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Based on review of Medical Staff Bylaws/Rules and Regulations, Emergency Department (ED) policies and procedures, ED central log, and physician and staff interviews, it was determined that the facility lacked an effective system to ensure that all patients that presented to the ED were placed on the Central Log, received a medical screening examination, stabilizing treatment.

Findings were:

Cross refer to A2405 as it relates to failure of the facility to obtain and put a name in the central log for a pregnant patient presenting to the Emergency Department. (Patient #21).

Cross refer to A2406 as it relates to failure of the facility to perform a medical screening for a pregnant patient presenting to the Emergency Department. (Patient #21).

Cross refer to A2407 as it relates to failure of the facility to provide stabilizing treatment for a pregnant patient presenting to the Emergency Department. (Patient #21).



The CNO and Quality/Risk Manager reported that an investigation had been initiated after having learned of the incident. However, the investigation was in still in progress at the time of the survey, the following action plan had been developed:

*The Emergency Medical Screening, Stabilization, Treatment, and Transfer policy was reviewed and revised on 09/23/11 and will be presented to the Medical Executive Committee (MEC) at their scheduled October 2011 meeting. The revisions included clarification that triage could be performed at either the ED or OB department, wherever the patient presents. There was also clarification regarding the qualified medical professional definition to include labor and delivery nurse in consultation with physician via telephone to perform medical screenings. (This was present in the OB triage policy, but not in this policy).

*A section was added to the policy on physician responsibilities and hospital staff responsibilities that was not present in the current policy. Also, added a section on false labor certification and on use of hospital helipad.

*Additionally, information on specific documentation required to include with transfer was also added to the policy.

*The OB Triage and Initial Basic Medical Screening of Obstetrical Patients policy was reviewed and revised on 09/21/11. The policy allowed for nurses in the OB department to perform medical screenings after triage by the ED nurse is completed. That is not the current practice at the facility. Currently, OB patients are not being triaged by the ED if the patient is greater than 20 weeks gestation, the patients are being transferred to the OB department for triage and screening. Revisions to the policy defined the medical screening of the OB patient whether the patient presents to the ED or the OB department. Criteria to determine active labor in consultation with the physician was added. Clarification of the labor and delivery nurse responsibilities for physician notification of medical screening was done and the method of documentation of physician certification was revised.

*The Triage and Medical Screening Record was revised to include the active labor criteria and physician certification documentation (currently being documented in the nursing assessment).

*The Triage policy was reviewed and the facility will enforce that OB patients presenting to the ED will be triaged by the ED nurse prior to a medical screening by the OB nurse in consultation with the physician.

*Medical Staff Bylaws/Rules and Regulations were reviewed. Current rules and regulations defined who was allowed to perform medical screenings for ED patients. The rules and regulations now include the medical screening for OB patients by the OB nurse in consultation with the physician. This addition will be presented to MEC on 10/21/11, then forwarded to Medical Staff on 11/15/11, then forwarded to governing body at their next scheduled meeting.

*Mandatory re-education will be given to all staff regarding EMTALA regulations and all policy changes.

*Re-education to Medical Staff will be scheduled again and be presented by McNeary Risk Management attorney (last presented by attorney in November 2010).

Based on review of the central log, policy and procedure, and staff and physician interviews, it was determined that the facility failed to ensure that each individual who presented to the ED for treatment were maintained on a central log for a pregnant patient for 1 of 21 sampled patients (#21).

Findings were:

Review of facility policy entitled "Emergency Medical Screening, Stabilization, Treatment and Transfer" revealed that a list of all patients that presented to the ED would be maintained. At a minimum, the log would contain the patient name, chief complaint, and disposition of case. The log was to be maintained for five (5) years.

Review of the central log for 09/09/11 revealed no evidence of the pregnant patient (#21)having been registered on the log the day that she presented to the ED.

