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Based on interview and record review, the hospital failed to ensure that it was in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by the following:

1. Failure to provide adequate protective monitoring for two of 20 sampled patients (Patients 2 and 15, who were both admitted with suicidal thoughts). Patient 15 eloped (left the hospital) thus potentially being a risk to the health and safety of himself and others. (Refer to A 2407, findings 1 and 2).

2. Failure to have a well defined process to determine that labor and delivery nurses were qualified to perform medical screening examinations for pregnant patients who presented to the obstetrical (OB - birthing) unit for emergency care. (Refer to A 2406)

These failures have the potential for emergency conditions to not be adequately evaluated and treated which could lead to patient harm, including death.

Based on interview and record review, for those patients presenting to the hospital's obstetrical (for birthing) unit (OB) for labor and other obstetrical emergencies, the hospital failed to maintain a central log in which each patient presenting for emergency care was listed along with all of the information required by CFR 489.24. The specific information missing from some pages of the ED log were the patients' correct presenting chief complaint (the medical problem which prompted the patient to come to the ED), disposition (admit, transfer or discharge) and disposition date/time (20 of 294 patient entries on log, Patients 12, 21 through 39). This failure had the potential to result in the facility's inability to accurately track the care given to each patient.

Findings:

1. A concurrent interview and record review of the hospital's Obstetric Central Logs for 7/1 to 11/24/14 was conducted with the Chief Nursing Officer (CNO) and Nurse Manager (NM) A, on 11/24/14 at 3:30 pm.

a. The OB log had chief complaint entries that were blank for Patients 12, 24 and 33.

b. The OB log had blank entries for disposition, and disposition date and time for Patients 21, 22, 24, 26, 28, 29, 32, 35, and 36.

c. The OB log had blank entries for disposition date and/or time for Patients 23, 25, 27, 30, 31, 34, 37, 38, and 39.

CNO and NM A acknowledged that the log was used for emergency patients who presented at the OB department and that it was not complete for the required information.

Based on interview and record review, the hospital failed to have a well defined process to ensure that all individuals conducting medical screening examinations (MSE - to determine whether an emergency medical condition exists) were determined qualified by the hospital bylaws, or rules and regulations when the hospital policy failed to have defined process to determine who, how, and when labor and delivery (L&D) nurses were determined to be qualified to perform the MSE on pregnant patients presenting to the Obstetrical (OB) unit. This failure had the potential for unqualified nurses to perform an examination that was not to the standards of the medical staff or the standard of practice which could result in the a decline in the mother and fetus (unborn baby) well-being, including death.

Findings:

On 11/24/14 at 3:30 pm, the Chief Nursing Officer (CNO) stated the pregnant patients who presented at the OB department for labor or other obstetrical emergencies had their MSEs performed by the L&D nurses. CNO reported that they had a policy that was approved by the medical staff that authorized the L&D nurses to perform the MSE for pregnant patients.

The hospital Medical Staff Rules and Regulations, dated 9/2014, read, "Medical Screening may be performed in the Obstetrical Unit by qualified nursing personnel in accordance with the current Medical Staff approved Hospital policy and procedure."

CNO provided the Medical Staff approved policy, titled, "Medical Screening Exam - Perinatal (before, during, and after birth) Guidelines," last reviewed 12/19/13, which read, "A medical screening exam by qualified personnel will be offered to any individual who presents herself to the Perinatal Department seeking any examination and/or treatment to determine if the individual has an emergency medical condition or is in active labor... Perinatal RNs (registered nurses) are considered qualified medical personnel, able to perform the medical screening exam." The policy contained elements of an assessment, physician notification parameters, and patient disposition instructions. The policy did not contain any description of the process for how a "perinatal" nurse becomes qualified to perform the MSE.

On 11/24/14 at 3:40 pm, CNO and Nurse Manager (NM) A stated that the policy was not exactly correct because not all perinatal nurses were authorized to perform the MSE. The L&D nurses were authorized but the post-partum (after birth) nurses were not authorized. NM A stated that the nurses that were new to the hospital L&D unit were observed and then their skills were checked off. When asked if all the L&D nurses, who performed MSE currently, had skills check off forms in their personnel records, NM A replied that she had just looked for two nurses' check off forms and was unable to locate them. CNO acknowledged that the policy lacked criteria that effectively defined when and how a nurse became qualified to perform the MSE in the OB unit.

Based on interview and record review, the facility failed to ensure that two of 20 sampled emergency department (ED) patients, who presented to the ED with suicidal ideations (thoughts of killing themselves), were provided protective supervision, such as one-to-one (1:1) supervision per facility policy. (Patients 2 and 15) This failure resulted in Patient 15, a suicidal patient who was at a danger to himself, to elope (leave) from the facility and had the potential to harm himself or others.

Findings:

1. On 11/24/14, Patient 15's record was reviewed. Patient 15 arrived at the ED by police escort on 9/21/14 at 3:15 pm with the presenting complaint of suicidal thoughts and a plan to hang himself with a rope. The record indicated that Patient 15 was awaiting evaluation by a mental health worker. Patient 15's record indicated that he was last assessed by nursing staff at 4 pm and was noted to not be in the facility at 5:15 pm. Patient 15 had eloped from the facility approximately 1.25 hours after he was last seen.

On 11/24/14, the ED policy, titled, "Sentinel Event Alert Issue 46," dated 1/19/11, indicated patients presenting with an obvious suicide attempt will have screening using the SAD PERSONS acronym (scale)... If the SAD PERSONS score is 8 or higher, ... suicide precautions and a care plan were to be implemented, and the physician notified. The policy further indicated, "If the person at risk exhibits warning signs, empower staff to take a proactive, substantive action. (For example, placing the individual under constant observation or in an environment with fewer hazards, if one is available.)

The Joint Commission online contains a reference, "Suicide Risk: A Guide for ED Evaluation and Triage," that recommended one-to-one observation and/or security for patients at risk for suicide.

Patient 15's record contained a form, titled, "Suicide Risk Assessment," that contained a SAD PERSONS scale used to assess risk for suicide. Patient 15's SAD PERSONS score was not totaled but when the assigned points were added, they totaled 10 points which indicated suicide precautions should have been instituted. Patient 15's record did not contain evidence that suicide precautions such as one to one (1:1) supervision was instituted, that a suicide risk care plan was developed, or that the physician notified.

On 11/24/14 at 4:10 pm, the Chief Nursing Officer (CNO) acknowledged that 1:1 supervision was not provided for Patient 15 as required by the facility policy to prevent him from harming himself or eloping.

2. Patient 2's record was reviewed. Patient 2 presented to the ED on 10/29/14 at 9:20 am with complaint of suicidal ideations. Patient 2 was transferred to a hospital with the ability to provide psychiatric specialty care at 9 pm. Patient 2's record contained an initial assessment done at 10 am and no further nursing assessments or notations until 8:15 pm, over 10 hours later, when a second set of vital signs (temperature, pulse, respirations, blood pressure) was recorded. Patient 2's record contained no evidence of supervision to ensure Patient 2's safety was ensured during the ED stay of over 10 hours.

Patient 2's record contained a SAD PERSONS score of 11 which indicated that suicide precautions and care plan were to be implemented. This form contained a notation that read, "Pt placed on 1:1." Patient 2's record did not contain evidence that suicide precautions such as one to one (1:1) supervision were actually instituted, that a suicide risk care plan was developed, or that any nursing assessment or interventions were implemented.

On 11/24/14 at 4:10 pm, CNO acknowledged that no assessments or protective supervision were documented for Patient 2, for over 10 hours.