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Based on review of hospital EMTALA (Emergency Medical Treatment and Labor Act) policies, staff/physician and patient interviews and record reviews the facility failed to ensure staff followed their policies to maintain compliance with EMTALA. The facility failed to ensure 1 of 20 patients (Patient 2) received a Medical Screening Exam sufficient to determine whether an emergency medical condition existed.

Findings are:

A. Record review of facility policy titled "EMTALA PLAN" dated 02/15 defines an Emergency Medical Condition as a medical condition manifesting itself by acute symptoms of sufficient severity 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. Under the section titled "Labor" the policy sates "A woman experiencing contractions is in true labor unless a physician certifies that after a reasonable time of observation, the woman is in false labor." Under the section titled "Procedures: Medical Screening Examination" the policy states "For any individual who comes to the hospital seeking emergency services, an appropriate medical screening evaluation must be completed to determine whether or not an emergency medical condition exists."

Upon request for the OB MSE policy the facility provided an undated facility customized document titled "Lippincott Procedures - Obstetrical medical screening and transfer guidelines/antepartum (before delivery)." Under the section titled "Examination to Confirm Labor" the document showed "The RN will assess the patient, completing the outpatient or ER Record for all patients reporting for evaluation. When determining whether or not the patient is in true labor, the Obstetrics Evaluation Scoring Sheet will be filled out." ... the relevant portion of the policy continued ... After observing for 1 hour a second assessment will be performed, unless the patient's progress into labor of distress obviates the need for further assessment. The scoring sheet includes a vaginal examination, contractions, vaginal discharge, Vital signs, Fetal heart rate, history of significant medical condition, maternal trauma, edema and Fetal heart tones strip. The physician reviews the information and determines the labor status of the patient. If the patient is in false labor the physician must sign and certify that determination. If discharged "the medical record shall contain the time of discharge, the vital signs of the patient and fetus at discharge, and the labor status of the patient at discharge."

B. Review of patient # 2's electronic ED medical record revealed the patient arrived on 1/5/19 at 12:10 AM complaining of contractions. Under the section titled "History" ED physician "A" documented the patient was pregnant with her 5th child and had 4 living children. ED physician A documented patient # 2 was 37 weeks and 5 days into her pregnancy and "presents to the ER [Emergency Room] after feeling a gush of vaginal fluid just prior to arrival. Further documentation showed that the patient had "No actual contractions yet." "Pt [Patient] supposed to deliver at [name of Hospital C]." ED physician A documented the patient was not in acute distress and had a gravid (pregnant) abdomen that was non tender. Under the section titled "Plan of Care" ED physician A documented patient # 2's current problem was "Spontaneous rupture of fetal membranes" and the plan was "Recommend pt go to hospital where she is to deliver baby for labor check; needs further evaluation to see if membranes ruptured. Do not suspect labor at this time." ED physician A discharged patient # 2 to travel to Hospital C by private vehicle 103 miles away.

C. In an interview on 1/10/19 at 11:10 AM, Obstetrician G confirmed that he sees obstetrical patients each Thursday at the Jennie Melham clinic. Obstetrician G stated that he recalled seeing patient # 2 at the clinic and confirmed that she wanted to deliver her baby vaginally after having previously undergone a Cesarean section (C-section). Obstetrician G stated that he performs these type of deliveries (vaginal birth after C-section) at Hospital C and that either he or one of his partners is always on call and can be reached by the patient or another physician. Obstetrican G stated that patient # 2 required a vaginal exam and a nitrazine test (nitrazine paper is used to test for the presence of amniotic fluid if a pregnant woman experiences prelabor rupture of membranes) on 1/5/19. Obstetrician G confirmed that neither were completed by the ED physician as part of patient # 2's medical screening examination.

D. During an interview on 1/9/19 at 12:30 PM, the Director of Nursing confirmed that the CAH has the capabilities to perform emergency deliveries and that if mother and baby are stable, they are kept on the medical floor until time for discharge.

