Based on review of facility documentation, medical records (MR), observation, and staff (EMP) interview, it was determined the facility failed to create a medical record for an Emergency Department patient encounter in one of 24 patient encounters reviewed (Patient1). Findings include: Review on February 15, 2018 of facility policy "Obstetric Patient Presents to the Emergency Department," last reviewed September 14, 2017, revealed "Purpose: To direct the nursing care of an obstetric patient with obstetric complaints or symptoms who presents to the emergency department for care. Persons Affected: All staff caring for obstetric patients, including all emergency department staff members Policy: The policy is to ensure proper communication, safety, and medical care of the obstetric patient presenting to the emergency department. ... " Attached to this policy was a flowsheet (algorithm) titled "GBH Emergency Department: Triage of the Pregnant Patient." The first box stated "Obvious symptoms of Active Labor, Rupture of Membranes, Contractions " with arrow pointing to the next box stating "Place Courtesy Call to OB x , Immediately transport to OB ... " Review on February 15, 2018 of the facility's "EMTALA System Policy," revealed "Patient Transfer and Emergency Medical Treatment and Labor Act (EMTALA) Purpose: ... To comply with the Emergency Medical Treatment and Labor Act (EMTALA)... Any person who comes to a facility requesting assistance for a potential emergency medical condition/ emergency service will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists ... Definitions: Emergency Medical Care Log is in the Geisinger's electronic health record which is maintained on all individuals who present to the emergency department seeking medical care. The log shall be kept for five years and contain specific patient information including: Patient identification Medical record and encounter number Patient type Presentation time Provider evaluation note Discharge time Disposition categorized as treated and released, admitted , discharged , transferred, elopement, left without being seen, or refusal of treatment (AMA). ... Hospital Property or Premises includes the entire main hospital campus, including the parking lot, sidewalk, driveway, and any parts of the hospital that are within 250 yards of the main buildings ... Guidelines to observe when registering a patient: Do not interfere with the timeliness of the medical screening ... Do not say or imply anything that may discourage the patient from seeking the medical screening ..." Interview with EMP2 on February 15, 2018 at 9:20 AM confirmed the patient's name (Patient1) and the date/time of the incident as February 12, 2018 at approximately 4:30 AM. EMP2 confirmed there was no medical record created for Patient1 for the encounter on February 12, 2018 at the Geisinger Bloomsburg Hospital. Review on February 15, 2018 of the Emergency Department medical records for February 12, 2018 revealed no medical record for Patient1. Interview with EMP9 on February 15, 2018 at 10:50 AM revealed the facility still had the security footage from February 12, 2018, and there was only one pregnant-appearing person that entered through the ambulatory ED entrance around 4:48 AM. EMP9 revealed the security footage date/time was correct and in real time. Observation on February 15, 2018 at 10:51 AM, of the security footage from February 12, 2018 revealed there was only one visibly-pregnant patient (Patient1) with a male arriving through the ED ambulatory entrance on February 12, 2018 at 4:48 AM. Patient1 spoke to the Patient Access Representative/registration clerk (EMP5). There was no audio on the security footage. EMP5 picked up the telephone and was seen conversing on the telephone. Meanwhile, the patient left the registration desk while the male stayed behind at the registration desk at 4:49 AM. Patient1 returned to the registration desk at 4:51 AM. The patient continued standing and was rocking side to side, and at one point stood behind chair and bent from the waist flattening her back while holding onto the back of the chair. EMP5 remained on the telephone and appeared to talk with Patient1 and the accompanying male. At 4:53 AM EMP5 handed a blue absorbent pad to Patient1, and Patient1 and the male walked out of the facility and did not return. Telephone interview on February 15, 2018 at 3:25 PM, with the OB Staff (EMP12) who was on the telephone call with the EMP5 at the time of the incident with Patient1 on February 12, 2018 revealed the following: EMP12 took the call from EMP5 on February 12, 2018, in the early AM. EMP5 had a mom who was 35 weeks pregnant in the Emergency Department and was asking if it was OK to send her to Labor and Delivery. EMP5 stated the patient (Patient1) had not called the midwife. EMP12 noted this patient was pre-term, and there was not