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Based on review of facility policies and procedures, Medical Staff Bylaws/Rules and Regulations, facility logs, video surveillance, and physician and staff interviews, it was determined that the facility failed to ensure compliance with 42 CFR 482.24, Special Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Findings were:

Cross refer to A2403 as it relates to failure of the facility to establish a medical record for a patient presenting to the Emergency Department

Cross refer to A2405 as it relates to failure of the facility to obtain and put a name in the central log for a patient presenting to the Emergency Department.

Cross refer to A2406 as it relates to failure of the Emergency Department physician being informed of the patient presenting so as to perform an appropriate medical screening.

Cross refer to A2407 as it relates to failure of the facility to provide stabilizing treatment for a patient presenting to the Emergency Department.

Cross refer to A2409 as it relates to failure of the facility to effect an appropriate transfer.

Based on review of facility policy and procedure, video surveillance, and physician and staff interviews, it was determined that the facility failed to establish a medical record for a pregnant woman in labor, presenting to the emergency department (ED) on 08/28/2010.

Findings were:

During an interview at 10:00 a.m. on 09/08/2010, the nurse (interview #1) stated he/she was on duty in the ED on 08/27/10 from 7:00 p.m. until 08/28/10 at 7:00 a.m. The nurse related that he/she was in the nurse's station and heard a noise coming from the back door (the ambulance entrance). The nurse was not sure what the noise was but headed back to the door. When the nurse opened and unlocked the door, a man was heading back toward a truck. The truck, according to the nurse, was parked in the ambulance area, with the front of the truck facing the door and the head lights were on. The nurse asked the man if he/she could help him. The man replied that his wife was in labor. The nurse replied by saying, "We have no OB (obstetric) department or nursery here". The nurse then asked the man where the wife's doctor was and the man replied, "Athens. I will take her there". The man then walked to the driver's side of the truck, got in and drove away. The nurse again locked the door and returned to the nurse's station. The nurse stated that he/she told the paramedic who was working with the nurse about the incident but related the incident to no one else. The nurse indicated that he/she had not reported it to the ED physician. The nurse stated that he/she felt that when the husband walked away and got in the truck, he was withdrawing any request for help. When questioned, the nurse stated that the man had not indicated the extent of the woman's labor, nor had the nurse questioned him regarding the labor. The nurse stated that he/she saw another person in the passenger side of the truck but, due to the truck's head lights and the reflection, the nurse was not able to see the person very well or detect any signs of concern. The nurse stated that he/she had not asked any further questions before the man left. The nurse had not obtained a name and was unsure as to the time of the event.

During the same interview, the nurse stated he/she understood about the responsibilities and obligations related to Emergency Medical Treatment and Labor Act (EMTALA). The nurse indicated that he/she felt this incident did not apply because the nurse had not refused to provide services. Instead, the husband had chosen to leave. The nurse confirmed, however, that he/she had told the man that the facility had no OB services.

A review of the video surveillance at 4:30 p.m. on 09/07/2010 of the above incident revealed a view of the back door (ambulance entrance) and the hallway. The nurse (#1) entered the hallway at approximately 4:33 a.m. on 08/28/10 and approached the ambulance entrance door. The nurse unlocked the door and remained at the door, but slightly outside. It appeared that the nurse was interacting with someone, but another individual could not be seen on the video. Lights from a vehicle were seen shining on the windows and door. The nurse then closed the door, locked it, and returned to the nurse's station office. The vehicle lights were seen moving away as the nurse reentered the hallway. The interaction at the back door between the nurse and the individual lasted approximately thirty-two (32) seconds. Another person, whom the facility identified as a radiology technician, was seen in the hallway as the nurse was closing the back door. The technician and the nurse went in different directions with no obvious interaction.

