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Based on review of hospital policy and procedure, medical record reviews, staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 13 sampled DED patients (Patient # 6) who presented to the hospital for evaluation and treatment status post 2 falls and was discharged home; and 1 of 4 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home (Patient #29) without receiving an appropriate medical screening examination by a qualified medical personnel.

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A 2406.

2. The hospital's Dedicated Emergency Department (DED) physician failed to provide within the capabilities of the staff and facilities available at the hospital further medical examination and treatment as required to stabilize a patient's Emergency Medical Condition (EMC) for 1 of 13 sampled DED (Patient # 6) who presented to the hospital for evaluation and treatment and were discharged home; and 1 of 4 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home (Patient #29).

~ Cross refer to §489.24(d)(1-3) Stabilizing Treatment, Tag A 2407.

Based on hospital policy and procedure review, medical record reviews, Medical Staff Rules and Regulations review, staff and physician interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 13 sampled DED patients (Patient # 6) who presented to the hospital status post 2 falls for evaluation and treatment and was discharged home; and 1 of 4 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home (Patient #29) without receiving an appropriate medical screening examination by a qualified medical personnel.

The findings include:

Review on 08/17/2017 of hospital policy "EMTALA, Medical Screening & Stabilization, Refusal of Treatment" revised 10/2016 revealed "1 All individuals who arrive at the Emergency Department (ED) seeking medical treatment will receive a MSE to ascertain whether an Emergency Medical Condition exists. This screening will include diagnostic or therapeutic services routinely available... 2. Triage is not a MSE...5. Obstetrical patients presenting to the ED:
a. < 20 weeks gestation will receive a MSE in the ED
b. > 20 weeks gestation with a pregnancy related complaint will receive a MSE in the L&D Suite.
c. > 20 weeks gestation with a non- pregnancy related complaint will receive a MSE in the ED....3. Stabilized for DISCHARGE means that it has been determined, within reasonable medical probability, that an individual has reached the point where his/her continued care, including diagnostic work-up and treatment, could be reasonably performed on an outpatient basis. The individual should be given a plan for appropriate follow up care with discharge instructions.
a. An individual may also be discharged from the ED for admission as an inpatient..."


The facility's a policy and procedure titled, "Admission to Labor and Delivery Including Medical Screening Examination", LD 460.02, initial Approval 04/79, last revised 02/14 was reviewed. The policy and procedure specified in part, "Purpose: The purpose of this policy is to outline the steps involved in the assessment and care of inpatients and outpatients in the Labor and Delivery Department including medical screening requirements...Procedure: ...2. Registered Nurses in Labor and Delivery completing the Medical Screening Exam must have completed the fetal monitoring competency requirements."

Review of the Medical Staff Rules and Regulations, revised April 4, 2011 revealed in part, "1.15 Persons Qualified to Conduct Medical Screening Examinations those persons, other than Emergency Medicine Department Physicians/and or admitting physicians, who are qualified to conduct a "medical screening examination "... are physician assistants, midwives, nurse practitioners, Registered Nurses from Labor and Delivery department who meet the requirements for fetal monitoring."

1. Closed medical record review on 08/16/2017 of Patient #6 revealed a 76 year old female who presented to Hospital A's (Nash General Hospital) DED on 06/26/2017 at 2042 via wheelchair for a chief complaint of "patient fell down stairs leaving hospital". Record review revealed triage began at 2053 with vital signs BP 150/92; heart rate 80; respiratory rate: 16; SpO2 (oxygenation) : 100%. Record review revealed "Assess/Tx Level of Consciousness: Alert; Orientation Assessment: Identifies self, Not oriented to place ... " Record review revealed the patient was transported to CT scan at 2150. Record review revealed " ED Adult Neuro Assessment at 2151 Neuro Muscular: Characteristics of Speech: Clear; Gait Quality: unable to assess; ED Neuro Assessment Add Note: Fall walking down stairs, positive LOC (Loss of Consciousness). Patient does not remember fall. Patient not oriented to year, place, time. Patient has cuts to bilateral elbows, swelling to R side of head and back side of head ... Glasgow Coma Score: 14 ... " The patient was discharged home on 06/27/2017 at 0032 in a wheelchair in the care of her son and daughter with discharge and follow up instructions given.