An interview (#7) was conducted at 10:00 a.m. on 09/28/11 with an obstetrical (OB) nurse in the administrative conference room. The nurse reported being familiar with the pregnant patient from previous visits and stated that the patient called the OB unit late on the night of 09/08/11. The patient reported having nausea and diarrhea. The nurse gave the patient some advice on how to relieve the symptoms and recommended that she may need to be seen if symptoms were not relieved. The patient was advised to call back in an hour to report on her status. The nurse did indicate to the patient that all beds in the Labor and Delivery Unit were currently full. The patient called back in an hour and the OB nurse transferred the call to the OB physician who was on the unit at the time and was between cesarean-section deliveries. The interviewee did not hear the conversation between the patient and the doctor. However, the nurse was told later that the doctor had advised the patient to go to the nearest facility. The interviewee reported that later during his/her shift the ED registrar called the OB ward clerk to report that the patient had presented to the ED. The ward clerk conferred with the interviewee who recommended that the patient should follow the previous recommendations given by the OB doctor during their earlier phone conversation. The interviewee had no further involvement with the patient but heard later that the patient had left to go to another facility. The OB nurse reported that it was the practice that OB patients who presented to the ED were sometimes examined by the OB staff in the ED or brought to the OB unit for examination if space was available.


An interview (#4) was conducted at 3:00 p.m. on 09/27/11 with a registrar in the administrative conference room. The registrar reported that he/she was at the front desk in the ED when the patient arrived and stated that she was having contractions and needed to be seen. The interviewee spoke with a staff member in the OB unit, as per routine, and informed the staff member that the patient was requesting to be seen. The registrar was informed that the OB unit was full and that the patient should be instructed to go to a nearby facility. The interviewee reported that he/she consulted with another registrar as he/she was unclear how to proceed. The patient was not entered in the central log nor was the ED staff informed of the patient's arrival during the time the registrar was in contact with the OB staff. The other registrar contacted the nursing house supervisor who came and spoke to the patient and family. The interviewee reported that he/she only heard parts of the conversation between the patient and the nursing supervisor. At one point, the interviewee heard the patient ask the nursing supervisor what the facility would do if the patient was actually having the baby and the supervisor replied that the patient would then be seen in the ED. The interviewee reported that the patient and family left the facility after speaking with the house supervisor.


An interview (#1) was conducted at 1:00 p.m. on 09/27/11 with the Nursing House Supervisor in the Administrative Conference Room. The supervisor reported that he/she was familiar with the event and confirmed that he/she was working at the time the patient presented to the hospital. The interviewee reported that he/she was contacted by the OB nurse when the patient presented to the ED. The interviewee went to speak to the patient who requested to see the Obstetrician (Interviewee #3). The patient was informed that the Obstetrician was not available. The interviewee reported that the patient did not want to be examined in the ED but only wanted to see the Obstetrician. The interviewee stated that the family then made a decision to go to Statesboro and left the facility. The supervisor reported that once the patient had made the decision to not be examined in the ED, he/she felt that it was all right for the patient to go to another facility. According to the interviewee, the OB physician was not informed that the patient had presented to the ED. When questioned about the patient's refusal to be seen in the ED, the house supervisor confirmed that refusal for treatment had not been documented. The supervisor also confirmed that patient (#21) had not been entered in the central log nor had a medical record been established.

An interview was conducted with the Chief Nursing Officer (CNO) and Quality/Risk Manager at 4:00 p.m. on 09/26/11 in the Administrative Conference Room. The interviewees were aware that the pregnant patient presented to the ED on 09/09/11. They confirmed that the patient (#21) was not entered in the central log. In addition, the interviewees reported that they were aware the the patient presented to another facility after leaving this facility. The facility failed to ensure that their policy was followed as evidenced by failing to maintain a Central Log on Patient #21 on 9/9/2011, a pregnant female in distress requested medical assistance.

Based on review of facility policy and procedure, Medical Staff Bylaws/Rules and Regulations, and staff and physician interviews, it was determined that the facility failed to ensure that a pregnant patient upon presentation to the ED on 09/09/11 received a medical screening examination (MSE) that was within the capability and capacity of he ED for 1 of 21 sampled patients (#21).

