HospitalInspections.org

Based on medical record reviews, review of policies and procedures, review of Medical Staff Rules and Regulations, web site review, and interviews, it was determined the facility failed to provide stabilizing treatment as required that was within the capabilities of the staff and facilities that is available at the hospital prior to discharging 1 (#3) of 20 sampled patient who presented to the hospital 23 weeks pregnant and complaining of abdominal pain. Refer to findings in Tag A-2407.

Based on medical record reviews, review of facility policies, review of Medical Staff Rules and Regulations, and interviews the facility failed to effect an appropriate transfer through qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures for one (1) (#3) of twenty (20) sampled patients who was 23 weeks pregnant with preeclampsia. The facility also failed to send medical records or copies related to the emergency medical condition which the individual presented that are available at time of transfer /discharge including history, records related to the individuals emergency medical condition for 1 (#3) of 20 sampled patients. Refer to Tag A-2409.

2407
Based on medical record reviews, review of policies and procedures, review of Medical Staff Rules and Regulations, web site review, and interviews, it was determined the facility failed to provide stabilizing treatment as required that was within the capabilities of the staff and facilities that is available at the hospital prior to discharging 1 (#3) of 20 sampled patient who presented to the hospital 23 weeks pregnant and complaining of abdominal pain. Refer to findings in Tag A-2407.



Findings include:

Medical Record review for Piedmont Henry Hospital
Review of Patient #3's medical record revealed the twenty-five (25) year old patient presented directly to the facility's Labor and Delivery department on 12/1/2017 at 6:17 AM with complaints of abdominal pain. A Consent for Treatment was signed by the patient on 12/1/2017 at 6:20 AM, which included provision of Patient Rights.
The patient was triaged and examined by an RN on 12/1/17 at 6:36 AM, who noted the patient complained of right upper side abdominal pain since previous night. Vital signs were 98-73-22 182/118.
Past medical history included:
- anemia (blood lacks enough healthy red blood cells or hemoglobin),
- high blood pressure
- pre-eclampsia (condition in pregnancy characterized by high blood pressure, sometimes with fluid retention and protein in the urine) HELLP syndrome (Elevated Liver enzymes, and Low Platelet count- cells involved in clotting- syndrome. Life-threatening pregnancy complication usually considered to be a variant or complication of pre-eclampsia with previous pregnancy),
- idiopathic thrombocytopenic purpura (ITP- bleeding disorder in which the immune system destroys platelets),
- lupus (An inflammatory disease caused when the immune system attacks its own tissues),
- pulmonary embolism (blood clot in lung)
MD #1 was notified 12/1/17 at 10:16 AM and 11:49 AM, and examined the patient at 12:52 PM.
MD orders at 6:51 AM included: continuous fetal monitoring,
Abdominal ultrasound: There is a single intrauterine pregnancy in cephalic presentation. The amniotic fluid volume is subjectively normal. Impression: Single intrauterine pregnancy with an average ultrasonographic gestational age of 23 weeks and 0 days.
Labs:
- ALT (enzyme normally present in liver cells that is released into the bloodstream when the liver is damaged), result 79, reference 14
- 54 U/L
- AST (enzyme normally present in liver cells that is released into the bloodstream when the liver is damaged), result 134, reference
15 - 41 U/L
- BUN (blood urea nitrogen-test which evaluates kidney and liver function), result 11, reference 7 - 18 mg/dL
- Calcium, result 8.1, reference 8.6 - 10.2 mg/dL
CBC (complete blood count) results:
Platelets result 101, reference 130 - 400 K/uL L
RBC (red blood cells) result 3.48, reference 4.00 - 5.40 M/mm3
Hemoglobin (red protein responsible for transporting oxygen in the blood) result 10.9, reference 11.4 - 16.0 g/dL
Hematocrit (ratio of the volume of red blood cells to the total volume of blood) result 31.9 reference 34.0 - 47.0 %
Monocytes Absolute (type of white blood cell) result 0.6, reference 1.0 - 3.0 K/uL
Neutrophils Relative result 63%, no reference
- Creatinine, (chemical waste generated from muscle reactions- evaluates kidney function) result 0.71, reference 0.30 - 1.00 mg/dL
- Lactate dehydrogenase (LDH- Enzyme found in nearly all living cells. When tissues are damaged by injury or disease, they release more LDH into the bloodstream. Conditions that can cause increased LDH in the blood include liver disease, heart attack, anemia, muscle trauma), result 574, reference 135 - 225 U/L
- Total protein, result 5.9, reference 6.2 - 8.2 g/dL
- Sodium, result 138, reference 136 - 145 mmol/L
- Uric acid (produced from the natural breakdown of the body's cells and from the foods eaten), result 6.1, reference 2.5 - 6.2 mg/dL
- Type and screen, result ' O' positive, ab screen negative
- Fibrinogen (protein that is essential for blood clot formation), result 557, reference range 194 - 496 mg/dl
- RPR (screening blood test for syphilis), result non-reactive
- HIV-1 and HIV-2 antibodies (human immune deficiency virus), result negative
- Hepatitis B surface antigen, result non-reactive
- Rubella antibody, result positive
- Lactated ringer ' s solution (mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water) 1 Liter administered at 7:07 AM,
- Hydralazine (medication which treats high blood pressure) 10 mg injection every six (6) hours as needed for high blood pressure - administered at 7:07 AM
- Percocet 5-325 mg tablets, 2 tablets - administered at 8:02 AM
Vital signs were:
6:42 AM: 71 180/111
6:43 AM: 68 179/113
7:12 AM: 81 175/114
7:26 AM: 86 156/87
7:41 AM: 86 153/95
7:56 AM: 89 144/85, pain 6/10
8:11 AM: 96 162/105
8:26 AM: 92 155/101
8:41 AM: 95 132/78
8:56 AM: 97 131/80, pain 0/10
9:11 AM 89 133/78
9:26 AM 83 123/70
9:41 AM 83 124/73
9:56 AM: 81 133/80, pain 0/10
10:11 AM: 80 120/72
10:26 AM: 90 115/69
10:41 AM: 77 126/74
1:38 PM: 98.3-77-18 139/94, pain 0/10 (last set)
*Per MayoClinic.com, a normal blood pressure reading is below 120/80, although some doctors prefer to see readings lower than 115/ 75. Prehypertension occurs when the blood pressure reading is between 121/80 and 139/ 89. High blood pressure is defined as anything above 140/90. Low blood pressure occurs when the reading drops below 90/50. A diagnosis of high or low blood pressure can be made using either the systolic or diastolic reading if only one of the two measurements is outside of normal range.
Fetal heart rate via external ultrasound:
8:02 AM: 150
9:00 AM: 150
10:41: 140
11:10 AM: 140
12:20 PM: 140
*Per https://radiopaedia.org/articles/fetal-heart-rate:
Normal heart rate for 23-week fetus is approximately 130 bpm, with a beat-to-beat variation of approximately 5 to 15 beats per minute can be allowed.