Review of ED Physician Note on 06/26/2017 at 2255 revealed "Basic Information: History Limitation: Cognitive impairment ... History of Present Illness: Patient is a 76-year-old female with a PMH including hyperlipidemia, hypertension, and aortic valve defect presenting to the ED with a chief complain of head pain onset today secondary to a fall. Per daughter, the patient was visiting her husband at the heart center, when she went down 3-5 steps of stairs while holding on to the rail. The patient bumped against the wall and then tumbled sideways while hitting her head on every step and denies LOC. Family reports patient having a large bump on the back of her head and right side of face. Patient fell yesterday and her glasses cut under her right eye and reopened today secondary to fall. Patient also complains of left ear pain and pain over her whole head. She has not taken any pain medication prior to arrival. Patient denies right hip pain and back pain. Patient is on Plavix (Medication- Blood Thinner) ... Physical Examination: General: Alert, no acute distress, well nourished, calm cooperative ... Head: Normocephalic, contusion right zygomatic arch area, On exam: Right temporal, hematoma, no abrasion, no laceration, On exam: Mild parietal (midline) hematoma, no abrasion, no laceration ... Musculoskeletal: Normal ROM, normal strength, no swelling, no deformity ...Right, arm hematoma ... Right elbow, skin tear and hematoma, no bleeding ... Left elbow, skin tear, Lower extremity: Bilateral, hip no tenderness ...Neurological: Alert and oriented to person, place, time and situation ...normal coordination observed, Gait: Normal (by observation). Medical Decision Making: Radiology results: Reported at 06/26/2017 2242, Computed tomography (CT) reviewed radiologist ' s report, emergency physician interpretation ... Head: No acute intracranial hemorrhage, herniation or hydrocephalus. Multiple sites of scalp hematoma without underlying fracture. Confluent and patchy area of supratentorial white matter hypodensity, nonspecific, but most likely sequela of chronic microvascular changes. Face: No acute facial fracture. No intraorbital hematoma. Bilateral lens replacements. Slight asymmetric fullness of the right base of tongue, oropharyngeal tonsil, likely due to positioning. C- Spine: No acute fracture or traumatic malalignment. No prevertebral soft tissue swelling ...Pain Status: Headache Improved. Notes: Recheck on patient. Discussed with patient work up, relevant results, and plan for discharge. Patient was given ED warnings, discharge instructions, and follow up instructions. Patient understands and agrees with plan for discharge. Patient was informed and verbalizes understanding to return to ER immediately if symptoms worsen, persist, worsen, new symptoms or follow up cannot be obtained. Any questions have been addressed. Patient feels comfortable going home at this time ... Patient has been stable and is at her normal baseline ... "

Review of an Outpatient MRI of the Brain with and without contrast report from Hospital A on 06/28/2017 at 1246 revealed IMPRESSION: 1. On DWI sequence, increased signal within the left occipital lobe is consistent with recent demyelination versus acute infarct; no gadolinium enhancement at this level is noted. 2. Scalp hematomas the largest of which is noted within the scalp of the posterior parietal region .... "

Closed medical record review of Patient #6 DED visit to Hospital B on 06/29/2017 at 1042. Revealed the patient had a chief complaint of "stroke symptoms". Record review revealed "Chief Complaints Updated: + Stroke Symptoms (Pt fell down some stairs at the hospital on Monday (6/26/2017) but cannot remember how or why she fell. Pt went to see her doctor and had an MRI. Per pt "the doctor said I had a hematoma and an infarct and said I needed to go to a hospital so my family said to come here." Pt also states that family was going to drive her but she was having trouble walking." Record review of ED Physician Notes revealed "Medical Decision Making: 1119 discussed with primary care physician. He will fax brain MRI results. There is concern for acute left occipital infarct versus demyelination this area [sic]. We'll plan for admission for syncope and possible acute stroke on MRI done yesterday ... Record review revealed the patient was discharged from Hospital B on 07/03/2017.

