Based on review of policies and procedures and staff interviews it was determined the facility failed to take reasonable steps to secure the individuals written informed refusal by failing to document the individual had been informed of the risks and benefits of the examination or treatment or both for 1 (#1) of 20 sampled patients to the emergency department. Refer to findings in Tag A-2407. Based on review of patient care report (ambulance report), facility's Event Description Report and Policy and procedure it was determined the facility failed to appropriately transfer 1 (Patient #1) of 20 sampled patients who presented to the emergency department in active labor. Refer to findings in Tag A-2409.

Based on interview, review of the policy and procedure, and review of the Central Log the facility failed to ensure patients presenting to the Emergency Department (ED) for treatment were documented on the Central Log for 1 (#1)of 20 patients sampled, Patient #1. Findings: Review of the event description on 04/08/18 at 7:50 AM for Patient #1 showed the Patient presented to the ED with her significant other to the waiting room. Patient #1 was new to the area and asked a friend which hospital had obstetric services because her water broke. The friend informed her of the hospital across the street had obstetric services, but had dropped her at this facility. Patient #1 asked the paramedic at the desk which facility this was and asked if it had obstetric services. The paramedic at the desk informed it did not. The triage RN (Registered Nurse) had the charge nurse speak with the patient. The charge nurse informed patient #1 that the physician at this facility could see her and then if needed, she could be transported to the facility across the street. Patient #1 refused and asked about getting EMS (Emergency Medical Services) to transport her to the other facility. Staff stayed with the patient until EMS arrived and advised EMS that this facility would have taken care of her, but patient #1 had refused. Review of Central Log for 04/08/18 showed that Patient #1 did not sign in to the Central Log. Review of the facility's policy and procedure titled "EMTALA - Definitions and General Requirements" (Emergency Medical Treatment and Labor Act) revised 02/01/16 showed it is a log that the facility is required to maintain on each individual whether she refused treatment or if treatment was given. The purpose of the Central Log is to track care provided to each individual where EMTALA is triggered. Review of the facility's policy and procedure titled "Florida EMTALA - Central Log Policy" revised 02/01/2016 showed the purpose is to establish guidelines for tracking the care provided to each individual seeking care in a dedicated emergency department for a medical condition. The hospital will maintain a Central Log containing information on each individual who requests emergency services. Whether he/she left before medical screening or refusal of treatment. The Central Log at a minimum must contain the name of the individual and if that individual refused treatment. During an interview on 05/29/18 at 9:23 AM with the Director of Quality it was stated that she remembered this case. The patient did refuse care, many attempts were made from the RNs (Registered Nurses) to have the patient be checked and the patient refused. This facility should have had her sign in or had more than one RN witness the refusal. During an interview on 05/29/18 at 10:10 AM with Staff A, RN, who was triage RN when patient #1 presented to the ED (Emergency Department), she stated the Patient presented to triage. The paramedic in triage, was advised by the patient that her water broke and the triage RN went to get the Charge Nurse. Staff A states she did not put Patient #1's name on the Central Log or have the patient sign any refusal form.

Based on review of policies and procedures and staff interviews it was determined the facility failed to take reasonable steps to secure the individuals written informed refusal by failing to document the individual had been informed of the risks and benefits of the examination or treatment or both for 1 (#1) of 20 sampled patients to the emergency department. Findings were: The facility's policy and procedure titled, "Against Medical Advice (AMA), Patient Leaving/Elopement," PolicySTATID: 56; Effective: 4/12/2015; Approved: 4/16/2018 was reviewed. The policy revealed in part, "PURPOSE: Establish criteria for documentation of patients leaving AMA (against medical against). POLICY ... 3. If after an explanation of potential consequences, the patient still wishes to leave AMA, request the patient sign the AMA form." The facility's Policy and procedure titled, "Florida EMTALA- Medical Screening Examination and Stabilization Policy" PolicyStatID: 98; Effective: 4/1/2018; Approved: 4/1/2018 was reviewed. The policy specified in part, " Refusal to consent to Treatment: Written Refusal- Partial Refusal of Care or Against Medical Advice. If a physician or QMP has begun the MSE or any necessary treatment and an individual refuses to consent to a test, examination or treatment or refuses any further care and is determined to leave against medical advice, after being informed of the risks and benefits of the hospital's obligation under EMTALA, reasonable attempts shall be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individuals refusal to sign the Partial Refusal of Care or the Against Medical Advice Form ...The medical record must contain a description of the screening and the examination or both if applicable, that was refused by or on behalf of the individual ...Documentation of Information. If an individual refuses to sign a consent form, the physician of nurse must document that the individual has been informed of the risks and benefits of the examination and/or treatment but refused to sign the form." During an interview on 05/29/18 at 9:23 AM with the Director of Quality it was stated that she remembered this case. The patient (#1) did refuse care, many attempts were made from the RNs (Registered Nurses) to have the patient (#1) be checked and the patient refused. This facility should have had her (patient #1) sign in or had more than one RN witness the refusal. During an interview on 05/29/18 at 10:10 AM with Staff A, RN, who was triage RN when patient #1 presented to the ED (Emergency Department), she stated the Patient presented to triage. The paramedic in triage, was advised by the patient that her water broke and the triage RN went to get the Charge Nurse. Staff A states she did not have Patient #1 sign any refusal form.

