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Based on review of medical records, policies and procedures, and staff interviews, the, it was determined that the facility failed to provide an appropriate medical screening examination that was 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 existed for a pregnant patient in labor that presented to the emergency department requesting medical care/assistance for 1 of 21 sampled patients medical records reviewed. Refer to findings in Tag A-2406.

Based on review of medical records and policies and procedures it was determined the hospital failed to provide within the capabilities of the staff and facilities available at the hospital for further medical examination and treatment as required to stabilize 1 (#21) of 21 sampled patients when a pregnant patient presented to the hospital ' s ED in labor on 9/18/2015.
Refer to findings in Tag A-2407.


Based on review of medical records, policies and procedures, and staff interview revealed that the facility failed to provide for an appropriate transfer based on EMTALA guidelines for 1 (#21) of 21 sampled patients when a pregnant patient presented to the hospitals ' ED in labor on 9/18/2015. Refer to findings in Tag A-2409.

Review of the facility's emergency room central log (manual and computerized), policy and procedure and staff interview the hospital failed to maintain a central log for each individual who comes to the emergency department seeking assistance for 1 (#21) of 21 sampled patients medical record reviewed.
Findings:

Policy and Procedure
The hospital ' s policy titled " Emergency Department patient Registration " policy # 310-313, effective 1/2010 was reviewed. The policy stated in part, " All Emergency Department patient information will be maintained in a log. "
A review of the hospital ' s hand written and computerized log revealed that patient #21 was not logged into the hospital ' s ED central log when she presented to the hospital ' s ED on 9/18/2015. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that Patient #21 was entered into the ED log when presented to the hospital ' s ED on 9/18/2015.

Interviews
Interview on 9/30/15 at 2:40 PM, with personnel #4, revealed that he/she recalled a pregnant patient that came to the ER one early morning with having abdominal pain. Personnel #4 recalled that the patient had recently moved to the area and had no local Obstetrician. Personnel #4 revealed that he/she never documented anything about this patient being the

Based on review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination that was 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 existed for a pregnant patient in labor that presented to the emergency department requesting medical care/assistance for 1 (#21) of 21 sampled patients medical records reviewed.

Findings:

Policies and Procedures


Review of policy entitled EMTALA Guidelines for Emergency Department Services, number 685, revised 12/10/2012 revealed that all patients presenting to the hospital ER and seeking care, must be accepted and evaluated. The policy required that all patients receive a medical screening exam which included providing all the necessary tests and services within the capability of the hospital. An unstable patient may only be transferred for the reason of medical necessity. The hospital must provide medical treatment within its capacity that minimizes the risks to the individual's health and in the case of a woman in labor, the health of the unborn child with a physician's certification that the risks of transferring the patient are outweighed by the potential benefits The individual risks and benefits must be documented and the medical record must support this.

Review of policy entitled Emergency Department Patient Registration, number 811. Effective date of 1/2010 revealed in part, " All patients will be evaluated by the triage nurse prior to being seen by the Admitting Department (Registration) Clerk. The clerk will immediately notify the triage nurse of a pregnant patient with pain or bleeding. "

Medical Record Review- Hospital B

Patient #21 ' s medical record from the hospital (Hospital B) where the patient presented after leaving Optim Medical Center- Tattnall on 9/18/2015 was reviewed. Review of the hospital ' s OB (obstetrical) History and Physical revealed that patient #21 date and time of admission was 9/18/2015. The patient ' s Chief Complaint was listed as " Contractions and vomiting. " History of Present Illness: ...G (Gravida -total number of confirmed pregnancies) 5P (para- total number of pregnancies after 20 weeks) 4 at 41 weeks and 5 days by her report. Patient states she ' s had 2 prenatal visits ...and was given due date of September 7 ...Patient has not had recent prenatal care ...Patient developed ...severe nausea vomiting with around midnight last night. Contractions started ...Patient reports fetal movement. Medical History: ...Neurologic: Reports: Seizures- diagnosed as child usually takes Depakote (medication used to treat seizures), has not been taken during pregnancy ...Psychological: Reports ...Increased stress ...Review of Systems: ..Genitourinary: Contractions, denies, vaginal bleeding, leaking fluid. Musculoskeletal: Other: Low back pain ...Exam: Fetal Heart rate- 165 ...Contraction Frequency: One every 3 minutes ...Assessment/Plan: (1) Insufficient prenatal care ...Status: Acute ...Assessment ...Currently patient seems to be in early active labor we will keep patient and manage. ..This is her second pregnancy with limited prenatal care we will obtain social services for evaluation. (2) Active labor at Term Current Visit: Yes Status: Acute (3) Tachycardia found on measurement of baseline fetal heart rate ...Assessment and Plan: patient was initially fetal tachycardia with decreased variability. Feta heart tracing has improved with hydration of the mother. Patient by report was sick and markedly dehydrated. We will give IV hydration and watched tracing closely. At this point we will anticipate vaginal delivery as long as fetal heart tracing continues to improve. " Documentation on the LD (labor and Delivery) Flow sheet dated 9/18/2015 (08:32-0910) revealed in part, Nurse to BS (bedside) to clarify patient treatment prior to arrival Pt (patient) and S/O (significant/other) explain that they presented to Reidsville Hospital (Optim Medical Center- Tattnall) with labor complaints and were told they couldn ' t provide care for her at that hospital and she would need to be taken to another hospital. S/O states that they were told this before they could even finish signing in before the nurse gave them this information. S/O reports that they left her ID (identification) and Medicaid card at the desk " Review of the Delivery Summary sheet revealed that on 9/18/2015 at 10:12 EDT (Eastern Daylight Time) a live baby boy was delivered. A review of the " Post-Partum Discharge Summary " revealed that the patient had a spontaneous vaginal delivery and that the baby was having seizures and was transferred to another acute care hospital.