Medical Record Review for Hospital B.
Review of Patient #3's medical record from Hospital B revealed the twenty-five year old patient presented to the facility on 12/1/2017 at 4:15 PM with complaints of high blood pressure.
A History and Physical examination was performed by MD #9 on 12/1/2017 at 6:17 PM, which noted the patient was twenty-five (25) weeks and one (1) day pregnant, and had a history of lupus, pulmonary thrombo-embolus (blood clot in lung) in 2010 and 2015, idiopathic thrombocytopenic purpura (ITP), multiple blood transfusions, and migraines
The patient was admitted for evaluation/management of elevated BP and abnormal liver function tests (LFT) and decreased platelets. The MD noted that the patient had experienced RUQ pain the previous PM that became progressively worse overnight. Her BP was 170/120 at home. Patient immediately went to Henry Medical Center (HMC) for evaluation where she was noted to have elevated BPs and abnormal PIH labs. She was discharged home with instructions to go to Facility B
triage or her OB's office immediately for evaluation. Due to concerns for unsupervised care in a patient with possible HELLP, the patient requested transfer by ambulance. MD #9 had spoken to MD #1 at HMC and voiced concerns for discharge and offered to accept the patient as a transfer to S Facility B, however the concerns were not considered and the patient was told by the social worker since she was already discharged, and MD #1 felt she did not need to be transferred, she would have to pay for an ambulance to transfer her. At that point, the patient voiced frustration and decided to leave and presented to Facility B for evaluation.
Abnormal labs at 4:35 PM
- Red cell distribution width (RDW) result 17.2, reference 13.2-15.2
- Platelet count result 112, reference 140-440
- Creatinine result 0.6, reference 0.7-1.2
- AST result 180, reference 5-40
- ALT result 96, reference 7-56
- Lactate Dehydrogenase result 717, reference 91-180
4:54 PM: BP 173/110, Hydralazine 10 mg IV given
6:10 PM fetal heart rate: 135
6:12 PM BP: 142/86
6:35 vital signs: 98.1, respiratory rate 16, oxygen saturation 99%
12/1/2017 orders included:
- Admit to Labor and Delivery
- Neuro checks every 4 hours
- Continuous fetal monitoring until BP stable and/or uterine contractions
- Hourly pulse oximetry
- Urinary catheter to bedside drain bag, Strict intake and output (I&O)
- Seizure precautions
- Continuous Sequential compression device
- laboratory studies
- Ultrasound
- Hydralazine 10 mg IV
- Magnesium Sulfate, 4 grams in 100 ml, 25 ml per hour, (treatment of early labor)
- Lactated Ringers solution, 1 liter,
- Celestone Soluspan 30 mg IM (steroid, used to treat inflammation)
- Magnesium Sulfate, 40 grams in 1,000 ml, 2 gm per hour drip
- Heparin 5000 unit ' s subcutaneous injection every 12 hours (treats/prevents blood clots)
- Percocet 5/325 mg, 2 tablets by mouth
A consultation was performed by MD #10 on 12/2/2017 at 9:10 AM, with recommendations as follows:
1. Close maternal and fetal surveillance
2. Currently not on BP meds. BP meds (IV or PO) as needed to keep BP 120/80-160/105
3. Continue prophylactic dose Heparin
4. Serial labs (daily for now)
5. Needs umbilical artery Dopplers for IUGR
6. Magnesium for neuro-protection and for seizure prophylaxis while patient being evaluated; d/c after 24 hours if no plans for delivery
7. Complete antenatal steroids
8. Complete 24-hour urine collection
9. Neonatology consultation
12/10/2017 at 1:26 AM: vital signs - heart rate 85, BP 162/108. Received Hydralazine 5 mg IV

