Signature Healthcare Brockton 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: 41143 The Hospital failed to ensure compliance with EMTALA regulations as one Patient (#1) out of a total sample of 30 patients, 1. was not recorded on the Hospital’s central Emergency Department log after presenting to the Hospital seeking evaluation and treatment (see tag A2405) and 2. was not provided a Medical Screening Evaluation by a qualified provider after presenting to the Hospital seeking evaluation and treatement (see tag A2406).”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 41143 Based on record review and interviews, the Hospital failed to ensure one Patient (#1) out of a total sample of 30 patients was recorded on the Hospital’s central Emergency Department log after presenting to the Hospital seeking evaluation and treatment. Patient #1 Presented to the Hospital with pregnancy with signs of labor and was directed to go to another hospital without a MSE being performed by a provider. Findings include: Review of 42 CFR Section 489.20(r)(3) indicated the following: - A central log on each individual who “comes to the emergency department,” as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. Patient #1 presented to the Hospital’s Emergency Department (ED) on 7/19/25 at approximately 12:25 A.M. with concerns of pregnancy labor. Review of Patient #1’s medical records failed to indicate Patient #1 was ever registered for the 7/19/25 presentation to the Hospital, evaluated by a provider to determine if the Patient was in labor, nor if the Patient ever received any stabilizing treatment. Review of the Hospital’s central ED log failed to indicate Patient #1 was ever added to the log for 7/19/25 nor was refused treatment at the Hospital. During an interview with Register #1 on 7/28/25 at 12:30 P.M., she said she was working the overnight shift into 7/19/25. She said between 12:00 A.M. and 1:00 A.M. on 7/19/25, Patient #1 arrived at the ED registration desk. She said Patient #1 was pregnant, uncomfortable, experiencing pain, and was asking to go to labor and delivery. She said she called up to the maternity unit, spoke with a nurse on the maternity unit and informed the nurse Patient #1 had presented to the ED for obstetrics evaluation. She said the nurse on the maternity unit told her Patient #1 could not be seen at the Hospital’s maternity unit as the unit was on diversion and the Patient would need to go to another hospital. She said she was uncomfortable telling Patient #1 he/she could not be seen at the Hospital. She said Patient #1 was never registered for his/her presentation to the Hospital on 7/19/25. Register #1 said the ED triage nurse overheard her discussing Patient #1 with another registration staff member after the Patient had left the Hospital, and the triage nurse said the Patient should have been seen in the ED and transferred to another Hospital after evaluation if necessary. During an interview with the Patient Access Manager on 7/28/25 at 1:05 P.M., she said the Hospital’s process is to not turn any patients away seeking care. She said if the maternity unit would not take a patient for evaluation, the registration staff should inform the ED triage nurse to have the patient assessed. She said Patient #1’s incident on 7/19/25 was discussed with the Patient Access staff. She said the Patient Access staff will be taking EMTALA training assessment tests to further understand any knowledge deficits with EMTALA regulations within the department; and training will be implemented based on the results of the testing. The Hospital failed to ensure Patient #1’s presentation to the Hospital on 7/19/25 was documented on the central ED log.”

“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: 41143 Based on record review and interviews, the Hospital failed to ensure one Patient (#1) out of a total sample of 30 patients, received a medical screening evaluation (MSE) to determine whether an emergency medical condition existed. Patient #1 Presented to the Hospital pregnant with signs of labor and was directed to go to another hospital without a MSE being performed by a provider. Findings include: Review of the Hospital policy titled “EMTALA - Emergency Medical Treatment and Labor Act Screening and Stabilization Policy”, dated March 2018, indicated the following: -An EMTALA obligation is triggered when an individual comes to a dedicated emergency department and the individual or a representative acting on the individual’s behalf requests an examination or treatment for a medical condition. -The MSE must be completed by an individual qualified to perform such an examination to determine whether an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. -The MSE may vary depending on the individual’s signs and symptoms: Pregnant women: The medical records should show evidence that the screening examination, includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membranes, to document whether or not the woman is in labor. -Once the Hospital has provided an appropriate MSE and stabilizing treatment within its capability, an appropriate transfer may be effected by following the appropriate transfer provisions. Review of the Hospital policy titled “Management and Disposition of Obstetrical Patients in the Emergency Department”, dated March 20, indicated the following: -Patients who enter through the ED entrance stating they have been sent by their obstetrician for care in maternity will be sent by Patient Access staff to maternity. Patient Access staff will notify maternity staff by phone that the patient is en route. -Patients who arrive through the ED entrance stating they believe they are in labor will be sent by the Patient Access staff to maternity, with telephone communication. -If the patient upon entry to the hospital is uncomfortable, unable to sit, believes delivery is imminent, the patient will be assisted onto an ED stretcher. The ED provider will determine if the patient needs to be examined or should be transferred directly to