Based on EMTALA policy review, Medical Staff Bylaws review, Medical Record reviews, and Physician and Staff interviews the hospital failed to ensure patients with an emergency medical condition were appropriately transferred by failing to ensure all required elements were completed prior to transfer for 2 of 7 sampled transfer patients (#5, #26) The findings include: Review of the "EMTALA-Medical Screening and Treatment of Emergency Medical Conditions" policy, last revised 08/2017, revealed "...If an Emergency Medical Condition is found to exist, the Hospital will...(b) an appropriate transfer to another medical facility...Appropriate transfer occurs (once a physician has certified the need for transfer or the patient has requested transfer after an explanation of the risks and the Hospital's obligation to provide stabilizing services) when: 1. 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; 2. the receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment; 3. the transferring Hospital sends to the receiving Hospital all medical records...related to the Emergency Medical Condition for which the individual has presented...4. the transfer is effected through qualified personnel, transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer..." 1. L&D record review, on 09/04-05/2018, of Patient #5 revealed the Patient arrived to the hospital at 0800 "...for triage and observation for PPROM (Preterm Premature Rupture of Membranes)....Amnisure (test for ruptured membranes) positive. ..." Review of current symptoms noted "pelvic pressure" but no contractions were noted. The record stated MD #1 was in the room at 0814. Review of a Physician Progress Note, timed at 0825, revealed "...G (Gravida) 5 - just moved to (City name) 2 months ago....EDD (Estimated Delivery Date) 10/31 - 28 wks (weeks) by previous care in (State name) until 2 months ago. No care since moving....SROM (spontaneous rupture of membranes) clear this AM....no pain. Large amount clear fluid....No UC (uterine contractions) on monitor. ..." The Progress Note stated a vaginal exam was done and the patient was 2 cm dilated, 80% effaced, breech presentation, and minus 2 (-2) station. Review of Physician Orders revealed an order, at 0825, to transfer Patient #5 to Hospital C. Review of a form titled "REQUEST FOR TRANSFER/CONSENT TO TRANSFER/ CERTIFICATION FOR TRANSFER", dated 08/09/2018 at 0822, revealed a diagnosis of PROM (Premature Rupture of Membranes). The reason for transfer was handwritten as "Level 3 NICU". In regards to "Patient Condition upon Transfer", the form review revealed a checkmark beside the statement "...Stable: No material deterioration of the patient's medical condition, within reasonable medical probability, is likely to result from or occur during transfer. ..." Form review revealed sections for risks and benefits of transfer. In regards to "Risks of Transfer" an x mark was placed in the box beside "Risks related to condition" with "Premature Delivery" handwritten in. Form review did not reveal the name of the receiving facility, but did include the name of the accepting physician and the name of the facility staff member who confirmed available space and qualified personnel. Transfer form review did not reveal notation of which hospital documents were sent with Patient #5 during transfer. Further form review revealed the Physician's Certification for Transfer stated "I confirm the patient's condition and the benefits\risks of transfer as stated above. Based on the information available at this time, I have determined the medical benefits....outweigh the increased risks to this patient and, in the case of labor, to the unborn child." Review showed that MD #1 signed the certification on 08/09/2018 at 0835. Review of a form titled "HOSPITAL-HOSPITAL TRANSFER", dated 08/09/2018 and also signed by MD #1 at 0835 revealed lab results and progress notes were attached at transfer and the destination for transport was Hospital C. Review revealed the word "good" was circled as the condition at time of transfer. The form, per review, was signed by a RN (no time documented). Further review did not reveal a signature of the "Responsible Party receiving Medical Record for Transfer". Review of the Discharge Summary, dictated 08/11/2018 at 0345, revealed "...HOSPITAL COURSE: The patient is a 32-year-old, gravida 5....She has had no OB here in (City Name) and has moved here....two months ago. At her previous OB.... 28 weeks 1 day by that EDD (Estimated Delivery Date). She presented to Labor and Delivery at 8 a.m., with spontaneous rupture of membranes with clear fluid but with no pain.... On the monitor, we had uterine contractions (different from Progress Note which stated no contractions) with fetal heart tones reactive at 140s to 150s. On exam, cervix is 2 cm, 80% (effaced), breech, -3.... FINAL IMPRESSION: This 28 weeks with spontaneous rupture of membranes. I discussed with MFM (Maternal Fetal Medicine) at (Hospital C)....with Dr. (Name), who agrees to accept the patient in transfer.... EMS will be called to transfer and the patient will be transferred via EMS. ..." L&D Record review revealed Patient #5 was transported off the unit via EMS at 0948 (1 hour 13 minutes after MD signed the certification). Review of the Medical Record from Hospital B revealed Medical Record review from Hospital B, on 09/04/2018, revealed Patient #5 was transferred by ambulance from Hospital A. Review of the EMS record, dated 08/09/2018, revealed "...Team: ALS....Crew 1: Primary Caregiver (Name) EMT-P...Crew 2: Driver (Name) EMT-P. ..." Review revealed "...Pt. Condition: Worse. ..." and listed the receiving hospital as Hospital B. EMS record review revealed EMS left Hospital A at 0952 and arrived at Hospital B at 1011. Review of EMS Notes stated "Pt had come into the ER around 8 am with complications of her pregnancy.... Pt was stable no complaints at time of arrival, due to high risk Paramedic (Name) consulted .... about this transport and we were advised if pt stable and we were comfortable with pt to transport....Once we started transport pt was advised if she became uncomfortable or started having any contractions to let us know. Pt again was pain free....We had gotten to (city name) and pt stated she was hurting and felt like the baby was going to deliver ....we diverted to (Hospital B) due to distance to (City of Hospital C). ..." Review of Hospital B Notes, on 08/09/2018 at 1025, revealed " ...pt in via (ambulance) pt being transported from (Hospital A) to (Hospital C), pt told EMS feelings. EMS routed to (Hospital B). pt taken to ER room. ..." At 1035 documentation of the cervical exam stated the cervix was dilated to 4 centimeters, was 80% effaced), and fetal station was -2 (minus 2). Review of the History and Physical (H&P) revealed "...She was being transferred to (Hospital C)....but in route she started having vag pressure so the transfer was diverted to (Hospital B). I was call (sic) to come to the ED to evaluate the pt upon arrival.....SVE 4/80/-2 /most likely vertex (head presentation)....Magnesium sulfate 2 gm/hr was infusing. This continued....Decision was made to continue with routine antepartum care. ..." On 08/20/2018 at 0502, record review revealed "...At 4am awakened ....complaining of contractions... ." Review of the "Delivery Record" revealed Patient #5 delivered on 08/20/2018 (11 days after arrival to and transfer from Hospital A). Telephone interview, on 09/05/2018 at 1300, with MD #1 revealed Patient #5 came to L&D because of preterm premature rupture of membranes. MD #1 stated he examined the patient, and she was 2 centimeters dilated. Interview revealed it was unusual for a patient to be 2 cm at that point, "it could make you wonder about labor", but MD #1 stated she had no contractions. Interview revealed the Discharge Summary note which stated uterine contractions were noted was not accurate, it was a "misnote". Interview revealed Patient #5 was not reexamined prior to transfer. MD #1 stated he examined the patient and then did the transfer paperwork required. Interview revealed MD #1 did not see Patient #5 after the examination at 0835 and left the department around 0900. Interview revealed MD #1 thought Patient #5 was safe to be transferred by EMS and