Dch Regional Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 30952 Based on a review of the hospital Rules and Regulations, medical record (MR) review, DCH (Druid City Hospital) Emergency Department (ED) Statement on “EMTALA” Emergency Medical Treatment and Active Labor Act, facility policy and procedure, grievance documentation, ED bed occupancy, and interviews with staff it was determined the hospital failed to: 1. Provide ongoing patient monitoring and conduct an appropriate medical screening examination (MSE) within the capability of the hospital’s ED to determine whether an emergency medical condition existed for all patients who presented to the ED seeking care for an OB (obstetrics) related condition. 2. Ensure the patients received an appropriate transfer from the facility. These deficient practices affected one of five patients reviewed that presented to the ED with an OB related complication requesting a MSE, and one of two patient transfers reviewed from the facility. Findings Include: Cross Refer to findings at A 2406 and A 2409.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 30952 Based on a review of medical record (MR), hospital Rules and Regulations, DCH (Druid City Hospital) Emergency Department (ED) Statement on “EMTALA” Emergency Medical Treatment and Active Labor Act, facility policy and procedure, hospital grievance documentation, ED bed occupancy, and interviews with the staff it was determined the hospital failed to provide ongoing monitoring of a patient prior to the ED Provider Assessment, and determine the need for an appropriate medical screening examination (MSE) for a patient presenting to the hospital who was 17 weeks pregnant with vaginal bleeding, who delivered a fetus in the ED lobby bathroom. This did affect Patient Identifier (PI) # 4, one of five OB (obstetrics)/pregnancy record reviews, and had the potential to affect all OB/pregnant patients served by the facility. Findings include: DCH Health System Regional Medical Center Campus Northport Medical Center Campus Rules & Regulations Revisions through September 16, 2025 ...Article V11 ...Section 6: Qualified Medical Personnel (QMP) Authorized to conduct EMTALA MSEs QMP designated to perform MSE...include the following individuals: Physicians, Physician Assistants (PAs), and Certified Registered Nurse Practitioners (CRNPs) with applicable privileges. ...NMC (Northport Medical Center) Labor and Delivery Registered Nurses (RNs) with applicable competencies. Physicians, PAs, and CRNPs working in the following areas...have the performance of MSEs as a core privilege: Emergency Medicine... DCH Emergency Department Statement on “EMTALA” Emergency Medical Treatment and Active Labor Act Revised: October 2024 Summary: EMTALA imposes a legal duty on a hospital to provide to any individual who presents to the ED and requests an examination or an examination is requested on their behalf a medical screening examination...to determine whether an Emergency Medical Condition (EMC) exists, and if an EMC exists, any necessary stabilizing treatment must be provided to an individual for whom a prudent layperson would believe he/she would desire or require such treatment. ...MSE: DCH hospitals must provide a MSE...subject to the following: -The purpose of the MSE is to determine the existence or absence of an EMC. The scope of the MSE must be sufficient, based on individual circumstances, to accomplish this purpose. -The MSE must be completed by a “qualified medical personnel... The DCH Board of Directors formally designates specifically who may complete this exam... Physicians, Physician Assistants (PAs), and Certified Registered Nurse Practitioners...as a core privilege established in Medical Staff Rules & Regulations: Emergency Medicine” Trauma OB/GYN (gynecology)... Emergency Medical Condition (EMC): Generally, and [an] EMC is as determined by the screening practitioner, subject, however, to the following: A woman in active labor is considered to have an EMC... Facility Policy Triage Guidelines No number documented. Revised: April 2025 ...II. Policy: ...C. Patients requiring immediate treatment or assessment by an ED provider will be brought to an ED treatment area urgently and an ED provider will be notified. ...IV. Procedure: A. Pivot/Triage Assessment...performed by the Registered Nurse (RN) who is initially assessing the patient...brief, focused screen and determines if the patient needs immediate intervention. The patient will be assigned an Emergency Severity Index (ESI) utilizing the ENA’s (Emergency Nurse Association) ESI. If the patient does not require immediate intervention, then a more comprehensive triage assessment (Intake) will be performed. B. Intake Assessment: The goal of the comprehensive triage assessment is to gather sufficient