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Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination, stabilizing treatment, and an appropriate discharge/transfer for one (1) of 20 sampled medical records (Patient #1) when the 29 week gestation pregnant patient presented to the Labor and Delivery Unit with an emergent medical condition.

Cross refer to A-2406 as it related to failure to provide an appropriate medical screening exam.

Cross refer to A-2407, as it relates to failure to provide stabilizing treatment.

Cross refer to tag A-2409 as it related to failure to provide an appropriate transfer.

Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that an appropriate medical screening exam was provided for one (1) of 20 sampled medical records (#1). Specifically, the facility failed to provide a medical screening exam for Patient #1 when the 29 week gestation pregnant patient presented to the Labor and Delivery Unit with an emergent medical condition.

Findings were:

Review of the Emergency Department (ED) medical record of Patient #1 revealed that the patient walked into the ED and presented to the Greeter on 2/8/19 at 1:31 p.m. Documentation by Greeter BB at 1:59 p.m. revealed that the patient came in with a chief complaint of a headache and denied any pregnancy complaints. The same notation revealed that the patient became angry and at 1:46 p.m. Patient # 1 left the facility. The note revealed that the patient was angry because she was not going directly to Labor and Delivery (L&D). The greeter documented that when it was explained to the patient that she would see the ED Doctor first, she became angry and left the facility. Further review revealed that Nurse Coordinator NN charted in the medical record at 4:57 p.m. that the patient had left the facility at 1:35 p.m. prior to triage.

There was no information available on Patient # 1 from her exit of the ED at 1:46 p.m. until the following medical record from Obstetrical (related to childbirth and the processes involved with it) Emergency Department (OBED).

Review of (L&D) medical record revealed Patient #1 arrived at 3:42 p.m. to the OBED (Obstetrical Emergency Department) on second floor of the facility. Registered Nurse (RN) MM documented she was a walk-in patient from home. Patient #1 reported that her reason for visit was headache, seeing spots, nausea and vomiting that morning, dizziness and mild cramping. The record revealed the patient has had some high blood pressure this pregnancy and is currently taking Labetalol (a medication used to treat high blood pressure). The patient ' s Obstetrician (doctor who specializes in the care of pregnant women and their unborn baby) was documented as her primary Dr. KK. The clinic summary revealed her estimated date of confinement (due date) was 4/22/19 and that she was at 29.5 weeks gestation (period of development, normal gestation or length of pregnancy is 40 weeks). Initial Vital Signs were documented at 3:59 p.m. as Pulse(P)-109 (normal Pulse 60-100 in adults) and Blood Pressure (BP)-138/87 (normal blood pressure in adults 120/80-140/90). Registered Nurse MM ' s assessment of Patient #1 at 3:59 p.m. revealed Patient #1 had swelling in both lower extremities (legs and feet), headache for several hours, and she was not currently in active labor.
Vital signs at 4:04 p.m. were P-103 and BP-151/94
Vital signs at 4:09 p.m. were P-103 and BP-156/104
Vital signs at 4:14 p.m. were P-100 and BP 153/84
Vital signs at 4:19 p.m. were P-102 and BP 155/83
Fetal Heart Monitoring revealed the fetal heart rate (rate at which the unborn baby ' s heart beats) baseline was 150 beats per minute (bpm). Normal fetal heart rate is between 120-160 bpm.
Further review of the medical record revealed at 4:29 p.m. that RN MM notified Dr. KK that his patient who was pregnant with her first child and at the time 29.5 weeks gestation was in L&D at the facility. The record reveals that Dr KK was told that Patient #1 had been seen in his office for symptoms of preeclampsia (preeclampsia is a condition that pregnant women develop that is marked by high blood pressure, elevated levels of protein in the urine, and often swelling in the feet, legs, and hands). Dr. KK was informed that the patient was taking Labetalol 100 milligrams twice a day. RN MM noted that she reported to Dr. KK that the triage assessment revealed Patient #1 ' s headache was rated 10 on a pain scale where 1 is mild and 10 is the most severe and was unrelieved by Tylenol, that she had been seeing spots before her eyes, dizziness, nausea and vomiting during the morning, and swelling and soreness in her lower extremities. RN MM report further revealed the blood pressure readings ranging from 130s/80s to 150s/100s were discussed. RN MM notified Dr. KK that the patient was due for her Labetalol at that time. Fetal monitor tracing was reviewed with Dr. KK. Dr. KK gave a phone order to discharge the patient with instructions not to go home but to report to another facility in town where he would see Patient #1. Patient #1 was discharged at 4:26 p.m. with instructions to go directly to the other acute care hospital per her own obstetrician ' s directions. Patient #1 left with her significant other in a personal vehicle. There was no record of the on-call OB physician being called.

At the time of the survey no records were available from the receiving facility.

Review of the Medical Staff Bylaws, Rules and Regulations of the facility, approved by the Medical Executive Committee 3/11/14, The General medical Staff 4/4/14, and the Board of Trustees 4/22/14, revealed the following:
ARTICLE X - Emergency Services
10.1. General:
Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care. Such emergency services and care will be provided without regard to the patient's race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing medical condition, physical or mental handicap, insurance status, economic status, sexual orientation or ability to pay for medical services, except to the extent such circumstance is medically significant to the provision of appropriate care to the patient.
10.2. Medical Screening Examinations:
Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified Medical personnel who can perform medical screening examinations within applicable Hospital policies and procedures are defined as:
(a) Emergency Department:
(1) members of the Medical Staff with clinical privileges in Emergency Medicine;
(2) other Active Staff members; and
(3) appropriately credentialed allied health professionals.
(b) Labor and Delivery:
(1) members of the Medical Staff with OB/GYN (gynecology - practitioner who specializes in the care/treatment of female reproductive organs) privileges;
(2) Certified Nurse Midwives with 0B privileges; and
(3) Registered Nurses who have achieved competency in Labor and Delivery and who have validated skills to provide fetal monitoring and labor assessment.
10.3. On-Call Responsibilities:
It is the responsibility of the scheduled on-call physician to respond to calls from the Emergency Department in accordance with Hospital policies and procedures.