During an interview at 10:30 a.m. on 09/08/2010, the ED physician (interview #4) confirmed that he/she was responsible for covering the ED on 08/27/10 from 7:00 p.m. until 08/28/10 at 7:00 a.m. The physician also confirmed the nurse (#1) was on duty at the same time. The physician stated that the ED had been fairly typical and nothing out of the usual had occurred or had been reported. The physician received a telephone call from the Medical Director of the ED several days later asking him/her about the incident. According to the physician, he/she had no knowledge of the incident prior to that time. The physician, to the best of his/her knowledge, was in the on-call room when the incident occurred. The physician recalled receiving a call from the nurse at approximately 5:00 a.m. to examine a patient in the ED. The physician stated the nurse had never reported the incident to him/her.

An interview at 2:00 p.m. on 09/07/2010 with the Medical Director for the ED (interview #2) revealed that the Medical Director had become aware of the incident on 08/30/2010 and had contacted the ED physician (#4). The Medical Director confirmed that the ED physician was unaware of the incident prior to the call.

A review of facility policy entitled "Triage Classification", recently revised (no date), revealed that the registered nurse will evaluate and categorize each patient upon arrival to the ED. The evaluation was to include the patient's name and age, mode of arrival, chief complaint (presenting symptoms), current medications, allergies, medical history, vital signs, and observations. A medical record was to be established and this information was to be documented in the record.

An interview at 10:00 a.m. on 09/07/2010 with the Chief Nursing Officer (CN0-interview #3) revealed that the CNO had been informed about the incident on 08/29/2010. The incident, according to the CNO, happened at about 4:30 a.m. on 08/28/10. The CNO was aware that the woman who presented to the facility was in active labor and had delivered a baby after leaving the facility and en route to Athens. The CNO confirmed that the nurse on duty (#1) was the only one who had contact with the patient's husband and the facility was unaware of the name of the patient. A medical record had not been established.

Based on review of facility policy and procedure, the ED Logbook, and staff interviews, it was determined that the facility failed to maintain a central log on each patient that came to the Emergency Department seeking treatment.

Findings were:

Review of facility policy entitled "Log Book", last revised and approved 1997, revealed that each patient seeking treatment in the emergency department must be registered into a continuing log book, The log book will contain: identification (name, age, sex, and account number), date, time and mode of arrival, chief complaint or nature of injury, disposition, and time of discharge from the ED. The ED nurse was responsible for assuring the correct data was entered onto the log. The log book was to be be kept in the ED.

A review of the log book for the dates of 08/27/10-08/28/10 lacked documentation related to the pregnant woman having presented to the ED.

During an interview at 10:00 a.m. on 09/08/2010, the nurse (interview #1) stated he/she was on duty in the ED on 08/27/10 from 7:00 p.m. until 08/28/10 at 7:00 a.m. The nurse related that he/she was in the nurse's station and heard a noise coming from the back door (the ambulance entrance). The nurse was not sure what the noise was but headed back to the door. When the nurse opened and unlocked the door, a man was heading back toward a truck. The truck, according to the nurse, was parked in the ambulance area, with the front of the truck facing the door and the head lights were on. The nurse asked the man if he/she could help him. The man replied that his wife was in labor. The nurse replied by saying, "We have no OB (obstetric) department or nursery here". The nurse then asked the man where the wife's doctor was and the man replied, "Athens. I will take her there". The man then walked to the driver's side of the truck, got in and drove away. The nurse again locked the door and returned to the nurse's station. The nurse stated that he/she told the paramedic who was working with the nurse about the incident but related the incident to no one else. The nurse indicated that he/she had not reported it to the ED physician. The nurse stated that he/she felt that when the husband walked away and got in the truck, he was withdrawing any request for help. When questioned, the nurse stated that the man had not indicated the extent of the woman's labor, nor had the nurse questioned the man about the labor. The nurse stated that he/she saw another person in the passenger side of the truck but, due to the truck's head lights and the reflection, the nurse was not able to see the person very well or detect any signs of concern. The nurse stated that he/she had not asked any further questions before the man left. The nurse had not obtained a name and was unsure as to the time of the event.