thought she would be leaving shortly after he left the department. In relation to explaining the risks and benefits of transfer, interview revealed MD #1 wrote preterm delivery because the patient had a greater risk of preterm delivery in general. Preterm delivery was not discussed with the patient as a risk of transfer. MD #1 stated if he thought she was in labor he would not have put her in the ambulance. MD #1 further stated he did not specifically discuss any risks of transfer with Patient #5, he told her it would be safer to be in a hospital with a NICU. Interview revealed MD #1 discussed benefits of transfer, but not risks associated with transfer. Interview with RN #2, on 09/05/2018 at 1335, revealed she was the Charge Nurse on 08/09/2018 and completed the EMS form. Interview revealed she could not specifically recall, but most likely called EMS. RN #2 stated the Hospital - Hospital Transfer form was filled out by nursing and RN #2 probably was the one who circled the patient was in good condition, which would have been based on what the doctor stated. Interview revealed RN #2 could not recall what records were sent during transfer and stated they should have gotten EMS to sign the form stating that records were received. 2. Medical record review for Patient #26, revealed the [AGE] year old pregnant patient arrived to the hospital L&D unit on 02/19/2018 at 1122 " ...for observation & transfer due to PPROM ....states she noticed she was leaking clear fluid around 0900 that would not stop, this was confirmed by Dr. (Name of MD #4) in the office that she was PPROM & was sent to L&D. Denies any uc's (uterine contractions) or abd. (abdominal) tightening ....States good FM (fetal movement). ..." The record stated Patient #26 was a gravida 4, para 4 and the gestational age of the fetus was listed as 29 weeks. Review of form titled "REQUEST FOR TRANSFER/CONSENT TO TRANSFER/CERTIFICATION FOR TRANSFER", dated 02/19/2018 at 1430, revealed the patient's diagnosis was "PPROM" and the transfer was because of the "Need for level 3 NICU". The form stated "Patient Condition upon Transfer...Stable. ..." In the "Acknowledgment & Name of Receiving Facility" section "Staff Person Name" was stated, with an underlined area to be completed and under the line was a statement "Receiving facility staff person confirming available space and qualified personnel for treatment". Handwritten above the line was "(Hospital C name) Maternal-Fetal", with the time contacted noted as 1100. Review did not reveal the name of a specific staff person who confirmed the receiving facility had available space and qualified personnel. Form review also revealed a statement "Accepting Physician Name" and on that line was handwritten "(Hospital C name) Labor & Delivery" and the accepting time 1100. Form review did not indicate the name of a specific physician who accepted Patient #26. Further review of the Request for Transfer form revealed the "Physician or Qualified Medical Person's Certification for Transfer" was signed by MD #5 on 02/19/2018 at 1250 (1 hour, 40 minutes prior to Patient #26's transfer out of Hospital A). Review of the "HOSPITAL-HOSPITAL TRANSFER" form noted MD #5's signature and the time 1250. Further review revealed a RN signature timed at 1427 (1 hour 37 minutes after MD #5 signed). Record review failed to reveal any Progress Notes or Discharge Notes from MD #4 or MD #5 while Patient #26 was in Hospital A. Review revealed the only physician documentation noted while in L&D were the signatures of MD #5 on the "REQUEST FOR TRANSFER/CONSENT TO TRANSFER/CERTIFICATION FOR TRANSFER" form, the "HOSPITAL-HOSPITAL TRANSFER" form, and the EMS form. . Interview with MD #4, on 09/06/2018 at 1505, revealed MD #4 saw Patient #26 in the office on the morning of 02/19/2018. Interview revealed the patient was 1 cm dilated and was leaking amniotic fluid. Interview revealed Patient #26 was not having contractions. MD #4 stated she sent Patient #26 to the hospital to prepare for transfer to a "Level 4 for maternal fetal medicine care". Interview revealed Patient #26 had an emergency medical condition. MD #4 stated she was "stable" but needed transfer and a steroid and antibiotics prior to transfer. Further interview revealed MD #4 did not see Patient #26 in the hospital, that a partner (MD #5) was already at the hospital. Interview revealed "I think she saw her (Patient #26)". MD #4 indicated they had talked about possibly sending Patient #26 directly from the office to Hospital C but they wanted meds and labs and a physician to physician transfer. Interview revealed MD #4 contacted Hospital C, but did not record the name of the doctor who accepted the patient, and did not realize that was necessary. Telephone interview, on 09/14/2018 at 1225, with MD #5 revealed MD #5 was on the unit and the nurses stated MD #4 had seen a patient in the office and would be coming over to the hospital to do the paperwork. MD #5 stated she told nursing that was not necessary, she would do the paperwork. Interview revealed MD #5 filled out the transfer forms. MD #5 stated she did not examine the patient and did not write any notes. MD #5 stated MD #4 had assessed the patient in the office and determined she had ruptured membranes. Then, the patient came to L&D, the nurse monitored her, she had no contractions, the fetal heart tones and vital signs were stable, so that was a medical assessment. Interview revealed MD #5 based the certification that Patient #26 was stable on MD #4's assessment in the office and the nurse assessment at the hospital. Interview revealed MD #5 signed the form at 1250, left the unit and had no involvement after that. MD #5 stated she felt sure she walked in and spoke with Patient #26 but did not examine or evaluate her. Interview revealed if MD #4 had not seen the patient in the office or if anything on the monitor strip was concerning, then MD #5 would have seen her. Further interview revealed it was the only time this type of situation had happened, MD #4 was coming to sign the paperwork, MD #5 was already there and said that was not needed, MD #5 would sign it and did. NC 012

Based on EMTALA policy review, Medical Staff Bylaws, Labor and Delivery medical record reviews, and physician and staff interviews; the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings include: The hospital's medical staff failed to provide an appropriate ongoing medical screening examination to an individual who presented with preterm premature rupture of membranes for 1 of 8 sampled patients presenting to the hospital's Labor and Delivery (L&D) department for evaluation and treatment. (Pt #26) ~ Cross refer to §489.24(a) and (c) Medical Screening Exam, Tag A2406. The hospital failed to to ensure patients with an emergency medical condition were appropriately transferred by failing to ensure all required elements were completed prior to transfer for 2 of 7 sampled transfer patients (#5, #26) ~ Cross refer to §489.24(e) Transfer - Tag A2409

Based on EMTALA policy review, Medical Staff Bylaws review, medical record reviews, and physician and staff interviews the hospital medical staff failed to provide an appropriate ongoing medical screening examination to an individual who presented to the hospital's Labor and Delivery (L&D) department with preterm premature rupture of membranes (PPROM) for 1 of 8 sampled patients who presented to the hospital's L&D department for evaluation and treatment. (Pt #26) The findings include: Review of a policy titled "EMTALA-Medical Screening and Treatment of Emergency Medical Conditions", last revised 08/2017, revealed "Any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exist...ii. Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the facility's capability and available personnel, including on-call physicians. The Medical Screening Examination must be performed by a Physician or other Qualified Medical Personnel. