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Based on review of the ER Log, medical records, EMS trip report, Bylaws of the Medical Staff of Monroe County Hospital, Rules and Regulations of the Medical Staff of Monroe County Hospital, on-call physicians' schedules, Professional Services agreement between HospitalMD (HMD), LLC and Monroe County Hospital, policies and procedures, ED physicians' schedules, staff interview, EMS interviews, facility's corrective actions, personnel files, credential files, and computer query of pregnant women who presented to the ER that were transferred to another facility, and observations, it was determined that the facility failed to comply with 42 CFR Parts 489.20 and 489.24 for one (1) patient #4, of twenty-two (22) sampled patients.

Findings were:

Cross refer to A2405, the facility failed to maintain documentation in the facility's central log of each patient who presented to the Emergency Room, including patient #4, a pregnant woman who presented after her water broke;

Cross refer to A2406, the facility failed to provide an appropriate Medical Screening Exam (MSE) for patient #4, when a request was made, to determine whether or not an Emergency Medical (EMC) existed;

Cross refer to A2407, the facility failed to provide stabilizing treatment as required for patient #4, a pregnant woman who presented to the emergency department after her water broke; and

Cross refer to A2409, the facility failed to provide an appropriate transfer for patient #4, a pregnant woman whose water had already broken.

Based on review of the facility's Emergency Room (ER) Log, staff interviews, and policies and procedures, the facility failed to maintain documentation in the facility's central log of each patient who presented to the Emergency Room, including patient #4, a pregnant woman who presented after her water broke.

Findings:

Review of the facility's Emergency Room (ER) Log revealed evidence that on 06/03/13 there was only one (1) patient receiving treatment in the ER at 1:35 a.m. This patient arrived on 06/02/13 at 10:42 p.m. and was discharged on 06/03/13 at 3:28 a.m. The next patient entered on the log did not arrive in the ER until 06/03/13 at at 7:57 a.m. The ER Log revealed patient #4 was not entered into the ER Log until 06/24/13. However, the ER log noted that patient #4 actually presented to the ED on 06/03/13 at 2:00 a.m. and the discharge time was noted as 06/03/13 at 2:15 a.m.

During an interview with the Patient Access Supervisor on 09/10/14 at 11:30 a.m., confirmed she was notified on 06/03/13 of the incident involving patient #4 by Patient Access / Registration Clerk #6. The Supervisor stated the patient had not been put into the ER log and that she entered the patient into the log on 06/24/13.

During an interview with the Director of Quality Improvement on 09/11/14 at 11:45 a.m., the Director confirmed that patient #4 was not entered into the ER log until 06/24/13 but that the patient's actual date of service was 06/03/13. The Director confirmed that on 06/03/13 the facility did not have an ER Log policy.

Based on record review, and interview Monroe County Hospital failed to provide an appropriate medical screening examination (MSE) for one patient (#4) who presented to the Emergency Room (ER) after her water, with a history of premature labor seeking treatment on 06/03/13 of the twenty-two (22) sampled patietn medical records reviewed.

As a result of Monroe County Hospital's failure to provide a MSE an immediate and serious threat to patient #4 ' s health and safety and the safety of the patient's unborn child occurred.


Findings:

Review of the facility's Emergency Room (ER) Log revealed patient #4 presented to the ED on 06/03/13 at 2:00 a.m. and was discharged time at 06/03/13 at 2:15 a.m.

Review of patient #4's medical record revealed Registration Clerk #6 called Registered Nurse (RN) #7 to the waiting room to speak with patient #4, a pregnant woman whose water had broken. The nurses' notes revealed the patient was 36 weeks pregnant and that the patient had contacted her private physician to inform the physician that her water had broken. The nurse noted that the patient was from out-of-state and that arrangements had been made for a physician in Macon to follow her care while she was in Georgia. The nurse noted that the patient denied having any contractions and that the patient had driven herself to the ER. The nurse noted that she went to the nurses' station and called ER physician #8 and informed the physician of the following:
--that the woman was 36 weeks pregnant,
--that her water had broken and that the woman denied having any contractions,
-- that this was the woman's second pregnancy and that the first child had been a pre-term delivery,
--that the woman had a physician in Macon covering her pregnancy, and
--that the woman wanted or needed to get to Macon.