An interview at 10:00 a.m. on 09/07/2010 with the Chief Nursing Officer (CN0-interview #3) revealed that the CNO had been informed about the incident on 08/29/2010. The incident, according to the CNO, happened at about 4:30 a.m. on 08/28/10. The CNO confirmed that the nurse on duty (#1) was the only one who had contact with the patient's husband and the facility was unaware of the name of the patient and no entry had been made into the log book.

Based on review of Medical Staff Bylaws/Rules and Regulations, policies and procedures, video surveillance, and physician and staff interviews, it was determined that the facility failed to provide a medical screening for the pregnant woman who presented to the ED on 08/28/2010.

Findings were:

A review of the Medical Staff Bylaws/Rules and Regulations revealed evidence that the ED physician on duty was to see every patient seeking treatment. The emergency treatment was to consist of: 1. patient evaluation, including history,physical, and appropriate lab test/x-rays 2. Diagnosis 3. Stabilization, and 4. Disposition, including arrangements for follow up care.

A review of facility policies entitled "EMTALA Guidelines for Emergency Department Services", effective 10/01/2009, and "Medical Screening Exam", effective 12/04/09, revealed that all patients presenting to ED or elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay. All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. In the absence of an actual request for services, if an observer would believe, based on the individual's appearance or behavior, that the individual needs an examination or treatment for a medical condition, the person must be accepted and evaluated for treatment.

During an interview at 10:00 a.m. on 09/08/2010, the nurse (interview #1) stated he/she was on duty in the ED on 08/27/10 from 7:00 p.m. until 08/28/10 at 7:00 a.m. The nurse related that he/she was in the nurse's station and heard a noise coming from the back door (the ambulance entrance). The nurse was not sure what the noise was but headed back to the door. When the nurse opened and unlocked the door, a man was heading back toward a truck. The truck, according to the nurse, was parked in the ambulance area, with the front of the truck facing the door and the head lights were on. The nurse asked the man if he/she could help him. The man replied that his wife was in labor. The nurse replied by saying, "We have no OB (obstetric) department or nursery here". The nurse then asked the man where the wife's doctor was and the man replied, "Athens. I will take her there". The man then walked to the driver's side of the truck, got in and drove away. The nurse again locked the door and returned to the nurse's station. The nurse stated that he/she told the paramedic who was working with the nurse about the incident but related the incident to no one else. The nurse indicated that he/she had not reported it to the ED physician. The nurse stated that he/she felt that when the husband walked away and got in the truck, he was withdrawing any request for help. When questioned, the nurse stated that the man had not indicated the extent of the woman's labor, nor had the nurse questioned the man regarding the labor. The nurse stated that he/she saw another person in the passenger side of the truck but, due to the truck's head lights and the reflection, the nurse was not able to see the person very well or detect any signs of concern. The nurse stated that he/she had not asked any further questions before the man left. The nurse had not obtained a name and was unsure as to the time of the event.

During the same interview, the nurse stated he/she understood about the responsibilities and obligations related to Emergency Medical Treatment and Labor Act (EMTALA). The nurse indicated that he/she felt this incident did not apply because the nurse had not refused to provide services. Instead, the husband had chosen to leave. The nurse confirmed, however, that he/she had told the man that the facility had no OB services.

A review of the video surveillance at 4:30 p.m. on 09/07/2010 of the above incident revealed a view of the back door (ambulance entrance) and hallway. The nurse (#1) entered the hallway at approximately 4:33 a.m. on 08/28/10 and approached the ambulance entrance door. The nurse unlocked the door and remained at the door, but slightly outside. It appeared that the nurse was interacting with someone, but another individual could not be seen on the video. Lights from a vehicle were seen shining on the windows and door. The nurse then closed the door, locked it, and returned to the nurse's station office. The vehicle lights were seen moving away as the nurse reentered the hallway. The interaction at the back door between the nurse and the individual lasted approximately thirty-two (32) seconds. Another person, whom the facility identified as a radiology technician, was seen in the hallway as the nurse was closing the back door. The technician and the nurse went in different directions with no obvious interaction. .