Findings were :

Patient #21's medical record was reviewed from the hospital where she went to after leaving Meadows Regional Medical Center on 9/9/2011. Review of the hospital's progress noted dated 9/9/2011 revealed in part, " This is a 20 year old ...female, gravida 2 (number to indicate the number of pregnancies a woman has had), Para 1 (birth of a viable offspring), with intrauterine pregnancy at 34-35 weeks...The patient says she called Dr.----- earlier this morning because she was having lower abdominal pain and spotting. At that time she was told that the hospital was full. The patient went to the Vadalia Hospital (Meadows Regional Medical Center) and reports they had no Labor and delivery beds for her. They recommended that she come to Statesboro. Objective: Upon arrival here, the patient was examined and found to be 3-4 cm (centimeters), 50 percent effaced (process where the cervix prepares for delivery) and -2 station (fetal head position in the pelvis). She was found to be having regular contractions. Assessment and plan;' The patient has been started on Mg (magnesium) Sulfate (Drug used to treat pre-term labor) and the contractions have markedly slowed down. Review of the OB (obstetrical ) progress note dated 9/9/2011 at 3:46 a.m. specified in part, Scant amt (amount) of light pink spotting in Pt (patient) panties. No Bleeding or spotting noted when pt wiped... 3:34 am EFM (Electronic Fetal Monitoring) and Toco (recording uterine contractions) applied, Abd (abdomen) soft to palp (palpitation)....LD (labor and Delivery) Flowsheet 05:57 a.m. IV (Intravenous-needle inserted into veins through which fluids and/or medications could be administered)) Started.. 06:56 Magnesium Sulfate started IV Bolus , .. then to be followed by 2 GM/HR (grams/hr) continuous rate. 10:13 a.m. Foley catheter inserted... 10:36 a.m.. . . Antibiotic Unasyn 3 GM hung...OB progress notes 8:03 am Physician in room and speaking with patient...10:02 am Physician at bedside..... pt advised to transfer to (another acute care hospital).....11:08 am EMS (emergency medical services) here for transport to (another acute care hospital). A review of the hospital transfer form dated 9/9/2011 indicated that patient#21 the reason for transfer was, " For equipment or services not available at this facility NICU (neonatal intensive care unit)." The medical record at the hospital where patient #21 was transferred was reviewed. A review of the Discharge summary indicated that on 9/9/2011 patient #21 was admitted to the hospital. Patient #21's principle diagnosis was listed as "Principal Diagnosis: intrauterine pregnancy . . . in pre term labor." Patient #21 was discharged from the hospital on 9/12/2011.


Review of Medical Staff Bylaws/Rules and Regulations revealed that all patients that presented to the ED received a MSE. The MSE must be performed by a physician or a physician extender (physician assistant or nurse practitioner).

Review of facility policy entitled " Emergency Medical Screening, Stabilization, Treatment and Transfer " revealed that any individual who came to the ED requesting evaluation or treatment would be provided with an appropriate MSE without regard to diagnosis, financial status, race, color, national origin, or handicap. The policy indicated that the medical screening was to be performed by a physician, a physician assistant, or a nurse practitioner. In the case of obstetrical patients that were twenty (20) weeks gestation or greater, an obstetric registered nurse could perform the medical screening.

An interview (#7) was conducted at 10:00 a.m. on 09/28/11 with an obstetrical (OB) nurse in the administrative conference room. The nurse reported being familiar with the pregnant patient from previous visits and stated that the patient called the OB unit late on the night of 09/08/11. The patient reported having nausea and diarrhea. The nurse gave the patient some advice on how to relieve the symptoms and recommended that she may need to be seen if symptoms were not relieved. The patient was advised to call back in an hour to report on her status. The nurse did indicate to the patient that all beds in the Labor and Delivery Unit were currently full. The patient called back in an hour and the OB nurse transferred the call to the OB physician who was on the unit at the time and was between cesarean-section deliveries. The interviewee did not hear the conversation between the patient and the doctor. However, the nurse was told later that the doctor had advised the patient to go to the nearest facility. The interviewee reported that later during his/her shift the ED registrar called the OB ward clerk to report that the patient had presented to the ED. The ward clerk conferred with the interviewee who recommended that the patient should follow the previous recommendations given by the OB doctor during their earlier phone conversation. The interviewee had no further involvement with the patient but heard later that the patient had left to go to another facility. The OB nurse reported that it was the practice that OB patients who presented to the ED were sometimes examined by the OB staff in the ED or brought to the OB unit for examination if space was available. The failed to ensure that their policy titled "Emergency Medical Screening and Stabilization" policy was followed as evidenced by failing to ensure that a screening examination was performed by a physician, a physician assistant, or a nurse practitioner for patient on 9/9/2011.