Review of the facility ' s policies included but were not limited to the following

I - OB Patients in The Emergency Department, Policy Number 2335733, last reviewed: 4/2016 revealed that the hospital provides available, appropriate emergency services to a woman who seeks hospital care for the safe delivery of her child.
GUIDELINES:
1. The evaluation and emergency medical care of any obstetrical patient presenting to the Emergency Department shall comply with the Georgia Emergency Medical Services to pregnant Women Act of 1984 and the Federal COBRA Act of 1986 and EMTALA (Emergency Medical and Labor Act) and they will be registered on the EMTALA log.
2. A gravid (pregnant) patient greater than 20 weeks, the Women's Center charge nurse should be notified and will respond promptly to assess the patient.

II - Policy EMTALA- Medical Screening Examination and Stabilization Policy, Policy Number 3612508, last revised 05/2017, revealed the purpose was to establish guidelines for providing appropriate medical screening exam (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA.
An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and:
1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or
2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition (EMC). Further, if a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists, or (ii) with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilization treatment shall be applied in a non-discriminatory manner (e.g., no different level of care because of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law).
Procedure:
1. When an MSE is Required
A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: (i) to any individual, including a pregnant woman having contractions, who requests such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior needs an MSE. An MSE shall be provided to determine whether the individual is experiencing an EMC or a pregnant woman is in labor. An MSE is required when:
a. The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition, including where:
i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition.
The MSE of the individual must be documented. This type of screening cannot be performed by the triage nurse. If an EMC is determined to exist and the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under EMTALA ceases.
Note: The MSE and other emergency services need not be provided in a location specifically identified as a DED. The hospital may use areas to deliver emergency services that are also used for other inpatient or outpatient services. MSEs or stabilization may require ancillary services available only in areas or facilities of the hospital outside of the DED.
b. The individual arrives on the hospital property other than a DED and makes a request or another makes a request on the individual's behalf for examination or treatment for an EMC.
i. Screening where the individual presented: If an individual is initially screened in a department or location on-campus other than the DED, the individual may be moved to another hospital department or facility on-campus to receive further screening or stabilizing treatment without such movement being a transfer. The hospital shall not move the individual to an off-campus facility or department (such as an urgent care center or satellite clinic) for an MSE.
3. Extent of the MSE
a. Determine if an EMC exists. The hospital must perform an MSE to determine if an EMC exists. It is not appropriate to merely
"log in" or triage an individual with a medical condition and not provide an MSE. Triage is not equivalent to an MSE. Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be screened by a physician or other QMP.
b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.
c. An on-going process. The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.
d. Judgment of physician or QMP. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP performing the examination function according to algorithms or protocols established and approved by the medical staff and governing board.
e. Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual's signs and symptoms:
i. Depending on the individual's presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures.
ii. Pregnant Women: The medical records should show evidence that the screening examination includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membranes (i.e., ruptured, leaking and intact), to document whether or not the woman is in labor. A woman experiencing contractions is in true labor unless a physician, certified nurse-midwife or other QMP acting within his or her scope of practice as defined by the hospital's medical staff bylaws and State medical practice acts, certifies in writing that after a reasonable time of observation, the woman is in false labor. The recommended timeframe for such physician certification of the QMP's determination of false labor should be within 24 hours of the MSE, however, the medical staff bylaws, rules and regulations can provide guidance on the timeframe.
4. Who May Perform the MSE
a. Only the following individuals may perform an MSE:
i. A qualified physician with appropriate privileges;
ii. Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges; or
iii. A qualified staff member who:
--is qualified to conduct such an examination through appropriate privileging and demonstrated competencies;
--is functioning within the scope of his or her license and in compliance with state law and applicable practice acts (e.g., Medical or Nurse Practice Acts);
-- is performing the screening examination based on medical staff approved guidelines, protocols or algorithms; and
-- is approved by the facility's governing board as set forth in a document such as the hospital bylaws or medical staff rules and regulations, which document has been approved by the facility's governing body and medical staff. It is not acceptable for the facility to allow informal personnel appointments that could change frequently.
b. Qualified Medical Personnel. QMPs may perform an MSE if licensed and certified, approved by the hospital's governing board through the hospital's by-laws, and only if the scope of the EMC is within the individual's scope of practice.
i. The designation of QMP is set forth in a document approved by the governing body of the hospital. Each individual QMP approved to provide an MSE under EMTALA must be appropriately credentialed and must meet the requirements for annual evaluations set forth in the protocol agreements with physicians and the State's medical practice act, nurse practice act or other similar practice acts established to govern health care practitioners. Only appropriately credentialed Advanced Practice Registered Nurses (APRN)s, Physician Assistants (PA)s and physicians may perform MSEs in the DED.
iii. Labor and Delivery QMP. QMPs in the labor and delivery DED may be appropriately-approved RNs and must communicate their findings as to whether or not a woman is in labor to the obstetrician on call, the laborist, or the ED physician.
iv. Limitations. The hospital has established a process to ensure that:
--a physician examines all individuals whose conditions or symptoms require physician examination;
--an ED physician on duty is responsible for the general care of all individuals presenting themselves to the emergency department; and
--the responsibility remains with the ED physician until the individual's private physician or an on-call specialist assumes that responsibility, or the individual is discharged.

