Based on interviews, review of Facility #1's video surveillance footage, review of Facility #1's Emergency Department (ED) registration logbook and policies, and review of medical records from Facility #2 and Facility #3, it was determined the facility failed to ensure a medical examination and stabilizing medical treatment were provided for one (1) of twenty-one (21) sampled patients (Patient #1) that presented to Facility #1's Emergency Department (ED) for treatment. Interviews and review of Facility #1's ED video footage revealed Patient #1's family member (MDS) dated [DATE] and informed ED Registration Clerk #2 that Patient #1 was in the parking lot, in labor, and ready to push. ED Registration Clerk #2 informed Patient #1's family member that Facility #1 did not offer Obstetric (OB) services and no longer employed any OB nurses. Interviews revealed Patient #1's family left Facility #1 with Patient #1; however, review of Facility #1's ED log revealed no documented evidence that Patient #1 ever (MDS) dated [DATE]. Interviews and record review revealed after leaving Facility #1, Patient #1's family member drove to Facility #2 (a critical access hospital 16 miles away), and the patient delivered Twin A in the parking lot and Twin B in the ED of Facility #2. Facility #2 then transferred Patient #1, Twin A, and Twin B to Facility #3 (18 miles away). Facility #3 admitted and assessed the patients, but arranged for Twin A and Twin B to be transferred to Facility #4 (89 miles away) due to their inability to provide the level of care the twins required. Patient #1 was treated at Facility #3 for Undiagnosed Pregnancy, Previous Cesarean Section, Precipitous Delivery of Twins, Postpartum Bleeding, Severe Anemia, and Uterine Blood Clots and was discharged on [DATE]. Attempts to obtain the twins' medical records from Facility #4 were unsuccessful. Refer to 42 CFR 489.20 (r)(3) Emergency Department Registration Log (A2405) and 42 CFR 489.24 (a) and (c) Medical Screening Exam (A2406).

Based on interview and review of the Emergency Department's (ED's) registration logbook, it was determined the facility failed to maintain a log of patients that presented to the ED for treatment. Patient #1 (MDS) dated [DATE] in labor. Interviews with staff revealed the patient left the facility after being told the facility did not provide labor and delivery care. However, there was no documented evidence that Patient #1 was entered on the ED logbook. In addition, the facility failed to ensure a discharge disposition was documented on the ED's registration logbook for eighteen (18) of forty (40) patients who presented to the ED from 10/16/18 through 10/17/18. The findings include: Interview with the ED Manager on 10/29/18 at 12:30 PM revealed the facility did not have a policy that addressed registration or entering patients' names on the ED registration logbook. Interview with Registration Clerk #2 on 10/29/18 at 7:30 PM and observation of facility video footage revealed on 10/17/18 at 5:46 AM, a male approached the facility ED registration clerk and stated that Patient #1 was in labor. Interview with Security Guard #1 on 10/29/18 at 2:19 PM revealed the clerk informed the individual that the facility did not provide labor and delivery services. Further observation of video footage revealed the individual left the facility and drove away. Review of the ED log dated 10/16/18 through 10/17/18 revealed there was no documented evidence that Patient #1 had presented to the facility and requested treatment for his/her emergency medical condition. Continued review of the ED log revealed there were 40 patients registered in the logbook; however, there was no discharge disposition documented for 18 of the registered patients. Interview with the ED Manager on 10/29/18 at 12:30 PM revealed all patients needed to be recorded in the ED registration logbook along with their disposition. The Manager stated that it was her understanding that it was the responsibility of the ED registration clerk to enter and update all patient information in the ED registration logbook. Interview with ED Registration Clerk #2 on 10/29/18 at 7:30 PM revealed that it was her responsibility to log each patient's name in the ED logbook that requested treatment. Continued interview with ED Registration Clerk #2 revealed she recalled Patient #1's family member entering the ED lobby and asking about services; however, she failed to obtain any identifying information and did not log any information regarding Patient #2 into the ED logbook.