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred....3....A Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to discharge or transfer..." Review of the "Medical Staff Bylaws", last reviewed 07/2018, revealed "...5.3....Patients at term (defined as 37 or more weeks gestation), determined to be complaining of labor onset and not suffering from any apparent complications, will be transported to the Labor and Delivery Unit with qualified medical personnel...For patients at term and without other complications, the medical screening examination required....may be performed by a qualified RN under the orders of and in telephone contact with the obstetrical physician where permitted under state law...5.4 PATIENTS PRESENTING TO LABOR AND DELIVERY UNIT Any patient admitted directly to the Labor and Delivery Unit for onset of labor by order of her treating physician or otherwise shall undergo the screening described in Section 5.2, above...6.1 (a) Screening... (3) All patient shall be examined by qualified medical personnel, which shall be defined as a physician, or in the case of a woman in labor, a registered nurse trained in obstetric nursing, where permitted under state law and Hospital policy, who may determine true, false or no labor but may not make a medical diagnosis..." Labor and Delivery (L&D) Medical Record review, on 09/06/2018, revealed Patient #26 presented to the L&D unit after seeing her obstetrician in the office. Review of Patient #26's Obstetrician's office notes revealed " ...Appt. Date/Time 02/19/2018 10:10AM" and a chief complaint (CC) of "ob check". Review revealed a Prenatal Flowsheet and noted the patient was 29 weeks, with ".... PPROM (Preterm Premature Rupture of the Membranes-Amniotic membrane surrounding the baby breaks (ruptures) before 37 weeks of pregnancy). See a/p (assessment/plan). ..." Review of these notes revealed " ...HPI : [AGE] year old G4P2104 ....who present (sic) today.... for leakage of fluid. She states it started this morning. She was lying in bed when she felt a large gush of fluid. She has continued to leak clear fluid since it happened. She denies contractions, cramping and vaginal bleeding + (positive) fetal movement. ..." Form review revealed a Review of Systems and a Physical Exam were completed in the office. Review of the Physical Exam revealed " ...Pelvic: ....on speculum exam + pooling in vagina + leakage ....visually 1 cm dilated, + nitrazene, + ferning (tests for rupture of membranes). Sterile vaginal exam: deferred. ..." Further review of Women's Services Notes revealed an Assessment/ Plan that stated " ...1. PPROM ....Will refer/send to (Hospital C) MFM .... First to (Hospital A) for: 1. NST (Non stress test) 2. Begin antibiotics ....3. Begin betamethasone (In-Utero steroid-medication used to treat pre-term labor)....4. Begin magnesium )Magnesium Sulfate medication used to treat Pre-term labor) ....5. Order CMP/CBC (blood tests) ....7. OB US (ultrasound). ..." Review of Patient #26's Labor and Delivery record noted a Telephone Order from MD #4 on 02/19/2018 at 1100 to "Triage & observe for PPROM ... ." (prior to Patient #26's arrival to L&D). Review of the "LABOR AND DELIVERY OBSERVATION RECORD" revealed the [AGE] year old patient arrived to the hospital 02/19/2018 at 1122 " ...for observation & transfer due to PPROM ....states she noticed she was leaking clear fluid around 0900 that would not stop, this was confirmed by Dr. (Name of MD #4) in the office that she was PPROM & was sent to L&D. Denies any uc's (uterine contractions) or abd. (abdominal) tightening ....States good FM (fetal movement). ..." The record stated Patient #26 was a gravida 4, para 4, with 4 living children. An estimated due date was documented as 05/19/2018 with a gestational age of 29 weeks. Per the record, an electronic fetal monitor was applied in L&D and fetal heart baseline ranged from 125-130. No contractions were noted. At 1135, documentation noted an IV was inserted and labs were drawn and at 1135 an indwelling urinary catheter was inserted. An Amnisure test (checks for ruptured membranes) was noted as done with a result of negative. The L&D Observation Record noted at 1224 that the fetal monitor was off for a bedside ultrasound, and noted Betamethasone was given as ordered at 1300, followed by Ampicillin (antibiotic) and Magnesium Sulfate. At 1355, documentation noted a category one tracing on the fetal monitor, and at 1357 Erythromycin was administered as ordered. Fetal heart baseline at 1415 was noted as 130. At 1430 contractions were documented as 0 and vital signs were documented as Temperature 98.2, Pulse 83, Respirations 16, BP 105/70. Per record review, the bolus of Magnesium Sulfate was completed and a bag of IV fluid with Magnesium Sulfate was hung at 1430, after which report was given to EMS and Patient #26 was transferred to Hospital C. Review of form titled "REQUEST FOR TRANSFER/CONSENT TO TRANSFER/CERTIFICATION FOR TRANSFER", dated 02/19/2018 at 1430. Review revealed documentation that the patient's diagnosis was "PPROM" and the transfer was because of the "Need for level 3 NICU". The form stated "Patient Condition upon Transfer ...Stable. ..." Further review of the form revealed the "Physician or Qualified Medical Person's Certification for Transfer" was signed by MD #5 on 02/19/2018 at 1250 (1 hour, 40 minutes prior to Patient #26's transfer out of Hospital A). Review of the "HOSPITAL-HOSPITAL TRANSFER" form noted MD #5's signature and the time 1250. Further review revealed a RN signature timed at 1427. Review of a form called "(Hospital Name) (County Name) EMERGENCY MEDICAL SERVICE CERTIFICATION OF MEDICAL NECESSITY FOR AMBULANCE TRANSPORTATION" revealed, at the top of the form, "(County Name) EMS Physician Certification Statement for Non-Emergency Ambulance Services". Form review revealed three (3) sections, the first of which was labeled "SECTION I - GENERAL INFORMATION". This section noted Patient #26's name and date of birth, and stated a transport date of 02/19/2018. On page 2 of the form was "SECTION III - SIGNATURE OF PHYSICIAN ..." which showed MD #5's signature, with the date signed noted as 02/19/2018. Record review failed to reveal any Progress Notes or Discharge Notes and did not reveal any physician documentation of a Medical Screening Exam while in the Labor and Delivery Department on 02/19/2018. Review revealed the only physician documentation was a medical examination done in the physician's office prior to sending Patient #26 to the L&D unit for care, ongoing evaluation, and transfer. Review revealed the only physician documentation while Patient #26 was in Hospital A were the signatures of MD #5 on the "REQUEST FOR TRANSFER/CONSENT TO TRANSFER/CERTIFICATION FOR TRANSFER" form, the "HOSPITAL-HOSPITAL TRANSFER" form, and the EMS form. Interview with MD #4, on 09/06/2018 at 1505, revealed MD #4 saw Patient #26 in the office on the morning of 02/19/2018. Interview revealed the patient was 1 cm dilated and had positive nitrazine and ferning, and it was determined Patient #26 was leaking amniotic fluid. Interview revealed MD #4 sent Patient #26 to the hospital for a non-stress test, to prepare for transfer to a "Level 4 for maternal fetal medicine care", and to receive medications including Betamethasone and antibiotics. Interview revealed Patient #26 was found in the office to have emergency medical condition. MD #4 stated the patient was "stable" but needed transfer and a steroid and antibiotics prior to transfer. Interview revealed MD #4 did not see Patient #26 in the hospital, and stated she thought the H&P in the office was a part of the hospital record and all that was needed. MD #4 noted that a partner (MD #5) was already at the hospital and stated "I think she saw her (Patient #26)". MD #4 stated MD #5 may have felt it was duplicate work and indicated they had talked about possibly sending the patient directly from the office but they wanted meds and labs and a physician to physician transfer. Telephone interview, on 09/14/2018 at 1225, with MD #5 revealed she was in L&D and learned from nursing that MD #4 had seen a patient in the office and would be coming over to do transfer paperwork. Interview revealed MD #5 told nursing that was not necessary, she would do the paperwork. MD #5 stated she did the transfer paperwork, but did not examine the patient and did not write any notes. MD #5 stated she did not do a Medical Screening Examination on Patient #26. MD #5 stated MD #4 had assessed the patient in the office and determined she had ruptured membranes. Then, the patient came to L&D, the nurse put her on the monitors, she had no contractions, the fetal heart tones and vital signs were stable, that was a medical assessment. Interview revealed MD #5 based her certification that Patient #26 was stable on MD #4's office examination and the nurse assessment at the hospital. MD #5 stated "I'm sure I walked in and spoke with her (Patient #26)" and further stated if MD #4 had not seen the patient in the office or if anything on the monitor strip was concerning, then MD #5 would have examined Patient #26. Further interview revealed MD #5 signed the Transfer forms and then left the unit. Interview revealed MD #5 was literally passing through the unit and was helping MD #4 out so she did not have to come to the hospital. Interview revealed this was the only time in her career that this situation had happened. In this case, MD #5 stated, MD #4 had seen the patient in the office, was coming to sign the paperwork, MD #5 was already at the hospital and said she would sign it and she did.