An interview (#3) was conducted at 12:00 p.m. on 09/27/11 with the OB physician in the administrative conference room. The physician reported that he/she was not very familiar with the patient but was aware that the patient had been seen previously in the office practice. The interviewee received a call from the patient somewhere between 12:00 a.m. and 3:00 a.m. on 09/09/11. The patient reported that she was having nausea, vomiting, and diarrhea. The patient also indicated that she had pre-term labor in a previous pregnancy. The physician recommended that the patient needed to be seen and advised her to go to her nearest facility. The physician was involved in numerous cesarean-section procedures that evening and advised the patient that the beds in the OB (Labor and Delivery) unit were full. However, the physician did not tell the patient not to come to this facility and reinforced the importance of going to the closest facility to the patient's home. The physician was later informed that the patient had come to the facility and that the nursing supervisor had spoken to the patient. The physician reported that he/she was not notified that the patient was at the facility and was not previously aware that the patient had come to the ED.

An interview (#4) was conducted at 3:00 p.m. on 09/27/11 with a registrar in the administrative conference room. The registrar reported that he/she was at the front desk in the ED when the patient arrived and stated that she was having contractions and needed to be seen. The interviewee spoke with a staff member in the OB unit, as per routine, and informed the staff member that the patient was requesting to be seen. The registrar was informed that the OB unit was full and that the patient should be instructed to go to a nearby facility. The interviewee reported that he/she consulted with another registrar as he/she was unclear how to proceed. The patient was not entered in the central log nor was the ED staff informed of the patient's arrival during the time the registrar was in contact with the OB staff. The other registrar contacted the nursing house supervisor who came and spoke to the patient and family. The interviewee reported that he/she only heard parts of the conversation between the patient and the nursing supervisor. At one point, the interviewee heard the patient ask the nursing supervisor what the facility would do if the patient was actually having the baby and the supervisor replied that the patient would then be seen in the ED. The facility failed to ensure that the medical Staff bylaws/Rules and Regulations were followed as evidenced by a medical screening examination was not performed by a physician or a physician extender on patient #21 on 9/9/2011. The interviewee reported that the patient and family left the facility after speaking with the house supervisor.

An interview (#2) was conducted at 9:30 a.m. on 09/27/11 with a second registrar in the administrative conference room. The interviewee reported that he/she was in an office near the registration desk when the patient arrived. He/she was contacted by the registrar at the front desk for advice on how to handle a situation with a pregnant patient who had presented to the ED. The front desk registrar had been advised by an OB unit staff member to tell the patient to go to a facility in Swainsboro or Statesboro because this facility's OB unit was full. The registrar was not comfortable relaying that information to the family. This interviewee also contacted the OB unit for clarification because the patient was over twenty (20) weeks pregnant and these patients were routinely seen in the OB unit. Again, the registrar was told that the OB unit was full and that the patient had been told earlier to go to another facility. The interviewee contacted the house supervisor who came to talk to the patient. The interviewee reported that the patient appeared to be in some distress. During the supervisor's discussion with the patient the registrar became involved with other duties. When the registrar observed the patient leaving the ED, he/she was informed by the house supervisor that the supervisor had to send the patient to another facility. The interviewee reported that he/she discussed the incident with his/her supervisor the following morning. The registrar also indicated that pregnant patients over twenty (20) weeks pregnant have been seen previously in the ED when the OB unit was full. The facility failed to ensure that their policy titled "Emergency Medical Screening, Stabilization" was followed as evidenced by; Patient #21 presented to the hospital on 9/9/2011, and was greater than 20 weeks pregnant. The facility failed to provide patient #21 with a medical screening examination by an obstetric registered nurse as indicated in the policy.