E. In an interview on 1/10/19 at 8:45 AM, ED nurse B stated that patient # 2 came to the ED with her husband on 1/5/19 and was walking "gingerly" in her night gown and had a minimal amount of bloody drainage on the vaginal pad. ED nurse B stated that patient # 2 was able to understand English but was not fluent. ED nurse B stated the patient said her OB (obstetrical) physician was OB physician G. ED nurse B was with ED physician A when he saw patient # 2 around 5 minutes after the patient's arrival. ED nurse B stated that ED physician A stood off to the side of the bed and said there was "nothing to do for you here as we (this facility) don't do OB." "So you need to go see your OB." ED nurse B said neither she nor ED physician A called OB physician G who could have provided the patient's history and telephone advice. ED nurse B recalled that ED physician A repeated that the patient needed to go to Hospital C and "the sooner the better." ED nurse B stated that ED physician A did not touch the patient and briefly looked at the Tocometer strips (a machine used to produce a recording strip of the fetal heartbeat and the uterine contractions). ED nurse B stated that ED physician A told her we are "not going to transfer, not an EMTALA violation" so she got the discharge paperwork ready and discharged patient # 2. When asked if she felt the patient received an adequate MSE she replied "no" she should have done a Nitrazine test (a pH sensitive testing paper used to determine the presence of amniotic fluid leaking from ruptured membranes) and ED physician A should have felt the patient's abdomen and performed a vaginal exam.

Based on medical record review, nursing interviews, physician interviews, patient interview, interpreter interview and review policies and procedures related to EMTALA the facility failed to provide 1 of 20 (Patient 2) a MSE (Medical Screening Examination) sufficient to determine if the patient had an EMC ( Emergency Medical Condition). This failure has the potential to place all ED patients presenting to the Emergency Department (ED) at risk of serious harm or death from an untreated EMC. Findings are:

A. Electronic Medical Record Review on 1/9/19 of Patient 2's ED record revealed the patient arrived on 1/5/19 at 12:10 AM. Chief complaint is listed as "Contractions." Under the section titled "History" ED physician "A" documented the patient was pregnant with her 5th child and had 4 living children, Gravida 5 Para 4. ED physician A noted the patient was 37 weeks and 5 days into the pregnancy and "presents to the ER [Emergency Room] after feeling a gush of vaginal fluid just prior to arrival. No actual contractions yet. Pt [Patient] supposed to deliver [Name of Hospital C]." Hospital C is 103 miles from the ED. The MSE was conducted by ED physician A. ED physician A noted the patient was in no acute distress and had a gravid (pregnant) abdomen that was non tender. ED physician A made no other physical examination notes or evaluation related to the nursing assessment of the patient. Under the section titled "Plan of Care" ED physician A documented current problem as "Spontaneous rupture of fetal membranes" and plan as "Recommend pt go to hospital where she is to deliver baby for labor check; needs further evaluation to see if membranes ruptured. Do not suspect labor at this time." Physician order dated 1/5/19 stated to "D/C [discharge] to maternity hospital [Hospital C] for labor check."

Review of ED Nursing assessment documentation by Registered Nurse (RN) "B" on 1/5/19 beginning at 12:10 AM noted the patient "said her water broke around 23:40 and was having some bloody show." Bloody show is the passage of a small amount of blood or blood tinged vaginal discharge near the end of pregnancy. It is caused by the detachment of the cervical mucous plug that seals the cervix during pregnancy, and is one of the signs labor commencing soon. Vital signs were Blood Pressure (BP) 139/80, Oral Temperature 97.5 degrees Fahrenheit, Heart Rate 82 and Respirations of 16. The nurse applied a Tocometer, an instrument that records contractions and fetal heart rate on a timed strip. The Tocometer was placed on the patient for 27 minutes. Fetal heart rate was 130s to 140 per the strip reading. RN A documented "did not see any contractions on the fetal strip." RN A noted the patient was having "vaginal bleeding." RNA also documented the presence of family friend (identified as Family Friend #1) at 12:39 AM who interpreted for the patient. The patient discharged from the ED at 1:00 AM. Vital signs at 12:50 AM note BP of 122/84, heart rate of 79 and respirations at 20 per minute. RN A documented "Discharge instructions given to patient, she verbalized understanding through her interpreter and had no further questions." Discharged from ED and told to call [Name of Hospital C] and /or go to [Name of Hospital C] for further evaluation.

B. Telephone interview with ED physician A on 1/10/19 at 10:35 AM revealed the physician reported that he was aware the hospital does deliver some babies but there is no physician on call to deliver so there is no capability. ED physician A stated that a vaginal examination was not done because of risk of infection if the patient's membranes were ruptured. ED physician A stated the patient was "definitely not in labor" and was not actively having contractions. ED physician A stated that his obstetrical experience was limited to delivering 40 babies in residency then supervising Residents for 3 years until 2008. ED physician A stated he was not aware the nurse could do a vaginal examination until later but would not have recommended she perfom one.