Based on policy review, closed medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D) physician failed to ensure an appropriate transfer by failing to complete a written physician's certification for transfer documenting the increased risks associated with the transfer for the specific Emergency Medical Condition (EMC); failing to send to the receiving facility copies of all medical records available at the time of the transfer; and failing to ensure the written physician's certification was signed and/or dated and timed by the transferring physician to closely match the time of transfer for 6 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #1, #23, #24, #25, #7 and #6). The findings include: Review of the hospital's policy, "EMTALA (Emergency Medical Treatment and Active Labor Act)", revised 03/2015, reviewed 08/2015, revealed "... (Hospital A's) use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). ...IV. PROCEDURE: H ... 1 .... b. With certification: The individual may be transferred if a physician... has certified that the medical benefits expected from transfer outweigh the risks. The date and time of the certification should be close in time to the actual transfer ... 2. c. (Hospital A) must send to the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (2) records related to the individual's emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; (8) the written patient consent or physician certification to transfer; and (9) the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. (Name of hospital) must forward relevant records, pending lab work and test results to the receiving facility that was not available at the time of transfer ... " Review of the hospital's form "Request for Transfer/Consent to Transfer/Certification for Transfer", revised 02/2014, revealed "...Risk of Transfer: Medical condition could worsen during transport, Transportation risks, and Risk related to condition________________. " 1. Closed medical record review of Patient #1 revealed a [AGE] year-old female who presented to Hospital A's labor and delivery unit on 02/12/2016 at 2323 with a chief complaint of "vaginal bleeding." Record review revealed Patient #1 was seen by Physician A on 02/13/2016 at 0018. Review of Physician's orders dated 02/13/2016 at 0115 revealed a verbal order for transport to Hospital B. Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 05/2009, with the risks of transfer section of the form blank. Further record review revealed no documentation in the medical record by the physician that the risks for transfer were explained to Patient #1. Review of transfer form revealed no documented date and time of Physician A's certification of the patient's condition at the time of transfer. Review of the transfer form and medical record revealed no documentation of the pertinent medical records copies sent to Hospital B for Patient #1. Record review revealed Patient #1 was transferred to Hospital B on 02/13/2016 at 0145. Telephone interview on 03/17/2016 at 1350 with Physician A revealed "I have never had EMTALA (Emergency Medical Treatment and Labor Act) training." Interview revealed risk of transfer "delivery enroute". Interview revealed "I would have reviewed with the patient". Interview on 03/16/2016 at 1445 with Physician B revealed "risk related to patient's condition should be documented on the transfer form". Interview on 03/17/2016 at 1105 with AS #2 (administrative staff) confirmed that there was no documentation in the medical record or on the transfer form for the risks of transfer for Patient #1. Interview revealed that there was no documentation in the medical record or on the transfer form for the date and time of the physician's certification to transfer for Patient #1. Interview revealed that there was no documentation in the medical record or on the transfer form of the pertinent medical records copies sent to Hospital B. 2. Closed DED (dedicated emergency department) medical record review of Patient #23 revealed a [AGE] year-old male who presented to Hospital A's DED on 12/28/2015 at 1519 with a chief complaint of "found supine on ground by wife, pt (patient) responsive, lac (laceration) to back of head, coded (breathing and heart stopped) in front of first responders and cpr (cardio-pulmonary resuscitation) initiated". Record review revealed Patient #23 was seen by Physician D on 12/28/2015 at 1520. Review of Physician D's dictated notes on 12/28/2015 at 1554 revealed "History of Present Illness: The patient presents following fall ...Posterior Scalp ...symptoms is swelling and bleeding ....intubated (breathing tube placed), CPR, and transcutaneous pacing ...for severe bradycardia (heart rate less than 60) ...Impression and Plan...Multiple fractures of skull ...Acute subdural hematoma Calls-Consults - Spoke with Physician E who accepted her for transfer to Hospital B. Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 02/2014, with the risks of transfer related to condition checked with no written documentation of the risks for Patient #23. Further record review revealed no documentation in the medical record by the physician that the risks for transfer were explained to Patient #23. Review of transfer form and medical record revealed no documentation of the pertinent medical records copies sent to Hospital B for Patient #23. Record review revealed Patient #23 was transferred to Hospital B on 12/28/2015 at 1701. Interview on 03/16/2016 at 1445 with Physician B revealed "risk related to patient's condition should be documented on the transfer form". Interview on 03/17/2016 at 1105 with AS #1 confirmed that there was no documentation in the medical record or on the transfer form for the risks related to condition for Patient #23. Interview revealed that there was no documentation in the medical record or on the transfer form of the pertinent medical records copies sent to Hospital B for Patient #23. 3. Closed DED (dedicated emergency department) medical record review of Patient #24 revealed a [AGE] year-old male who presented to Hospital A's DED on 11/27/2015 at 1258 with a chief complaint of "neck pain r/t (related to) right side. fell a week ago". Record review revealed Patient #24 was seen by Physician B on 11/27/2015 at 1607. Review of Physician B's dictated notes on 11/27/2015 at 1619 revealed "History of Present Illness: ...The patient presents with thoracic pain, upper back injury and neck pain ...Type of injury: fall and from a height ...On the CXR (chest x-ray) they identified compressed vertebrae concerning for possible fractures. Wife reports that this morning he was hallucinating and he now has no control of his legs and cannot stand or walk on his own ...Plan: Condition: Guarded Disposition: Transfer to other location: Hospital C ...Notes: Patient has findings consistent with epidural abscess at multiple spinal levels. Cervical cord compression. I have discussed with ortho (orthopedics service) at Hospital A and spine surgeon is unavailable. Patient will need transfer to tertiary care center for further evaluation and management. He has finding that suggest sepsis, with delirium. Possible meningitis/encephalitis. Call placed to Hospital C to arrange transfer". Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 02/2014, with no documentation of the pertinent medical records copies sent to Hospital C for Patient #24. Further review of medical record revealed no documentation of the pertinent medical records copies sent to Hospital C for Patient #24. Record review revealed Patient #24 was transferred to Hospital C on 11/27/2015 at 2106. Interview on 03/17/2016 at 1105 with nursing management confirmed that there was no documentation in the medical record or on the transfer form of the pertinent medical records copies sent to Hospital B for Patient #24. 4. Closed DED (dedicated emergency department) medical record review of Patient #25 revealed a [AGE] year-old male who presented to Hospital A's DED on 03/14/2016 at 0056 with a chief complaint of "Family reports pt (patient) has Rt (right) sided weakness for one hour". Record review revealed Patient #25 was seen by Physician F on 03/14/2016 at 0100. Review of Physician F's dictated notes on 03/14/2016 at 0102 revealed "History of Present Illness: The patient presents with vision changes. ...Was staggering and falling to one side ...Reexamination/Reevaluation: CT with bleed FFP (fresh frozen plasma) ordered and will transfuse when available Given IV (intravenous) meds (medications) to lower BP (blood pressure 0126 hrs (hours): Calls being placed to Hospital C to arrange transfer Spoke to Physician G, transfer arranged". Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 12/2008, with the risks of transfer related to condition blank with no written documentation of the risks for Patient #25. Further record review revealed no documentation in the medical record by the physician that the risks for transfer related to the condition were explained to Patient #25. Review of transfer form revealed no documented date and time of Physician F's certification to transfer. Review of transfer form and medical record revealed no documentation of the pertinent medical records copies sent to Hospital C for Patient #25. Record review revealed Patient #25 was transferred to Hospital C on 03/14/2016 at 0235. Interview on 03/16/2016 at 1445 with Physician B revealed "risk related to patient's condition should be documented on the transfer form". Interview on 03/17/2016 at 1105 with AS #1 confirmed that there was no documentation in the medical record or on the transfer form for the risks of transfer for Patient #25. Interview revealed that there was no documentation in the medical record or on the transfer form for the date and time of physician's certification to transfer for Patient #25. Interview revealed that there was no documentation in the medical record or on the transfer form of the pertinent medical records copies sent to Hospital C. 5. Closed DED (dedicated emergency department) medical record review of Patient #7 revealed a [AGE] year-old female who presented to Hospital A's DED on 10/31/2015 at 1730 with a chief complaint of "Patient fell in bathroom. States fell and slipped onto floor when she heard a 'pop' in her right lower leg. States only has pain during movement, otherwise no pain". Review of Physician H's dictated notes on 10/31/2015 at 1940 revealed "History of Present Illness: The patient presents following fall. ... Location: right lower extremity. The character of symptoms is pain. The degree at present is moderate. ... Diagnosis: femur fracture, right. ..." Record review revealed an orthopedic consult was conducted. Review of the consult notes recorded on 10/31/2015 at 2202 revealed "... We feel the patient will likely need surgical fixation with open reduction and internal fixation using a locked distal femoral plate. ... I would recommend transfer to one of the trauma centers ..." Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 02/2014, with the risks of transfer related to condition blank with no written documentation of the risks for Patient #7. Further record review revealed no documentation in the medical record by the physician that the risks for transfer related to the condition were explained to Patient #7. Review of the transfer form and medical record revealed no documentation of the pertinent medical records copies sent to Hospital B for Patient #7. Record review revealed Patient #7 was transferred to Hospital B on 10/31/2015 at 2350. Interview on 03/16/2016 at 1445 with Physician B revealed "risk related to patient's condition should be documented on the transfer form". Interview on 03/17/2016 at 1205 with AS #1 confirmed that there was no documentation in the medical record or on the transfer form for the risks related to condition for Patient #7. Interview revealed that there was no documentation in the medical record or on the transfer form of the pertinent medical records copies sent to Hospital B for Patient #7. 6. Closed DED (dedicated emergency department) medical record review of Patient #6 revealed a [AGE] year-old male who presented to Hospital A's DED accompanied by his parent on 01/19/2016 at 1015 with a chief complaint of "Has been thinking about SI (suicide ideations) since Thursday, no hx (history) of same, started with a bad dream, planned to hang yourself, denies previous attempts ..." Record review revealed Patient #6 was seen by Physician I on 01/19/2016 at 1202. Review of Physician I's dictated notes on /2016 at 1202 revealed "History of Present Illness: ... The patient presents with psychiatric problem and suicidal ideation. The onset was six days ago. The course/duration of symptoms is worsening. Character of symptoms depressed. The degree of symptoms is severe. Self injury: none. ... Patient states plan to hang himself. ... Diagnosis: Depression, Suicide Intent. ... Plan: Transfer to other location. ..." Record review revealed a "Request for Transfer/Consent to Transfer/Certification for Transfer" form, revised 02/2014, with the risks of transfer related to condition blank with no written documentation of the risks for Patient #6. Further record review revealed no documentation in the medical record by the physician that the risks for transfer related to the condition were explained to Patient #6's parent prior to transfer. Review of the transfer form and medical record revealed no documentation of the pertinent medical records copies sent to Hospital D for Patient #6. Review revealed the physician signed the Certification of Transfer on 01/19/2016 at 1315 (5 hours and 41 minutes prior to the patient's departure). Record review revealed Patient #6 was transferred to Hospital D via law enforcement on 01/19/2016 at 1856. Interview on 03/16/2016 at 1445 with Physician B revealed "risk related to patient's condition should be documented on the transfer form". Interview on 03/17/2016 at 1220 with AS #1 confirmed that there was no documentation in the medical record or on the transfer form of the risks associated with transfer. Interview revealed there was no documentation of pertinent medical records copies sent to Hospital B for Patient #6. Interview revealed the physician certified the condition of the patient at 1315 and the patient departed at 1856. Interview confirmed the physician failed to certify the condition of the patient as close to the time of departure as possible. NC 728

Based on hospital policy review, medical record reviews, physician and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24. The findings include: 1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 25 sampled DED patients who presented to the DED (Patient #5) with complaint of chest pain. ~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406. 2. The hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D) physician failed to ensure an appropriate transfer by failing to complete a written physician's certification for transfer documenting the increased risks associated with the transfer for the specific Emergency Medical Condition (EMC); failing to send to the receiving facility copies of all medical records available at the time of the transfer; and failing to ensure the written physician's certification was signed and/or dated and timed by the transferring physician to closely match the time of transfer for 6 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #1, #23, #24, #25, #7 and #6). ~ Cross refer to §489.24(e)(1)-(2) Appropriate Transfer, Tag A2409.

