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Based on review of personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure annual Emergency Medical Treatment and Active Labor Act (EMTALA) training was completed for six of six personnel files reviewed (PF1, PF2, PF3, PF4, PF5, and PF6).

Findings include:

Interview with EMP9 on December 7, 2017, at approximately 9:15 AM, confirmed EMTALA training was part of the facility required yearly compliance training for their employees.

Review on December 6, 2017, of PF1 through PF6 revealed these individuals worked in the facility's Emergency Department. There was no documentation of EMTALA training in PF1 through PF6 for 2017.

Interview with EMP9 on December 7, 2017, at approximately 9:15 AM revealed the Guthrie Towanda Memorial Hospital (GTMH) Intranet EMTALA training was missed for 2017.

Interview with EMP1 on December 7, 2017, at 9:20 AM, revealed the GTMH Intranet EMTALA training was missed for 2017, as the training changed from the GTMH Intranet to the Robert Packer Hospital (RPH) Guthrie Learn in 2016. EMP1 confirmed the EMTALA training was not noted to be missing from the Guthrie Learn website until the EMTALA event occurred on November 25, 2017.

Interview with EMP10 on December 7, 2017, at 9:25 AM, revealed the GTMH Intranet training website was stopped on June 30, 2015, and the RPH Guthrie Learn training website was started on July 1, 2015. No EMTALA training was completed for 2016, as it was not part of the Guthrie Learn trainings, and the EMTALA training was not noted to be missing until the EMTALA event occurred on November 25, 2017.

Cross reference:
489.20(4)(3) Emergency Room Log
489.24(2) and 489.24(c) Medical Screening Exam
489.24(3)(1-3) Stabilizing Treatment
489.24(3)(1)-(2) Appropriate Transfer

Based on review of facility documentation, medical records (MR), and staff (EMP) interview, it was determined the facility failed to maintain an accurate Emergency Department log for one of 20 medical records reviewed (MR1).

Findings include:

Review on December 6, 2017 at 10:20 AM of facility policy "EMTALA (Emergency Medical Treatment [and] Labor Act of 1986)," last reviewed/revised by the facility on December 1, 2017 revealed "Policy: It is the policy of the Guthrie Towanda Memorial Hospital, a Medicare participating hospital, to comply with EMTALA rules and regulations ... Procedure/Protocol: 1. The ED [Emergency Department] will log in every patient who presents with his or her complaint/diagnosis and disposition..."

Review on December 6, 2017 at 10:45 AM of MR1 revealed the patient presented to the ED on November 22, 2017 for rib pain. At the end of the document was an addendum by EMP3 dated/timed for November 25, 2017 at 1030 "11/25/17 at 1030 Received a phone call from RPH [Robert Packer Hospital] Maternity. Stated a pt of theirs called them and stated she is having bleeding. She may come to the GTMH [Guthrie Towanda Memorial Hospital] ER [Emergency Room]. Pt arrived [at] our ER. Dr. [CF1] and writer spoke with pt. Pt instructed to go to RPH ER for further assessment. Signs of imminent delivery not present."

Review on December 6, 2017 at 2:40 PM of the Emergency Department log for November 25, 2017 revealed no documentation of patient registration for MR1.

Interview with EMP1 on December 6, 2017 at 10:15 AM confirmed there was no registration of MR1 on the Emergency Department log.

Based on review of facility documentation, medical records (MR), and staff (EMP) interview, it was determined the facility failed to provide an appropriate medical screening examination within the capability of the hospital's Emergency Department in one of 20 medical records reviewed (MR1).

Findings include:

Review on December 6, 2017 at 10:20 AM of the facility policy "EMTALA (Emergency Medical Treatment [and] Labor Act of 1986)," last reviewed/revised by the facility on December 1, 2017 revealed "Policy: It is the policy of the Guthrie Towanda Memorial Hospital, a Medicare participating hospital, to comply with EMTALA rules and regulations ... Procedure/Protocol: ... 2. Every patient that presents to the ED [Emergency Department] will be given a medical screening examination regardless of the acuity of his/her condition. Key Points/Rationale: A patient presents when they enter a dedicated emergency department of the hospital or on the campus within 250 yards of the main building seeking care or evaluation of an emergency medical condition. 3. The Medical Screening Examination will not be delayed in order to obtain financial information nor induce the patient to leave without MSE by drawing payor issues or financial demands to the attention of patient or family prior to the completion of the MSE and initiation of stabilizing care. ..."