Based on review of patient care report (ambulance report), facility's Event Description Report and Policy and procedure it was determined the facility failed to appropriately transfer 1 (Patient #1) of 20 sampled patients who presented to the emergency department in active labor. Findings were: 1. Ambulance Report for Patient #1 A review of the Patient #1's Patient Care Report dated 4/8/2018 at 7:58 was reviewed. The report revealed the patient's chief complaint was, "water broke at 7 am someone dropped them off at Ocala Regional. We are transporting the patient to Hospital B (Acute care hospital)." The patient's vital signs were listed as Blood Pressure 150/83; Heart rate: 93; Respirations:20; and oxygen saturation: 98% on room air. Further review of the report revealed the patient was in active labor. The section of the note titled "Additional Comments" specified in part, "Rescue ...dispatched urgently to ORMC (Ocala Regional Medical Center) for a transfer to Hospital B, 37 y.o.f (year old female) was in their waiting room due to her water breaking at 7 AM, they told her that they can't treat her due to not having a labor and Delivery service at that hospital. Pt. stood up and pivoted to the stretcher. Patient monitored en route to Hospital B. She is a G6P5, her contractions are approximately 5 minutes apart. Pt had no changes throughout transport. Once at Hospital B, pt. taken straight to L & D (labor and delivery)." 2. Event Description Report Review of the event description on 04/08/18 at 7:50 AM for Patient #1 showed the Patient presented to the ED with her significant other to the waiting room. Patient #1 was new to the area and asked a friend which hospital had obstetric services because her water broke. The friend informed her of the hospital across the street had obstetric services, but had dropped her at this facility. Patient #1 asked the paramedic at the desk which facility this was and asked if it had obstetric services. The paramedic at the desk informed patient #1, it did not. The triage RN (Registered Nurse) had the charge nurse speak with the patient. The charge nurse informed patient #1 that the physician at this facility could see her and then if needed, she could be transported to the facility across the street. Patient #1 refused and asked about getting EMS (Emergency Medical Services) to transport her to the other facility. Staff stayed with the patient until EMS arrived and advised EMS that this facility would have taken care of her, but patient #1 had refused. 3. Policy and Procedure The facility's policy and procedure titled "Florida EMTALA- Transfer Policy" PolicyStatID: 12; Effective: 2/1/2016; Approved: 2/1/2016 was reviewed. The policy revealed in part , "POLICY: Any transfer of an individual with an EMC (Emergency Medical Condition) must be initiated wither by a written request for transfer from the individual or the legally responsible person acting on the individual's behalf or by a physician order with the appropriate physician certification as required under EMTALA. EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC apply to any emergency department ("ED") ...1. Transfer of Individuals Who Have Not Been Stabilized. A. if an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer and meets the following conditions: 1. Transfer of Individuals Who Have Not Been Stabilized a. If an individual who has come to the emergency department has an EMC that has been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer and meets the following conditions: 1. The individual or a legally responsible person on the individual's behalf requests the transfer, after informed of the hospital's obligations under EMTALA and or the risks and benefits of such transfer. The request must be in writing and indicate the reasons for the request as well as indicate that the individual is aware of the risk and benefits of transfer. b. A transfer will be appropriate transfer if: i. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child; ii. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment; iii. The transferring hospital sends the receiving hospital copies of all medical records related to the EMC for which the individual requested emergency services that are available at the time of transfer ...; iv. The transfer is effected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transport." The facility failed to ensure that their policy and procedure was followed as evidenced by failing to: a. Document that patient #1 was aware of the risk and benefits of transfer; b. To provide medical treatment that was within its capacity to minimize the risk to patient #1 who was in labor and the health of her unborn child; and c. Notify the receiving facility (Hospital B) to ensure they had space and qualified personnel to provide treatment for patient #1 and had agreed to accept patient #1 for treatment on 4/8/2018.