III - Women's ' Center Policy Policy Medical Screening Exam, Policy #1753921, last revised 03/2019 revealed the purpose to provide guidelines to insure a MSE is performed by QMP on patients presenting to the OB department requesting treatment.
PURPOSE:
To provide a Medical Screening Examination to any patient presenting to the L&D by qualified nursing personnel utilizing the Obstetrical Medical Screening Tab in the electronic medical record.
1. Notify the physician of patient arrival and obtain orders to assess the patient using the Medical Screening Tool found in Centricity Perinatal (CPN) medical record. Physician notification should be made within 30 minutes of the patient's arrival to the department. If the patient is not an established patient with an obstetrician at Doctors Hospital, she must be assigned to the obstetrician on call. The OB on-call list is available in Labor and Delivery, as well as the E.D.
2. Patients > 20 weeks pregnant may be evaluated in either the ED or L&D depending on the patient's presenting symptoms, unless the patient is unstable. Unstable patients will be evaluated and treated in the ED and stabilized prior to being transferred to L&D. The L&D RN will assist the ED staff as requested.
4. If the patient is discharged, complete another MSE with update of status of discharge disposition. The physician must certify the orders within 24 hours if "Read back and verified" is not documented, otherwise the orders may be verified within 30 days of patient discharge.
5. In the event of an emergency transfer to a higher level of care, and the physician is not physically present at the time of transfer, the QMP can sign the certification as long as the QMP is in consultation with the physician. Also, the physician must be in agreement with the certification and subsequently countersigns the certification. The date and time of such certification should closely match the date and time of transfer.
1. Obtain prenatal records if available and review. Notify physician of the patient's arrival. All OBED patients must have the Obstetrical Medical Screening Tool completed in CPN medical record found under the blue Admit tab. Results of medical screening will indicate if a provider must come in to examine the patient prior to discharge.
2. Documentation of patient assessment should be complete, thorough and recorded in the CPN electronic patient chart.
3. All fetal monitor strips are labeled or maintained and archived in the CPN system.
4. An initial MSE will be completed on ALL OBED patients, printed and placed on medical record...if OBED patient is stable and discharged undelivered, a reassessment MSE will be completed, printed and also placed on medical record. Please document required disposition on blue discharge tab.

During an interview on 4/08/19 at 11:10 a.m. Paramedic/Greeter BB said when pregnant patients arrive in the ED they are asked what is going on and what is their due date. If they are greater than 20 weeks and have any pregnancy related symptoms, they are immediately sent up to L&D for further evaluation. She expounded that pregnancy related symptoms might be nausea, vomiting, swelling, water leaking or even headache which could be a sign of preeclampsia. If symptoms are questionable for pregnancy related, the registrar is to immediately call the ED Physician Assistant or Nurse Practitioner to come and evaluate.

During the tour of the L&D unit on 4/8/19 at 11:30 a.m. an interview was conducted with L&D Clinical Director (EE). She confirmed that the facility has a Level II Neonatal (newborn)Intensive Care Unit that can care for babies born after 32 weeks gestation (developmental age of the unborn baby) without any complications. She said the L&D Unit will transfer a mother pending delivery prior to 32 weeks gestation to the hospital of her primary Obstetrician ' s choice.

During an interview on 4/9/19 at 9:50 a.m. in the Conference Room, Paramedic BB, confirmed that she was the ED Greeter on 2/8/19. The Paramedic explained that on 2/8/19 Patient #1 presented to the ED and reported that she was 29 weeks pregnant, had a headache and needed to go to L&D. The Paramedic said she asked the patient if she was having any pregnancy related issues such as: abdominal cramping, abdominal pain, back pain or pressure, pelvic pain, nausea or vomiting, if her water had broken or if her mucus plug (protective barrier that blocks bacteria from entering the uterus). The Paramedic said Patient #1 denied any pregnancy related symptoms and repeated that she had a headache and need to go to L&D because she was 29 weeks pregnant. The Paramedic said Patient #1 then went to the registration desk and told the Registrar that she was 29 weeks pregnant and needed to go to L&D because she had a headache. Paramedic BB said the Registrar tried to register the patient but the patient got angry and turned to leave the ED. Paramedic BB reported that Patient #1 stated I can't believe you aren't sending me to L&D, I'm 29 weeks pregnant, I have a headache, swelling and my blood pressure is high, just as the patient walked out the ED door. The Paramedic said she then documented her note in the electronic medical record. Paramedic BB said she did not try to bring the patient back into the ED because the patient was angry and there were about 14 patients at the desk. The Paramedic confirmed that she did not think about getting the Charge Nurse to speak with the patient. The Paramedic said she has worked in the facility's ED since August 2017 and has been a Paramedic since 2006. Paramedic BB stated that she receives EMTALA training annually and since this episode she has completed three (3) or four (4) OB related Healthstream courses.

During an interview on 4/9/19 at 10:35 a.m. in the Conference Room, RN MM confirmed that she was working L&D on 2/8/19 and that she remembers providing care for Patient #1. RN MM said she has been a RN since 2014, a L&D nurse since 2015, and has been working at the facility since February 2018. The RN said she remembers that the L&D Charge Nurse informed her that Patient #1 would be arriving and that the patient was experiencing a headache and pregnancy induced hypertension (high blood pressure). RN MM said she was setting up the room when Patient #1 arrived and that she helped the patient put on a gown and attached the fetal monitor (evaluates the baby's heartrate). RN MM said she asked the patient what brought her to the hospital and was informed that the patient was seen by the Dr. KK in his office and had lab work, I think that day to see if the patient was pre-eclamptic. RN MM reviewed her notes and said the patient's symptoms included: headache, dizziness, seeing spots, nausea, vomiting and mild cramping. RN MM explained that the patient was not admitted at this point and had only been triaged by RN MM. RN MM said she completed Patient #1's assessment and was informed by the patient that she was prescribed Labetalol but that she had forgotten to take her medication that day. RN MM said her first thought was to call Patient #1's Dr. KK to get orders. RN MM explained that she called the Patient's doctor KK and gave him an update of the patient's condition, the patient's blood pressure reading and informed the physician that the patient had missed taking her blood pressure medication. RN MM said she asked the physician what he wanted to do and he asked her to repeat the patient's blood pressure and then gave orders for the patient to be discharged with instructions for the patient to go directly to another local acute care hospital. RN MM said she thought this was odd and wondered whether this should be done. RN MM said she asked the physician KK if he wanted the patient transported (by ambulance) and the physician replied "no, just tell the patient to come straight here and not to go anywhere else". RN MM said she asked the physician KK if he wanted her to give the patient the Labetatol and he replied no. RN MM said she discussed this with the L&D Charge Nurse and the L&D Charge Nurse asked about Patient #1's blood pressure and then told RN MM that the physician ordered the patient to be discharged so that's what we will do. RN MM added that after speaking with the patient's physician it never occurred to her that the on-call OB physician could be contacted. RN MM said that she received EMTALA training 4/7/19 but had also had EMTALA training in the past. RN MM confirmed that EMTALA training is required annually. RN MM explained that she has also completed the Obstetrical Medical Screening Tool Healthstream training.