Based on hospital policy and procedure review, medical record reviews, grievance file review and physician and staff interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 1 of 25 sampled patients who presented to the DED (Patient # 5) with complaint of chest pain. The findings include: Review of the facility's (Hospital A) EMTALA Policy and Procedure, revised March 2015 revealed: [the "Medical Screening Examination" or "MSE" means the screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist]...the (named) facility "will provide an appropriate medical screening examination within the capability of the hospital's dedicated emergency department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists and (named) facility will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as required to stabilize the emergency medical condition, or (b) arrange for transfer of the individual to another medical facility in accordance with procedures ...IV. PROCEDURE: A. Triage and Registration 1.Triage a. As soon as practical after arrival, individuals who come to the emergency department should be triaged in order to determine the order in which they will receive a medical screening examination ... B. Medical Screening Examination ...1. (Hospital A) shall provide a medical screening examination to any individual who comes to the emergency department ...3. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred. The medical screening examination, and ongoing patient assessment, must be documented in the medical record. Review of Hospital A's STEMI (ST cardiac wave elevated myocardial infarction) Protocol, revised 2015, revealed " PURPOSE: STEMI Protocol will be utilize (sic) for patients presenting with symptoms indicative of a cardiac event. PROCEDURE: 1. Walk-in Patient: A. Patients presenting with coronary symptoms will be treated as STEMI until ruled out for acute event by EKG interpretation ...C. An EKG should be completed ASAP with target time goal of 10 minutes of arrival ...upon completion it will be taken to the ED physician for interpretation. A. If the EKG is STEMI, the ED physician will activate the STEMI protocol ...the following will be initiated ...Medical and Pharmacological Regimen: ...Heparin 60 IU/kg bolus, Chest X-ray, Cath Lab Staff will receive report from patient nurse ... " . Review of Hospital A's Assessment, Documentation and Nursing Process-Emergency Department Policy and Procedure, revised 11/2014 revealed ...REASSESSMENT a. Reassessment will be based on patient's vital signs and assessment, triage and the patient's condition as diagnostic tests and therapies are completed ...d. Those patients who have been triaged and placed in the waiting room will be re-assessed according to their assigned triage category as follows: ...ESI Level 3- approximately every hour. 5. Nursing Interventions/Patient Response a. Will be documented in the medical record as they occur by qualified nursing personnel. B. Narrative notes will be required in the following circumstances: ...4. Change in the patient ' s condition ... " Review of Hospital A's Pain Management Policy, revised 8/2015 revealed "POLICY: A. All patients will have a comprehensive pain assessment completed on admission ... PROCEDURE: A. Each patient will be assessed and monitored for the presence of pain 1. On admission ...5. With each new report of pain ...7. Immediately for unexpected intense pain ...C. All licensed staff will be responsible for the education of the patient and/or family in regard to pain and pain management ...D. Comprehensive pain assessment includes: 1.Location of pain 2. Intensity of pain, using a 0-10 pain scale or other appropriate scale. 3. Quality of pain 4. Alleviating factors ...5. Aggravating factors. 6. How the pain affects the patient ' s quality of life. 7. Associated symptoms (nausea, vomiting, shortness of breath, etc.) 8. Identification of any barriers that may affect pain relieving measures ...9. Physical examination of the pain site and referring patterns ...12. Document pain assessment on the nursing flowsheet or electronic medical record ... I. It is the responsibility of all hospital employees to facilitate the pain relieving process and expedite interventions needed". Closed DED (Dedicated Emergency Department) medical record review of Patient #5 revealed a [AGE] year old male who presented ambulatory to Hospital A DED with his wife on 01/10/2016 at 0737 with a chief complaint of chest pain. Record review revealed triage was started by a Registered Nurse (RN) at 0738. Review revealed a 12 lead ECG (electrocardiogram) was done upon arrival and read by the physician at 0739. Review revealed results were normal sinus rhythm and normal ECG, NSTEMI (non-elevated ST wave Myocardial infarction). Review of triage notes revealed vital signs at 0752 were recorded as blood pressure 185/104 (normal 90-140/60-90), heart rate 85, respirations 22 (normal range 14-20), temperature 97.7 F (Fahrenheit) (normal range 98.0-100.5) and oxygen saturation 98% (room air). Triage set an urgent level of ESI 3. Chief complaint was documented by the Triage nurse as chest pain since last night, also nausea, vomiting and diarrhea. No other nursing or physician documentation was found until 01/10/2016 at 1121 (3 hours and 44 minutes after arrival) recording a disposition of LWOT (left without treatment) with the patient's condition recorded as unchanged. No physician orders were found, no lab tests found and no radiology orders found for this DED visit. Review revealed Patient #5 presented to Hospital E DED on 01/10/2016 at 1125 (four minutes later). Review of the triage assessment from Hospital E dated 01/10/2016 at 1323 revealed Patient #5 presented with chest pain that started "last night" at approximately 2300 with nausea, vomiting and SOB (shortness of breath) after waiting 4 hours and failing to receive treatment at Hospital A. Patient #5 was triaged at 1125 and assessed as alert, skin color was pink, respiratory pattern was unlabored, placed on continuous cardiac monitoring, a STAT (immediate) ECG was initiated, pulse oximetry and lab set were obtained. Vital signs at 1125 were: temperature 97.5 F, blood pressure 192/97, heart rate 99, respiratory rate 18 and oxygen saturation of 97% on room air. Pain was assessed using