C-2400 Based on interview and record review, the facility failed to ensure compliance with 42 CFR 489.24, by failing to ensure its policy and procedure regarding EMTALA addressed training and competence for staff. Findings include: Patient U (MDS) dated [DATE] at approximately 10:21 p.m. with a chief complaint of abdominal pain and being 36 weeks pregnant. It was determined that the hospital failed to conduct a medical screening exam (please refer to citation A-2405 for additional details), failed to determine the need for stabilizing treatment of the mother or unborn fetus (please refer to citation A-2407 for additional details), and failed to conduct an appropriate transfer (please refer to citation A-2409 for additional details). Through the course of this investigation, it was determined that the facility failed to sufficiently address the issue of staff training and demonstrated competency evaluations for staff regarding knowledge and comprehension of EMTALA requirements. On 3/16/15 at 10:05 a.m., an interview was conducted with the Hospital Nurse Supervisor who was on duty during the time that (Patient U) presented to the Hospital Emergency Department (ED) seeking medical assistance. The Hospital ' s Emergency Department Staffing Plan states that the Nurse Supervisor is expected to provide nurse back up to the ED when additional nurse staffing is required and not otherwise available. During this interview, the Nurse Supervisor stated, " I am the Nursing Supervisor for the Hospital; I started in November and I honestly didn ' t have knowledge of EMTALA at all. " On 3/16/15 at 3:10 p.m. during an interview with the Registered Nurse (RN) who was on duty in the hospital ED when (Patient U) presented to the ED. The RN was asked if (he/she) was aware of a pregnant patient presenting to the ED during the time in which they were dealing with the 2 critical patients and the DO and Nursing Supervisor were present. The RN stated that (he/she) was not aware of the arrival of a pregnant patient as (he/she) was committed, with the DO, to the care of a critical patient that they were awaiting for Life Flight transfer. The RN was asked, " are you familiar with EMTALA rules? " The RN responded, " I have a large picture of it. The medical screening exam, everyone is entitled to a medical screening exam. " On 3/18/15 at 12:25 p.m., a telephone interview was conducted with the Doctor of Osteopathic Medicine (DO) who was the Hospitalist working on the night that (Patient U) presented to the ED. The Hospitalist oversees the care of hospital inpatients and see ' s patients in the ED that have been accepted for admission to the hospital. The hospitalist also provides back up to the ED provider during times of crisis in which the need for physician care exceeds the safe capacity of the sole ED provider due to high volume and level of critical need for interventions. During this interview, the DO stated that (he/she) was called to the ED to assist because they had two very critical patients. The DO stated that (he/she) arrived in the ED shortly after one critical patient had come in by ambulance and (he/she) worked with that patient and stayed with that patient until the patient left the ED via Life Flight. The DO was asked if (he/she) was familiar with EMTALA Regulations, and if (he/she) had received any training in EMTALA requirements. The DO stated, " I ' ve heard of it ... basically I believe it pertains to the appropriate use of the Emergency Department resources. I ' m not usually in the ED so I don ' t really get involved or have much exposure to EMTALA. I think I had some training on it at some point. " On 3/16/15 at 3:25 p.m. during an interview with the Registered Nurse (RN) /Emergency Department Director, the surveyor was informed that the facility was conducting chart audits regarding the ED provider signatures and counter signatures by the physician Medical Director. The RN Emergency Department Director stated, " we use on-line training for EMTALA. We have a nursing administrative assistant that makes sure that their certifications and trainings are up to date. The Hospital ' s EMTALA Policy which was revised 11/2011 and documented as reviewed on 8/8/14 states (under item #23 -Compliance, on page 10), " All employees, contracted agents, Medical Staff, and Allied Medical Staff are delegated the authority and responsibility to promptly report any and all complaints, allegations, or information that comes to his/her attention that involves any actual or potential violation of this policy directly to the Compliance Officer or Risk Manager. " The policy does not address staff training or education regarding EMTALA. On 3/16/15 at 9:05 a.m., in an interview with the Vice President of Quality for the hospital, the surveyor was informed that the hospital conducts EMTALA training by incorporating it into the patient rights section of their on line learning program. A review of the hospitals internal investigation and corrective action plan for the EMTALA Violation dated 3/13/15 does identify contributors to the occurrence and includes " A lack of awareness of the hospitals EMTALA obligations or possibly a lack of empowerment by staff to speak up regarding the hospitals EMTALA obligations to patients. " This document does include a recommended action for, " Mandatory education to be completed by all direct and indirect staff who are involved in processing patients who present to be seen in the ED. Including physician and allied health staff, Nursing, Registration, Administration. " There is no evidence that the hospital has a plan to change the EMTALA Policy to address training and competency evaluations as well as timelines for retesting of competency, nor is there a sufficient process to ensure that the staff can demonstrate competence and understanding of the regulations to ensure that there is not a repeat violation of EMTALA.