An interview (#1) was conducted at 1:00 p.m. on 09/27/11 with the Nursing House Supervisor in the Administrative Conference Room. The supervisor reported that he/she was familiar with the event and confirmed that he/she was working at the time the patient presented to the hospital. The interviewee reported that he/she was contacted by the OB nurse when the patient presented to the ED. The interviewee went to speak to the patient who requested to see the Obstetrician (Interviewee #3). The patient was informed that the Obstetrician was not available. The interviewee reported that the patient did not want to be examined in the ED but only wanted to see the Obstetrician. The interviewee stated that the family then made a decision to go to Statesboro and left the facility. The supervisor reported that once the patient had made the decision to not be examined in the ED, he/she felt that it was all right for the patient to go to another facility. According to the interviewee, the OB physician was not informed that the patient had presented to the ED. When questioned about the patient's refusal to be seen in the ED, the house supervisor confirmed that refusal for treatment had not been documented.

An interview was conducted with the Chief Nursing Officer (CNO) and Quality/Risk Manager at 4:00 p.m. on 09/26/11 in the Administrative Conference Room. The interviewees were aware that the pregnant patient presented to the ED on 09/09/11. They confirmed that the patient did not receive a medical screening examination prior to leaving the facility. In addition, the interviewees reported that they were aware the the patient presented to another facility after leaving this facility. The facility failed to ensure that a medical screening examination was provided for patient #21 on 9/9/2011 that was within the capability and capacity of the hospital's emergency department.

Based on review of facility policy and procedure and staff and physician interviews, it was determined that the facility failed to provide stabilizing treatment (refer to Tag 2406) to a pregnant patient that presented to the ED on 09/09/11 that was within the capability and capacity of the hospital's emergency department for 1 of 21 sampled patients (#21).

Findings were:

A review of facility policy entitled "Emergency Medical Screening, Stabilization, Treatment and Transfer" revealed that a patient was considered to be treated and stabilized when the treating physician determined that a patient's medical condition had been resolved and/or that no deterioration of the condition was likely, within medical probability, to result from or occur during a transfer. Stabilized was defined as the continued care, including diagnostic work-up and/or treatment can be safely performed on an out-patient basis, or later on an in-patient basis, provided a patient was given a plan for appropriate follow-up care with discharge instructions.

An interview (#7) was conducted at 10:00 a.m. on 09/28/11 with an obstetrical (OB) nurse in the administrative conference room. The nurse reported being familiar with the pregnant patient from previous visits and stated that the patient called the OB unit late on the night of 09/08/11. The patient reported having nausea and diarrhea. The nurse gave the patient some advice on how to relieve the symptoms and recommended that she may need to be seen if symptoms were not relieved. The patient was advised to call back in an hour to report on her status. The nurse did indicate to the patient that all beds in the Labor and Delivery Unit were currently full. The patient called back in an hour and the OB nurse transferred the call to the OB physician who was on the unit at the time and was between cesarean-section deliveries. The interviewee did not hear the conversation between the patient and the doctor. However, the nurse was told later that the doctor had advised the patient to go to the nearest facility. The interviewee reported that later during his/her shift the ED registrar called the OB ward clerk to report that the patient had presented to the ED. The ward clerk conferred with the interviewee who recommended that the patient should follow the previous recommendations given by the OB doctor during their earlier phone conversation. The interviewee had no further involvement with the patient but heard later that the patient had left to go to another facility. The OB nurse reported that it was the practice that OB patients who presented to the ED were sometimes examined by the OB staff in the ED or brought to the OB unit for examination if space was available. The facility failed to ensure that their policy and procedure on stabilizing treatment was followed as evidenced by failing to provide stabilizing treatment to a pregnant patient complaining of having contractions and staff observing that patient (#21) was in distress on 9/9/2011.

An interview (#3) was conducted at 12:00 p.m. on 09/27/11 with the OB physician in the administrative conference room. The physician reported that he/she was not very familiar with the patient but was aware that the patient had been seen previously in the office practice. The interviewee received a call from the patient somewhere between 12:00 a.m. and 3:00 a.m. on 09/09/11. The patient reported that she was having nausea, vomiting, and diarrhea. The patient also indicated that she had pre-term labor in a previous pregnancy. The physician recommended that the patient needed to be seen and advised her to go to her nearest facility. The physician was involved in numerous cesarean-section procedures that evening and advised the patient that the beds in the OB (Labor and Delivery) unit were full. However, the physician did not tell the patient not to come to this facility and reinforced the importance of going to the closest facility to the patient's home. The physician was later informed that the patient had come to the facility and that the nursing supervisor had spoken to the patient. The physician reported that he/she was not notified that the patient was at the facility and was not previously aware that the patient had come to the ED.