information to support a triage severity rating decision. Based on the findings of the intake assessment, for patients in the lobby, the triaging nurses may take the patient to an appropriate treatment area or have the patient return to the waiting area until a room is available... C. Ongoing Monitoring of Patients Prior to ED Provider Assessment: 1. Because the patient’s condition can change at any time, escalation of the ESI level may be warranted. Should this occur, the triage nurse will take appropriate actions/interventions. ...F. Pregnant Patients: 1. Pregnant patients < (less than) 20 Weeks Gestation with any complaint: a. Will stay in the...ED and be assessed by an ED Provider. b. Pregnant patients 12-20 weeks gestation will have Fetal Heart Tones (FHT) performed and documented by RN... Appendix A ESI Triage Algorithm, Version 5 ...B. High-risk situation? or Confused/lethargic/disoriented? or Severe pain/distress? If yes reassess acuity decision, High-risk vital signs (vs)...> 18 y (year) age HR (heart rate) > 100... D. High-risk vital signs: Reassess to determine whether the patient has one or more vital signs outside the normal parameters for the patient... Findings include: 1. PI # 4 presented to the ED on 8/18/25 at 5:19 PM, the reason for visit documented on the ED Sign In Form by PI # 4 was “heavy bleeding and cramping, 17 weeks, 1 day pregnant.” Review of the MR revealed the ED Triage-Pivot Assessment conducted (in ED lobby) on 8/18/25 at 5:47 PM. The documentation revealed the patient stated complaint was heavy (vaginal) bleeding, cramping, with no airway impairment, breathing unlabored, skin color normal, bleeding no. ED Triage vs revealed temperature (T) 98.3, pulse rate (PR) 105 (H-high), respiration rate (RR) 18, 98 oximetry (blood oxygen saturation), blood pressure (BP) 107/72, ED ESI Level 2-Emergent. Further review of the 8/18/25 ED Triage-Pivot Assessment included documentation dated 8/18/25 at 5:31 PM, the frequency of VS monitoring was Q1HR (every one hour). Review of the ED Intake Assessment documentation dated 8/18/1/25 at 6:14 PM revealed patient complaint heavy bleeding, cramping, 17 weeks pregnant, started 1 hour ago, bled through 2 (two) pads within last hour...sees named physician for OB care, has had issues with spontaneous bleeding during this pregnancy. Pain intensity 7 (1-10 scale, 10 worst pain) lower abdomen, cramping, ED ESI Level 2- Emergent. There were no FHTs documented as assessed during the ED Intake Assessment as per facility Triage Guidelines for pregnant patients’ gestation 12-20 weeks. MR review revealed VS were documented 8/18/25 at 7:30 PM, one 1 (hour) thirty-three minutes later, PR 109, (H) and BP 102/69. There was no documentation vaginal bleeding and abdominal cramping/pain was reassessed. Review of the ED provider HPI (history physical interview) revealed the chief complaint (cc) OB/precipitous (sudden/rapid) delivery, and time seen by provider was 8/18/25 at 9:11 PM. The ED physician documented, presenting with heavy vaginal bleeding that started earlier today, 17 weeks pregnant, exam general 20 year in labor. ED Course/MDM (medical decision making) 20-year-old female presenting with heavy vaginal bleeding, found to have a miscarriage, discussed case with OB on-call physician, will take patient to the OR (operating room). Escalation to admission/observation considered for patient. Review of the Nurse Note documentation dated 8/18/25 10:51 PM by the ED Treatment RN revealed at “...2130 (9:30 PM) Patient brought to room with fetus in her arms with placenta attached mother states she had the baby in the bathroom in waiting room. Placenta still attached in vagina. Active bleeding from vagina. VS 98.6, PR 98, RR 19, BP 146/71. 2133 (9:33 PM) On call OB physician arrived and clamped cord and cut cord placenta remained in vagina during short er stay. Patient taken directly to OB by on call physician, and fetus and OB staff. Gave report to...RN (OB) patient and fetus arrived in ob. Care handed over to ob...” The MR documentation revealed VS (vital signs) were not completed per the protocol Q1HR between 5:47 PM and 7:30 PM, and not again until 9:31 PM, when PI # 4’s T 98.6, 110 PR (H), RR 18, BP 100/67, 100 pulse oximetry. The hospital failed to follow its protocol for Q1HR VS monitoring for the ED ESI Level-2 Emergent. Review of the ED RN Treatment Comment documentation dated 8/18/25 at 9:33 PM, revealed PI # 4 delivered in the bathroom of the ED waiting room. Fetus showed no signs of life at birth placenta attached inside of vagina act (active) bleeding. The ED OB/Precipitous Delivery Assessment documentation revealed imminent delivery, large amount thick red vaginal discharge, fetal heart rate zero, resuscitation efforts N/A (not applicable). Further record review revealed ED Discharge