Patient #21 presented to OPTIM Medical Center -Tattnall on 9/18/2015 with abdominal pain. The patient left the facility without being triaged by the emergency department nurse and did not receive an appropriate medical screening examination by the ED physician as stated in the hospital ' s policy and procedure.

The facility failed to ensure their policies and procedures were followed as evidenced by failing to provide as required on 9/18/2015 that patient #21 who presented to the hospital ' s ER seeking care was not provided an appropriate medical screening examination, appropriate tests and services that were within the capability of the hospital. The hospital also failed to provide medical treatment on 9/18/2015 for patient #21 that was within its capacity that minimized the risks to her health, and her unborn child as she was in labor when she presented to Optim Medical Center- Tattnall.

Interviews


In an interview with the registration clerk (RC- Personnel #5) on 9/29/15 at 3:30 p.m. he/she stated that when an ER patient comes to the window, the patient is asked to fill out a "quick registration" form and provide identification. The RC enter the information into the computer. The patient's identification shows up on computerized board/screen in the ER. The RC notifies the nurse of the patient and the patient's complaint. The nurse brings the patient back to the triage area or a treatment room. After the nurse completes the triage, the RC asks for insurance information and gives the patient a packet of information to be completed. The patient is seen by the physician. Based on Physician order the Nurse is responsible for transfers and discharges, and the RC would record discharged patients in the computer. Personnel #5 did not know of any ER patient who has ever been refused treatment or told to go to another facility for treatment. He/she revealed that only physicians can do an Emergency Medical Screening and nurses do the assessment. If a licensed practical nurse (LPN) performs the assessment, a registered nurse (RN) will sign after him/her.


Interview on 9/30/15 at 11:05 am, with credential staff #9 revealed that he/she has been employed for two (2) years in the Emergency Room (ER), on the 7 a.m. - 7 p.m. shift. Credential #9 stated that his/her observation of the usual process for expectant patients that present to the ER is that the patient would sign in at the registration window, the registration clerk alerts the nurse and the nurse would triage and alert the physician. Critical patients or patients in labor would be processed faster to see the physician. During the triage process, pregnant patients would be questioned about their pregnancy and which Obstetrician is caring for them. Obstetrician would be contacted right away by the ER physician. If a baby is born, there would be a transfer as soon as possible. Pregnant patients with no prenatal care or an Obstetrician would be asked where they wanted to be transferred; if no preference is indicated, would transfer to one of the larger hospitals. Credentialing staff #9 had never heard of any instance of a pregnant patient being turned away or being told that they could not be treated at this facility



Interview on 9/30/15 at 2:40 pm, with personnel #4, revealed that he/she recalled a pregnant patient that came to the ER one early morning with having abdominal pain. Personnel #4 recalled that the patient had recently moved to the area and had no local Obstetrician. He/she overheard the patient's friend talking to the RC at the window. Personnel #4 went into the waiting area to ask if patient's Obstetrician had to be contacted. The friend replied that they had recently moved into the area and their Obstetrician was not local, and asked if the patient could deliver here. Personnel #4 stated that he/she told the patient and her friend that this facility does not deliver babies unless delivery is imminent. The patient ' s friend asked for the closest place that delivers babies. Personnel #4 told them Statesboro or Vidalia. He/she told the patient that the physician would do an exam and if the patient was in labor, could transfer to a facility that delivers. Personnel #4 revealed that the patient did not appear to be in pain or distress. The patient and her friend only stayed for a few minutes. Personnel #4 recalled encouraging them to call the patient's Obstetrician. The patient left without completing the quick registration form. Personnel #4 revealed that he/she never documented anything about this patient being there, and did not recall reporting the incident to anyone.