During an interview at 10:30 a.m. on 09/08/2010, the ED physician (interview #4) confirmed that he/she was responsible for covering the ED on 08/27/10 from 7:00 p.m. until 08/28/10 at 7:00 a.m. The physician also confirmed the nurse (#1) was on duty at the same time. The physician stated that the ED had been fairly typical and nothing out of the usual had occurred or had been reported. The physician received a telephone call from the Medical Director of the ED several days later asking him/her about the incident. According to the physician, he/she had no knowledge of the incident prior to that time. The physician, to the best of his/her knowledge, was in the on-call room when the incident occurred. The physician recalled receiving a call from the nurse at approximately 5:00 a.m. to examine a patient in the ED. The physician stated the nurse had never reported the incident to him/her.

An interview at 10:00 a.m. on 09/07/2010 with the Chief Nursing Officer (CN0-interview #3) revealed that the CNO had been informed about the incident on 08/29/2010. The incident, according to the CNO, happened at about 4:30 a.m. on 08/28/10. The CNO was aware that the woman who presented to the facility was in active labor and had delivered a baby after leaving the facility and en route to Athens. The CNO confirmed that the nurse on duty (#1) was the only one who had contact with the patient's husband. The CNO related that the facility had self reported the incident of 08/28/10 as a potential EMTALA (Emergency Medical Treatment and Labor Act) occurrence and that the following corrective actions had been taken or will be taken by the facility:

1. Increase requirements of education and competency regarding EMTALA guidelines.

2. Improve outdoor signage to better emphasize the main emergency room entrance.

3. Remove the nurse from the schedule until further investigation was completed.

4. Installation of a camera at the ambulance entrance that cold be viewed at the nurse's station.

5. Installation of an intercom system at the ambulance entrance so as to provide communication with the nurse's station.

Based on review of facility policies and procedures, video surveillance, and physician and staff interviews, it was determined that the facility failed to provide stabilizing treatment for a pregnant woman presenting to the ED on 08/28/10.

Findings were:

Review of facility policy entitled, "EMTALA Guidelines for Emergency Department Services", last revised 10/1/2009, revealed that an emergency medical condition is a condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future. Among emergency conditions listed was pregnancy with contractions.

Review of facility policy #2123, entitled "Emergency Delivery", last revised 6/2/2010, indicated that on arrival to the ED, any patient who is in active labor and is 16 to 18 weeks or more pregnant, shall be escorted directly to the OB/GYN Room in the ED for evaluation. Any patient who is in active labor on arrival to the ED, and time does not allow for safe transportation to Labor and Delivery, will be evaluated by the ED physician: If birth is imminent; 1. prepare for delivery, 2. contact receiving hospital/EMS/patient's physician of imminent delivery in the ED, 3. request infant warmer be brought to the ED, 4. contact the patient's obstetrician or, if patient has no obstetrician, contact the obstetrician on call, and 5. prepare for possible resuscitation.

During an interview at 10:00 a.m. on 09/08/2010, the nurse (interview #1) stated he/she was on duty in the ED on 08/27/10 from 7:00 p.m. until 08/28/10 at 7:00 a.m. The nurse related that he/she was in the nurse's station and heard a noise coming from the back door (the ambulance entrance). The nurse was not sure what the noise was but headed back to the door. When the nurse opened and unlocked the door, a man was heading back toward a truck. The truck, according to the nurse, was parked in the ambulance area, with the front of the truck facing the door and the head lights were on. The nurse asked the man if he/she could help him. The man replied that his wife was in labor. The nurse replied by saying, "We have no OB (obstetric) department or nursery here". The nurse then asked the man where the wife's doctor was and the man replied, "Athens. I will take her there". The man then walked to the driver's side of the truck, got in and drove away. The nurse again locked the door and returned to the nurse's station. The nurse stated that he/she told the paramedic who was working with the nurse about the incident but related the incident to no one else. The nurse indicated that he/she had not reported it to the ED physician. The nurse stated that he/she felt that when the husband walked away and got in the truck, he was withdrawing any request for help. When questioned, the nurse stated that the man had not indicated the extent of the woman's labor, nor had the nurse questioned him regarding the labor. The nurse stated that he/she saw another person in the passenger side of the truck but, due to the truck's head lights and the reflection, the nurse was not able to see the person very well or detect any signs of concern. The nurse stated that he/she had not asked any further questions before the man left. The nurse had not obtained a name and was unsure as to the time of the event.