C. Interview with RN B on 1/10/19 at 8:45 AM revealed the patient came to the ED with her husband and was walking "gingerly". The patient was able to understand English but was not fluent. Her husband was more fluent. The patient reported she had bloody show and ruptured membranes. She shook her head when asked if she contractions. She and husband said she had no pain. Patient related this was her fifth baby. RN B recalled the patient came in her nightgown and had a minimal amount of bloody drainage on the vaginal pad. RN B asked who the patients OB (Obstetrical) MD was and she said it was MD "G". RN B was with EDMD A when he went in to examine the patient around 5 minutes after her arrival. She said EDMD A stood off to the side of the bed and said there was "nothing to do for you here as we (this facility) doesn't do OB. So you need to go see your OB. The patient's friend interpreted for her and said she was planning to deliver at [Name of Hospital C]. RN B said neither she nor the EDMD called MD G. MD G could have provided the patient's history and telephone advice. RN B recalled the EDMD repeating that the patient needed to go to Hospital C and the sooner the better. RN B recalled EDMD A did not touch the patient and briefly looked at the Tocometer strips. RN B also stated that EDMD A told her we are "not going to transfer, not an EMTALA violation" so she got the discharge paperwork ready and discharged the patient. When asked if she felt the patient received an adequate MSE she replied "no, she should have done a Nitrazine test ( a paper test that helps in determining the presence of amniotic fluid leaking from ruptured membranes) and EDMD A should have touched her to feel abdomen and do a vaginal exam.

D. Interview with MD G an OB specialist from Hospital C on 1/10/19 at 11:10 AM. MD G comes to this hospital weekly for specialty clinic services of those patients that will receive repeat scheduled C Sections. MD G stated someone is always on call in his group at Hospital C. He recalled Patient 2 had 3 vaginal deliveries and 1 Cesarean delivery (surgical opening of womb to deliver the fetus). The patient wanted to deliver vaginally. MD G stated that MSE should include a vaginal exam and Nitrazine test. In this case neither were completed as by the ED physician as part of the MSE. MD G stated that he comes to this hospital on Thursdays for Clinic. All the patients are educated that they will deliver at [Name of Hospital C] if the mother desires a V BAC (Vaginal Birth after Ceserean). Patients are told that they are to call our practice (on call provider for group) and we will help them know where to go.
E. Interview with RN E, OB Nursing Manager on 1/10/19 at 8:00 AM. RN E stated that the hospital currently does only Non Stress Tests (Tests for fetal well being using Tocometer) and Scheduled Cesarean sections. In October 2018 RN E recalled an active labor patient came to the clinic while MD G was here and an unplanned/unscheduled Cesarean section was done. RN E stated the role for OB services is to evaluate and stabilize the patient in the ER then either transfer the patient or can emergently deliver them. Last emergency vaginal delivery was 12/31/18, an OB patient without prenatal care who presented to ED dilated 6-8 (cm) centimeters (10 is ready to deliver). The patient and baby remained at the hospital post delivery until discharge.
RN E reviewed Patient 2's ED visit record dated 1/5/19. The review included interpretation of the Tocometer strip. RN E stated that there was a contraction on the strip. RN E stated that there was concern that the MSE was not complete to determine labor. RN E's expectation for evaluation of labor is a longer monitoring record of fetal heart tones, 2 vaginal exams 1 hour apart to assess the cervix (dilation) and a Nitrazine test. RN E stated that without a vaginal examination labor status cannot be determined. RN E stated that Patient 2 had "an inappropriate discharge of patient with early labor and lack of a full MSE of patient due to no vaginal examination."

F. Interview with Family Friend (FF) "1" on 1/10/19 at 11:30 AM. FF 1 works as a Medication Aid in the Clinic and is a friend of Patient 1. She helps them with interpreting English. FF 1 recalled getting a call from Patient 2 asking her to come to the hospital because she was having contractions. While in ER Patient 2 told her that her water broke around 11:40 PM and she having bad contractions. Patient 2 told her she was "barely making it walking into ED." The nurse asked her questions and hooked her up to the monitor to check baby and make sure she was fine. FF 1 said the Doctor came in and said "What's going on, why are you here." Patient 2 told him "My water broke and want to be sure I can make it (to Hospital C). Again the Doctor said "Why here? Nothing I can do for you. You need to go where you are going to deliver?" FF 1 said the ED MD didn't take time to check her and said "he's not fit" to do this stuff. FF 1 was upset and told Patient 2 "Hey let's go". Patient 2 said if he isn't qualified lets go. They told her to discharge, drink water and go to [Name of Hospital C].