During a phone interview on 4/9/19 at 12:30 p.m. with Dr. KK he reported that he remembered Patient #1. He confirmed he was her primary OB and had seen her earlier in the week of 2/8/19 in his office. He stated he had not sent her to the Emergency Department for evaluation. He reported that Patient #1 did have chronic (persisting for a long time or recurring) hypertension (high blood pressure) and had shown some protein (small molecules that play critical roles in the body) in her urine (if high amounts of protein are found in the urine late in a pregnancy, it may indicate kidney disease or preeclampsia). Dr. KK said he had sent labs off to be tested and sent the patient to see a urologist (physician who specializes in the treatment of the urinary tract {body 's drainage system for removing urine}) to rule out kidney (bean shaped organs that filter blood to remove wastes and make urine) damage and preeclampsia. Dr. KK reported he was at another acute care hospital in the local area when RN MM called to tell him his patient was at their facility. He confirmed that RN MM had provided him with her assessment of the patient and given him all the vital signs. He said he did not think the patient was that unstable. Dr. KK said he told RN MM where he was and asked that the patient not be admitted to her facility but be sent over to where he was for further evaluation. He explained that the facility where he was located at that time was not far and was able to provide specialized care if there were complications with the pregnancy. He confirmed that RN MM asked about emergency transport by ambulance, but he said he did not think Patient #1 ' s condition warranted emergency transport. He confirmed that Nurse MM asked if he wanted Patient #1 to get her Labetalol at that time and he told her no. Dr. KK said he assumed care when Patient #1 arrived at his location. He said he evaluated her and told her they would just watch her for a few days in the hospital. He said she was stable at that time. He said he left the hospital and was called back to the hospital in less than 30 minutes. When he arrived back at the hospital he found an emergency delivery was warranted and the baby was delivered by Cesarean-Section (surgery where the baby is taken out through the mother ' s abdomen).

Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that stabilizing treatment was provided for one (1) of 20 sampled medical records (Patient #1). Specifically, the facility failed to provide stabilizing treatment to Patient #1 when the 29 week gestation pregnant patient presented to the Labor and Delivery Unit with an emergent medical condition.

Findings were:

Review of (L&D) medical record revealed Patient #1 arrived on 2/08/19 at 3:42 p.m. to the Obstetrical (related to childbirth and the processes involved with it) Emergency Department (OBED) on second floor of the facility. Registered Nurse (RN) MM documented she was a walk-in patient from home. Patient #1 reported that her reason for visit was headache, seeing spots, nausea and vomiting that morning, dizziness and mild cramping. The record revealed the patient has had some high blood pressure this pregnancy and is currently taking Labetalol (a medication used to treat high blood pressure). The patient ' s Obstetrician (OB - doctor who specializes in the care of pregnant women and their unborn baby) was documented as her primary Dr. KK. The clinic summary revealed her estimated date of confinement (due date) was 4/22/19 and that she was at 29.5 weeks gestation (period of development, normal gestation or length of pregnancy is 40 weeks). Initial Vital Signs were documented at 3:59 p.m. as Pulse(P)-109 (normal Pulse 60-100 in adults) and Blood Pressure (BP)-138/87 (normal blood pressure in adults 120/80-140/90). Registered Nurse MM ' s assessment of Patient #1 at 3:59 p.m. revealed Patient #1 had swelling in both lower extremities (legs and feet), headache for several hours, and she was not currently in active labor.
Vital signs at 4:04 p.m. were P-103 and BP-151/94
Vital signs at 4:09 p.m. were P-103 and BP-156/104
Vital signs at 4:14 p.m. were P-100 and BP 153/84
Vital signs at 4:19 p.m. were P-102 and BP 155/83
Fetal Heart Monitoring revealed the fetal heart rate (rate at which the unborn baby ' s heart beats) baseline was 150 beats per minute (bpm). Normal fetal heart rate is between 120-160 bpm. Further review of the medical record revealed at 4:29 p.m. that RN MM notified Dr. KK that his patient who was pregnant with her first child and at the time 29.5 weeks gestation was in L&D at the facility. The record reveals that Dr KK was told that Patient #1 had been seen in his office for symptoms of preeclampsia (preeclampsia is a condition that pregnant women develop that is marked by high blood pressure, elevated levels of protein in the urine, and often swelling in the feet, legs, and hands). Dr. KK was informed that the patient was taking Labetalol 100 milligrams twice a day. RN MM noted that she reported to Dr. KK that the triage assessment revealed Patient #1 ' s headache was rated 10 on a pain scale where 1 is mild and 10 is the most severe and was unrelieved by Tylenol, that she had been seeing spots before her eyes, dizziness, nausea and vomiting during the morning, and swelling and soreness in her lower extremities. RN MM report further revealed the blood pressure readings ranging from 130s/80s to 150s/100s were discussed. RN MM notified Dr. KK that the patient was due for her Labetalol at that time. Fetal monitor tracing was reviewed with Dr. KK. Dr. KK gave a phone order to discharge the patient with instructions not to go home but to report to another facility in town where he would see Patient #1. Patient #1 was discharged at 4:26 p.m. with instructions to go directly to the other acute care hospital per her own obstetrician ' s directions. Patient #1 left with her significant other in a personal vehicle. There was no record of the on-call OB physician being called.

At the time of the survey no records were available from the receiving facility.

Review of the Medical Staff Bylaws, Rules and Regulations of the facility, approved by the Medical Executive Committee 3/11/14, The General medical Staff 4/4/14, and the Board of Trustees 4/22/14, revealed the following:
ARTICLE X - Emergency Services
10.1. General:
Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care. Such emergency services and care will be provided without regard to the patient's race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing medical condition, physical or mental handicap, insurance status, economic status, sexual orientation or ability to pay for medical services, except to the extent such circumstance is medically significant to the provision of appropriate care to the patient.