12/10/2017 at 2:14 AM: variable deceleration (various decrease in heart rate) noted, patient repositioned, O2 at 10 liter/minute via non-rebreathable face mask. MD notified, order received to continue very close fetal surveillance. Fetal heart rate 140.
12/10/2017 at 3:15 AM: MD in unit, evaluated fetal heart tracing. Instruction received to prepare patient for cesarean section due to category 2 tracing and severe pre-eclampsia.
12/10/2017 Operative Report for primary emergent classical cesarean section
Pre-operative diagnosis: 25-year-old at 26 weeks and 3 days with intrauterine growth restriction (IUGR- weight below the 10th percentile for gestational age) and severe pre-eclampsia with SLE, Lupus flare, ITP, history of pulmonary embolus two occasions, delivered for deteriorating fetal status with multiple severe variable decelerations and known absent end diastolic flow (indicates fetal vascular stress), breech presentation (bottom first instead of head first position).
A one (1) pound, four (4) ounce female baby was delivered at 5:35 AM. Apgar score (method to summarize health of a newborn on scale of 0-10; 7-10 is excellent condition) 8 and 9. Patient tolerated the procedure well.

Interviews
Interview with MD #1 on 12/13/2017 at 2:00 PM in the conference room revealed that he/she had been on staff since 2013, and had practiced in the Atlanta area for seven (7) years prior. The MD stated that he/she currently only worked at Piedmont Henry Hospital, and was on-call for the emergency room. MD #1 confirmed that he/she had been trained in EMTALA in 2017.
On review of Patient #3 ' s medical record, he/she stated that he/she was aware of the patient's history of Lupus and of having Hemolysis (the rupture or destruction of red blood cells), HELLP with her previous pregnancy. The physician explained that it was the first time he/she had seen Patient #3, and her complaint was upper right abdominal pain. He/she went on stating that the patient's hemoglobin was 10.9, hematocrit was 31.9, platelets were low; uric acid, BUN, creatinine, and bilirubin (pigment formed in the liver by the breakdown of hemoglobin) were normal; ALT and AST were elevated. An ultrasound confirmed the patient was twenty-three weeks, and was normal. Fetal heart tones were also normal.
The MD stated that provided treatment was based on physical examination, results of laboratory studies, and elevated blood pressure. He/she stated further that in the situation, he/she would be attempting to rule out chronic hypertension (high blood pressure), pregnancy induced hypertension (PIH), exacerbation (worsening) of lupus, and rule out pre-eclampsia.
MD #1 explained that Patient #3's regular obstetrical (OB) physician had telephoned him/her due to the patient requesting to be seen in the office, as he/she had instructed, but the OB physician wanted the patient to be seen in Facility B triage. MD #1 also stated that the patient's blood pressure was under control, and he/she and the patient's regular OB physician wanted the patient to receive continued evaluation and further care. He/she stated that he/she believed the patient was stable and it was okay for her to be seen by her regular OB physician due to her blood pressure being normalized and her pain being resolved. MD #1 further stated that he/she had never reached a conclusion on a discharge diagnosis. He/she went on stating that an elevated blood pressure on admission had not met the definition of HELLP; that the patient was stable enough for continued care by her OB physician, and that the patient's OB physician had instructed him/her of where he/she wanted that to happen. MD #1 explained that he/she would not have discharged Patient #3 if he/she had felt the patient was unstable. He/she further stated that he/she had routinely taken care of high risk patients, patients with a multitude of diagnosis, and other provider's patients; and, took pride in being able to do so.