G. Phone Interview with Patient 2 on 1/14/19 at 12:47 PM using Certified Languages Interpreter Services. The patient said she came to the hospital because she was having contractions but they went away. The patient said that referring to EDMD A that "he didn't do anything, told me to go where baby delivered. I had more contractions and stopped by [Name of Hospital B]- they said I needed a Cesarean section, they told me my life and baby's in danger. I didn't want a Cesarean section so I left. I was scared. I left and went to [Hospital C].

H. Interview with MD "D", Chief of Staff and Chief of ED on 1/14/18 at 12:45 PM. MD D stated that if a OB patient comes to the ED that the MSE includes checking to see if the patient is in active labor, has any complications, do a NST (Tocometer) for at least 20 minutes. Laboratory testing and vaginal exam depends on circumstances. If patient is in labor, call their attending physician and see what they want to do. Options if too far can deliver here in an emergency situation. A ED MD should be able to do an OB delivery.
MD D is the only physician on staff at the hospital that can do Cesarean sections. He does not take call. The ED MD called him in December 2018, bad weather roads, he said he was able to put a team together and did an emergency Cesarean section on a patient.
MD D reviewed the ED record of Patient 2's visit on 1/5/19. He reported there should have been a better MSE to determine labor, not enough time on the monitor, MD did not make any notes regarding the NST. The EDMD should have called the patient's OB provider. He said there was not a reason not to do a vaginal exam unless possible placenta previa. Ultrasound was available on call on 1/5/19 that could have helped determine that. MD D stated that the exam should have included checking the perineum. MD D stated "Yes" when asked if the patient could have had an EMC.

I. Record review of facility policy titled "EMTALA PLAN" dated 02/15 defines an Emergency Medical Condition as a medical condition manifesting itself by acute symptoms of sufficient severity 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. Under the section titled "Labor" the policy sates "A woman experiencing contractions is in true labor unless a physician certifies that after a reasonable time of observation, the woman is in false labor." Under the section titled "Procedures: Medical Screening Examination" the policy states "For any individual who comes to the hospital seeking emergency services, an appropriate medical screening evaluation must be completed to determine whether or not an emergency medical condition exists."
Upon request for the OB MSE policy the facility provided an undated facility customized document titled "Lippincott Procedures - Obstetrical medical screening and transfer guidelines/antepartum (before delivery). Under the section titled "Examination to Confirm Labor" the document states "The RN will assess the patient, completing the outpatient or ER Record for all patients reporting for evaluation. When determining whether or not the patient is in true labor, the Obstetrics Evaluation Scoring Sheet will be filled out." The scoring sheet is to be completed except for patients less than 37 weeks and without uterine contractions, overt bright red vaginal bleeding, history of placenta previa or presence of actual herpes lesions will not receive vaginal examinations until approved by the attending physician. After observing for 1 hour a second assessment will be performed, unless the patient's progress into labor of distress obviates the need for further assessment. The scoring sheet includes a vaginal examination, contractions, vaginal discharge, Vital signs, Fetal heart rate, history of significant medical condition, maternal trauma, edema and Fetal heart tones strip. The physician reviews the information and determines the labor status of the patient. If the patient is in false labor the physician must sign and certify that determination. If discharged "the medical record shall contain the time of discharge, the vital signs of the patient and fetus at discharge, and the labor status of the patient at discharge"

J. Review of Hospital B Patient 2's Medical Record dated 1/5/19 notes the patient arrived at 2:40 AM. Patient 2 was Gravida 7 Para 4. She had 1 previous Cesarean section, 3 VBAC'S, and 2 miscarriages. Prenatal records were obtained. Patient 2 presented with complaints of contractions. She was planning to deliver at [Hospital C] with another VBAC and stopped here for evaluation enroute there. She complained of regular contractions, small amounts of bleeding and ruptured membranes. On exam she was 4 cm, 50 percent effaced (thinning of the cervix). Monitoring showed regular contractions. She was counseled that VBAC'S are not done at this hospital and she would be planned for a repeat Cesarean section. She desired to leave AMA. Risks/Benefits explained. She left at 3:30 AM. Hospital C notified.

K. Review of Hospital C Patient 2's Medical Record dated 1/5/19 notes the patient arrived at 4:57 AM. She was 4 cm dilated and had 2 milliliters of clots in the bed. Concern regarding abruption of placenta led to a Cesarean section performed at 8:12 AM.