Telephone interview with EDRN #1 on 08/16/2017 at 1830 revealed she remembers the patient and family. Interview revealed the patient could not remember the fall, nor if she felt dizzy prior to the fall. Interview revealed the daughter witnessed the fall and per the conversation with the nurse and the daughter the patient "just stopped and fell." Interview revealed the daughter doesn't feel she tripped. Interview revealed the patient was confused on arrival but back to baseline which was alert and oriented to person, place and time at discharge. Interview revealed the patient ambulated around the nurses' station with assistance prior to discharge. The interview also revealed the nurse failed to document the ambulation of the patient as well as the updated mental status prior to patient discharge from Nash General Hospital on 6/26/2017.

Telephone interview with Physician #1 on 08/16/2017 at 2005 revealed during her assessment of the patient, she was alert, orient to person, family, time but not to events of the fall. Interview revealed the patient had a previous fall the day prior. Interview reveled the patient had equal strength in all four extremities. Interview revealed all radiology reports were negative. Interview revealed she discussed how important follow up was and what signs and symptoms to monitor for possible head injury. Interview revealed physician did not ambulate the patient nor trial ambulate the patient prior to discharge. Interview revealed she believes the MSE was appropriate and patient was stable for discharge. The facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department for patient #6 on 6/26/2017.

2. Closed medical record review on 08/17/2017 of Patient #29 revealed a 20 year old female gravida 1 (number of pregnancies) ; Para 0 (pregnancies carried beyond 20 weeks) 35 weeks in gestation who presented to Labor and Delivery on 06/30/2017 at 2037 and triaged at 2046 with a stated complaint of "Blood pressures elevated and decreased fetal movement". Record review revealed the patient has a history of hypertension since the age of 13. Record review revealed the patient denies contractions, leakage of fluid, urge to push and vaginal bleeding. Record review revealed the patient was placed on a Continuous External Fetal monitor at 2107 with a fetal heart rate baseline of 145 and the patient's vital signs were BP 117/77; heart rate 101; respiratory rate 20; Temperature 36.7 C. Record review of pain assessment revealed "left side pain since arrival" rates 5/10= moderate pain. Record review revealed no vaginal exam performed. Record review revealed OBMD #1 was notified at 2148 "(Information Provided to Clinician) Pt's c/o (complaint of) increased BP yesterday and today 140/96 and 145/95; decreased fetal movement; denies cx (contractions) lof (leakage of fluid) or bleeding; fhr wnl (fetal heart rate within normal limits); one variable notes; fhr pattern; bp;s neg dipstick; left side pain; on Procardia for chronic htn since age 13 ... Response from Clinician ... See physician orders." Record review revealed Orders entered 6/30/2017 at 2148 by OBRN #1- Physician orders: Order Admission: Plan L& D Observation; Order: Communication Order: (Pt may have 1gm of Tylenol if she wants it); Order: Discharge Patient; Order: Fetal Heart Monitor External; Order: Perinatal Care Quality Measures; Order: Vital Signs ..." Record review revealed all orders were electronically signed by OBMD#1 on 07/01/2017 0101. Record review revealed BP at 2152 113/76; heart rate 91. Record review revealed the patient was discharged at 2212 with instructions for Third Trimester Pregnancy. Record review revealed no discharge diagnosis or physician noted documented in the medical record.

Telephone interview on 08/17/2017 at 1410 with OBMD #1 revealed she did not come in to evaluate Patient #29. Interview revealed she does not give a diagnosis on any patient she does not evaluate nor does she go back and review the charts once orders are given on patients the Labor and Delivery nurses contact her for. Interview revealed if the nurses request her to come in and evaluate the patient, she will. Interview revealed she is not aware a diagnosis needs to be documented in a record where a Labor and Delivery Registered Nurse performs a MSE.
The facility failed to ensure that an appropriate medical screening examination was provided by a physician or a nurse practitioner to determine whether or not an emergency medical condition existed for Patient #6 on 6/30/2017. According to the facility's Medical Staff Rules and Regulations Labor and Delivery Nurses conduct medical screening examinations who meet the requirements for fetal monitoring.