a neonatal intensive care unit at this hospital. EMP12 advised it was best if the patient contacted her midwife to make arrangements that would be best for Patient1 and her baby. EMP12 related the next contact EMP12 had regarding this patient was from an outside facility, noting the patient was in their hospital. EMP12 was not aware the patient had left the hospital. Interview with EMP5 on February 16, 2018 at 7:00 AM revealed Patient1 and her significant other presented on February 12, 2018 at approximately 4:30 AM, noting she was pregnant and her water broke. EMP5 stated that EMP5 asked the patient's first and last name and confirmed the patient's (Patient1's) name and address in the medical record system. EMP5 called the OB department and while the phone was ringing EMP5 asked if the patient (Patient1) had called the midwife and the patient said no. The patient asked to use the bathroom. EMP5 stated the OB staff answered. EMP5 provided the patient's name and medical record number. EMP5 informed OB staff (EMP12) that the patient had not contacted her midwife and that her (Patient1's) water broke. EMP12 asked how far along the patient was. As the patient was in the bathroom, EMP5 asked the significant other, who noted the patient was 35 weeks pregnant. EMP5 noted there was discussion among the OB staff during the call noting they were not staffed for a preterm patient. EMP12 asked that EMP5 have the patient or significant other contact the midwife for further instructions. EMP5 told the patient (Patient1) and significant other that the OB staff would prefer they call the midwife first. The significant other of Patient1 asked EMP5 why they could not just go upstairs? EMP5 offered to assist with the call to the midwife. At this point, the patient was removing something from her pocket, and EMP5 thought this was the midwife's contact information. The significant other stated they would just go to (outside facility); he turned and left, and the patient followed behind him.

Based on review of facility documentation, medical records (MR), and staff (EMP) interview, it was determined the facility failed to maintain an accurate Emergency Department log for one of 24 patient encounters reviewed (Patient1). Findings include: Review on February 15, 2018 of the facility's "EMTALA System Policy," revealed "Patient Transfer and Emergency Medical Treatment and Labor Act (EMTALA) Purpose: ... To comply with the Emergency Medical Treatment and Labor Act (EMTALA)... Any person who comes to a facility requesting assistance for a potential emergency medical condition/ emergency service will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists ... Definitions: Emergency Medical Care Log is in the Geisinger's electronic health record which is maintained on all individuals who present to the emergency department seeking medical care. The log shall be kept for five years and contain specific patient information including: Patient identification Medical record and encounter number Patient type Presentation time Provider evaluation note Discharge time Disposition categorized as treated and released, admitted , discharged , transferred, elopement, left without being seen, or refusal of treatment (AMA). ... Hospital Property or Premises includes the entire main hospital campus, including the parking lot, sidewalk, driveway, and any parts of the hospital that are within 250 yards of the main buildings ... Guidelines to observe when registering a patient: Do not interfere with the timeliness of the medical screening ... Do not say or imply anything that may discourage the patient from seeking the medical screening ..." Interview with EMP2 on February 15, 2018 at 9:20 AM revealed the patient's name (Patient1) and gave the date/time of the incident as February 12, 2018 at approximately 4:30 AM. Review on February 15, 2018 of the Emergency Department log for February 12, 2018 revealed no documentation of Patient1's name entered on the ED log. Interview with EMP5 on February 16, 2018 at 7:00 AM revealed Patient1 and her significant other presented on February 12, 2018 at approximately 4:30 AM, noting she was pregnant and her water broke. EMP5 confirmed this patient (Patient1) was not entered in the ED log. Cross Reference: 489.20(r)(1) Hospital Must Maintain Records