Assessment documentation dated 8/18/25 at 10:54 PM that PI # 4 left the ED at 9:33 PM. The facility failed to identify PI # 4’s presenting signs as active labor, re-assess a patient identified as high risk, ESI 2, Emergent, and provide a MSE. An interview was conducted on 9/18/25 at 7:00 AM with Employee Identifier (EI) # 1, DO (doctor of osteopathy) ED physician. EI # 1 reported on 8/18/25 he/she went to the ED lobby bathroom after being told PI # 4 delivered. EI # 1 reported PI # 4 was taken to ED 8 where he/she examined the patient after a miscarriage. EI # 1 reported the on-call OB physician, came down and PI # 4 and fetus were taken to Labor and Delivery (L&D). EI # 1 stated, “I believe she was taken to the OR.” EI # 1 denied knowledge of and being informed PI # 4’s water had broken or that vaginal bleeding had increased. EI # 1 reported, “I think we were getting her a bed ready.” EI # 1 reported it was a busy night, “I don’t know what could have been done differently if no room was available ...” EI # 1 reported he/she monitors the ED board and high acuity patients are seen as priority. EI # 1 reported the standard of care is when presentation is less than 20 weeks gestation, care is managed in the ED, if greater than 20 weeks with pregnancy complaints, the patient is sent to L&D. EI # 1 reported ultrasounds were ordered typically after the provider performed a MSE. EI # 1 reported L&D was not notified until after PI # 4’s delivery. EI # 1 confirmed the fetus was not delivered alive at 17 weeks. An interview was conducted on 9/18/25 at 7:33 PM with EI # 5, ED Treatment RN, who reported his/her contact with PI # 4 occurred briefly after delivery on 8/18/25. EI # 5 reported the OB provider and OB staff arrived at few minutes later, cut the umbilical cord, and PI # 4 and baby were taken to L&D. An interview on 9/18/25 at 1:30 PM was conducted with EI # 6, ED RN, Pivot Assessment I. EI # 6 reported the Pivot RN is stationed at the ED registration desk during the entire shift. EI # 6 confirmed he/she conducted PI # 4’s initial pivot triage assessment in the ED lobby, which included complaint review, vs, identification (ID) band placement, height/weight, pregnancy history, sepsis criteria screen. EI # 6 reported PI # 4 complained of vaginal bleeding and abdominal pain, was 17 weeks pregnancy gestation. EI # 6 checked vital signs, and PI # 4 was assigned ESI 2-Emergent level. PI # 4 remained in the lobby waiting, later was taken back for ED triage intake, and returned to the lobby to wait. EI # 6 denied knowledge or reports of condition changes in PI # 4, including that PI # 4’s water may have broken. EI # 6 reported it was a busy day, there were no hospital beds available, we were holding patients in ED, there were a lot of ESI-2s. EI # 6 reported at shift change at 7:00 PM, 24 patients were in the lobby including PI # 4. An interview was conducted on 9/18/25 at 1:49 PM with EI # 7, ED RN, Intake Assessment I, who confirmed she/he conducted the intake triage assessment on 8/18/25. EI # 7 confirmed PI # 4 was triaged as ESI 2-Emergent. PI # 4’s chief complaint (CC) was vaginal bleeding, abdominal pain, and vs were stable. EI # 7 reported he/she provided pads for bleeding upon request. EI # 4 confirmed PI # 4 reported bleeding through two pads within the last hour. EI # 7 reported after changing pads, PI # 4 returned to the lobby. “I asked her if she had any leaking, she said no, felt pressure, no bulging .... I told her if anything changes, I never heard back from her ...” EI # 7 reported the OB protocol was initiated, and labs obtained. EI # 7 stated fetal heart tones (FHT) are done for gestation greater than 12 weeks as part of the OB protocol. PI # 4’s MR was reviewed with EI # 7 who confirmed FHT were not as assessed and documented during intake assessment per the facility OB protocol. An interview was conducted on 9/18/25 at 3:21 PM with EI # 8, ED RN, Pivot Assessment II. EI # 8 confirmed he/she took over on 8/18/25 at 7:00 PM as Pivot Assessment RN. PI # 4 was in the lobby with a family member (mother), the family member approached the registration area, reported PI # 4’s vaginal bleeding had increased, and wanted to know when she/he was going to be seen. EI # 8 reported he/she exited the ED lobby, into the ED treatment area, and informed ED physician of the report of increased vaginal bleeding. EI # 8 stated upon return to the lobby registration desk, PI # 4 was in the ED lobby bathroom with the Patient Care Technician that responded to the emergency call light. EI # 8 reported PI # 4 had delivered the baby, placenta was intact, still bleeding. EI # 8 stated ED staff arrived, and PI # 4 was taken to the ED Treatment Area. EI # 8 reported the evening of 8/18/25 was “slammed, packed wall to wall, nowhere is sit, numerous