Based on interviews, review of Facility #1's video surveillance footage, review of Facility #1's Emergency Department (ED) registration logbook and policies, and review of medical records from Facility #2 and Facility #3, it was determined the facility failed to provide, within its capabilities, a medical screening examination and stabilizing medical treatment for one (1) of twenty-one (21) sampled patients (Patient #1) who presented to the facility (Facility #1). Interviews and review of Facility #1's ED video footage revealed Patient #1's family member (MDS) dated [DATE] and informed ED Registration Clerk #2 that Patient #1 was in the parking lot, in labor, and ready to push. ED Registration Clerk #2 informed Patient #1's family member that Facility #1 did not offer Obstetric (OB) services and no longer employed OB nurses. Patient #1's family member left Facility #1 and drove to Facility #2 (a critical access hospital 16 miles away) and delivered Twin A in the parking lot and Twin B in the ED of Facility #2. Facility #2 transferred Patient #1, Twin A, and Twin B to Facility #3 (18 miles away). Facility #3 admitted and assessed Patient #1, Twin A, and Twin B, and then arranged for Twin A and Twin B to be transferred to Facility #4 (89 miles away) due to their inability to provide the level of care Twin B required. Patient #1 was admitted to Facility #3 and diagnosed and treated for Undiagnosed Pregnancy, Previous Cesarean Section, Precipitous Delivery of Twins, Postpartum Bleeding, Severe Anemia, and Uterine Blood Clots. The findings include: Review of the facility policy titled, "Admission to the ED," approval date of July 2017, revealed any patient who came to the facility for emergency medical evaluation or treatment would receive a triage assessment and appropriate services would be rendered by the ED physician. Review of the facility policy titled, "Patient Transfers to Acute Care Hospitals (EMTALA)," approved June 2017, revealed the purpose of the policy was to ensure compliance with EMTALA and provide a mechanism to request and ensure the safe transfer of patients. An Emergency Medical Condition was defined as a medical condition manifested by acute symptoms of [DIAGNOSES REDACTED]. Continued review of the policy revealed the facility did not offer Obstetric services and those individuals would be transferred to facilities that had the capability to treat them. Review of the facility policy titled, "Patient Rights and Responsibilities," approved February 2017, revealed all patients had the right to receive quality and continuity of care by skilled doctors and staff and to have emergency procedures without unnecessary delay. Review of Facility #1's video footage of the ED from 10/17/18 revealed Patient #1's family member entered Facility #1's ED lobby at approximately 5:46 AM. Patient #1's family member was observed to speak with ED Registration Clerk #2, and then Patient #1's family member left the ED lobby at approximately 5:47 AM. At 5:48 AM on 10/17/18, ED Registration Clerk #2 and Security Guard #1 were looking out the window/door into the parking lot. Review of Facility #1's ED log for 10/16/18 and 10/17/18 revealed at approximately 5:46 AM on 10/17/18, when Patient #1 presented to the ED, the facility had one (1) patient registered in the facility. Review of Facility #1's schedules for October 2018 revealed Registered Nurse (RN) #1, RN #3, and Physician #2 were working at the time Patient #1 presented to the ED for treatment. Interview with ED Registration Clerk #2 on 10/29/18 at 7:30 PM, revealed she was working at Facility #1 on 10/17/18 when Patient #1's family member came into the ED. ED Registration Clerk #2 stated the family member told her that Patient #1 was in the car and possibly in labor. The clerk stated she informed the family member that Facility #1 did not provide OB services, but that he was welcome to bring the patient into the facility. Patient #1's family member then asked, "You don't have a doctor here?" and the clerk responded, "Yes, we just don't have an OB." The ED Registration Clerk further stated that she recalled the family member stating that Patient #1 was "ready to push" and she asked the family member if he could get the patient into a wheelchair. The clerk stated the family member left the facility lobby, and while she was waiting, she saw the family member drive the patient out of the parking lot. Further interview revealed the clerk notified Physician #2 and RN #3 that they "just dodged a bullet" because a pregnant woman in labor just left the facility. Interview with Security Guard #1 on 