Telephone interview with RN #7 on 12/13/2017 at 2:45 PM revealed that he/she had worked at the facility as an OB RN for approximately twenty (20) years, and received EMTALA training annually. The RN recalled Patient #3's visit, stating that he/she had received report on Patient #3 at about 7:30 AM. RN #7 explained that the patient had complained of right upper quadrant pain, and elevated blood pressure, which had already been treated, and was trending down. Patient #3 was still complaining of right upper quadrant pain. The RN stated that he/she assessed the patient, and found no other symptoms related to pre-eclampsia or HELLP syndrome, such as headache, blurred vision, spots before eyes, hyperreflexia, facial edema, edema in hands or feet, and epigastric (upper stomach) pain. He/she stated that the patient was very dehydrated, and had not voided until discharge. RN #7 stated that he/she had spoken to MD #1, informing him/her of the assessment, and the MD had ordered two (2) tablets of Percocet (Tylenol and narcotic pain medicine) for the pain. The RN stated that after administering the Percocet, the patient's blood pressure had gone down significantly, and the patient had fallen asleep. On reassessment of Patient #3, the patient denied pain on palpation (touch), and stated that he/she felt much better.
RN #7 explained that he/she spoke to MD #1, who gave him/her discharge instructions for the patient. Although the patient had an appointment with her primary OB physician, MD #1 wanted her to receive follow up that day. RN #7 stated that Patient #3 had telephoned her primary OB physician's office to request an earlier appointment, but was unsuccessful. The RN stated that he/she had also provided information to the office while the patient was on speaker phone, and the office had said they would get back to the patient regarding being seen. RN #7 stated that he/she had left the patient's room to prepare the discharge, when the patient's primary OB physician had telephoned the nurse ' s station asking for him/her. The primary OB physician had stated that he/she had reviewed the patient's chart via EPIC (electronic medical record system), and asked questions about the patient's vital signs. The primary OB physician stated that he/she wanted the patient to go to the hospital. RN #7 stated that he/she informed the physician that would be a MD to MD request, and provided the physician with MD #1's phone number.
Policies and Procedures/ Medical Staff, Podiatry/Dentist, Allied Health Professional, Rules and Regulations
Review of facility policy #3663432, Transfer Activities in Accordance with EMTALA Requirements, originated 2/1/2012, last reviewed 4/1/2014, version effective 5/30/2017, revealed:
3. Definitions
Stabilized or to Stabilize -
A. With respect to an emergency medical condition:
- That no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of an individual from the hospital; or
- To provide such medical treatment of the condition as is necessary to assure, within reasonable
medical probability, that no material deterioration of the condition is likely to result from or occur
during the transfer of the individual from the Hospital
4. Policy
It is the policy of Piedmont Healthcare that Piedmont Healthcare Hospitals shall abide by the requirements set
forth in EMTALA regulations for patients presenting to the hospital seeking emergency treatment by:
- Providing necessary stabilizing treatment for emergency medical conditions and labor.

Review of Piedmont Henry Hospital, Henry County, Stockbridge, GA, Medical Staff, Podiatry/Dentist, Allied Health Professional, Rules and Regulations, current version - revised - Revised January 2012, revealed:
Article III. Transfer:
Patients transferred or discharged to other facilities require the physician and hospital to do the following:
C. Provide necessary stabilizing treatment for emergency medical conditions and women in labor

The facility failed to ensure that an individual (#3) with an emergency medical was stabilized as required prior to discharge as evidenced by telling patient #3 on 12/1/2017 to go directly to facility B for continued evaluation and further care. As Piedmont Henry Hospital was equipped with such staff, services, or equipment necessary to stabilize the patient.

2409

Based on medical record reviews, review of facility policies, review of Medical Staff Rules and Regulations, and interviews the facility failed to effect an appropriate transfer through qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures for one (1) (#3) of twenty (20) sampled patients who was 23 weeks pregnant with preeclampsia. The facility also failed to send Facility Ball medical records or copies related to the emergency medical condition which the individual presented that are available at time of transfer /discharge including history, records related to the individuals emergency medical condition
for 1 (#3) of 20 sampled patients.