ambulances in ...” EI # 8 was asked if PI # 4 was re-assessed for condition changes. EI # 8 denied any re-assessment and reported she did not think she documented anything in PI # 4’s MR that evening. Review of the facility grievance documentation dated 8/21/25 for services on 8/18/25 revealed ED wait time, communication, care/treatment were concerns verbalized by PI # 4’s mother. The grievance included documentation ED staff were notified there was a concern that PI # 4’s water had broken. Review of PI # 4’s record documentation with EI # 4, ED Nurse Manager, confirmed there were no re-assessments for complaints documented including abdominal pain, vaginal bleeding, possible membrane rupture, and vs were not monitored Q1HR per protocol. EI # 4 reported FHTs are performed once patients are in an ED Treatment room, not in triage. EI # 4 confirmed he/she spoke with a representative of PI # 4 about ED wait time, staff communication, and treatment. EI # 4 reported the ED lobby video was not viewed during the grievance investigation and is no longer available as it purges every 14 days. An interview was conducted on 9/19/25 at 8:15 AM with EI # 3, System Director of Emergency Services and EI # 2, Director of Quality Safety. The surveyor requested the ED bed census breakdown on 8/18/25 between 5:00 PM and 10:00 PM. The surveyor asked EI # 3 how the facility addressed its volume increase, or if the facility implemented actions in its surge volume plan. EI # 3 confirmed Senior leadership received every two hours text regarding patient volume, no additional ED Nurses or physician providers were added on 8/18/25 to the ED staffing. On 9/19/25 at 2:15 PM, EI # 4 provided the ED bed occupancy documentation which revealed 17 of 18 ED medical beds were occupied between 5:00 PM and 10:00 PM, the EKG triage room and GYN 2, not routinely used for care were open and staffed with an RN. There were four patients whose care was provided in the ED hallways. EI # 4 confirmed the ED bed occupancy on 8/18/25 revealed ED bed 11 B was unoccupied and available between 5:00 PM and 9:00 PM when PI # 4 was in the ED lobby awaiting a MSE to determine if an EMC existed. The facility failed to identify PI # 4 was in danger of delivery. There were no re-assessments and ongoing monitoring documented for a patient who presented with heavy vaginal bleeding, abdominal pain/cramping, an ED ESI Level -2, Emergent, high-risk patient, to determine the need for a MSE.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) 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; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 30952 Based on medical record (MR) review, hospital Statement on Emergency Medical Treatment and Active Labor Act (EMTALA), and staff interview it was determined the facility failed to ensure patients received an appropriate transfer from the facility. This affected Patient Identifier (PI) # 12, one of two medical records reviewed containing transfers, and had the potential to affect all patients transferred from this facility. Findings include: DCH (Druid City Hospital) Emergency Department (ED) Statement on “EMTALA” Emergency Medical Treatment and Active Labor Act Revised: October 2024 ...Transfer: A patient protected by the EMTALA obligations may be transferred to another facility under two circumstances: 1. Patient request 2. The transferring facility does not have the resources necessary to provide the patient stabilizing treatment and the patient requires a higher level of care. This is known as a Medically Indicated Transfer. Medically Indicated Transfers The transferring hospital’s duties are to: 1. Certify that the benefits of transfer outweigh the risks 2. Obtains the patient’s informed consent A. Written consent of patient or guardian, if available B. Emergency consent doctrine applies if actual consent is not available 3. Arrange an appropriate transfer ...C. Send documentation with the patient i. complete medical record ii. informed consent to transfer iii. certification that transfer is medically indicated D. Provide adequate and appropriate transport... The findings include: 1. PI # 12 presented to the hospital ED on 9/16/25 at 11:00 PM with a chief complaint of blood pressure, elevated. A review of the MR revealed PI # 12 was transferred to an outside facility via Emergency Medical Service ground. The MR contained no documentation of the physician certification, risk and benefits, patient consent to transfer, and medical records being sent to the accepting facility. An interview was conducted on 9/19/25 at 8:56 AM with Employee Identifier # 4, Nurse Manager, ED, who confirmed there is no documentation of the physician certification, risk and benefits, patient consent to transfer, and medical records sent to accepting facility for PI # 12.”