10/30/18 at 2:19 PM revealed he was working and was present in the lobby when Patient #1's family member presented to Facility #1's ED on 10/17/18. Security Guard #1 stated that Patient #1's family member told ED Registration Clerk #2 that "his wife was in the car and in labor." Security Guard #1 stated the clerk informed Patient #1's family member that "they didn't do OB anymore and those nurses did not work here anymore." Continued interview revealed Patient #1's family member stated "she was ready to push," and ED Registration Clerk #2 offered to register the patient; however, Patient #1's family member left the lobby and then left the facility with Patient #1. Interview with RN #3 on 10/29/18 at 3:34 PM, revealed she recalled ED Registration Clerk #2 reporting to her and Physician #2 that the clerk told Patient #1's family member that Facility #1 did not offer OB services when the patient presented in labor. RN #3 stated that if she had been notified of the situation, she would have gone to the parking lot and attended to Patient #1; however, she was not aware of the situation until after Patient #1 had already left. Interview with Physician #2 on 10/29/18 at 7:00 PM revealed she was working on 10/17/18, but was unaware that Patient #1 presented to Facility #1's ED until after the patient had left. Physician #2 stated that ED Registration Clerk #2 told her and one of the nurses about Patient #1's family member entering the lobby and stating that Patient #1 "was in the car and in labor." Physician #2 stated she would have gone to the parking lot and treated Patient #1 if she had been aware of the situation. Interview with the ED Manager on 10/29/18 at 12:30 PM revealed that she was unaware of the incident until someone that worked at Facility #2 informed her that a patient had been turned away from Facility #1 and delivered a baby in the parking lot of Facility #2. The ED Manager stated that all ED staff had been trained on EMTALA and knew that they should never turn a patient away for any reason. Interview with RN #4 on 10/19/18 at 4:00 PM revealed he was working in the ED at Facility #2 on 10/17/18 when Patient #1 arrived at Facility #2. RN #4 stated Patient #1's family member came to the ambulance bay of the ED, and RN #4 went to the patient's car to assess the patient. RN #4 stated he found Patient #1 in the car and stating, "Something is coming out of me." RN #4 stated that he asked, "How far along are you?" and Patient #1 replied, "I'm not pregnant. I think I have a kidney stone." RN #4 stated he went into the facility to notify the ED physician and when they returned to the car, Patient #1 was delivering Twin A. RN #4 stated they got Patient #1 into the ED and then delivered Twin B. Continued interview with RN #4 revealed Patient #1's family member told them that they had been to Facility #1 and were told "they didn't deliver babies and did not have a doctor there." Patient #1's family member told them that Facility #2 was "as far as we could make it." Review of the medical record of Patient #1 from Facility #2 revealed Patient #1 presented to Facility #2 on 10/17/18 at 6:05 AM, with a spontaneous delivery of a live viable infant in the automobile prior to being brought into the ED. The record revealed Patient #1 delivered another infant approximately fifteen (15) minutes after the first. Further review revealed Patient #1, Twin A, and Twin B were transferred to Facility #3 on 10/17/18 at 9:50 AM. Review of the medical record for Patient #1 from Facility #3 revealed Facility #3 admitted Patient #1 on 10/17/18 at 11:00 AM with diagnoses that included [DIAGNOSES REDACTED]#1 on 10/18/18. Review of the medical record for Twin B from Facility #3 revealed Facility #3 admitted Twin B on 10/17/18 at estimated 34 weeks gestational age, and weight of 1290 grams (2.8 pounds). Further review revealed Twin B had [DIAGNOSES REDACTED] with a 40% discordance (weighed 40% less than Twin A). Continued review of the record revealed Facility #3 determined on 10/17/18 that Twin B required services that Facility #3 could not provide and arrangements were made to transfer Twin B to Facility #4. Review of the medical record for Twin A from Facility #3 revealed Facility #3 admitted Twin A on 10/17/18, with an estimated gestational age of 34 weeks (six weeks early), and weight of 2100 grams (4.6 pounds). Continued review of the record revealed that due to the need to transfer Twin B to Facility #4, Facility #3 transferred Twin A as well so as to not separate the babies. Attempts to obtain the twins' medical records from Facility #4 were unsuccessful.