Telephone interview on 08/17/2017 at 1440 with OBRN #1 revealed she was the nurse for Patient #29. Interview revealed the L&D unit sees all patients greater than 20 weeks in gestation. Interview revealed sometimes we request the MD to come in and sometimes we don't. Interview revealed we work the patients up and if all results are normal we call the physician and let them know and send the patients home. Interview revealed they do not write diagnosis on the medical records. Interview revealed if she requests a MD to come see the patient, they will.

Interview on 08/17/2017 at 1610 with OBMD #2 revealed he does not give a diagnosis for patients he does not personally evaluate on the L&D in conjunction with the Nurses who perform the MSEs. Interview revealed he feels the nurses are competent to evaluate simple complaints other than labor checks in consultation with the OB on call. Interview revealed he would come in and evaluate a patient if needed.

Based on hospital policy and procedure review, medical record reviews, staff and physician interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide within the capabilities of the staff and facilities available at the hospital further medical examination and treatment as required to stabilize a patient's Emergency Medical Condition (EMC) for 1 of 13 sampled DED (Patient # 6) who presented to the hospital for evaluation and treatment and were discharged home; and 1 of 4 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home (Patient #29).

The findings include:

Review on 08/17/2017 of hospital policy "EMTALA, Medical Screening & Stabilization, Refusal of Treatment" revised 10/2016 revealed "1 All individuals who arrive at the Emergency Department (ED) seeking medical treatment will receive a MSE to ascertain whether an Emergency Medical Condition exists. This screening will include diagnostic or therapeutic services routinely available... 2. Triage is not a MSE...5. Obstetrical patients presenting to the ED:
a. < 20 weeks gestation will receive a MSE in the ED
b. > 20 weeks gestation with a pregnancy related complaint will receive a MSE in the L&D Suite.
c. > 20 weeks gestation with a non- pregnancy related complaint will receive a MSE in the ED....3. Stabilized for DISCHARGE means that it has been determined, within reasonable medical probability, that an individual has reached the point where his/her continued care, including diagnostic work-up and treatment, could be reasonably performed on an outpatient basis. The individual should be given a plan for appropriate follow up care with discharge instructions.
a. An individual may also be discharged from the ED for admission as an inpatient..."


1. Closed medical record review on 08/16/2017 of Patient #6 revealed a 76 year old female who presented to Hospital A ' s DED on 06/26/2017 at 2042 via wheelchair for a chief complaint of " patient fell down stairs leaving hospital " . Record review revealed triage began at 2053 with vital signs BP 150/92; heart rate 80; respiratory rate: 16; SpO2 (oxygenation) : 100%. Record review revealed "Assess/Tx Level of Consciousness: Alert; Orientation Assessment: Identifies self, Not oriented to place ... " Record review revealed he patient was transport to CT scan at 2150. Record review revealed " ED Adult Neuro Assessment at 2151 Neuro Muscular: Characteristics of Speech: Clear; Gait Quality: unable to assess; ED Neuro Assessment Add Note: Fall walking down stairs, positive LOC. Patient does not remember fall. Patient not oriented to year, place, time. Patient has cuts to bilateral elbows, swelling to R side of head and back side of head ... Glasgow Coma Score: 14 ... " The patient was discharged home on 06/27/2017 at 0032 in a wheelchair in the care of her son and daughter with discharge and follow up instructions given.