Based on review of facility documentation, medical records (MR), and staff (EMP) interview, it was determined the facility failed to provide an appropriate medical screening examination within the capability of the hospital for one of 24 patient encounters reviewed (Patient1). Findings include: Review on February 15, 2018 of facility policy "Obstetric Patient Presents to the Emergency Department," last reviewed September 14, 2017, revealed "Purpose: To direct the nursing care of an obstetric patient with obstetric complaints or symptoms who presents to the emergency department for care. Persons Affected: All staff caring for obstetric patients, including all emergency department staff members Policy: The policy is to ensure proper communication, safety, and medical care of the obstetric patient presenting to the emergency department. ... " Attached to this policy was a flowsheet (algorithm) titled "GBH Emergency Department: Triage of the Pregnant Patient." The first box stated "Obvious symptoms of Active Labor, Rupture of Membranes, Contractions " with arrow pointing to the next box stating "Place Courtesy Call to OB x , Immediately transport to OB ... " Review on February 15, 2018 of the facility's "EMTALA System Policy," revealed "Patient Transfer and Emergency Medical Treatment and Labor Act (EMTALA) Purpose: ... To comply with the Emergency Medical Treatment and Labor Act (EMTALA)... Any person who comes to a facility requesting assistance for a potential emergency medical condition/ emergency service will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists ... " Interview with EMP2 on February 15, 2018 at 9:20 AM revealed the patient's name (Patient1) and gave the date/time of the incident as February 12, 2018 at approximately 4:30 AM. Review on February 15, 2018 of Emergency Department medical records revealed there was no documentation of a medical record or medical screening examination for Patient1 who presented on February 12, 2018, in the early AM. Interview on February 16, 2018, at 7:18 AM with EMP13 revealed the following: EMP13 was working the morning of February 12, 2018 when this patient presented to Registration. EMP13 stated they were not notified this patient was in the ED until after the patient (Patient1) left the hospital. Telephone interview on February 16, 2018, at 8:15 AM with EMP15 revealed the following: EMP15 was working in the Emergency Department the morning of February 12, 2018 noted the registration clerk contacted the ED Unit Desk Clerk after the patient (Patient1) left the hospital. EMP15 did not know what the situation was until after the couple left the hospital. EMP15 stated if the ED had been aware that OB was not agreeable to see the patient, EMP15 would have had the triage nurse and EMP15 evaluate the patient and then provide an appropriate transfer for the patient. Interview on February 16, 2018, at 9:15 AM with EMP18 revealed they worked in the Emergency Department the morning of February 12, 2018. EMP18 did not see this patient, and did not know this patient (Patient1) was in the ED until the patient was gone. Cross Reference: 489.20(r)(1) Hospital Must Maintain Records 489.20(r)(3) emergency room Log

Based on review of facility documentation, medical records (MR), and staff (EMP) interview, it was determined the facility failed to provide stabilizing treatment within the capability of the hospital in one of 24 encounters reviewed (Patient1). Findings include: Review on February 15, 2018 of the facility's "EMTALA System Policy," revealed "Patient Transfer and Emergency Medical Treatment and Labor Act (EMTALA) Purpose: ... To comply with the Emergency Medical Treatment and Labor Act (EMTALA)... Stabilization: Each facility governed by this policy is responsible for treating and stabilizing, within its capacity and capability, any individual who presents him/herself to the facility with an emergency medical condition. A patient is considered stabilized when the treating physician has determined, with reasonable clinical confidence, that the patient's emergency medical condition is resolved. ... " Interview with EMP2 on February 15, 2018 at 9:20 AM revealed the patient's name (Patient1) and gave the date/time of the incident as February 12, 2018 at approximately 4:30 AM. Review on February 15, 2018 of Emergency Department medical records revealed there was no documentation of a medical record or stabilizing treatment for Patient1. Cross Reference: 489.20(r)(1) Hospital Must Maintain Records 489.20(r)(3) emergency room Log 489.24(a) and 489.24(c) Medical Screening Exam

Based on review of facility documentation, medical records (MR), and staff (EMP) interview, it was determined the facility failed to provide an appropriate transfer within the capability of the hospital for one of 24 patient encounters reviewed (Patient1). Findings include: Review on February 15, 2018 of the facility's "EMTALA System Policy," revealed "Patient Transfer and Emergency Medical Treatment and Labor Act (EMTALA) Purpose: ... To comply with the Emergency Medical Treatment and Labor Act (EMTALA)... Any person who comes to a facility requesting assistance for a potential emergency medical condition/ emergency service will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists ... Patient Transfers from Geisinger: Duties of Geisinger Transferring Hospital: Physician will certify that the benefits of the transfer outweigh the