Based on interview and a review of the Emergency Department's registration logbook, it was determined the facility failed to ensure one (1) of twenty-one (21) sampled patients (Patient #1) was registered in the facility's Emergency Department registration logbook. Patient #1 presented to the grounds of the Emergency Department (ED) on 07/07/15 but left without receiving a medical screening. There was no evidence patient #1 was logged into the ED registration logbook (refer to A2405). Based on interview, incident report, and a review of the facility's policy it was determined the facility failed to ensure a medical screening was provided for one (1) of twenty-one (21) patients (Patient #1) that presented to the grounds of the facility's Emergency Department (ED) on 07/07/15 seeking treatment. Interview revealed Patient #1 was transported by emergency medical services (EMS) to the facility's emergency room on [DATE] with complaints of difficulty breathing. Patient #1's family member was present along with EMS personnel when staff told EMS that the facility could not accommodate the patient due to the patient's weight/size. The facility failed to provide a medical screening/assessment for patient #1 and told EMS to transport the patient to a facility that could accommodate bariatric patients. (Refer to A2406).

Based on interview and a review of the Emergency Department's registration logbook, it was determined the facility failed to ensure one (1) of twenty-one (21) sampled patients (Patient #1) was registered in the facility's Emergency Department registration logbook. Patient #1 presented to the grounds of the Emergency Department (ED) on 07/07/15 but left without receiving a medical screening. There was no evidence patient #1 was logged into the ED registration logbook. The findings include: Review of the facility policy titled "emergency room Records" revealed the facility had a policy to ensure that necessary systems were in place to record a complete and legible emergency department record. Further review of the policy revealed a control register was continuously kept and included at least the following information on each patient: 1. Patient Identification. 2. Time/Means of arrival 3. Person(s) transporting patient. 4. History of present complaints and physical finding. Interview with the Emergency Medical Technician (EMT) on 07/21/15 at 12:40 PM revealed Patient #1 presented by ambulance to the facility on [DATE] at approximately 7:20 PM. According to the EMT, the closest hospital diverted care and told EMS they could not accommodate the patient due to the patient's size/weight. The EMT stated a call was then dispatched to the above facility who agreed to accept the patient. The EMT stated patient #1 remained in the ED parking lot on the floor of the ambulance while facility staff came in/out for over an hour. The EMT stated information was provided to the facility to register the patient. Review of the EMS (Emergency Medical Service) transportation record dated 07/07/15 and the audio recording of the 911 call confirmed that the EMS dispatch had contacted the facility regarding Patient #1 and staff at the faciity had agreed to accept the patient. According to the EMS report, EMS staff transported the patient to the facility's ED for treatment. Continued review of the EMS report revealed ED staff refused to accept the patient due to the patients weight. Review of the ED registration log dated 07/07/15 revealed no evidence that patient #1 was ever logged into the ED registration logbook. Interview with the registration clerk (#1) who was working at the time of the incident stated staff could not get Patient #1 out of the ambulance due to the patient's weight/size. Registration Clerk #1 stated patients who presented to the ED were normally logged into the ED registration logbook. Registration Clerk #1 stated patient #1 was not logged in "but I guess we should have." The Director of Nursing (DON) on 07/21/15 at 10:45 AM stated it was facility policy to maintain the ED logbook with at least the patient's name, date of birth, and complaint until more information could be obtained. The DON gave no explanation why patient #1 was not logged on the ED registration logbook.