Review of ED Physician Note on 06/26/2017 at 2255 revealed " Basic Information: History Limitation: Cognitive impairment ... History of Present Illness: Patient is a 76-year-old female with a PMH including hyperlipidemia, hypertension, and aortic valve defect presenting to the ED with a chief complain of head pain onset today secondary to a fall. Per daughter, the patient was visiting her husband at the heart center, when she went down 3-5 steps of stairs while holding on to the rail. The patient bumped against the wall and then tumbled sideways while hitting her head on every step and denies LOC. Family reports patient having a large bump on the back of her head and right side of face. Patient fell yesterday and her glasses cut under her right eye and reopened today secondary to fall. Patient also complains of left ear pain and pain over her whole head. She has not taken any pain medication prior to arrival. Patient denies right hip pain and back pain. Patient is on Plavix ... Physical Examination: General: Alert, no acute distress, well nourished, calm cooperative ... Head: Normocephalic, contusion right zygomatic arch area, On exam: Right temporal, hematoma, no abrasion, no laceration, On exam: Mild parietal (midline) hematoma, no abrasion, no laceration ... Musculoskeletal: Normal ROM, normal strength, no swelling, no deformity ...Right, arm hematoma ... Right elbow, skin tear and hematoma, no bleeding ... Left elbow, skin tear, Lower extremity: Bilateral, hip no tenderness ...Neurological: Alert and oriented to person, place, time and situation ...normal coordination observed, Gait: Normal (by observation). Medical Decision Making: Radiology results: Reported at 06/26/2017 2242, Computed tomography (CT) reviewed radiologist ' s report, emergency physician interpretation ... Head: No acute intracranial hemorrhage, herniation or hydrocephalus. Multiple sites of scalp hematoma without underlying fracture. Confluent and patchy area of supratentorial white matter hypodensity, nonspecific, but most likely sequela of chronic microvascular changes. Face: No acute facial fracture. No intraorbital hematoma. Bilateral lens replacements. Slight asymmetric fullness of the right base of tongue, oropharyngeal tonsil, likely due to positioning. C- Spine: No acute fracture or traumatic malalignment. No prevertebral soft tissue swelling ...Pain Status: Headache Improved. Notes: Recheck on patient. Discussed with patient work up, relevant results, and plan for discharge. Patient was given ED warnings, discharge instructions, and follow up instructions. Patient understands and agrees with plan for discharge. Patient was informed and verbalizes understanding to return to ER immediately if symptoms worsen, persist, worsen, new symptoms or follow up cannot be obtained. Any questions have been addressed. Patient feels comfortable going home at this time ... Patient has been stable and is at her normal baseline ... "

Review of an Outpatient MRI of the Brain with and without contrast report from Hospital A on 06/28/2017 at 1246 revealed IMPRESSION: 1. On DWI sequence, increased signal within the left occipital lobe is consistent with recent demyelination versus acute infarct; no gadolinium enhancement at this level is noted. 2. Scalp hematomas the largest of which is noted within the scalp of the posterior parietal region .... "

Closed medical record review of Patient #6 DED visit to Hospital B on 06/29/2017 at 1042. Revealed the patient had a chief complaint of " stroke symptoms " Record review revealed " Chief Complaints Updated: + Stroke Symptoms (Pt fell down some stairs at the hospital on Monday but cannot remember how or why she fell. Pt went to see her doctor and had an MRI. Per pt " the doctor said I had a hematoma and an infarct and said I needed to go to a hospital so my family said to come here. " Pt also states that family was going to drive her but she was having trouble walking. " Record review of ED Physician Notes revealed " Medical Decision Making: 1119 discussed with primary care physician. He will fax brain MRI results. There is concern for acute left occipital infarct versus demyelination this area [sic]. We ' ll plan for admission for syncope and possible acute stroke on MRI done yesterday ... Record review revealed the patient was discharged from Hospital B on 07/03/2017.

Telephone interview with EDRN #1 on 08/16/2017 at 1830 revealed she remembers the patient and family. Interview revealed the patient could not remember the fall, nor if she felt dizzy prior to the fall. Interview revealed the daughter witnessed the fall and per the conversation with the nurse and the daughter the patient " just stopped and fell. " Interview revealed the daughter doesn ' t ' feel she tripped. Interview revealed the patient was confused on arrival but back to baseline which was alert and oriented to person, place and time at discharge. Interview revealed the patient ambulated around the nurses ' station with assistance prior to discharge. The interview also revealed the nurse failed to document the ambulation of the patient as well as the updated mental status prior to patient discharge.

