Loma Linda University Children’s Hospital

“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: 47360 Based on interview and record review, the facility failed to implement and maintain it’s Emergency Medical Treatment and Active Labor Act (EMTALA), policy and procedures (P&Ps), when six of 21 sampled patient (Patients 12, 16, 18, 19, 20, and 21) presented to the Obstetrics Emergency Department (OBE) were not provided a timely Medical Screening Examination (MSE- a medical exam specific to a patient’s symptoms or injury to determine if an emergency medical condition exists) and not continuously monitored while in the OBE waiting room for an extended period of time. (Refer to Tag A-240 6) These unit inefficiencies and throughput failures resulted in six of 21 sampled patients leaving without being seen (LBWS) after arriving to the OBE for emergency medical care which resulted in the facilities inability to determine if an emergency medical condition existed and the potential for delay of treatment which could jeopardize the safety to the patient and fetus.”

“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: 47360 Based on interview and record review, the facility failed to ensure it’s Emergency Medical Treatment and Labor Act (EMTALA) obligations were implemented in the Obstetric Emergency Department (OBE - labor and delivery and obstetric emergency department) for six of 21 sampled patients (Patients 12, 16, 18, 19, 20, and 21) when: 1. For Patient 18, there was no documented Medical Screening Examination (MSE- an examination performed by a qualified medical provider to determine if a patient has and emergency condition), or documentation of continuous monitoring after Patient 18 was triaged (process of sorting people based on how urgently they need medical care) and placed at waiting room until she was documented as eloped (left without notifying staff) approximately four and a half hours later. 2. For Patient 19, there was no documented MSE, or documentation of continuous monitoring after Patient 19 was triaged and placed in the waiting room until she was documented as eloped approximately 10 hours later. 3. For Patient 20, there was no documented MSE, or documentation of continuous monitoring after Patient 20 was triaged and placed in the waiting room until she was documented as eloped approximately six hours later. 4. For Patient 21, there was no documented MSE, or documentation of continuous monitoring after Patient 21was triaged and placed in the waiting room until she was documented as eloped approximately six hours later. 5. For Patient 12, there was no documented MSE, or documentation of continuous monitoring after Patient 12 was triaged and placed in the waiting room until she was documented as eloped approximately four and a half hours later. 6. For Patient 16, there was no documented MSE, or documentation of continuous monitoring after Patient 16 was triaged and placed in the waiting room until she was documented as eloped approximately four and a half hours later. These failures resulted in the facilities inability to effectively screen and identify patients with an emergency medical condition that required immediate medical intervention, inappropriate monitoring of patients seeking emergency care, delaying quality care, and the potential for significant risks to patient safety. Findings: 1. During a review of the facility’s “Obstetrics Emergency Department Log” (OBE Log) for December 2025, the “OBE Log” indicated, Patient 18 arrived at the OBE on December 22, 2025, at 7:03 PM for urticaria (itchy rash or hives) and eloped (left the OBE without telling staff) on December 21, 2025, at 11:34 PM. During a concurrent interview and record review on February 2, 2026, at 2:50 PM, with the Clinical Nurse Specialist Fellow (CNSF), Patient 18’s “Labor & Delivery Timeline” dated December 22, 2025, was reviewed. The “Labor & Delivery Timeline” (L&D Timeline) indicated, there was no documented evidence to indicate Patient 18 was provided an MSE by a qualified medical provider. The “L&D Timeline” further indicated, Patient 18’s vital signs (measurements of the body’s most basic functions including heart rate, temperature, blood pressure and respiratory rate) were obtained, triage was completed and Patient 18 was sent to the waiting room. The CNSF stated, nurses are not trained to perform an MSE and the MSE must be done by a qualified provider (physician, physician assistant or nurse practitioner). The CNSF stated, the was no documented evidence of vital signs or monitoring of Patient 18 after triage while in the waiting room. The CNSF stated, there is no nursing documentation regarding the circumstances of Patient 18’s elopement from OBE approximately four and a half hours after patient’s arrival to the unit. The CNSF stated, the OBE requires staff to obtain vital signs every hour when a patient is in the waiting room. The CNSF stated, staff are expected to call out twice for a patient in the waiting room, if there is no response then call the patient via phone if they have left the waiting room and document these steps in the patients chart when elopement from the unit is suspected. The CNSF further stated, patients should be monitored while in the waiting room with vital signs completed every hour and any change in the patients condition should be reported to the Registered Nurse (RN). During a concurrent interview and record review, on December 3, 2026, at 12:20 PM, with Physician 1, Patient 18’s “Labor and Delivery Timeline” was reviewed. The “L&D Timeline” indicated, Patient 18 registered to the OBE with a chief complaint of hives to face and neck and no MSE was documented for over four hours. There were no vital signs documented every hour. Physician 1 verified there was no documented MSE or continual assessment of Patient 18. Physician 1 stated, with that chief complaint, he expected a provider would have seen Patient 18 as soon as possible, provided a timely MSE and assessed for lip or oral swelling. 