During the same interview, the nurse stated he/she understood about the responsibilities and obligations related to Emergency Medical Treatment and Labor Act (EMTALA). The nurse indicated that he/she felt this incident did not apply because the nurse had not refused to provide services. Instead, the husband had chosen to leave. The nurse confirmed, however, that he/she had told the man that the facility had no OB services.

A review of the video surveillance at 4:30 p.m. on 09/07/2010 of the above incident revealed a view of the back door (ambulance entrance). The nurse (#1) entered the hallway at approximately 4:33 a.m. on 08/28/10 and approached the ambulance entrance door and hallway. The nurse unlocked the door and remained at the door, but slightly outside. It appeared that the nurse was interacting with someone, but another individual could not be seen on the video. Lights from a vehicle were seen shining on the windows and door. The nurse then closed the door, locked it, and returned to the nurse's station office. The vehicle lights were seen moving away as the nurse reentered the hallway. The interaction at the back door between the nurse and the individual lasted approximately thirty-two (32) seconds. Another person, whom the facility identified as a radiology technician, was seen in the hallway as the nurse was closing the back door. The technician and the nurse went in different directions with no obvious interaction.

During an interview at 10:30 a.m. on 09/08/2010, the ED physician (interview #4) confirmed that he/she was responsible for covering the ED on 08/27/10 from 7:00 p.m. until 08/28/10 at 7:00 a.m. The physician also confirmed the nurse (#1) was on duty at the same time. The physician stated that the ED had been fairly typical and nothing out of the usual had occurred or had been reported. The physician received a telephone call from the Medical Director of the ED several days later asking him/her about the incident. According to the physician, he/she had no knowledge of the incident prior to that time. The physician, to the best of his/her knowledge, was in the on-call room when the incident occurred. The physician recalled receiving a call from the nurse at approximately 5:00 a.m. to examine a patient in the ED. The physician stated the nurse had never reported the incident to him/her.

An interview at 10:00 a.m. on 09/07/2010 with the Chief Nursing Officer (CN0-interview #3) revealed that the CNO had been informed about the incident on 08/29/2010. The incident, according to the CNO, happened at about 4:30 a.m. on 08/28/10. The CNO was aware that the woman who presented to the facility was in active labor and had delivered a baby after leaving the facility and en route to Athens. The CNO confirmed that the nurse on duty (#1) was the only one who had contact with the patient's husband and the facility was unaware of the name of the patient.

Based on review of facility policies and procedures, video surveillance, and physician and staff interviews, it was determined that the facility failed to effect an appropriate transfer for the pregnant woman presenting to the ED on 08/28/2010.

Findings were:

Review of facility policy entitled "EMTALA Guidelines for Emergency Department Services", last revised 10/1/2009, revealed that the facility may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during, or after transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of their medical condition, they are legally unstable as per EMTALA. This applies to a pregnant woman, in that the woman is not considered legally stable until the baby and placenta have been delivered. The hospital may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable patient to another facility may only be for the reason of medical necessity.

Review of facility policy #2303 entitled "Transfer of a Patient to Another Facility, recently revised, indicated that if the physician determines that the patient should be transferred to another facility for further care, the patient must not be in imminent labor.