a verbal range of 0-10, intensity was 7 with a comfort goal of 4. Aspirin 325 milligrams was administered for pain. Review of lab results at 1146 revealed troponin (lab study that can indicate cardiac damage) of 6.180 (high). A cardiovascular consult was ordered. The Cardiologist assessed Patient #5 at 1330 and ordered an immediate cardiac catheterization which revealed three vessel coronary artery disease. Review of the physician's Discharge Summary dated 01/10/2016 at 1519 revealed a call placed to a cardiovascular surgeon, following the cardiac catheterization, determined an urgent coronary artery bypass was indicated. Patient #5 was transported via ambulance with continuous cardiac monitoring and oxygen back to Hospital A at 1448, where cardiac surgery is available. Review of Hospital A's closed medical record revealed Patient #5 was transferred from Hospital E via ambulance to Hospital A for cardiovascular surgery on 01/10/2016 at 1628 with a diagnosis of severe coronary artery disease. Review of Discharge Summary dated 01/11/2016 revealed Patient #5 underwent a coronary bypass graft x 3 and was discharged home on 01/14/2016. Review of a physician progress noted dated 01/10/2016 at 1700 revealed "Incident Report- [Patient #5] presented to (Hospital A) ED early AM 01/10/2016 with complaints of CP (chest Pain)/Nausea/Vomiting/Diaphoresis. Nurse in ED does EKG which is interpreted as WNL (within normal limits). Patient sent to waiting room. After 2-3 hours of not being seen, patient goes to (Hospital E) where he has + (positive) Troponins. Multiple other patients apparently left as well. LHC (Left Heart Catheterization) done at (Hospital E) with critical 3 vessel CAD (Coronary Artery Disease). Patient transferred back to (Hospital A) for CABG (Coronary Artery Bypass Grafts). Patient and family extremely upset they were turned away while having AMI (Acute myocardial Infarction). Please evaluate/investigate situation as this is unacceptable care" signed by the cardiovascular surgeon. Review of Patient Complaint /Grievance Form dated 02/15/2016 at 1148 revealed the wife of Patient #5 called to complain about her husband's 3 hour long wait in the ED waiting room on 01/10/2016 that necessitated her having to take him to Hospital E's DED for treatment. Telephone interview with the wife of Patient #5 on 03/16/2016 at 0835 revealed a nurse who finally came out after requesting help at the front desk "several times", told complainant "other people were in the ED dying too and that they would have to wait". The nurse was described as older, with short blonde hair and skinny". The interview further revealed complainant asked for help because her husband (Patient #5) was having increased chest pain and was lying on the floor in the waiting room. Complainant revealed she did finally "leave without treatment because no one would come out and they had waited over 3 hours and saw 2 other couples leave without treatment for the same reason." Interview with RN #1 on 03/15/2016 at 1430 revealed a thin, older nurse with short blonde hair who recalled working with the Patient #5 and his wife. RN#1 described Patient #5 as "not gray or diaphoretic and with a normal EKG." This nurse was assigned as Charge Nurse on 01/10/2016 between 0700 and 1900. Interview revealed a busy morning in the ED during that time. Interview further revealed that nurses will come to the waiting room to reassess waiting patients unless the ED was backed up with other patients. RN #1 did not recall being asked to reassess Patient #5 for increased pain. Interview with Patient Access Rep #1 on 03/17/2016 at 1000 revealed she recalled overhearing Patient #5's wife being very upset with RN #1, that the wife stated her husband was "having chest pain so why are we still sitting her versus going back. I want a doctor to see him." Patient Access Rep could not recall how RN #1 responded but did recall that no reassessment was done by the nurse. Interview with AS (administrative staff) #1 on 03/15/2016 at 1250 revealed Patient's with "chest pain and a normal EKG are assessed as ESI Level 3 and placed in the waiting room. Triage nurse or charge nurse is expected to reassess this patient every hour, reassess pain level or change in condition and document in the medical record. For patients with ongoing pain and escalating symptoms, the triage or charge nurse will place that patient in a hallway bed in the ED". Expectations for Patient #5 are that he would have been placed in a hallway bed, been prioritized and the house supervisor would have been called to alert for needed additional staffing (also known as a Code Purple). Interview with AS #3 on 03/16/2016 at 1049 revealed expectation would have been for a Code Purple to have been activated by the DED charge nurse or physician on 01/10/2016 to ensure nursing assessment and reassessment needs of DED patients were met. Interview regarding waiting room patients not being assessed hourly and as needed further revealed "this complacency is something that needs to be addressed ... I spoke with the complainant (Patient #5's wife) personally and am very concerned." Interview with Physician C (DED Medical Director) on 03/16/2016 at 1540 regarding Patient #5 who was not given a medical screening exam (MSE) and left without treatment, revealed that a "patient presenting with chest pain should have an EKG which is read ASAP (as soon as possible) so a determination for STEMI versus non-STEMI can be made. A change in condition, like increased pain, should bring the waiting room patient to the DED room for a medical screening exam". Interview with Physician B (DED physician on duty when Patient #5 presented) on 03/17/2016 at 0850 revealed no MSE (medical screening examination) was performed for Patient #5 on 01/10/2016. The expectation is that in the case of a patient's deteriorating condition, the doctor would be notified by the nurses assessing these patients and a MSE would be performed. Regarding how patients are prioritized to be given an MSE, an electronic, real time display is watched by each "physician to monitor ESI levels along with pertinent details like age and presenting symptoms in order to select appropriately. We also rely on nursing assessments and reassessments to catch changes in a patient's ESI-level."