C-2405 Based on document review and interviews with key personnel on March 16 through 19, 2015, it was determined that Millinocket Regional Hospital (MRH) failed to Include the tracking of all individuals who come to the Emergency Department seeking assistance by deleting or not recording individuals who leave the ED prior to be evaluated or triaged. The findings include: 1. An interview with the Millinocket Regional Hospital Emergency Department Licensed Practical Nurse (ED LPN), conducted on March 16, 2015 at approximately 1:30 PM, the ED LPN Validated that there was no record of Patient U coming to the ED on March 12, 2015 at approximately 10:21 PM seeking assistance stating, in part, " if no one documents on a patient, say they come in and then leave before they are triaged of see anybody their information is removed from the list and the number becomes a "skipped number". Everyone that comes in get an "L" number when they are registered. If they leave and aren't seen by anybody, not triaged, all their information is removed. " 2. A review of the MRH electronic records for March 12, 2015 failed to contain an entry for (Patient U) indicating that (Patient U) had presented to the Emergency Department requesting care.

C-2406 Based on document review and interviews with key personnel on March 16 through 19, 2015 it was determined that Millinocket Regional Hospital (MRH) failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for one (1) of twenty-one (21) sampled patients. (Patient U) The findings include: 1. During an interview with the Vice President of Quality on March 16, 2015 at approximately 09:05 AM, The Vice President reported that the patient had come to the emergency department on March 12, 2015 at approximately 10:21 PM ... " As the Administrator on Call I was checking in when I was informed that the patient had gone to Lincoln without being seen by anyone in the ED. " 2. During an interview with the MRH ED Provider on March 16, 2015 at approximately 2:15 PM, the ED Provider stated, " I didn't see the patient or talk to him/her. All I heard about him/her from the front desk was that he/she was pregnant... thirty-something weeks along... and had abdominal pain. I told the supervisor to say we would be happy to see him/her but there would be some delay because we had two critical patients...All the beds were full... we were at capacity or more. We would be happy to see him/her but we would need to send him/her somewhere else anyway. " 3. During an interview with the MRH Nursing Supervisor on March 16, 2015 at approximately 10:05 AM, the Nursing Supervisor stated, " I heard (ED LPN) say "we have a thirty six (36) week pregnancy in the waiting room", and I heard (ED Provider) say "Can we ask him/her to go to Lincoln." I went to the waiting room and asked (Patient U) if it would be OK if he/she went to Lincoln. I explained to him/her there was no OB/GYN here and it would be the same result... that we would transfer him/her to another hospital. I then called Penobscot Valley Hospital (PVH) and spoke with an ED provider there... a doctor. PVH has an OB/GYN unit that is closing in May. " 4. During an interview with the Penobscot Valley Hospital (PVH) OB Physician (OB MD), conducted on March 18, 2015 at approximately 10:41 AM, The OB MD reported " (Patient U) told me that he/she was at the Millinocket (Regional Hospital) and they could not see him/her because they were too busy and they told him/her to come here. " 5. Millinocket Regional Hospital could not provide any documentation of the performance of a medical screening examination for (Patient U) when requested during this investigation.