Review of the facility ' s policies included but were not limited to the following

I - Emergency Medical Treatment and Labor Act (EMTALA) - Provision of On-Call Coverage Policy, Policy Number 2559775, last reviewed: 07/2016
revealed the hospital must maintain a list of physicians on its medical staff who have privileges at the hospital or, if it participates in a community call plan, a list of all physicians who participate in such plan. Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with Emergency Medical Conditions (EMC) who are receiving services in accordance with the resources available to the hospital.
PROCEDURE: Maintain a List. Each hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC. The Medical Staff Bylaws or appropriate policy and procedures must define the responsibility of on-call physicians to respond, examine, and treat patients with an EMC.

II - OB Patients in The Emergency Department, Policy Number 2335733, last reviewed: 4/2016 revealed that the hospital provides available, appropriate emergency services to a woman who seeks hospital care for the safe delivery of her child.

GUIDELINES:
7. Stabilizing Treatment Within Hospital Capability
The determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an EMC of a woman in labor, that the woman has delivered the child and placenta; or in the case of an individual with a psychiatric or behavioral condition, that the individual is protected and prevented from injuring himself/ herself or others.
a. Stable. The physician or QMP providing the medical screening and treating the emergency has determined within reasonable clinical confidence, that the EMC that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist. Once the individual is stable, EMTALA no longer applies. (The individual may still be transferred; however, the "appropriate transfer" requirement under EMTALA does not apply.)
c. Stabilizing Treatment and Individuals Whose EMC's Are Resolved. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. The EMC that caused the individual to present to the DED must be resolved, but the underlying medical condition may persist. Hospitals are expected within reason to assist/provide discharged individuals the necessary information to secure follow-up care to prevent relapse or worsening of the medical condition upon release from the hospital.
8. When EMTALA Obligations End
The hospital's EMTALA obligation ends when a physician or QMP has made a decision:
a. That no EMC exists (even though the underlying medical condition may persist);
b. That an EMC exists and the individual is appropriately transferred to another facility; or
c. That an EMC exists and the individual is admitted to the hospital for further stabilizing treatment; or
d. That an EMC exists and the individual is stabilized and discharged.

During the tour of the L&D unit on 4/8/19 at 11:30 a.m. an interview was conducted with L&D Clinical Director (EE). She confirmed that the facility has a Level II Neonatal (newborn)Intensive Care Unit that can care for babies born after 32 weeks gestation (developmental age of the unborn baby) without any complications. She said the L&D Unit will transfer a mother pending delivery prior to 32 weeks gestation to the hospital of her primary Obstetrician ' s choice.

During an interview on 4/9/19 at 10:35 a.m. in the Conference Room, RN MM confirmed that she was working L&D on 2/8/19 and that she remembers providing care for Patient #1. RN MM said she has been a RN since 2014, a L&D nurse since 2015, and has been working at the facility since February 2018. The RN said she remembers that the L&D Charge Nurse informed her that Patient #1 would be arriving and that the patient was experiencing a headache and pregnancy induced hypertension (high blood pressure). RN MM said she was setting up the room when Patient #1 arrived and that she helped the patient put on a gown and attached the fetal monitor (evaluates the baby's heartrate). RN MM said she asked the patient what brought her to the hospital and was informed that the patient was seen by the Dr. KK in his office and had lab work, I think that day to see if the patient was pre-eclamptic. RN MM reviewed her notes and said the patient's symptoms included: headache, dizziness, seeing spots, nausea, vomiting and mild cramping. RN MM explained that the patient was not admitted at this point and had only been triaged by RN MM. RN MM said she completed Patient #1's assessment and was informed by the patient that she was prescribed Labetalol but that she had forgotten to take her medication that day. RN MM said her first thought was to call Patient #1's Dr. KK to get orders. RN MM explained that she called the Patient's doctor KK and gave him an update of the patient's condition, the patient's blood pressure reading and informed the physician that the patient had missed taking her blood pressure medication. RN MM said she asked the physician what he wanted to do and he asked her to repeat the patient's blood pressure and then gave orders for the patient to be discharged with instructions for the patient to go directly to another local acute care hospital. RN MM said she thought this was odd and wondered whether this should be done. RN MM said she asked the physician KK if he wanted the patient transported (by ambulance) and the physician replied "no, just tell the patient to come straight here and not to go anywhere else". RN MM said she asked the physician KK if he wanted her to give the patient the Labetalol and he replied no. RN MM said she discussed this with the L&D Charge Nurse and the L&D Charge Nurse asked about Patient #1's blood pressure and then told RN MM that the physician ordered the patient to be discharged so that's what we will do. RN MM added that after speaking with the patient's physician it never occurred to her that the on-call OB physician could be contacted.

During a phone interview on 4/9/19 at 12:30 p.m. with Dr. KK he reported that he remembered Patient #1. He confirmed he was her primary OB and had seen her earlier in the week of 2/8/19 in his office. He stated he had not sent her to the Emergency Department for evaluation. He reported that Patient #1 did have chronic (persisting for a long time or recurring) hypertension (high blood pressure) and had shown some protein (small molecules that play critical roles in the body) in her urine (if high amounts of protein are found in the urine late in a pregnancy, it may indicate kidney disease or preeclampsia). Dr. KK said he had sent labs off to be tested and sent the patient to see a urologist (physician who specializes in the treatment of the urinary tract {body ' s drainage system for removing urine}) to rule out kidney (bean shaped organs that filter blood to remove wastes and make urine) damage and preeclampsia. Dr. KK reported he was at another acute care hospital in the local area when RN MM called to tell him his patient was at their facility. He confirmed that RN MM had provided him with her assessment of the patient and given him all the vital signs. He said he did not think the patient was that unstable. Dr. KK said he told RN MM where he was and asked that the patient not be admitted to her facility but be sent over to where he was for further evaluation. He explained that the facility where he was located at that time was not far and was able to provide specialized care if there were complications with the pregnancy. He confirmed that RN MM asked about emergency transport by ambulance, but he said he did not think Patient #1 ' s condition warranted emergency transport. He confirmed that Nurse MM asked if he wanted Patient #1 to get her Labetalol at that time and he said told her no. Dr. KK said he assumed care when Patient #1 arrived at his location. He said he evaluated her and told her they would just watch her for a few days in the hospital. He said she was stable at that time. He said he left the hospital and was called back to the hospital in less than 30 minutes. When he arrived back at the hospital he found an emergency delivery was warranted and the baby was delivered by Cesarean-Section (surgery where the baby is taken out through the mother ' s abdomen).

Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate discharge/transfer for one (1) of 20 sampled medical records (Patient #1). Specifically, the facility failed to appropriately transfer/discharge Patient #1 when the 29 week gestation pregnant patient presented to the Labor and Delivery Unit with an emergent medical condition.

Findings were:

Review of (L&D) medical record revealed Patient #1 arrived on 2/08/19 at 3:42 p.m. to the Obstetrical (related to childbirth and the processes involved with it) Emergency Department (OBED) on second floor of the facility. Registered Nurse (RN) MM documented she was a walk-in patient from home. Patient #1 reported that her reason for visit was headache, seeing spots, nausea and vomiting that morning, dizziness and mild cramping. The record revealed the patient has had some high blood pressure this pregnancy and is currently taking Labetalol (a medication used to treat high blood pressure). The patient ' s Obstetrician (doctor who specializes in the care of pregnant women and their unborn baby) was documented as her primary Dr. KK. The clinic summary revealed her estimated date of confinement (due date) was 4/22/19 and that she was at 29.5 weeks gestation (period of development, normal gestation or length of pregnancy is 40 weeks). Initial Vital Signs were documented at 3:59 p.m. as Pulse(P)-109 (normal Pulse 60-100 in adults) and Blood Pressure (BP)-138/87 (normal blood pressure in adults 120/80-140/90). Registered Nurse MM ' s assessment of Patient #1 at 3:59 p.m. revealed Patient #1 had swelling in both lower extremities (legs and feet), headache for several hours, and she was not currently in active labor.
Vital signs at 4:04 p.m. were P-103 and BP-151/94
Vital signs at 4:09 p.m. were P-103 and BP-156/104
Vital signs at 4:14 p.m. were P-100 and BP 153/84
Vital signs at 4:19 p.m. were P-102 and BP 155/83
Fetal Heart Monitoring revealed the fetal heart rate (rate at which the unborn baby ' s heart beats) baseline was 150 beats per minute (bpm). Normal fetal heart rate is between 120-160 bpm. Further review of the medical record revealed at 4:29 p.m. that RN MM notified Dr. KK that his patient who was pregnant with her first child and at the time 29.5 weeks gestation was in L&D at the facility. The record reveals that Dr KK was told that Patient #1 had been seen in his office for symptoms of preeclampsia (preeclampsia is a condition that pregnant women develop that is marked by high blood pressure, elevated levels of protein in the urine, and often swelling in the feet, legs, and hands). Dr. KK was informed that the patient was taking Labetalol 100 milligrams twice a day. RN MM noted that she reported to Dr. KK that the triage assessment revealed Patient #1 ' s headache was rated 10 on a pain scale where 1 is mild and 10 is the most severe and was unrelieved by Tylenol, that she had been seeing spots before her eyes, dizziness, nausea and vomiting during the morning, and swelling and soreness in her lower extremities. RN MM report further revealed the blood pressure readings ranging from 130s/80s to 150s/100s were discussed. RN MM notified Dr. KK that the patient was due for her Labetalol at that time. Fetal monitor tracing was reviewed with Dr. KK. Dr. KK gave a phone order to discharge the patient with instructions not to go home but to report to another facility in town where he would see Patient #1. Patient #1 was discharged at 4:26 p.m. with instructions to go directly to the other acute care hospital per her own obstetrician ' s directions. Patient #1 left with her significant other in a personal vehicle. There was no record of the on-call OB physician being called.

At the time of the survey no records were available from the receiving facility.

Review of the Medical Staff Bylaws, Rules and Regulations of the facility, approved by the Medical Executive Committee 3/11/14, The General medical Staff 4/4/14, and the Board of Trustees 4/22/14, revealed the following:

ARTICLE XII - Transfer to Another Hospital or Healthcare Facility
12.1. Transfer:
The process for providing appropriate care for a patient, during and after transfer from the Hospital to another facility, includes:
(a) assessing the reason(s) for transfer;
(b) establishing the conditions under which transfer can occur;
(c) evaluating the mode of transfer/transport to assure the patient's safety; and
(d) ensuring that the organization receiving the patient assumes responsibility for the patient's care after arrival at that facility.
12.2. Procedures:
(a) Patients will be transferred to another hospital or facility based on the patient's needs and the Hospital's capabilities. The attending physician will take the following steps as appropriate under the circumstances:
(1) identify the patient's need for continuing care in order to meet the patient's physical and psychosocial needs;
(2) inform patients and their family members (as appropriate), in a timely manner, of the need to plan for a transfer to another organization;
(3) involve the patient and all appropriate practitioners, Hospital staff, and family members involved in the patient's care, treatment, and services in the planning for transfer; and
(4) provide the following information to the patient whenever the patient is transferred:
(i) the reason for the transfer;
(ii) the risks and benefits of the transfer; and
(iii) available alternatives to the transfer.
(b) When patients are transferred, appropriate information will be provided to the accepting practitioner/facility, including:
(1) reason for transfer;
(2) significant findings;
(3) a summary of the procedures performed, and care, treatment and services provided;
(4) condition at discharge;
(5) information provided to the patient and family, as appropriate; and
(6) working diagnosis.
12.3. Emergency Medical Treatment and Labor Act (EMTALA) Transfers:
The transfer of a patient with an emergency medical condition from the ED to another hospital will be made in accordance with the Hospital's applicable EMTALA policy.