During an interview at 10:00 a.m. on 09/08/2010, the nurse (interview #1) stated he/she was on duty in the ED on 08/27/10 from 7:00 p.m. until 08/28/10 at 7:00 a.m. The nurse related that he/she was in the nurse's station and heard a noise coming from the back door (the ambulance entrance). The nurse was not sure what the noise was but headed back to the door. When the nurse opened and unlocked the door, a man was heading back toward a truck. The truck, according to the nurse, was parked in the ambulance area, with the front of the truck facing the door and the head lights were on. The nurse asked the man if he/she could help him. The man replied that his wife was in labor. The nurse replied by saying, "We have no OB (obstetric) department or nursery here". The nurse then asked the man where the wife's doctor was and the man replied, "Athens. I will take her there". The man then walked to the driver's side of the truck, got in and drove away. The nurse again locked the door and returned to the nurse's station. The nurse stated that he/she told the paramedic who was working with the nurse about the incident but related the incident to no one else. The nurse indicated that he/she had not reported it to the ED physician. The nurse stated that he/she felt that when the husband walked away and got in the truck, he was withdrawing any request for help. When questioned, the nurse stated that the man had not indicated the extent of the woman's labor, nor had the nurse questioned the man regarding the labor. The nurse stated that he/she saw another person in the passenger side of the truck but, due to the truck's head lights and the reflection, the nurse was not able to see the person very well or detect any signs of concern. The nurse stated that he/she had not asked any further questions before the man left. The nurse had not obtained a name and was unsure as to the time of the event.

During the same interview, the nurse stated he/she understood about the responsibilities and obligations related to Emergency Medical Treatment and Labor Act (EMTALA). The nurse indicated that he/she felt this incident did not apply because the nurse had not refused to provide services. Instead, the husband had chosen to leave. The nurse confirmed, however, that he/she had told the man that the facility had no OB services.

A review of the video surveillance at 4:30 p.m. on 09/07/2010 of the above incident revealed a view of the back door (ambulance entrance) and hallway. The nurse (#1) entered the hallway at approximately 4:33 a.m. on 08/28/10 and approached the ambulance entrance door. The nurse unlocked the door and remained at the door, but slightly outside. It appeared that the nurse was interacting with someone, but another individual could not be seen on the video. Lights from a vehicle were seen shining on the windows and door. The nurse then closed the door, locked it, and returned to the nurse's station office. The vehicle lights were seen moving away as the nurse reentered the hallway. The interaction at the back door between the nurse and the individual lasted approximately thirty-two (32) seconds. Another person, whom the facility identified as a radiology technician, was seen in the hallway as the nurse was closing the back door. The technician and the nurse went in different directions with no obvious interaction.

During an interview at 10:30 a.m. on 09/08/2010, the ED physician (interview #4) confirmed that he/she was responsible for covering the ED on 08/27/10 from 7:00 p.m. until 08/28/10 at 7:00 a.m. The physician also confirmed the nurse (#1) was on duty at the same time. The physician stated that the ED had been fairly typical and nothing out of the usual had occurred or had been reported. The physician received a telephone call from the Medical Director of the ED several days later asking him/her about the incident. According to the physician, he/she had no knowledge of the incident prior to that time. The physician, to the best of his/her knowledge, was in the on-call room when the incident occurred. The physician recalled receiving a call from the nurse at approximately 5:00 a.m. to examine a patient in the ED. The physician stated the nurse had never reported the incident to him/her.

An interview at 10:00 a.m. on 09/07/2010 with the Chief Nursing Officer (CN0-interview #3) revealed that the CNO had been informed about the incident on 08/29/2010. The incident, according to the CNO, happened at about 4:30 a.m. on 08/28/10. The CNO was aware that the woman who presented to the facility was in active labor and had delivered a baby after leaving the facility and en route to Athens. The CNO confirmed that the nurse on duty (#1) was the only one who had contact with the patient's husband and the facility was unaware of the name of the patient.