In addition, nurse #7 noted that the ER physician #8 told her that it was alright for the woman to leave and go to Macon. The nurse noted that she informed the woman of the ER physician's response, asked the woman again if she was by herself and was informed that the woman had driven herself to the ER. The nurse noted that she escorted the woman to the patient's private automobile and that the woman then called 911. Nurses' notes revealed evidence that the nurse called the Emergency Medical Services (EMS) dispatch to let them know that they would be getting a call from the woman. The nurse also noted that she did not get the patient's name. This note was not signed by the nurse, but the Chief Executive Officer (CEO) confirmed that it was written by RN #7.

Continued review of the medical record revealed no evidence of a MSE.

Review of the EMS trip report revealed evidence that the ambulance attendants received a call on 06/03/13 at 2:23 a.m. to respond to a woman in labor (#4) and that the patient had a history of delivering prematurely. Documentation revealed the EMS were given the address of the Dialysis Center across the street from the hospital. The EMS report revealed evidence that the ambulance arrived on the scene at 2:29 a.m. Documentation revealed the patient was found sitting in a car and that the patient reported that her water had broken about 15 minutes prior to the EMS being called. The EMS report noted that the patient was actively feeling pressure but did not feel the need to push. The EMS report noted that the patient's history included three (3) pregnancies and two (2) deliveries. The report also noted that the patient had had no prenatal care because she had just found out a month ago that she was pregnant. In addition, the report noted that the patient had a history of pre-term labor. The EMS report noted that an assessment revealed there was no crowning and that the patient had no desire to push but felt some pressure in her rear end. The report noted the ambulance left the scene at 2:36 a.m. and arrived at the receiving facility at 2:48 a.m. where the patient was left in the care of the obstetric (specializing in the care of pregnant women) staff.

The "Bylaws of the Medical Staff of Monroe County Hospital", reviewed and last revised 11/20/13, revealed on page 4, that the medical staff is responsible for the quality of medical care in Monroe County Hospital and must accept and assume this responsibility subject to the ultimate authority of the Governing Body. Article Three (3) Medical Staff Membership, 3.05 revealed "Hospital-based Practitioners" included the contractual ER physicians.

The "Rules and Regulations of the Medical Staff of Monroe County Hospital", reviewed and last revised 03/27/12, revealed on page 25 of 41, "All patients presenting to the Emergency Department will receive a medical screening exam. Medical screening exams must be performed by a physician."

Review of the "Professional Services agreement between Hospital MD (HMD), LLC and Monroe County Hospital" entered into on 04/08/13, revealed on page 2, that the term "professional services" shall be those Emergency Medical (EM) Services described on Exhibit "A". On page 18, this contract revealed "HMD shall cause all physicians to comply with requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) that are applicable to Physicians or HMD and shall ensure that each individual presenting himself or herself to the Physician in the Department receives an appropriate examination and (if necessary) treatment. Furthermore, HMD shall comply with EMTALA in the transfer of patients from the Department to another facility." In addition, "HMD operates under the authority of the Hospital's policies and procedures that govern patient access and medical screening with respect to compliance with EMTALA. HMD's and Physicians role is limited only to performing the initial medical screening and subsequent stabilization treatment as required by EMTALA for "emergent" and "non-emergent" patients."

Review of the facility's "Medical Screening Examination Policy", dated 02/26/10, revealed federal law "requires all patients who come to a dedicated emergency department seeking and requesting treatment to receive an appropriate medical screening examination (MSE) to assure that no emergency medical condition (EMC) exists. It is the policy of the Monroe County Hospital to provide such medical screening examination for all patients presenting to the Emergency Department seeking evaluation or treatment."

Review of the June 2013 ED physicians' schedule revealed physician #8 was the ED physician on duty on 06/02/13 from 7:00 p.m. until 06/03/13 at 7:00 p.m.

Review of facility policy entitled "Emergency Delivery of the Newborn", dated 04/20/14, revealed "Any patient who is in active labor or pregnant will be evaluated by the Emergency Department Physician".

During a telephone interview with the ED physician #8 on 09/11/14 at 10:40 a.m., the physician confirmed that on 06/03/13 the nurse #7 had called the ED physicians' office to give the physician a brief update regarding patient #4. The physician explained that when he went to the waiting room patient #4 was gone. The physican stated, "I would have done the medical screening examination if the patient had been there".

During an interview with the Emergency Medical Services (EMS) attendant #5 on 09/10/14 at 3:00 p.m., the attendant confirmed that he worked for the county ambulance service. The attendant explained that on 06/03/13 a call was received from a pregnant patient #4 whose water had broken. The attendant stated the Dialysis Center's address was given as the destination.

