak with patients and inform them that we are able to provide care for her here at this facility and although we only have a level 2 NICU, baby and mother would be given the best care possible here. Patient still chose to leave at this time and this writer escorted them to their vehicle patient in wheelchair. Physician notified."

Review of the "Labor and Delivery Unit Patient Sign-In Sheet" no date documented, contained in the prior emergency department visit on the same date of 01/18/2025, documented by Patient #1 under Baby's Due Date was handwritten "04/16/25." According to the facility's policy, " ... the hospital must request that the individual complete the sign in sheet. The facility failed to provide evidence that a Labor and Delivery Unit Patient Sign-In-Sheet was filled out when patient #1 presented to the facility's ED upon her return visit on 1/18/2025 at 3:30 P.M. The facility failed to ensure that their policy and Procedure was followed as evidenced by failing to inform Patient #1 on 1/18/2025 at 3:30 P.M., of the hospital's obligation, to explain the risks and benefits of the examination and treatment and to secure her refusal to consent to examination or treatment. The facility also failed to make reasonable attempts to obtain a written refusal to consent to treatment or examination on the form provided for that purpose as stated in the facility's policy.



During an interview on 03/19/2025 at 3:10 PM Staff A, Registered Nurse (RN) stated, "I was at the triage area when the Unit Secretary said they [Patient #1 and significant other] had questions. The patient was holding her abdomen and said she couldn't urinate, and her abdomen was hurting. I personally don't remember her saying 10/10 pain. I asked how many weeks are you? I don't remember exactly what she said but it was under our 30 weeks. It was under our level II [is a higher level of care for moms and babies, including 32+ weeks of pregnancy and care for appropriate moderate to high-risk maternity patients]. Her husband told me 'I have a history', I don't remember exactly but stated, 'my baby died because it was transferred' and he didn't' want his baby at a different place than they were. He stated, 'I do not want my baby to go anywhere without us.' I offered information on the fact that we were a level II NICU [neonatal intensive care unit] and if she was under 30 weeks, the baby would be transferred and if the baby was unstable, they would be transferred. That there was a possibility they would need to be transferred. He kept saying 'I don't want this, I don't want this, what level is [name of a local hospital]'. I told him level III [subspecialty care] and they keep under 30-week babies, and he said they would go there. We told them me, and [Staff B's name]), we said stay here we will take care of you, we can provide wonderful care. She [Patient #1] was in a wheelchair because she was going back to the triage room. We came out to the waiting room through the door, asked her to please come in and get checked, we would take care of her, but they were very frustrated. They were getting upset about not wanting to have the baby moved away from them, and they asked if they can use a wheelchair to get to the car. They said 'No, can't we just use the wheelchair? No, we can go to [name of local hospital]', we had already put her in a wheelchair to go to the triage room. He did ask me what I would do, what they should do. I told him I couldn't say what to do, that we only had a level II nursery. He was frustrated and upset, and he insisted that the baby couldn't be transferred."

During an interview on 03/19/2025 at 3:58 PM, Staff C, Unit Customer Service Representative stated, "Her [Patient #1] and her husband came in, they said their symptoms, I was getting ready to give them paperwork to register them. The husband started asking questions about our NICU level. I got the charge nurse. The charge nurse and another nurse spoke to the patient and her husband. I believe it was [Staff B, RN and Staff A's RN names]. They said well, if you're really truly having concerns and you don't want to stay here, there is a hospital that is a level III. If you want to go somewhere that can take care of your needs, there is [name of a local hospital]. Of course, we told him we could still take her and see her here."


During an interview on 03/20/2025 at 8:48 AM, Staff B, RN stated, "I wasn't at the desk when she [Patient #1] came back in. She came in the same day at about 3 or 3:30 PM that afternoon. She went home and came back when her pain got worse that afternoon, but she was having significant 10 out of 10 pain when she returned. Her husband was asking about our level of NICU to [Staff A's name] and he was saying how he didn't want to be separated from the baby. She was sitting in a wheelchair waiting to come back to the triage room in the lobby when this was happening. He was asking what he should do. I do remember [Staff A's name] said, or maybe I said, "I can't tell you what to do." They decided to go to [name of local hospital]. [Staff A's name] did tell them [name of local hospital] had a Level III NICU because they knew they had a higher-level NICU. They said they were going to leave and go there. We helped them to the car in the wheelchair. They were just very upset about it and didn't want to be apart from the baby. I escorted them out of here and they went to [name of local hospital] for treatment."


During an interview on 3/20/2025 at 10:45 AM, the Director of OB/GYN (obstetrics/gynecology) stated, " We did have the capability of treating her [Patient# 1], we treated her earlier that day. We could have assisted them and transferred them to [name of local hospital] or even [name of a different hospital]. I don't think that was offered to them, the patient's husband wanted to drive to [name of local hospital]. It is my understanding that she [Patient #1] presented with wanting to be seen and having pain again. In fact, we did have her in a wheelchair ready to come back. I think she asked the Unit Secretary about the level NICU we have. She got the nurse who answered those questions and assisted them to their car to go to [name of local hospital]."



Review of the policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" with a revision date of 02/05/2021 read in part, 'Emergency Medical Condition (EMC) means: A medical condition manifesting itself by acute symptoms or 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: 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; serious impairment to bodily functions; or Serious dysfunction of any bodily organ. Medical Screening Examination (MSE) is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists, or a woman is in labor. Such screening must be performed by qualified medical personnel and within the hospital's capacity and capability ...Patient Refuses to Consent to Treatment. If an individual refuses to consent to examination or treatment, after being informed of the risks and benefits and the hospital's obligations under these rules, reasonable attempts shall be made to obtain a written refusal to consent to treatment or examination on the form provided for that purpose. In all cases, the hospital must request that the individual complete the sign-in sheet. Further, the individual's medical record shall contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. Documentation When Patient Leaves Without Being Seen, Against Medical Advice, Without Notifying Hospital Staff. If a patient informs the ED Registration staff that s/he is leaving prior to receiving an MSE, ED staff should obtain the patient's signature, date and time, on an "AMA" or "Refusal of Care" form, indicating that they have been informed of the risks of leaving the ED prior to receiving an MSE or prior to receiving stabilizing treatment for an EMC [emergency medical condition]. If the patient refuses to sign the form, staff should document the circumstances of the refusal."