2. During a review of the facility “OBE Log” for December 2025, the “OBE Log” indicated, Patient 19 arrived at the OBE on December 22, 2025, at 12:53 PM, for abdominal pain and eloped on December 23, 2025, at 12:43 AM. During a concurrent interview and record review on February 3, 2026, at 9:00 AM, with the CNSF, Patient 19’s “Labor & Delivery Timeline” (L&D Timeline) dated December 22, 2025, was reviewed. The “L&D Timeline” indicated, there was no documented evidence that Patient 19 was provided an MSE by a qualified medical provider. The L&D Timeline further indicated, Patient 19’s vital signs were obtained and triage was completed at 1:39 PM and Patient 19 was sent to the waiting room. The CNSF stated, there was no documented evidence to indicate Patient 19 received an MSE from a qualified provider during her 10 hour visit to the OBE. The CNSF further stated, there was no documented evidence of vital signs and continuous hourly monitoring of Patient 19 when in the OBE, other than one set of vital signs obtained at 5:35 PM. The CNSF further stated, there was no nursing documentation regarding the circumstances of Patient 19’s elopement from OBE approximately 10 hours after patient’s arrival to the unit. 3. During a review of the facility “OBE Log” for December 2025, the “OBE Log” indicated, Patient 20 arrived at the OBE on December 22, 2025, at 6:22 PM for vaginal bleeding and eloped on December 23, 2025, at 12:39 AM. During a concurrent interview and record review on February 3, 2026, at 8:45 AM, with the CNSF, Patient 20’s “Labor & Delivery Timeline” dated December 22, 2025, was reviewed. The L&D Timeline indicated, there was no documented evidence Patient 20 was provided an MSE by a qualified medical provider. The L&D Timeline further indicated, Patient 20’s vital signs were obtained and triage was completed at 6:38 PM and Patient 20 was sent to the waiting room, but there was no further documentation of continuous hourly monitoring, repeat vital signs or a note regarding patient elopement, approximately six hours later. The CNSF verified there was no documented evidence to indicate that Patient 20 was medically screened by a qualified provider during her six hour wait in the OBE. The CNSF verified there were no documented vital signs or notes from OBE staff while patient was in the waiting room . The CNSF further stated, there was no documented evidence of staff calling Patient 20 or the circumstances regarding elopement from the department. 4. During a review of the facility “OBE Log” for December 2025, the “OBE Log” indicated, Patient 21 arrived at the OBE on December 22, 2025, at 9:30 PM with the chief complaint of a fall and eloped on December 23, 2025, at 3:58 AM. During a concurrent interview and record review on February 3, 2026, at 8:30 AM, with the CNSF, Patient 21’s “Labor & Delivery Timeline” dated December 22, 2025, was reviewed. The L& D Timeline indicated, there was no documented evidence Patient 21 was provided an MSE by a qualified medical provider. The L&D Timeline further indicated, Patient 21’s vital signs were obtained and triage was completed at 10:13 PM and Patient 21 was sent to the waiting room, but there was no further documentation of continuous hourly monitoring, repeat vital signs or a note regarding patient condition until patient was marked as eloped, approximately six hours later. The CNSF verified there was no documented evidence to indicate that Patient 21 was medically screened by a qualified provider during her six hour wait in the OBE. The CNSF verified there were no documented vital signs or notes of continuous assessment while patient was in the waiting room. 5. During a review of the facility “OBE Log” for December 2025, the “OBE Log” indicated, Patient 12 arrived at the OBE on December 11, 2025, at 6:01 PM with the chief complaint of abdominal and back pain and eloped on December 11, 2025, at 10:29 PM. During a concurrent interview and record review on February 3, 2026, at 10:20 AM, with EOBG (Educator Obstetrics and gynecology), Patient 12’s EHR (electronic health record- a documentation where patient information and health status is documented electronically) was reviewed. The EHR indicated, Patient 12 came on December 11, 2025, at 6:01 PM, and was discharged at 10:29 PM documented as “eloped”. Patient 12’s EHR has no documented evidence to indicate Patient 12’s Medical Screening Examination (MSE) and elopement. The EOBG verified there was no documented evidence to indicate Patient 12’s MSE and elopement. 