Based on interview, incident report, and a review of the facility's policy it was determined the facility failed to ensure a medical screening was provided for one (1) of twenty-one (21) patients (Patient #1) that presented to the grounds of the facility's Emergency Department (ED) for treatment. Interview revealed Patient #1 was transported to the facility's emergency room on [DATE] by emergency medical services (EMS) with complaints of difficulty breathing. Patient #1's family member was present along with the EMS personnel when staff told EMS that the facility could not accommodate the patient due to the patients weight/size. The facility failed to provide a medical screening/assessment for patient #1 and told EMS to transport the patient to a facility that could accommodate bariatric patients. The findings include: A review of the facility's policy titled "EMTALA Policy" undated, revealed the facility provided appropriate medical screening examinations to individuals who presented to the ED and to individuals who presented on the campus property who requested examination or treatment of an emergency condition, and if one exists, either to stabilize the emergency condition or to transfer the individual appropriately and in conformity with legal and regulatory requirements. Review of the facility's contracts revealed an agreement had been signed between EMCARE Physician Services and the facility effective April, 2015 to provide twenty-four (24) hour emergency Physician Services to the members of the community who required immediate medical and hospital service through the Hospital's Emergency Department. Interview with the Emergency Medical Technician (EMT) on 07/21/1 at 12:40 PM revealed Patient #1 was transported to the facility's emergency room on [DATE] by emergency medical services (EMS) with complaints of difficulty breathing. According to the EMT, the facility agreed to accept the transport; however, upon arrival staff told EMS the facility could not accommodate the patient due to the patients weight/size. The EMT stated patient #1 remained on the floor of the ambulance for over an hour before EMS found a receiving hospital which was more than a hundred (100) miles away. The EMT stated patient #1 did not receive a medical screening at the above facility and there was a "heated discussion" when staff told EMS the patient needed to be transported to a bariatric hospital. Interview with Patient #1's family member on 07/23/15 at 10:00 AM revealed the mother was present along with the EMS personnel when staff told EMS the facility could not accommodate the patient due to the patients weight/size. The family member stated,"the hospital should be equipped to handle bariatric patients." According to the family member, patient #1 weighed 650 lbs. An interview was conducted on 07/21/15 at 6:30 PM with the House Patient Care Manager (HPCM) who was working on 07/07/15 at the time of the incident. The HPCM stated she received a phone call from the ED Nurse (Nurse #1) who reported EMS had transported a bariatric patient and the facility did not have a stretcher to support the patient's weight. The HPCM stated the ambulance was in the ED parking lot and the patient was lying on the floor of the ambulance. The HPCM requested another bariatric stretcher from the local County EMS but their stretcher was not wide enough to support the weight of the patient either. The HPCM stated she asked the ED Physician to go outside and assess patient #1 but the ED Physician refused. The HPCM stated she notified the DON but the ED Physician continued to refuse to go out and assess the patient. Interview with Nurse #1 on 07/22/15 at 9:30 AM revealed she was working when the ambulance arrived at the ED parking lot on 07/07/15. Nurse #1 stated her shift ended at 7:00 PM but she stayed over until 8:45 PM trying to help with the situation. Nurse #1 stated it was her understanding when she left work that EMS and facility staff was going to transfer the patient to a hospital bed so the patient could be seen in the emergency room by the ED Physician. The ED Physician stated in interview on 07/23/15 at 9:30 AM that patient #1's reported weight was approximately 900 lbs., and there was no success getting the patient out of the ambulance. The ED Physician stated the facility bariatric bed only held 450 lbs. and the bed was not an option. When asked why the ED Physician did not assess the patient or conduct a medical screening of the patient outside in the ambulance, the ED Physician stated, "Looking at the patient in an ambulance would not constitute a medical screening." Review of Patient #1's medical record from the second facility revealed when the patient (MDS) dated [DATE] at 10:49 PM, the patient received a medical screening and was admitted . Further review revealed the patient was medically screened at the second facility and diagnosed with Acute Chest Pain, Acute Renal Failure, Hypotension, Morbid Obesity, and Left Leg Mass.