During an interview with the EMS attendant #11 on 09/11/14 at 10:00 a.m., the attendant confirmed that a call was received from a pregnant woman whose water had broken and that the patient #4 the address was the Dialysis Center which is across the street from the hospital. The attendant said the patient was in an automobile and upon arrival to the hospital that the woman went straight up to receiving facility's obstetric (specializing in the care and treatment of pregnant women) unit.

During an interview with the Patient Access / Registration Clerk #6 on 09/11/14 at 3:00 p.m., the clerk stated that on 06/03/13 patient #4 came into the ER and reported that her water had broken or possibly broken. The clerk said that for any emergent patient she always called for a nurse. The clerk stated that when she called RN #7 the nurse replied we don't do obstetrics (OB). The clerk said that when I informed the nurse that the patient was holding her stomach the nurse came to the waiting room door. The clerk explained that she personally started to fill out the patient's demographics but stopped so that the nurse could talk with the patient. The clerk stated she then noticed the patient leaving and was informed by the nurse that the ED physician #8 said the patient could leave and that the nurse had told the patient to call 911.

During an interview with the Director of Quality Improvement on 09/11/14 at 11:45 a.m., the Director confirmed that a MSE was not completed for patient #4 on 6/03/2013.

Based on review of the ER Log, medical records, EMS trip report, Bylaws of the Medical Staff of Monroe County Hospital, Rules and Regulations of the Medical Staff of Monroe County Hospital, Professional Services agreement between HospitalMD (HMD), LLC and Monroe County Hospital, policies and procedures, ED physicians' schedules, staff interview, EMS attendant interviews, facility's corrective actions, personnel files, and credential files, it was determined that the facility failed to provide the patient with stabilizing treatment for a medical emergency condition when patient #4 presented to the Emergency Room (ER) requesting treatment on 06/03/13. As a result of Monroe County Hospital's failure to provide stablizing treatment an immediate and serious threat to patient #4 ' s health and safety and the safety of the patient's unborn child occurred.


Findings:

Review of the facility's Emergency Room (ER) Log revealed evidence that on 06/03/13 there was only one (1) patient receiving treatment in the ER at 1:35 a.m. This patient arrived on 06/02/13 at 10:42 p.m. and was discharged on 06/03/13 at 3:28 a.m. The next patient entered on the log did not arrive in the ER until 06/03/13 at at 7:57 a.m. The ER Log revealed patient #4 was not entered into the ER Log until 06/24/13. However, the ER log noted that patient #4 actually presented to the ED on 06/03/13 at 2:00 a.m. and the discharge time was noted as 06/03/13 at 2:15 a.m.

Patient #4's medical record revealed Registration Clerk #6 called Registered Nurse (RN) #7 to the waiting room to speak with patient #4, a pregnant woman whose water had broken. The nurses' notes revealed the patient was 36 weeks pregnant and that the patient had contacted her private physician to inform the physician that her water had broken. The nurse noted that the patient was from out-of-state and that arrangements had been made for a physician in Macon to follow her care while she was in Georgia. The nurse noted that the patient denied having any contractions and that the patient had driven herself to the ER. The nurse noted that she went to the nurses' station and called ER physician #8 and informed the physician of the following:
--that the woman was 36 weeks pregnant,
--that her water had broken and that the woman denied having any contractions,
-- that this was the woman's second pregnancy and that the first child had been a pre-term delivery,
--that the woman had a physician in Macon covering her pregnancy, and
--that the woman wanted or needed to get to Macon.

In addition, nurse #7 noted that the ER physician #8 told her that it was alright for the woman to leave and go to Macon. The nurse noted that she informed the woman of the ER physician's response, asked the woman again if she was by herself and was informed that the woman had driven herself to the ER. The nurse noted that she escorted the woman to the patient's private automobile and that the woman then called 911. Nurses' notes revealed evidence that the nurse called the Emergency Medical Services (EMS) dispatch to let them know that they would be getting a call from the woman. The nurse also noted that she did not get the patient's name. This note was not signed by the nurse, but the Chief Executive Officer (CEO) confirmed that it was written by RN #7.

The medical record lacked evidence of a any stabilizing treatment.

