1. The facility failed to meet the following requirements under the EMTALA regulation: Tag A2405 - Central Log On Each Individual Who Comes To The Emergency Department Tag A2406 - Medical Screening Exam Until Individual Is Stabilized Based on interviews and record review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. The facility failed to ensure an individual who "comes to the emergency department" seeking assistance and in active labor, was provided at a minimum, a medical screening examination. The facility also failed to document on a central log, an individual who "comes to the emergency department" seeking assistance was refused treatment. This deficiency affected 1 (#1) of 20 patients on their visit to the Emergency Department.

Based on record review and interview, the facility failed to document in the Central ED Log, a pregnant female who had come to the ED in labor. And, failed to document whether she refused treatment, was refused treatment, transferred, admitted and treated, stabilized and transferred, or discharged . This was true for 1 (#1) of 20 sampled patients. Findings include: Review of the ED log showed no evidence that patient #1, or her significant other, had sought medical attention at the ED on 12/12/16. During an interview on 1/3/17 at 2:40 p.m., staff member E said that although patient #1 came to the ED on 12/12/16, she did not get out of her car, and the event did not get entered into the log book because they had not considered her a patient. (See T2406 for more details on the event.)

Based on interview, observation, and record review, the facility failed to provide a medical screening exam for 1 (#1) of 20 sampled patients. An EMTALA obligation is triggered for a hospital when an individual comes by him or herself, or with another person to a hospital's dedicated emergency department and a request is made by the individual or on the individual's behalf, or a prudent layperson observer would conclude from the individual's appearance or behavior, a need for examination or treatment of a medical condition. Furthermore, if an individual who is not a hospital patient comes elsewhere on the hospital property an EMTALA obligation on the part of the hospital may be triggered if either the individual requests examination or treatment for an emergency medical condition or if a prudent layperson observer would believe that the individual is suffering from an emergency medical condition. Findings include: During an interview on 1/3/17 at 2:25 p.m., staff member E said she clearly remembered the incident from 12/12/16 when a man came into the Emergency Department. She said he thought his girlfriend was in labor. Staff member E stated she could see the van he had driven "in the circle," from the front desk. Staff member E said she asked who the provider was, and said to the man, they did not have prenatal care at the facility. She said, she asked who the OB was, and he said, she (the girlfriend) did not have any prenatal care. Staff member E said she told him they did not deliver babies, but could evaluate or they could go to Anaconda or Butte. She said she told him this hospital could deliver, in the case of an emergency, and that he had made the decision to go elsewhere. Staff member E said the pregnant woman stayed in the van and did not come into the building. Staff member E said she did not go out to the van to see the pregnant woman. She said, "From the front desk, the woman did not appear to be in distress." She then called both the hospital in Anaconda and the hospital in Butte, and gave them a "heads-up" that the pregnant woman was on her way. Staff member E said she could not remember if she asked the man (significant other) any screening questions related to the woman's condition. Staff member E said the Emergency Department physician had been with her at the desk, and had said, it might have been unsafe for her to have the baby here, with no prenatal care and an unknown history. She felt the whole encounter lasted about three minutes. During a review of the Emergency Department central log, no entry was found showing the pregnant woman at been at the ED. On 1/3/16 at 2:25 p.m., staff member E said they had not entered the visit into the ED log because they did not consider her a patient. During an observation and interview on 1/3/17 at 12:20 p.m., staff member G showed room ER04 and identified the room as the treatment for lacerations and orthopedics. Staff member G stated OB patients would go in ER04 as well, and the facility had the ability to deliver natural births although it was not common. Staff member G also stated it would be up to the physician to determine where a person presenting to the Emergency Department would go, and would be either Butte, or Anaconda, depending on where the the OB doctor was located. If no prenatal care was followed, it would be up to the doctor in the Emergency Department at the time the patient presented. They said the patient should be screened to determine where the patient in labor would go and how they would be transferred, either by ambulance or private vehicle; although the facility could deliver there if needed. During an interview on 1/3/17 at 3:30 p.m., staff member D said he was at the front desk when a man came in about his girlfriend being in labor. Staff member D said he told the man they would be happy to see her, but they were not an OB hospital, and if she (the pregnant woman) were stable she would be better served in Anaconda or Butte, because Anaconda and Butte were the nearest obstetrics hospitals. Staff member D said, "She (the pregnant woman) had no prenatal care, I guess." Staff member D said he could see the van in the "circle" but could not see the pregnant woman. Staff member D said the interaction lasted about 15 seconds. He said he did not go out to the van to see the pregnant woman, and that a medical screening exam should occur if she wished for it to occur, although he could not pull her out of the vehicle as she was not a patient. Staff member D said, in the event that he had assessed the pregnant woman and she had needed to be transferred to another hospital, he would have had a one-on-one conversation with a receiving physician regarding the transfer. A review of documentation from the second hospital showed staff had received a phone call from staff member E. The documentation described staff member E as having said, "A guy came running into the ED saying his pregnant wife was going to have a baby, and had no previous prenatal care. The doctor told him (the significant other) to bring her here, so their [sic] on their way........Pt and husband arrived and requested to be checked into the OB. Signs and symptoms of active labor, and taken directly to OB dept." The pregnant woman arrived at the hospital at 4:34 p.m., and was dilated to a seven or eight. The documentation showed the baby was delivered at 5:25 p.m. A review of Google Maps showed the distance between the two emergency departments was 27 miles door-to-door, and 39 miles to the next city hospital that had been offered as an option for OB services. A review of the EMTALA policy showed the facility would examine any person who, "Presents at a dedicated emergency department, and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition." A review of signage posted in the waiting room of the Emergency Department showed: "It's the law! If you have a medical emergency or are in labor. You have the right to receive within the capabilities of the hospital's staff and facilities: An appropriate medical screening examination. Necessary stabilizing treatment (including treatment of an unborn child.) and if necessary: An appropriate transfer to another facility even if: You cannot pay or do not have medical insurance or you are not entitled to Medicare or Medicaid. This Hospital does participate in the Medicaid program." Based on the above interviews with staff D and E, the (significant other) and the pregnant woman came to the Emergency Department in search of assistance.