In an interview on 10/1/30 at 9:40 a.m., personnel #6 recalled that a patient and a friend did come to the ER early in the morning on 9/18/15. The patient sat down and the friend came to the window to report that the patient was pregnant and hurting. Personnel #6 told the friend to fill out the quick registration form; patient's friend handed insurance card to personnel #6. Personnel #4 asked personnel #6, what was the patient's complaint. Personnel #6 told personnel #4 that patient was pregnant and that her stomach was hurting. Personnel #4 walked into the ER waiting area and was talking to the patient and her friend. He/she could not hear the conversation over the air conditioner. Patient and friend left without turning in a quick registration form or getting the insurance card back. Patient's insurance card was placed in the top drawer of the white box, where left cards are kept. Personnel #4 told personnel #6 that they left and were going to Vidalia. Nothing else was said.

Based on review of medical records and policies and procedures it was determined the hospital failed to provide within the capabilities of the staff and facilities available at the hospital for further medical examination and treatment as required to stabilize 1 (#21) of 21 sampled patients when a pregnant patient presented to the hospital ' s ED in labor on 9/18/2015.


Cross refer to A 2406 as it relates to failure to provide an appropriate MSE for Patient #21 on 9/18/2015.


Review of policy entitled Medical Screening Examination, policy number 812, effective date of
6/2010, revealed that the purpose of the medical screening was to determine if an emergency medical condition existed. Under EMTALA, hospitals must screen individuals presenting to hospital property requesting medical care to determine if an emergency medical condition exists. After the patient has been triaged, the physician will perform a medical screening examination to determine if an emergency medical condition exits. If an emergency medical condition is determined to exist the hospital shall provide any necessary stabilizing treatment, admit the patient as appropriate or transfer the patient as appropriate. If no emergency medical condition exists no further EMTALA requirements are required and financial information may be obtained.

The hospital failed to ensure that their policy and procedure was followed regarding stabilizing treatment as evidenced by failing to ensure that Patient #21 received stabilizing treatment and/or transferred as appropriate, when she presented to the hospital ' s ED in labor on 9/18/2015.

A 2409


Based on review of medical records, policies and procedures, and staff interview revealed that the facility failed to provide for an appropriate transfer based on EMTALA guidelines for 1 (#21) of 21 sampled patients when a pregnant patient presented to the hospitals ' ED in labor on 9/18/2015.


Findings:

Cross refer to Tag A-2406 as it relates to failure to provide an appropriate medical screening examination to patient #21 on 9/18/2015.


Policy and Procedure
Review of policy entitled Transfer of Patient to Another Facility from Emergency Department, number 590, last revised 12/10/2012 reveals that if the hospital is unable to provide the appropriate care, the patient is to be transferred to an appropriate facility that offers specialty care or a higher level of care. The physician determines that the patient should be transferred to another facility for further care and the physician certifies that the benefits of transfer outweigh the potential risks. Acceptance to receiving facility must be made physician to physician. Physician determines the mode of transfer and the nursing staff makes the arrangements for transportation. The nursing staff will call report to the receiving facility. A copy of the entire chart accompanies the patient.

Interviews

In an interview with the registration clerk (RC- Personnel #5) on 9/29/15 at 3:30 p.m. he/she explained that the facility does not have an obstetrical department (OB). The physician would determine if the patient was in active labor. The physician would notify the patient's OB to report findings and discuss where to transfer the patient. If there is not enough time to transfer the patient, ER physician will deliver the infant then arrange for transfer. Personnel #5 also stated that consents were included in the ER packet. The physician will perform the physician-to-physician acceptance for transfers and nurses will complete the report to the nurse of the receiving hospital. A copy of the patient's medical record is sent with the patient. The patient would then be transported by ambulance or helicopter, depending on the urgency.




The RC explained that the facility does not have an obstetrical department (OB). The physician would determine if the patient was in active labor. The physician would notify the patient's OB to report findings and discuss where to transfer the patient. If there is not enough time to transfer the patient, ER physician will deliver the infant then arrange for transfer.
Consents were included in the ER packet. The physician will perform the physician-to-physician acceptance for transfers and nurses will complete the report to the nurse of the receiving hospital. A copy of the patient's medical record is sent with the patient. The patient would then be transported by ambulance or helicopter, depending on the urgency.


Review of the medical record from hospital B revealed that on 9/18/2015 left hospital A via private vehicle and went to hospital B where she was admitted at approximately 6:00 a.m. Patient #21 delivered a baby boy on 9/18/2015 at 10:12 a.m. An appropriate transfer was not initiated by Optim Medical Center -Tattnall on 9/18/2015 for Patient #21. The hospital failed to provide an appropriate transfer for Patient #21 when she presented to the hospital ' s ED in labor on 9/18/2015.