Review of the EMS trip report revealed evidence that the ambulance attendants received a call on 06/03/13 at 2:23 a.m. to respond to a woman in labor (#4) and that the patient had a history of delivering prematurely. Documentation revealed the EMS were given the address of the Dialysis Center across the street from the hospital. The EMS report revealed evidence that the ambulance arrived on the scene at 2:29 a.m. Documentation revealed the patient was found sitting in a car and that the patient reported that her water had broken about 15 minutes prior to the EMS being called. The EMS report noted that the patient was actively feeling pressure but did not feel the need to push. The EMS report noted that the patient's history included three (3) pregnancies and two (2) deliveries. The report also noted that the patient had had no prenatal care because she had just found out a month ago that she was pregnant. In addition, the report noted that the patient had a history of pre-term labor. The EMS report noted that an assessment revealed there was no crowning and that the patient had no desire to push but felt some pressure in her rear end. The report noted the ambulance left the scene at 2:36 a.m. and arrived at the receiving facility at 2:48 a.m. where the patient was left in the care of the obstetric (specializing in the care of pregnant women) staff.

Review of the "Professional Services agreement between HospitalMD (HMD), LLC and Monroe County Hospital" entered into on 04/08/13. On page 18, this contract revealed "HMD shall cause all physicians to comply with requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) that are applicable to Physicians or HMD shall comply with EMTALA in the transfer of patients from the Department to another facility."

Review of facility policy entitled "Emergency Delivery of the Newborn", dated 04/20/14, revealed "Any patient who is in active labor or pregnant will be evaluated by the Emergency Department Physician".

During a telephone interview with the ED physician #8 on 09/11/14 at 10:40 a.m., the physician confirmed that on 06/03/13 the nurse #7 had called the ED physicians' office to give the physician a brief update regarding patient #4. The physician explained that when he went to the waiting room patient #4 was gone.

During an interview with the Emergency Medical Services (EMS) attendant #5 on 09/10/14 at 3:00 p.m., the attendant confirmed that he worked for the county ambulance service. The attendant explained that on 06/03/13 a call was received from a pregnant patient #4 whose water had broken. The attendant stated the Dialysis Center's address was given as the destination.

During an interview with the EMS attendant #11 on 09/11/14 at 10:00 a.m., the attendant confirmed that a call was received from a pregnant woman whose water had broken and that the patient #4 the address was the Dialysis Center which is across the street from the hospital and that the woman went straight up to receiving facility's obstetric (specializing in the care and treatment of pregnant women) unit.

During an interview with the Patient Access / Registration Clerk #6 on 09/11/14 at 3:00 p.m., the clerk stated that on 06/03/13 patient #4 came into the ER and reported that her water had broken or possibly broken. The clerk said that for any emergent patient she always called for a nurse. The clerk stated that when she called RN #7 the nurse replied we don't do obstetrics (OB). The clerk stated she then noticed the patient leaving and was informed by the nurse that the ED physician #8 said the patient could leave and that the nurse had told the patient to call 911.


During an interview with the Director of Quality Improvement on 09/11/14 at 11:45 a.m., the Director confirmed that patient #4 was not entered into the ER log until 06/24/13 but that the patient's actual date of service was 06/03/13. In addition, the Director confirmed that a medical record was initiated by nurse #7 and no stabilizing treatment was provided for patient#4 on 06/03/2013.

During an interview with the Chief Executive Officer on 09/11/14 at 1:30 p.m., the Chief Executive Officer confirmed that she was informed of the incident involving patient #4 on the morning of 06/03/13.

Based on record review and interview Monroe County Hospital, failed to provide an appropriate transfer for one patient (#4) of the twenty-two (22) sampled who presented to the Emergency Room (ER) requesting treatment of pregnancy after her water had broke, with a history of premature labor. As a result of Monroe County Hospital's failure to provide an appropriate transfer an immediate and serious threat to patient #4 ' s health and safety and the safety of the patient's unborn child occurred.

Findings:

Review of the facility's Emergency Room (ER) Log revealed patient #4 actually presented to the ED on 06/03/13 at 2:00 a.m. and the discharge time was noted as 06/03/13 at 2:15 a.m.

Patient #4's medical record revealed Registration Clerk #6 called Registered Nurse (RN) #7 to the waiting room to speak with patient #4, a pregnant woman whose water had broken. The nurses' notes revealed the patient was 36 weeks pregnant and that the patient had contacted her private physician to inform the physician that her water had broken. The nurse noted that the patient was from out-of-state and that arrangements had been made for a physician in Macon to follow her care while she was in Georgia. The nurse noted that the patient denied having any contractions and that the patient had driven herself to the ER. The nurse noted that she went to the nurses' station and called ER physician #8 and informed the physician of the following:
--that the woman was 36 weeks pregnant,
--that her water had broken and that the woman denied having any contractions,
-- that this was the woman's second pregnancy and that the first child had been a pre-term delivery,
--that the woman had a physician in Macon covering her pregnancy, and
--that the woman wanted or needed to get to Macon.