6. During a review of the facility “OBE Log” for January 2026, the “OBE Log” indicated, Patient 16 arrived at the OBE on January 15, 2026, at 3:38 PM with the chief complaint of dizziness and loss of consciousness (passed out) and eloped on January 15, 2026, at 8:51 PM. During a concurrent interview and record review on February 3, 2026, at 11:45 AM, with EOBG, Patient 16’s EHR was reviewed. The EHR indicated, Patient 16 came to the facility on January 15, 2026, at 3:38 PM and there was no documented evidence to indicate Patient 16’s MSE and time of discharge and the status or follow up. The EOBG stated, nurses are expected to document patient’s status. During a concurrent interview and record review, on December 3, 2026, at 12:15 PM, with Physician 1, the facility’s policy and procedure (P&P) titled, “Registered Nurse- Initiated Triage Assessment and Medical Screening Exam” dated October 23, 2025, was reviewed. The “P&P” indicated, “ ...Medical Screening Exam (MSE: the determination, with reasonable clinical confidence, of whether or not the individual has an emergency medical condition or a woman in labor. The MSE must be appropriate to the individual’s presenting signs and symptoms and be performed by a qualified medical personnel ...All patients who present to the Labor and Delivery unit shall be offered an emergency medical screening examination (MSE) and evaluation by qualified medical personnel to determine if any emergency medical condition exits ...MSE will be documented in the electronic medical record ...”. Physician 1 stated, the MSE should be performed as soon as possible once a patient presents to the OBE. Physician 1 stated, the purpose of an MSE is to ensure a patient is stable to remain in the waiting room until a room is available. The following missing MSE for Patients 12, 16, 18, 19, 20, and 21 with Physician 1. Physician 1 stated, there should not be a case where patients are not provided with an MSE for six or ten hours, the expectation was an MSE should be done as soon as possible. During a concurrent interview and record review on February 3, 2026, at 2:35 PM, with the Assistant Vice President of the Obstetrics Unit (AVPOB), the CNSF, and the Obstetrics Director (OD), the facility’s document titled, “[Name of Hospital] Maternity Services Obstetrical ED/Triage Evaluation Self-Study Packet” dated 2025, was reviewed. The document indicated, “ ...Staffing ...4) PCTs [Patient Care Technicians - staff qualified to work in the obstetric/L&D unit] assist in the registration of patients, taking initial and hourly vitals ...The PCT reports to the LVN [Licensed Vocational Nurse] if there are patient concerns. The LVN reports to the Triage RN or Team Leader ...Guidelines ...3) The priority of the Triage RN is managing the waiting room and assessment of new arrivals to the OB ED ...”. The AVPOB verified the department does not have a P&P specific to required monitoring and charting of patients that are in the waiting room. The AVPOB stated, the registration OBE staff are expected to follow the process outlined in the is training packet. The AVPOB stated, the PCT or LVN are expected to lay eyes on each patient in the waiting room every hour, obtain vital signs every hour and documentary concerns and patient vitals in the patient’s chart. The AVPOB stated, the PCT and LVN registration staff did not follow the units training and expectations. There should be documentation to show patients are continuously monitored while waiting in the waiting room. During a continued concurrent interview and record review on February 3, 2026, at 2:40 PM, with the CNSF, the AVPOB, and the OD, the facility’s document titled, “[Name of Hospital] Maternity Services Obstetrical ED/Triage Evaluation Self-Study Packet” dated 2025, was reviewed. The document indicated, “ ...Elopement vs [versus] Left Without Being Seen (LWBS) ...Sometimes patients leave our department and should be documented as Elopement, LWBS or AMA: Left Without Being Seen (LWBS) This happens when a patient registers and perhaps completes triage, but choses to leave the waiting room before they have been evaluated by a provider. It is usually a result of long wait times, and because the medical screening hasn’t occurred, the provider-patient relationship hasn’t officially started. Elopement: A patient who is already under our care ...leaves the unit unannounced and without authorization ...”.The OD stated, since Patients 12, 16, 18, 19, 20, and 21) did not have a documented MSE and were not evaluated by the provider these patients did not elope, and should have been documented as LWBS . The OD stated, the difference between elopement and LWBS is something the unit needs to educate staff. During a continued concurrent interview and record review on February 3, 2026, at 2:40 PM, with the CNSF, the AVPOB, and the OD, the facility’s document titled, “[Name of Hospital] Maternity Services Obstetrical ED/Triage Evaluation Self-Study Packet” dated 2025, was reviewed. The document indicated, “ ...When elopement of LWBS happens, it is the responsibility of the RN who finds that the patient has left to fulfill the requirements of this incident ... 1. Call for the patient in the waiting room ...2. Call the patient using the phone number listed on their check in sheet. If no answer, leave a discreet message with a call back number. 3. In 30-60 minutes call for the patient in the waiting room a 2nd time. 4. If no response, patient is considered eloped. A. Write a multidisciplinary note ...These steps may be taken by the TL [Team Lead] i f available and the Triage/Evaluation RN is busy with other patients. If the Triage/OB Evaluation RN is busy and the TL is not available these steps may be taken by the /charge Nurse or any designated RN ...”. The AVPOB stated, this process was not followed. The AVPOB stated, when a patient is unable to be located in the waiting room, the PCT or LVN should notify the RN. The AVPOB stated, the RN should attempt to call the patient and staff actions to reach the patient and any circumstances related to the patient leaving should be documented in the chart. The AVPOB stated, this is a shared responsibility among the unit staff and a patient leaving or not found in the waiting room should have the circumstances documented.”