An interview (#4) was conducted at 3:00 p.m. on 09/27/11 with a registrar in the administrative conference room. The registrar reported that he/she was at the front desk in the ED when the patient arrived and stated that she was having contractions and needed to be seen. The interviewee spoke with a staff member in the OB unit, as per routine, and informed the staff member that the patient was requesting to be seen. The registrar was informed that the OB unit was full and that the patient should be instructed to go to a nearby facility. The interviewee reported that he/she consulted with another registrar as he/she was unclear how to proceed. The patient was not entered in the central log nor was the ED staff informed of the patient's arrival during the time the registrar was in contact with the OB staff. The other registrar contacted the nursing house supervisor who came and spoke to the patient and family. The interviewee reported that he/she only heard parts of the conversation between the patient and the nursing supervisor. At one point, the interviewee heard the patient ask the nursing supervisor what the facility would do if the patient was actually having the baby and the supervisor replied that the patient would then be seen in the ED. The interviewee reported that the patient and family left the facility after speaking with the house supervisor.

An interview (#2) was conducted at 9:30 a.m. on 09/27/11 with a second registrar in the administrative conference room. The interviewee reported that he/she was in an office near the registration desk when the patient arrived. He/she was contacted by the registrar at the front desk for advice on how to handle a situation with a pregnant patient who had presented to the ED. The front desk registrar had been advised by an OB unit staff member to tell the patient to go to a facility in Swainsboro or Statesboro because this facility's OB unit was full. The registrar was not comfortable relaying that information to the family. This interviewee also contacted the OB unit for clarification because the patient was over twenty (20) weeks pregnant and these patients were routinely seen in the OB unit. Again, the registrar was told that the OB unit was full and that the patient had been told earlier to go to another facility. The interviewee contacted the house supervisor who came to talk to the patient. The interviewee reported that the patient appeared to be in some distress. During the supervisor's discussion with the patient the registrar became involved with other duties. When the registrar observed the patient leaving the ED, he/she was informed by the house supervisor that the supervisor had to send the patient to another facility. The interviewee reported that he/she discussed the incident with his/her supervisor the following morning. The registrar also indicated that pregnant patients over twenty (20) weeks pregnant have been seen previously in the ED when the OB unit was full.

An interview (#1) was conducted at 1:00 p.m. on 09/27/11 with the Nursing House Supervisor in the Administrative Conference Room. The supervisor reported that he/she was familiar with the event and confirmed that he/she was working at the time the patient presented to the hospital. The interviewee reported that he/she was contacted by the OB nurse when the patient presented to the ED. The interviewee went to speak to the patient who requested to see the Obstetrician (Interviewee #3). The patient was informed that the Obstetrician was not available. The interviewee reported that the patient did not want to be examined in the ED but only wanted to see the Obstetrician. The interviewee stated that the family then made a decision to go to Statesboro and left the facility. The supervisor reported that once the patient had made the decision to not be examined in the ED, he/she felt that it was all right for the patient to go to another facility. According to the interviewee, the OB physician was not informed that the patient had presented to the ED. When questioned about the patient's refusal to be seen in the ED, the house supervisor confirmed that refusal for treatment had not been documented.

An interview was conducted with the Chief Nursing Officer (CNO) and Quality/Risk Manager at 4:00 p.m. on 09/26/11 in the Administrative Conference Room. The interviewees were aware that the pregnant patient presented to the ED on 09/09/11. They confirmed that patient #21 did not receive stabilizing treatment prior to leaving the facility. In addition, the interviewees reported that they were aware the the patient presented to another facility after leaving this facility. The facility failed to ensure that on 9/9/2011 that patient #21 received stabilizing treatment that was within the capability and capacity of the hospital's ED and labor and delivery unit, to minimize the risks to the individual's health, and in this case the health of the unborn child.