In addition, nurse #7 noted that the ER physician #8 told her that it was alright for the woman to leave and go to Macon. The nurse noted that she informed the woman of the ER physician's response, asked the woman again if she was by herself and was informed that the woman had driven herself to the ER. The nurse noted that she escorted the woman to the patient's private automobile and that the woman then called 911. Nurses' notes revealed evidence that the nurse called the Emergency Medical Services (EMS) dispatch to let them know that they would be getting a call from the woman. The nurse also noted that she did not get the patient's name.

The medical record had no evidence of an appropriate transfer for patient #4.

Review of the EMS trip report revealed evidence that the ambulance attendants received a call on 06/03/13 at 2:23 a.m. to respond to a woman in labor (#4) and that the patient had a history of delivering prematurely. Documentation revealed the EMS were given the address of the Dialysis Center across the street from the hospital. The EMS report revealed evidence that the ambulance arrived on the scene at 2:29 a.m. Documentation revealed the patient was found sitting in a car and that the patient reported that her water had broken about 15 minutes prior to the EMS being called. The EMS report noted that the patient was actively feeling pressure but did not feel the need to push. The EMS report noted that the patient's history included three (3) pregnancies and two (2) deliveries. The report also noted that the patient had had no prenatal care because she had just found out a month ago that she was pregnant. In addition, the report noted that the patient had a history of pre-term labor. The EMS report noted that an assessment revealed there was no crowning and that the patient had no desire to push but felt some pressure in her rear end. The report noted the ambulance left the scene at 2:36 a.m. and arrived at the receiving facility at 2:48 a.m. where the patient was left in the care of the obstetric (specializing in the care of pregnant women) staff.

The "Rules and Regulations of the Medical Staff of Monroe County Hospital", reviewed and last revised 03/27/12, revealed the attending physician was required to write a transfer order and make the transfer arrangements, documentation of the accepting facility and accepting physician, and assess and stabilize the patient prior to transfer. A copy of all pertinent medical records was also to accompany the transferred patient.

Review of the "Professional Services agreement between HospitalMD (HMD), LLC and Monroe County Hospital" entered into on 04/08/13, revealed on page 2, that the term "professional services" shall be those Emergency Medical (EM) Services described on Exhibit "A". On page 18, this contract revealed "HMD shall cause all physicians to comply with requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA).

Review of the facility's "Transfer of Patients from MCH (Monroe County Hospital)", dated 06/2010, revealed the policy was to facilitate transfers from the hospital in accordance with state and federal laws and regulations.

During a telephone interview with the ED physician #8 on 09/11/14 at 10:40 a.m., the physician confirmed that on 06/03/13 the nurse #7 had called the ED physicians' office to give the physician a brief update regarding patient #4. The physician explained that when he went to the waiting room patient #4 was gone.

During an interview with the Emergency Medical Services (EMS) attendant #5 on 09/10/14 at 3:00 p.m., the attendant confirmed that he worked for the county ambulance service. The attendant explained that on 06/03/13 a call was received from a pregnant patient #4 whose water had broken. The attendant stated the Dialysis Center's address was given as the destination. The attendant stated there had been no complications enroute to the receiving facility. In addition, the attendant confirmed that if the hospital had called to transfer the patient the patient would have been picked-up at the hospital.

During an interview with the Patient Access / Registration Clerk #6 on 09/11/14 at 3:00 p.m., the clerk stated that on 06/03/13 patient #4 came into the ER and reported that her water had broken or possibly broken. The clerk said that for any emergent patient she always called for a nurse. The clerk stated that when she called RN #7 the nurse replied we don't do obstetrics (OB). The clerk said that when I informed the nurse that the patient was holding her stomach the nurse came to the waiting room door. The clerk explained that she personally started to fill out the patient's demographics but stopped so that the nurse could talk with the patient. The clerk stated she then noticed the patient leaving and was informed by the nurse that the ED physician #8 said the patient could leave and that the nurse had told the patient to call 911. The clerk stated she did not see anyone with the patient and did not hear the conversation between the nurse and physician.

During an interview with the Director of Quality Improvement on 09/11/14 at 11:45 a.m., the Director confirmed appropriate transfer of patient #4 on 06/03/2013 had not been arranged.