Review of the facility ' s policies included but were not limited to the following:
I- EMTALA-Transfer Policy 5178789, reviewed 7/2018 revealed the purpose was to establish guidelines for either accepting an appropriate transfer from another facility or providing an appropriate transfer to another facility of an individual with an EMC who requests or requires a transfer for further medical care. Any transfer of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual ' s behalf or by a physician order with the appropriate physician certification as required under EMTALA. EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC apply to any ED or dedicated emergency department (DED) of a hospital whether located on or off the hospital campus and all other departments of the hospital located on hospital property.
1. Transfer of Individuals Who Have Not Been Stabilized
a. If an individual who has come to the ED has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer and meets the following conditions:
i. The individual or a legally responsible person acting on the individual ' s behalf requests the transfer, after being informed of the hospital ' s obligations under EMTALA and of the risks and benefits of such transfer. The request must be in writing and indicate the reasons for the request as well as indicate that the individual is aware of the risks and benefits of transfer; or
ii. A physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of the woman in labor, to the woman or the unborn child, from being transferred. The certificate must contain a written summary of the risks and benefits upon which it is based; or
iii. If a physician is not physically present in the DED at the time the individual is transferred, a qualified medical person (QMP) has signed a certification after a physician in consultation with the QMP, agrees with the certification and subsequently countersigns the certification. The certification must contain a written summary of the risks and benefits upon which it is based. Note: The date and time of the physician or QMP certification should match the date and time of the transfer.
b. A transfer will be an appropriate transfer if:
i. The transferring hospital provides 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;
ii. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment;
iii. The transferring hospital sends the receiving hospital copies of all medical records related to the EMC for which the individual presented that are available at the time of transfer as well as the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; and
iv. The transfer is effected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transport.
Hospitals that request transfers must recognize that the appropriate transfer of individuals with unstabilized EMCs that require specialized services should not routinely be made over great distances, bypassing closer hospitals with the necessary capability and capacity to care for the unstabilized EMC.
c. Higher Level of Care. A higher level of care should be the more likely reason to transfer an individual with an EMC that has not been stabilized.
2. Additional Transfer-Related Situations
d. Transfers for High Risk Deliveries. A hospital that is not capable of handling the delivery of a high-risk woman in labor must still provide an MSE and any necessary stabilizing treatment as well as meet the requirements of an appropriate transfer even if a transfer agreement is in place. In addition, a physician certification that the benefits of transfer outweigh the risks of transfer is required for the transfer of the woman in labor.
4. Authority to Conduct a Transfer
The transferring physician is responsible for determining the appropriate mode of transportation, equipment and attendants for the transfer in such a manner as to be able to effectively manage any reasonably foreseeable complication of the individual ' s condition that could arise during the transfer. Only qualified personnel, transportation and equipment, including those life support measures that may be required during transfer shall be employed in the transfer of an individual with an unstabilized EMC. If the individual refuses the appropriate form of transportation determined by the transferring physician and decides to be transported by another method, the transferring physician is to document that the individual was informed of the risks associated with this type of transport and the individual should sign a form indicating the risks have been explained and the individual acknowledges and accepts the risks. All additional requirements of an appropriate transfer are to be followed by the transferring hospital.
5. Transfer Center Use
Hospitals may utilize a Transfer Center to facilitate the transfer of any individual from or to the ED of the transferring facility to the receiving facility. The transferring physician, after discussion with the individual patient or his or her legally authorized representative, determines the appropriate receiving facility for providing the care necessary to stabilize and treat the individual ' s emergent condition. The Transfer Center then facilitates the transfer from the transferring facility to the facility selected by the transferring physician and/or the patient.
At the ED Physician ' s request, the Transfer Center must facilitate a discussion between the ED Physician and the on-call physician of the receiving facility. The on-call physician does not have the authority to refuse an appropriate transfer on behalf of the facility.
The Transfer Center may, at the request of the transferring facility, provide information on the availability of Emergency Medical Services (EMS) or transport options for transfer of an individual.
PROCEDURE:
1. Transfers of Individuals Who Are Not Medically Stable
Requirements Prior to Transfer. After the hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC who is not medically stable, the hospital may arrange an appropriate transfer for the individual to another more appropriate or specialized facility. Evaluation and treatment shall be performed, and transfer shall be carried out as quickly as possible for an individual with an EMC which has not been stabilized or when stabilization of the individual's vital signs is not possible because the hospital does not have the appropriate equipment or personnel to correct the underlying process. The following requirements must be met for any transfer of an individual with an EMC that has not been stabilized:
a. Minimize the Risk. Before any transfer may occur, the transferring hospital must first provide, within its capacity and capability, medical treatment to minimize the risks to the health of the individual or unborn child.
b. Individual ' s Request or Physician ' s Order. Any transfer to another medical facility of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual ' s behalf or by a physician order with the appropriate physician or QMP and Physician certification as required under EMTALA. Any written request for a transfer to another medical facility from an individual with an EMC or the legally responsible person acting on the individual ' s behalf shall indicate the reasons for the request and that he or she is aware of the risks and benefits of the transfer.
c. Request to Transfer Made to Receiving Facility. The transferring hospital must call the receiving hospital or the Transfer Center if the facility is part of a Transfer Center network to verify the receiving hospital has available space and qualified personnel for the treatment of the individual. The receiving hospital must agree to accept the transfer and provide appropriate treatment. The transferring hospital must obtain permission from the receiving hospital to transfer an individual. This may be facilitated by a Transfer Center. Such permission should be documented on the medical record by the transferring hospital, including the date and time of the request and the name and title of the person accepting transfer. The transferring physician shall ensure that a receiving hospital has appropriate services and has accepted responsibility for the individual being transferred. If utilizing the services of a Transfer Center, the Transfer Center may assist in determining whether the receiving hospital has the appropriate services.
d. Document the Request. The transferring hospital must document its communication with the receiving hospital, including the request date and time and the name of the person accepting the transfer.
e. Send Medical Records. The transferring hospital must send to the receiving hospital copies of all medical records available at the time of transfer related to the EMC and continuing care of the individual. The transferring hospital may provide the Face Sheet with the appropriate information to the Transfer Center to assist Transfer Center in facilitating the transfer. But, the Transfer Center generally may not provide any information to, or respond to questions from, to the receiving facility or physician at the receiving facility, from the Face Sheet regarding whether or not the patient has insurance, or the type of insurance, or other information regarding the patient's ability to pay for services prior to acceptance of the patient except as required by a state or local plan for providing care to certain patient populations where insurance coverage is a determining factor in where the patient may receive care. Documentation sent to the receiving hospital must include:
--Copies of the available history, all records related to the individual ' s EMC, observations of signs or symptoms, patient ' s condition at the time of transfer, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests, monitoring and assessment data, any other pertinent information, and the informed written consent for transfer of the individual or the certification of a physician or QMP.
--The name and address of any on-call practitioner who refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; and
--The individual ' s vital signs which should be taken immediately prior to transfer and documented on the Memorandum of Transfer Form.
--Copies of available records must accompany the individual; and
--Copies of other records not available at the time of transfer must be sent to the receiving hospital as soon as practical after the transfer.
Medical and other records related to individuals transferred to or from the hospital must be retained in their original or legally reproduced form in hard copy, microfilm, or electronic media for a period of five years from the date of transfer.
f. Physician Certification of Risks and Benefits. A physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred. The certification should meet the following requirements:
--The certification must state the reason for transfer. The narrative rationale need not be a lengthy discussion of the individual ' s medical condition as this can be found in the medical record but should be specific to the condition of the patient upon transfer.
--The certification must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility and the risks associated with the transfer, including the time away from an acute care setting necessary to effect the transfer.
--The date and time of the physician certification should closely match the date and time of the transfer.
--Certifications may not be backdated.
g. QMP Certification. If a physician is not physically present at the time of the transfer, a QMP may sign the certification, after consultation with a physician, and transfer the individual as long as the medical benefits expected from transfer outweigh the risks. If a QMP signs the certification, a physician shall countersign it within 24 hours or a reasonable time period specified by the hospital bylaws, rules or regulations.
h. Send Memorandum of Transfer. A Memorandum of Transfer must be completed for every patient who is transferred to another separately licensed hospital. The Memorandum of Transfer and the patient ' s medical record must be sent with the patient at the time of the transfer. A copy of the Memorandum of Transfer shall be retained by the transferring hospital and incorporated into the patient's medical record.