A review on December 6, 2017 at 1:15 PM of the facility policy "Pregnant Women Presenting to the Emergency Department Not in Active Labor," last reviewed by the facility in November 2017, revealed "Procedure: 1. Obtain patients [sic] name and date of birth. 2. A Medical Screening Exam must be completed by the ED physician. A. Assess mothers [sic] health and reason for ED visit B. Assess gestational age of fetus based on patient stated LMP [Last Menstrual Period] and Gestational Wheel. C. Attempt to obtain fetal heart tones 3. Evaluate need for pelvic exam. 4. Evaluate need for phone consultation with OB physician for treatment or determine appropriate disposition. ..."

Review on December 6, 2017 at 10:45 AM of MR1 revealed the patient presented to the ED on November 22, 2017 for rib pain. At the end of the document was an addendum by EMP3 dated/timed for November 25, 2017 at 1030 "11/25/17 at 1030 Received a phone call from RPH [Robert Packer Hospital] Maternity. Stated a pt of theirs called them and stated she is having bleeding. She may come to the GTMH [Guthrie Towanda Memorial Hospital] ER [Emergency Room]. Pt arrived [at] our ER. Dr. [CF1] and writer spoke with pt. Pt instructed to go to RPH ER for further assessment. Signs of imminent delivery not present." For November 25, 2017, there was no documentation of vital signs, no documentation of vaginal examination, and no documentation of fetal heart tones.

Interview with EMP2 on December 6, 2017 at 10:50 AM confirmed there was no additional documentation in electronic or hard copy format for MR1. EMP2 confirmed there were no vital signs documented, no documentation of a vaginal examination, and no documentation of fetal heart tones for November 25, 2017.

Interview with EMP1 on December 6, 2017 at 11:00 AM related the facility had CF1 and EMP3 complete statements after the facility investigated the possible EMTALA violation for MR1 for November 25, 2017. The statements were completed by CF1 and EMP3 on November 28, 2017.

A review on December 6, 2017 at 11:05 AM of the late documentation/statement by CF1 revealed the following progress note: "I was asked to write my recollection on [MR1] visit on Nov 25. [another hospital] called that [MR1] is coming to Towanda because of blood noted in her legs today. Pt is 38 weeks pregnant with prenatal care. She was seen in the Towanda ER 3 days prior... [MR1] presented not in any pain, standing very comfortable because she noted blood in her legs. She was not crowning and not in imminent delivery. There was a lady that came with her. She was offered to go by ambulance to [another hospital's] OB but patient prefer to go by private vehicle. There was no chart made on her visit... " Signed by CF1.

A review on December 6, 2017 at 11:10 AM of the late documentation/statement by EMP3 revealed "11/29/2017 On 11/25/17 the ER clerk stated [another hospital's] OB had called stating one of their patients had called them stating she was having some bleeding. They told her to go to the ER. They stated she might stop at our ER. She arrived in our ER waiting area. The ER physician asked her questions. She was instructed to go to [another hospital's] ER." Signed by EMP3.

Telephone interview with CF1 on December 6, 2017, at 1:41 PM revealed the following: CF1 saw MR1 a few days before November 25, 2017 in the ED. CF1 stated MR1 came by private vehicle, a lady drove her to the hospital. CF1 stated another hospital called us to warn us because we do not have an OB [department]. Another hospital called to ER and relayed the patient complained of "blood in the legs" and 38 weeks pregnant. CF1 stated the patient walked into the Emergency Department waiting area and said she had no abdominal complaint. CF1 stated the patient did not get a chart, and the patient was standing very comfortable and decided with the lady with her that she would go to another hospital. CF1 stated the patient was stable. She was not having abdominal pain. CF1 stated we offered ambulance transport; she declined, and said she would drive with the lady who drove her. CF1 stated the patient was not in imminent labor, because you cannot crown while standing. CF1 confirmed that there were no vital signs taken for MR1; there was no vaginal examination performed for MR1; and there were no fetal heart tones obtained.

Based on review of facility documentation, medical records (MR) and staff (EMP) interviews, it was determined the facility failed to provide stabilizing treatment within the capability of the hospital's Emergency Department in one of 20 medical records reviewed (MR1).

Findings include:

Review on December 6, 2017 at 10:20 AM of the facility policy "EMTALA (Emergency Medical Treatment [and] Labor Act of 1986)," last reviewed/revised by the facility on December 1, 2017 revealed "Policy: It is the policy of the Guthrie Towanda Memorial Hospital, a Medicare participating hospital, to comply with EMTALA rules and regulations ... Procedure/Protocol: ... 4. The ED will provide necessary testing within the capability of the hospital (including on-call services) as needed to exclude the presence of legally defined emergency medical condition. Abnormal findings should be normalized if possible via treatment and documented by serial values or explained prior to discharge. 5. The ED will provide care to stabilize such that the patient is not likely to deteriorate from or during transfer or discharge. If the ED is not capable of appropriate stabilization, a medically appropriate transfer must be implemented. Key Points/Rationale: Patients will only be transferred for care not available at this facility or at patient/family request. ..."