maternity. -If the ED nurse or emergency physician has reason to believe that a woman who comes to the ED for evaluation and treatment may be in active labor with a known or suspected gestational age of 20 weeks or greater, the patient may be sent immediately to the maternity department for a medical screening examination. -If the patient’s gestational age is known or suspected to be less than 20 weeks, she should be evaluated by the Emergency Department staff, in the same fashion as any other non-pregnant patient. Review of the Hospital policy titled “Nurse Staffing Triage Policy”, dated October 2024, indicated the following: -Patient Registration Associate will greet patients that arrive through the ED entrance without delay. -The Patient Registration Associate will direct patients to the Triage Area without delay so that the triage nurse can perform a clinical assessment. -In the event that the triage nurse is unavailable, the charge nurse will be notified of the patient’s arrival via the hospital wireless phone. Patient #1 presented to the Hospital’s Emergency Department (ED) on 7/19/25 at approximately 12:25 A.M. with concerns of pregnancy labor. Review of Patient #1’s medical records failed to indicate Patient #1 was ever registered for the 7/19/25 presentation to the Hospital, evaluated by a provider to determine if the Patient was in labor, nor if the Patient ever received any stabilizing treatment. During an interview with the ED Triage Nurse on 7/28/25 at 12:16 P.M., she said she was working triage in the Hospital ED during the overnight shift into 7/19/25. She said she had been with a patient in triage, and after finishing triage with that patient had overheard registration staff at the ED reception desk talking about a pregnant patient having come in and the Hospital’s maternity unit being on diversion. She said the ED cannot turn away any patients who enter the Hospital for treatment or evaluation. She said she notified the nursing supervisor that Patient #1 had been told to go to another hospital for care without evaluation. She said during the overnight shift at the Hospital, pregnant patients coming in for obstetric/maternity care or concerns of labor need to enter the Hospital through the ED doors, present to the registration staff in the ED waiting room, and the registration staff will call the maternity unit to bring the patient to the maternity unit for evaluation. She said staff receive EMTALA training annually. During an interview with Register #1 on 7/28/25 at 12:30 P.M., she said she was working the overnight shift into 7/19/25. She said between 12:00 A.M. and 1:00 A.M. on 7/19/25, Patient #1 arrived at the ED registration desk. She said Patient #1 was pregnant, uncomfortable, experiencing pain, and was asking to go to labor and delivery. She said she called up to the maternity unit, spoke with a nurse on the maternity unit and informed her Patient #1 had presented to the ED for obstetrics evaluation. She said the nurse on the maternity unit told her Patient #1 could not be seen at the Hospital’s maternity unit as the unit was on diversion and the Patient would need to go to another hospital. Register #1 said she was uncomfortable telling Patient #1 he/she could not be seen at the Hospital. She said Patient #1 was never registered for his/her presentation to the Hospital on 7/19/25. She said the ED triage nurse overheard her discussing Patient #1 with another registration staff member after the Patient had left the Hospital, and the triage nurse said the Patient should have been seen in the ED and transferred to another Hospital after evaluation if necessary. During an interview with the Patient Access Manager on 7/28/25 at 1:05 P.M., she said the Hospital’s process is to not turn any patients away seeking care. She said if the maternity unit would not take a patient for evaluation, the registration staff should inform the ED triage nurse to have the patient assessed. She said Patient #1’s incident on 7/19/25 was discussed with the Patient Access staff. She said the Patient Access staff will be taking EMTALA training assessment tests to further understand any knowledge deficits with EMTALA regulations within the department; and training will be implemented based on the results of the testing. During an interview with the Charge Nurse on the maternity unit on 7/28/25 at 2:00 P.M., she said she was the charge nurse for the overnight shift into 7/19/25 for the maternity unit. She said the unit was busy that night. She said the previous shift had mentioned the maternity unit being on diversion due to all of the beds for labor and delivery and post-partum care being assigned with patients. She said she should have clarified whether the unit was on diversion or not with the nursing supervisor. She said when she received the call from the Register on 7/19/25 that Patient #1 had presented to the Hospital, she told the Register the unit was on diversion and the Patient should go to the nearest outside hospital for evaluation. She said she tried to call the Register a few minutes later to try to send Patient #1 up to the unit, but the Patient had already left. She said there could have been better communication during this event. She said the maternity unit reviewed this case as a team and have reviewed unit policies. She said it has been discussed as a unit that any patient presenting to the Hospital with concerns of labor or pregnancy complications should be evaluated and triaged on the maternity unit, and if patient volume is an issue, a transfer to another Hospital can be arranged for the patient once evaluated by a provider. During an interview with the Chief Nursing Officer on 7/28/25 at she said education related to the event with Patient #1 on 7/19/25 was ongoing. She said education points regarding EMTALA and the event was sent to the different department managers to distribute to their respective staff. She said a meeting was also planned for 7/30/25 to discuss process improvement between registration, maternity, and emergency staff.”