C-2407 Based on interview and record review, the facility failed to meet the emergency needs of patients by not providing necessary stabilizing treatment prior to transferring to another medical facility for one (1) of twenty-one (21) sampled patients (Patient U). Findings include: (Patient U) presented to Millinocket Regional hospital on [DATE] at approximately 10:21 p.m. with a chief complaint of abdominal pain and being 36 weeks pregnant. Upon entrance to the hospital Emergency Department (ED), (Patient U) was greeted by the registration clerk and information was entered into the hospital ' s electronic documentation system. The registration clerk contacted the staff inside the ED and advised them of the presence of (Patient U). There was no documentation of any medical examination or treatment of (Patient U) to determine (his/her) stability prior to transferring (Patient U) to another hospital. On 3/16/15 at 2:14 p.m., an interview was conducted with the Physician Assistant-Certified (PA-C) who was the medical provider on duty during the time when (Patient U) arrived seeking medical assistance. The PA-C stated, " I didn ' t see or talk to (Patient U). I told the supervisor to say that we would be happy to see (him/her), but there would be some delay because we had two critical patients. " The PA-C stated that the hospital was not on diversion and that the Hospitalist was in the ED to assist at the time (Patient U) arrived. On 3/18/15 at 12:00 p.m., an interview was conducted with the Hospitalist, a Doctor of Osteopathic Medicine (DO), who was on duty and assisting in the ED on 3/12/15. The DO stated that the ED was very busy the night of 3/12/15 and that he was called down to assist with a critical patient who was awaiting Life flight (an air medical helicopter) transport. The DO stated that (he/she) only treated and evaluated the critical patient awaiting Lifeflight and that (he/she) left the ED after this patient left by the transport team. The surveyor asked the DO if (he/she) was aware of a 36 week pregnant patient presenting to the ED and (he/she) stated, " no, I was not notified of that [a pregnant patient]. I ' m not usually in the ED and I am not an OB so I wouldn ' t necessarily be involved with pregnant patients. " During an interview with the hospital Nursing Supervisor on 3/16/15 at 10:05 a.m., (he/she) stated that (he/she) was in the ED when the ED Provider was informed of the presence of (Patient U). The Nursing Supervisor stated that (he/she) heard the ED Provider state " can we ask (him/her) to go to Lincoln. " The Nursing supervisor stated, " I went to the waiting room and asked [Patient U] if it would be ok if (he/she) went to Penobscot Valley Hospital. I explained to (Patient U) there was no Obstetrics and Gynecological (OB/GYN) here and it would be the same result, that (he/she) would be transferred to another hospital. " The Nursing supervisor stated that (he/she) called Penobscot Valley Hospital and spoke to the ED Provider to inform them that a pregnant patient was on the way to them. There was no evidence that any medical staff had conducted any form of medical evaluation to determine if the patient or unborn fetus were stable enough for a transfer to another facility. On 3/18/15 at 11:20 a.m. the surveyor conducted a telephone interview with the Registered Nurse who was the House Manager at Penobscot Valley Hospital on duty on 3/12/15 during the time that (Patient U) presented to Penobscot Valley Hospital from Millinocket Regional Hospital. The House Manager stated that (he/she) was informed by a member of the ED staff that a 36 week pregnant patient was enroute to them from Millinocket Regional Hospital but that they had no other details. The House Manager stated that (he/she) contacted the ED at Millinocket Regional Hospital to get additional information regarding the stability of this patient to determine if they needed to call in the OB physician. The House manager stated that (he/she) spoke to [Millinocket Nursing Supervisor] and (he/she) stated, " they said they sent this OB to us because they were too busy with two criticals. They said they had no OB/GYN so (he/she) would have had to wait any way, and then I asked if (he/she) was coming by ambulance and they said no. I then asked if (he/she) was seen by a provider and they said no ...nobody had seen (him/her). They just told her to go to Penobscot Valley Hospital. " The House Manager stated that when (Patient U) arrived they brought the patient into the Labor and Delivery Unit and conducted a medical screening and medical evaluation and the OB/GYN Provider came in to evaluate (Patient U). It was determined that the baby and mother were high risk for the need of a Neonatal Intensive Care Unit (NICU) and the OB/GYN Provider worked with the patient and the closest hospital with a NICU to arrange for safe transfer to that unit.