A review on December 6, 2017 at 1:15 PM of facility policy "Pregnant Women Presenting to the Emergency Department Not in Active Labor," last reviewed by the facility in November 2017, revealed "Procedure: 1. Obtain patients [sic] name and date of birth. 2. A Medical Screening Exam must be completed by the ED physician. A. Assess mothers [sic] health and reason for ED visit B. Assess gestational age of fetus based on patient stated LMP [Last Menstrual Period] and Gestational Wheel. C. Attempt to obtain fetal heart tones 3. Evaluate need for pelvic exam. 4. Evaluate need for phone consultation with OB physician for treatment or determine appropriate disposition. ..."

A review on December 6, 2017 at 1:30 PM of the facility policy "Maternal Transfer Procedure from the Emergency Department," last reviewed by the facility November 2017, revealed "Procedure ... 5. Take all appropriate steps for stabilization of patient as ordered by physician, i.e., IV access, labs, x-ray, ultrasound... "

Review on December 6, 2017 at 10:45 AM of MR1 revealed the patient presented to the ED on November 22, 2017 for rib pain. At the end of the document was an addendum by EMP3 dated/timed for November 25, 2017 at 1030 "11/25/17 at 1030 Received a phone call from RPH [Robert Packer Hospital] Maternity. Stated a pt of theirs called them and stated she is having bleeding. She may come to the GTMH [Guthrie Towanda Memorial Hospital] ER [Emergency Room]. Pt arrived [at] our ER. Dr. [CF1] and writer spoke with pt. Pt instructed to go to RPH ER for further assessment. Signs of imminent delivery not present." For November 25, 2017, there was no documentation of stabilizing interventions taken such as IV hydration, fetal heart tones or testing.

Interview on December 6, 2017 at 10:50 AM with EMP2 confirmed there was no additional documentation in electronic or hard copy format for MR1. EMP2 confirmed there was no documentation of stabilizing interventions or testing for MR1 for November 25, 2017.

Cross reference:
489.24(2) and 489.24(c) Medical Screening Exam

Based on review of facility documentation, medical records (MR), and staff (EMP) interviews, it was determined the facility failed to obtain a consent for transfer or refusal of transfer by ambulance, failed to complete the physician to physician telephone call and acceptance, failed to complete the nurse to nurse report, and failed to ensure copies of the patient's medical record were sent to receiving facility for one of 20 medical records reviewed (MR1).

Findings include:

Review on December 6, 2017 at 10:20 AM of the facility policy "EMTALA (Emergency Medical Treatment [and] Labor Act of 1986)," last reviewed/revised by the facility on December 1, 2017 revealed "Policy: It is the policy of the Guthrie Towanda Memorial Hospital, a Medicare participating hospital, to comply with EMTALA rules and regulations ... Procedure/Protocol: ... 5. The ED will provide care to stabilize such that the patient is not likely to deteriorate from or during transfer or discharge. If the ED is not capable of appropriate stabilization, a medically appropriate transfer must be implemented. Key Points/Rationale: Patients will only be transferred for care not available at this facility or at patient/family request. The ED must have an accepting facility prior to transferring any patient. Nurse to nurse and physician to physician reports must be given. The ED physician will document the name of the receiving physician. The ED will provide transfer by medically appropriate vehicles, personnel and life support equipment to the destination hospital. A patient who refuses transfer must sign the Refusal Transfer form. If a patient refuses a medically appropriate vehicle, they must sign refusal of ambulance. A private auto does not meet these standards. The ED will obtain written consent to transfer from the patient or responsible party if at all possible prior to transfer. The sending physician must document that specific risks/benefits were explained to the patient/responsible party. The ED will send all pertinent medical information to the receiving facility including labs, reports, records, etc. ..."

Review on December 6, 2017 at 10:45 AM of MR1 revealed the patient presented to the ED on November 22, 2017 for rib pain. At the end of the document was an addendum by EMP3 dated/timed for November 25, 2017 at 1030 "11/25/17 at 1030 Received a phone call from RPH [Robert Packer Hospital] Maternity. Stated a pt of theirs called them and stated she is having bleeding. She may come to the GTMH [Guthrie Towanda Memorial Hospital] ER [Emergency Room]. Pt arrived [at] our ER. Dr. [CF1] and writer spoke with pt. Pt instructed to go to RPH ER for further assessment. Signs of imminent delivery not present." For November 25, 2017, there was no documentation of consent for transfer or refusal of transfer by ambulance. There was no documentation of a physician to physician telephone call and acceptance. There was no documentation of a nurse to nurse report. There was no documentation of transport by ambulance. There was no documentation that copies of MR1 were sent to receiving facility.

Cross reference:
489.24(2) and 489.24(c) Medical Screening Exam
489.24(3)(1-3) Stabilizing Treatment