Telephone interview with Physician #1 on 08/16/2017 at 2005 revealed during her assessment of the patient, she was alert, orient to person, family, time but not to events of the fall. Interview revealed the patient had a previous fall the day prior. Interview reveled the patient had equal strength in all four extremities. Interview revealed all radiology reports were negative. Interview revealed she discussed how important follow up was and what signs and symptoms to monitor for possible head injury. Interview revealed physician did not ambulate the patient nor trial ambulate the patient prior to discharge. Interview revealed she believes the MSE was appropriate and patient was stable for discharge. The facility failed to ensure that patient #6 was stabilized on 6/26/2017 prior to discharge.


2. Closed medical record review on 08/17/2017 of Patient #29 revealed a 20 year old female gravida 1 (number of pregnancies) ; Para 0 (pregnancies carried beyond 20 weeks) 35 weeks in gestation who presented to Labor and Delivery on 06/30/2017 at 2037 and triaged at 2046 with a stated complaint of " Blood pressures elevated and decreased fetal movement " . Record review revealed the patient has a history of hypertension since the age of 13. Record review revealed the patient denies contractions, leakage of fluid, urge to push and vaginal bleeding. Record review revealed the patient was placed on a Continuous External Fetal monitor at 2107 with a fetal heart rate baseline of 145 and the patient ' s vital signs were BP 117/77; heart rate 101; respiratory rate 20; Temperature 36.7 C. Record review of pain assessment revealed " left side pain since arrival " rates 5/10= moderate pain. Record review revealed no vaginal exam performed. Record review revealed OBMD #1 was notified at 2148 " (Information Provided to Clinician) Pt ' s c/o (complaint of) increased BP yesterday and today 140/96 and 145/95; decreased fetal movement; denies cx (contractions) lof (leakage of fluid) or bleeding; fhr wnl (fetal heart rate within normal limits); one variable notes; fhr pattern; bp;s neg dipstick; left side pain; on Procardia for chronic htn since age 13 ... Response from Clinician ... See physician orders. " Record review revealed Orders entered 6/30/2017 at 2148 by OBRN #1- Physician orders: Order Admission: Plan L& D Observation; Order: Communication Order: (Pt may have 1gm of Tylenol if she wants it); Order: Discharge Patient; Order: Fetal Heart Monitor External; Order: Perinatal Care Quality Measures; Order: Vital Signs ... " Record review revealed all orders were electronically signed by OBMD#1 on 07/01/2017 0101. Record review revealed BP at 2152 113/76; heart rate 91. Record review revealed the patient was discharged at 2212 with instructions for Third Trimester Pregnancy. Record review revealed no discharge diagnosis or physician noted documented in the medical record.

Telephone interview on 08/17/2017 at 1410 with OBMD #1 revealed she did not come in to evaluate Patient #29. Interview revealed she does not give a diagnosis on any patient she does not evaluate nor does she go back and review the charts once orders are given on patients the Labor and Delivery nurses contact her for. Interview revealed if the nurses request her to come in and evaluate the patient, she will. Interview revealed she is not aware a diagnosis needs to be documented in a record where a Labor and Delivery Registered Nurse performs a MSE.

Telephone interview on 08/17/2017 at 1440 with OBRN #1 revealed she was the nurse for Patient #29. Interview revealed the L&D unit sees all patients greater than 20 weeks in gestation. Interview revealed sometimes we request the MD to come in and sometimes we don ' t. Interview revealed we work the patients up and if all results are normal we call the physician and let them know and send the patients home. Interview revealed they do not write diagnosis on the medical records. Interview revealed if she requests a MD to come see the patient, they will.

Interview on 08/17/2017 at 1610 with OBMD #2 revealed he does not give a diagnosis for patients he does not personally evaluate on the L&D in conjunction with the Nurses who perform the MSEs. Interview revealed he feels the nurses are competent to evaluate simple complaints other than labor checks in consultation with the OB on call. Interview revealed he would come in and evaluate a patient if needed. The facility failed to ensure that on 6/29/2017 patient #29 was stabilized prior to discharge on 6/30/2017, as evidenced by no evaluation was conducted by an advanced nurse practitioner or physician.