C-2409 Based on interview and record review, the facility failed to provide an appropriate transfer of a patient who presented to the Emergency Department seeking medical assistance for one (1) of twenty-one (21) sampled patients (Patient U). Findings include: (Patient U) (MDS) dated [DATE] at approximately 10:21 p.m. with a chief complaint of abdominal pain and being 36 weeks pregnant. Upon entrance to the hospital Emergency Department (ED), the patient was greeted by the registration clerk and information was entered into the hospital ' s electronic documentation system. The registration clerk contacted the staff inside the ED and advised them of the presence of (Patient U). There was no documentation of any medical examination or treatment of Patient U to determine his/her stability prior to transferring Patient U to another hospital. Interviews conducted with the Physician Assistant-Certified (PA-C) on 3/16/15 at 2:14 p.m., and the Hospitalist, a Doctor of Osteopathic Medicine (DO), on 3/18/15 at 12:00 p.m., who were both present in the ED when (Patient U) presented to the ED, confirmed that (Patient U) was not seen or evaluated by a medical provider prior to the transfer to Penobscot Valley Hospital. During an interview with the hospital Nursing Supervisor on 3/16/15 at 10:05 a.m., (he/she) stated that (he/she) was in the ED when the ED Provider (the PA-C) was informed of the presence of (Patient U). The Nursing Supervisor stated that (he/she) heard the ED Provider state " can we ask (him/her) to go to Lincoln. " The Nursing supervisor stated, " I went to the waiting room and asked (Patient U) if it would be ok if she went to Penobscot Valley Hospital. I explained to (Patient U) there was no Obstetrics and Gynecological (OB/GYN) here and it would be the same result that (he/she) would be transferred to another hospital. " The Nursing supervisor stated that (he/she) called Penobscot Valley Hospital and spoke to the ED Provider to inform them that a pregnant patient was on the way to them. There was no evidence that any medical staff had conducted any form of medical evaluation to determine if the patient or unborn fetus were stable enough for a transfer to another facility. There was no evidence that the risks and benefits of the transfer were fully discussed with the patient or that the receiving hospital was consulted to ensure that they had the capacity and ability to accept this patient prior to the patient being sent to the receiving hospital. Additionally, there is no evidence of physician certification for the transfer, On 3/18/15 at 11:20 a.m. the surveyor conducted a telephone interview with the Registered Nurse who was the House Manager at Penobscot Valley Hospital on duty on 3/12/15 during the time that (Patient U) presented to Penobscot Valley Hospital from Millinocket Regional Hospital. The House Manager stated that (he/she) was informed by a member of the ED staff that a 36 week pregnant patient (Patient U) was enroute to them from Millinocket Regional Hospital but that they had no other details. The House Manager stated that (he/she) contacted the ED at Millinocket Regional Hospital to get additional information regarding the stability of this patient to determine if they needed to call in the OB physician. The House manager stated that (he/she) spoke to [Millinocket Nursing Supervisor] and (he/she) stated, " they said they sent this OB to us because they were too busy with two criticals. They said they had no OB/GYN so (he/she) would have had to wait any way, and then I asked if (he/she) was coming by ambulance and they said no. I then asked if (he/she) was seen by a provider and they said no ...nobody had seen (him/her). They just told [him/her] to go to ABC Hospital. " The House Manager stated that when (Patient U) arrived they brought the patient into the Labor and Delivery Unit and conducted a medical screening and medical evaluation and the OB/GYN Provider came in to evaluate (Patient U). It was determined that the baby and mother were high risk for the need of a Neonatal Intensive Care Unit (NICU) and the OB/GYN Provider worked with the patient and the closest hospital with a NICU to arrange for safe transfer to that unit.