Based on hospital policies and procedures review, medical record review, hospital internal document review and staff interview, the hospital failed to prevent delay of a patient screening or treatment by unduly discouraging 1 of 22 sampled DED (dedicated emergency department) patients presenting to the hospital's DED for a screening and/or treatment of an emergency medical condition (Patient #16). Findings include: Review on 04/22/2015 of the hospital's policy "Emergency Department Patient Evaluation and Treatment" (Dates Reviewed: 11/2014) revealed "Nondiscrimination and No Delay: A medical screening examination and appropriate treatment will be provided without discrimination based on race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing, medical condition, physical or mental handicap, insurance status, economic status, or ability to pay for medical services, except to the extent that a circumstance such as age, sex, pre-existing medical condition, or physical or mental handicap is medically significant to the provision of appropriate medical care to the person. Provision of a medical screening examination and appropriate treatment will not be delayed in order to inquire about the method of payment or insurance status." Review on 04/22/2015 of the hospital's policy "EMTALA (Emergency Medical Treatment and Labor Act) Policy" (Reviewed: 05/2012) revealed "2. Registration: _____(Hospital Name) may not delay the provision of an appropriate medical screening examination or any necessary stabilizing medical examination and treatment in order to inquire about the individual's method of payment or insurance status. _____(Hospital Name) may, however, follow reasonable registration processes after triage has been completed, but prior to the provision of a medical screening examination, including asking whether an individual is insured and, if so, what the insurance is. Such processes, however, may not unduly discourage individuals from remaining for further evaluation. Further such inquiry shall not delay provision of the medical screening examination. Accordingly, insurance information should only be collected at times when an individual is waiting for an available examination room." A closed medical record review on 04/22/2015 for patient #16 revealed the patient was a [AGE] year-old female that presented to the hospital's DED (Hospital A) on 02/20/2015 with her mother for a complaint of "Stepped on a Nail." The review revealed the patient arrived at the DED's main entrance at 0011. No documentation was found in the medical record that the patient was ever triaged by a hospital registered nurse (RN) or was provided a medical screening examination from qualified personnel. The review of the medical record revealed only that the patient had a "Depart Summary and ED (Emergency Department) Discharge Form on 02/20/2015 at 0027 (total of 16 minutes after presenting to the ED). No documentation was found in the medical record that indicated why the patient and her mother left the DED without a medical screening examination or stabilizing treatment on 02/20/2015. Review on 04/22/2015 of the hospital's internal documentation review revealed the hospital received concerns from patient #16's mother and its accreditation agency related to the hospital's DED registration and nursing staff requiring the patient's social security number before any treatment was provided. The review revealed the patient's mother stated "On this evening 02/20/2015 around 11:30 we took my [AGE] year-old daughter to _____(Hospital Name) in _____(City). We were treated rudely to begin with. Left standing against a wall holding a check in form. When 15 minutes had passed with me watching them try to erase something on the computer, they finally called me over. I handed them my form a full twenty minutes after I walked through the door with my child in a wheelchair. Never asking why she was there, if she was having trouble breathing, any symptoms, nothing. Just let us stand there twenty minutes before having me "check in". I was admitted ly upset with this. The registration woman began asking me questions, one of which was my child's SSN (Social Security Number). I replied, I'm not giving you that, however, I'm giving giving you my permission to treat, her insurance card and a form of payment, to which she replied, let me see if that's good enough. She called the charge nurse over who asked the problem. I said she wants my child's SSN to treat her, which is not a requirement to render care. I'm not giving it, so that's done. The charge nurse then said, let me see if we can even see her. I replied, so you're refusing care for a child based on her SSN? The nurse said we're not refusing to see your child, just don't know if we can see her without her SSN." The documentation further revealed from the patient's mother in the documentation "The charge nurse came back and said "unfortunately, I've spoken to all of the higher ups and they said we needed her SSN to treat her." Further review of the hospital's internal documentation revealed "The hospital review revealed multiple breaks in expected hospital process and opportunities for improved patient care and customer service. Violation of hospital policy that requires patients presenting to the emergency department will receive medical screening evaluation without bias. Violation of hospital policy that requires emergency department registration to be completed with application of patient identification arm band. Violation of hospital process that guarantees customers will be treated with respect." The review further revealed the hospital described the events for 02/20/2015 as "Upon entry to ED patient presents to registration window and completes check in form (legal name, DOB (Date of Birth), age, sex, reason for visit, SSN, marital status, family doctor, Ebola virus screening, if necessary would you accept treatment that involves blood product, and if patient is a minor: parent/legal guardian name, relationship, DOB and SSN). Registration typically takes 3-5 minutes. Process ends with signing of consents and registration staff applying armband to patient." Further documentation revealed "Mother of minor patient (#16) presenting to the ED was not registered upon entry. No individuals in line at registration desk upon presentation. Mother and patient were directed to waiting room with registration form. Patient was not in view of registrar or triage nurse during remainder of interaction. The patient was required to wait more than 10 minutes while registrars worked together at computer. When the patient's mother presented to registration, discussion of SSN for minor child ensued per interviews. Per interview the child's SSN was not supplied on the form that mother was provided. The registrar requested the SSN and it became a barrier to administration of care. Registration was delayed with varying accounts of actual conversations but it was clear that registration and access to medical screening was delayed for acquisition of SSN. The patient was registered in system before triage nurse presented to the desk. Patient registration complete when access to care delayed continued." The documentation continued with "Medical Screening was not completed for minor child, identified as patient. Minor child sent to waiting area without medical triage. Potential access to care not impacted by department volume. There were less than 5 other individuals in the waiting area during the entire session. There were no other patients present at registration or triage area. Triage nurse presented and admitted ly discussion concerning need for SSN continued. Triage nurse went to have discussion with lead nurse on shift to whether SSN of minor was required for registration." Interviews on 04/23/2015 at 1505 with the hospital's Chief Nursing Officer, DED Nursing Director and Assistant Chief Nursing Officer revealed that the hospital recognized concerns after the event with patient #16 on 02/20/2015 occurred. The interviews revealed the a formal investigation was conducted at the hospital that included a root cause analysis as well as reports to the hospital's accrediting agency. The interviews revealed that the hospital recognized that the patient's lack or medical screening examination and treatment were related to a delay that came from the conversation of a social security number by the nursing staff and registration in the DED. The interviews also revealed that it was never an expectation for the hospital's staff to have to have a patient's SSN before any treatment was started. The interview also revealed that investigation through staff interviews revealed the staff felt that the mother had the patient's SSN and just refused to give it to them and this was the reason they kept pursuing it. The interviews confirmed this should not have occurred. In addition, the interviews revealed that the hospital recognized the need for improvement and begin to put changes in place through education and training. Interviews with the triage nurse and registration staff were unable to be completed during the survey due to the staff members no longer employed at the hospital and available for interview. A closed medical record review for hospital B revealed patient #16 (MDS) dated [DATE] at 0036 through 0604 for treatment related to "Stepped on a Nail." The review of the medical record revealed the patient received a medical screening examination and received treatment of an antibiotic medication, pain medication as needed, and a foot X-ray related to the injury. The patient was discharged from hospital B's DED with reported stable condition and a disposition of "Puncture wound of right foot." In summary, patient #16 ([AGE] year-old) was brought to hospital A's DED on 02/20/2015 after stepping on a nail at her home. The mother and patient presented to the main lobby of the hospital's DED for evaluation and treatment. The mother completed a quick registration form that included a space for the minor child's social security number (SSN). The mother did not write the patient's SSN on the form and returned it to the registrar. A discussion occurred before the patient was triaged that the hospital needed the child's SSN and this led to an admitted delay of a medical screening examination by hospital A. The mother left the DED of hospital A and took the patient to hospital B for the same complaint where she was medically screened and provided care and treatment of the right foot puncture wound. NC 423.