During the tour of the L&D unit on 4/8/19 at 11:30 a.m. an interview was conducted with L&D Clinical Director (EE). She confirmed that the facility has a Level II Neonatal (newborn)Intensive Care Unit that can care for babies born after 32 weeks gestation (developmental age of the unborn baby) without any complications. She said the L&D Unit will transfer a mother pending delivery prior to 32 weeks gestation to the hospital of her primary obstetrician's choice.

During an interview on 4/9/19 at 10:35 a.m. in the Conference Room, RN MM confirmed that she was working L&D on 2/8/19 and that she remembers providing care for Patient #1. RN MM said she has been a RN since 2014, a L&D nurse since 2015, and has been working at the facility since February 2018. The RN said she remembers that the L&D Charge Nurse informed her that Patient #1 would be arriving and that the patient was experiencing a headache and pregnancy induced hypertension (high blood pressure). RN MM said she was setting up the room when Patient #1 arrived and that she helped the patient put on a gown and attached the fetal monitor (evaluates the baby's heartrate). RN MM said she asked the patient what brought her to the hospital and was informed that the patient was seen by the Dr. KK in his office and had lab work, I think that day to see if the patient was pre-eclamptic. RN MM reviewed her notes and said the patient's symptoms included: headache, dizziness, seeing spots, nausea, vomiting and mild cramping. RN MM explained that the patient was not admitted at this point and had only been triaged by RN MM. RN MM said she completed Patient #1's assessment and was informed by the patient that she was prescribed Labetalol but that she had forgotten to take her medication that day. RN MM said her first thought was to call Patient #1's Dr. KK to get orders. RN MM explained that she called the Patient's doctor KK and gave him an update of the patient's condition, the patient's blood pressure reading and informed the physician that the patient had missed taking her blood pressure medication. RN MM said she asked the physician what he wanted to do and he asked her to repeat the patient's blood pressure and then gave orders for the patient to be discharged with instructions for the patient to go directly to another local acute care hospital. RN MM said she thought this was odd and wondered whether this should be done. RN MM said she asked the physician KK if he wanted the patient transported (by ambulance) and the physician replied "no, just tell the patient to come straight here and not to go anywhere else". RN MM said she asked the physician KK if he wanted her to give the patient the Labetalol and he replied no. RN MM said she discussed this with the L&D Charge Nurse and the L&D Charge Nurse asked about Patient #1's blood pressure and then told RN MM that the physician ordered the patient to be discharged so that's what we will do. RN MM added that after speaking with the patient's physician it never occurred to her that the on-call OB physician could be contacted.

During a phone interview on 4/9/19 at 12:30 p.m. with Dr. KK he reported that he remembered Patient #1. He confirmed he was her primary OB and had seen her earlier in the week of 2/8/19 in his office. He stated he had not sent her to the Emergency Department for evaluation. He reported that Patient #1 did have chronic (persisting for a long time or recurring) hypertension (high blood pressure) and had shown some protein (small molecules that play critical roles in the body) in her urine (if high amounts of protein are found in the urine late in a pregnancy, it may indicate kidney disease or preeclampsia). Dr. KK said he had sent labs off to be tested and sent the patient to see a urologist (physician who specializes in the treatment of the urinary tract {body ' s drainage system for removing urine}) to rule out kidney (bean shaped organs that filter blood to remove wastes and make urine) damage and preeclampsia. Dr. KK reported he was at another acute care hospital in the local area when RN MM called to tell him his patient was at their facility. He confirmed that RN MM had provided him with her assessment of the patient and given him all the vital signs. He said he did not think the patient was that unstable. Dr. KK said he told RN MM where he was and asked that the patient not be admitted to her facility but be sent over to where he was for further evaluation. He explained that the facility where he was located at that time was not far and was able to provide specialized care if there were complications with the pregnancy. He confirmed that RN MM asked about emergency transport by ambulance, but he said he did not think Patient #1 ' s condition warranted emergency transport. He confirmed that Nurse MM asked if he wanted Patient #1 to get her Labetalol at that time and he said told her no. Dr. KK said he assumed care when Patient #1 arrived at his location. He said he evaluated her and told her they would just watch her for a few days in the hospital. He said she was stable at that time. He said he left the hospital and was called back to the hospital in less than 30 minutes. When he arrived back at the hospital he found an emergency delivery was warranted and the baby was delivered by Cesarean-Section (surgery where the baby is taken out through the mother ' s abdomen).