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Based on staff interview and facility policy review, Hospital #1 failed to maintain a central log of all individuals who come to the Emergency Department (ED) seeking medical treatment to ensure the required information (refused treatment, was refused treatment, transferred, admitted and treated, stabilized and transferred, or discharged) was documented. This deficient practice affected one (1) out of 11 sampled patients, Patient #11.

Findings Include:

An interview on 05/21/2025 at 4:22 p.m. with the Registration Clerk confirmed a family member's sister presented to the clerk's desk stating her sister, Patient #11, was in labor and having contractions in the car. The Registration Clerk alerted the nurses that a pregnant lady in active labor was outside. The Registration Clerk also confirmed that the patient was not added to the ED Central Log because the sister did not provide a name.
In an interview on 05/22/2025 at 12:05 p.m. with Registered Nurse (RN) #1 it was confirmed that Patient #11 was not added to the ED log, a medical screening exam (MSE) was not provided, and a transfer was not offered.

Review of the facility's "EMTALA [Emergency Medical Treatment and Labor Act]" policy dated 09/13/2023 revealed " ...C. Central Log 1. The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, stabilized, and/or transferred or were discharged. The log must register all patients who are present for examination or treatment even if they leave prior to triage or MSE [Medical Screening Exam] ...2. The hospital had the discretion to maintain the central log in a form that best meets the needs of the hospital..."

During the exit conference on 05/22/2025 with the Chef Executive Officer, Director of Admissions/Safety Officer, and the Director of Nursing findings were discussed, and no further documentation was submitted for review.

Cross Refer to O2406 and O2409.

Based on staff interviews, medical record review, and facility policy review, Hospital #1 failed to complete a Medical Screening Exam (MSE) within the capability of the hospital's Emergency Department (ED) for an individual who was pregnant and having contractions on arrival to the ED for one (1) out of 11 sampled patients, Patient #11.

Findings Include:

In an interview on 05/22/2025 at 12:05 p.m. with Registered Nurse (RN) #1 it was confirmed that a medical screening exam (MSE) was not provided for Patient #11 on arrival to the ED on 05/13/2025. Patient #11 presented after midnight with complaint of contractions every three (3) minutes with no report of ruptured membranes. Patient #11 reported her Obstetrician was located at Hospital #2, but they (Patient #11 and her sister) stopped at Hospital #1 due to the frequency of her contractions. RN #1 explained the facility had an ED but did not have an Obstetric or Labor and Delivery Unit, but she could see a Provider at Hospital #1. Patient #11 asked if she should stay at Hospital #1 or travel to Hospital #2, which was 24 miles away. RN #1 said she would ask the facility ED Provider. RN #1 reported the ED Provider #1 advised Patient #11 to go to Hospital #2 now. No Medical Screening Exam (MSE) was provided before Provider #1's recommendation for Patient #11 to proceed to Hospital #2. RN #1 informed Patient #11 and her caregiver of the recommendation and the Patient left Hospital #1.

There was no medical record generated for Patient #11 at Hospital #1 for surveyor review.

Review of medical record for Patient #11 from Hospital #2 revealed she presented to the ED ambulance bay in a private vehicle with family member on 05/13/2025. Hospital #2's ED nurse called their Obstetric ED at 6:58 a.m. to report a patient presenting with a delivered baby in a car. Patient #11 reported she delivered about two (2) minutes prior to arrival and reported her water ruptured approximately one (1) minute prior to delivery. Medical record revealed the baby was not in distress, was crying with good tone and pink in color and umbilical cord intact. ED nurse clamped and cut the cord using a sterile technique and Patient #11 was taken to the Labor and Delivery Unit for placenta delivery and the baby was taken to the Newborn Nursery unit. Hospital #2's medical record also revealed the delivery was a non-sterile, non-controlled, spontaneous vaginal delivery in the patient's car. The placenta was also spontaneously delivered intact with a three (3) vessel cord, perineum intact, no lacerations.

Review of Hospital #1's policy titled "EMTALA [Emergency Medical Treatment and Labor Act]," dated 9/13/23 revealed "...POLICY: if an individual comes to the ED: A. The hospital will provide an appropriate MSE within the capability of the hospitals dedicated ED, including ancillary services routinely available, to determine whether an emergency medical condition exists. B. The hospital will: (a) provide an individual who is determined to have an emergency medical condition such further medical examination and treatment is required to stabilize the emergency condition, or (b) arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below ..."

During the exit conference on 05/22/2025 with the Chef Executive Officer, Director of Admissions/Safety Officer, and the Director of Nursing findings were discussed, and no further documentation was submitted for review.

Cross Refer to O2409.