risks which include written enumeration of the medical risks and benefits based on information at the time of transfer. Obtain the patient's informed consent. Arrange an appropriate transfer by providing treatment within the capacity of the hospital, arrange for acceptance by another facility, and transfer through qualified personnel and equipment. Transfer the medical record and copies of pertinent radiographic and laboratory findings to the receiving facility. ..." Review on February 15, 2016, of the facility's blank form "EMTALA Memorandum of Transfer" revealed the form contained all of the regulatory requirements including: medical condition at time of transfer, reason for transfer, description of risk and benefit analysis for the transfer, the mode of transportation during transfer as determined by the physician, documentation of notification to the receiving facility, accompanying documentation and patient, or responsible persons' consent to transfer. Interview with EMP2 on February 15, 2018 at 9:20 AM indicated the patient's name (Patient1) and gave the date/time of the incident as February 12, 2018 at approximately 4:30 AM. Review on February 15, 2018 of Emergency Department medical records revealed there was no documentation of a medical record or an EMTALA Memorandum of Transfer form for Patient1. Cross Reference: 489.20(r)(1) Hospital Must Maintain Records 489.20(r)(3) emergency room Log 489.24(a) and 489.24(c) Medical Screening Exam 489.24(d)(1-3) Stabilizing Treatment

Based on review of facility documents, medical records (MR) and interview of staff (EMP) it was determined the facility failed to report a patient transfer that may possibly have violated the Emergency Medical Treatment and Active Labor Act for one of two applicable MRs reviewed (MR1). Findings include: Review on January 13, 2015, of facility policy "EMTALA System Policy," last reviewed October 17, 2014, revealed "Patient Transfer and Emergency Medical Treatment and Labor Act (EMTALA) Purpose: To identify guidelines for providing the appropriate setting for conducting medical screening examinations; to identify providers eligible to perform emergency medical screening examinations; To comply with the Emergency Medical Treatment and Labor Act EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations. Departments that conduct medical screenings include: Emergency Departments of GMC ... Policy: Any person who comes to facility requesting assistance for a potential emergency medical condition/emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists. Persons with emergency conditions will be treated and their condition stabilized without regard to ability to pay for services. EMTALA does not apply to inpatients. The triage process recognizes that triage and a medical screening are two separate processes. ... " Review of the Central Log for Emergency Department (ED) for December 29, 2014, revealed 52 patients were seen in the ED on that date. Two transfers from [name of transferring facility] were listed on this log. Review of MR1 revealed the patient was received from [name of transferring facility] at 5:53 PM on December 29, 2014. The patient was brought in by police as a 302. The patient reported they were initially brought to [transferring facility]. While in the waiting room at [the transferring facility], MR1 was reportedly told there was no room for the patient, and was transferred to Geisinger-Bloomsburg to be evaluated. Further review revealed no transfer forms were sent with the patient. MR1 was evaluated in the ED at Geisinger-Bloomsburg and admitted to the behavioral health unit for treatment. Review of Patient Safety Reports from Geisinger-Bloomsburg Hospital revealed no report for this possible EMTALA incident. Interview of EMP1 at 10:22 AM confirmed MR1 was received at this facility at 5:53 PM on December 29, 2014, and was admitted to the behavioral health unit for treatment. OTH1 spoke to EMP1 on December 29, 2014, and was unclear how MR1 arrived at Geisinger-Bloomsburg. OTH1 told EMP1 they were concerned because they did not receive a call requesting the patient be transferred to Geisinger-Bloomsburg from [name of transferring facility] and no transfer forms were sent with the patient. Further interview with EMP1 revealed EMP1 called [name of the transferring facility] within 30 minutes of their knowledge of this incident on December 29, 2014, and spoke to OTH2 in the ED. EMP1 told OTH2 about the patient who appeared to have been sent to the facility from [name of the transferring facility]. EMP1 told OTH2 the patient might have been seen in the waiting room. EMP1 told OTH2 the facility did not receive a transfer phone call or paperwork with the patient. OTH2 told EMP1 they would investigate the incident. EMP1 confirmed Geisinger-Bloomsburg did not report this incident to the Department of Health.