Findings include:


Medical Record review for Piedmont Henry Hospital

Review of RN #7 nursing notes on 12/1/2017 at 11:49 AM revealed:
Patient #3 received discharge orders from MD #1 after he/she had reviewed labs and blood pressure; and, was aware that right upper quadrant (RUQ) pain was resolved with pain medications, blood pressure normalized. The patient was unable to obtain an appointment with her OB office the same day as a walk in per MD #1 request. RN #7 spoke to the patient's OB office to express MD #1's request. After a short while, the patient's private OB physician called to review the chart with RN #7. The patient's private OB physician was willing to receive the patient, but requested that she be transferred by ambulance. RN #7 informed the patient's private OB physician that he/she needed to speak to MD #1 directly, and a phone number was provided.
Approximately ten (10) minutes later, MD #1 phoned RN #7, stating that he/she had spoken to the patient's private OB physician and he/she was fine with the patient going to Facility B by family transport, not by ambulance, and the patient had agreed. RN #7 noted that he/she had spoken to his/her charge nurse, and manger. In turn, they had spoken to the Manager of risk management. Patient #3 was made aware of her options to be transferred by ambulance or have her brother drive her directly to Facility B, with the understanding she is to go directly to the triage area.
At 11:54 AM, the patient called out to RN #7 stating that she had spoken to her private OB physician, and requested to be transferred to Facility B via ambulance. RN #7 informed the patient that he/she would speak with his/her charge nurse for information on how to implement her request and let her know. RN #7 noted that the patient was symptom free at the time- blood pressure had normalized, and the patient had denied RUQ pain since pain medication took effect. The patient had stated that she wanted to go to Facility B via ambulance because her OB/GYN had recommended her that she do so.
At 1:30 PM, RN #7 noted that the Case Manager was in to see the patient, had discussed the mode of discharge and the patient's request of transport to Facility B by ambulance per her OB/GYN request. The patient decided to call her brother and have him take her directly to. Facility B. Patient verbalized understanding of symptoms of preeclampsia and denied contractions or any further RUQ pain since medications administered. The patient also denied headaches or any visual changes at the time.
On 12/1/17 at 3:04 PM, the patient was discharged via wheelchair in stable condition to her brother's car. The patient and her brother were aware that they should go to Facility B triage.
The record did not contain a discharge diagnosis, but did note HELLP not diagnosed, BP normal, pain resolved.
Discharge instructions were provided on pre-eclampsia and eclampsia. Instructions included directive to follow up immediately with OB MD at Facility B triage. (Office visit not possible per OB MD)
*Distance from Piedmont Henry Hospital to Facility B per Google maps is twelve (12) miles.

Medical Record Review for Hospital B.
The medical record review reveled in part, that Patient #3 was discharged home with instructions to go to Facility B triage or her OB's office immediately for evaluation. Due to concerns for unsupervised care in a patient with possible HELLP, the patient requested transfer by ambulance. MD #9 had spoken to MD #1 at HMC and voiced concerns for discharge and offered to accept the patient as a transfer to facility B, however the concerns were not considered and the patient was told by the social worker since she was already discharged, and MD #1 felt she did not need to be transferred, she would have to pay for an ambulance to transfer her. At that point, the patient voiced frustration and decided to leave and presented to Facility B for evaluation.

Interviews

An interview with MD #1 on 12/13/2017 at 2:00 PM was conducted in the conference room. MD #1 stated that he/she and the other OB physician agreed that Patient #3 would be evaluated in Facility B triage, and the OB physician asked if the patient could be transported by ambulance. MD #3 stated that he/she had responded that the patient was stable enough to be transported by private vehicle because the drive was seven (7) minutes or less, and the patient's brother was present available to transport. MD #1 explained that the nurse had reported the patient and her brother were agreeable to a private vehicle transport. MD #1 further stated that as he/she and the other OB physician finished their conversation, and the OB physician stated that since MD #1 had evaluated the patient, it was his/her call to make. He/she and the primary OB physician had no further correspondences. MD #1 stated that after the conversation with the OB physician, he/she telephoned the nurse to inform him/her that he/she was comfortable with Patient #3 being transported by personal vehicle. MD #1 also stated that he/she had waited on the phone while the nurse explained the instructions/recommendations to assure the patient understood, was able to go to triage immediately, and did not have questions or concerns. MD #1 stated that he/she heard the conversation, and the patient had confirmed such, and wanted to be seen by her primary physician. MD #1 stated that he/she had never reached a conclusion on a discharge diagnosis. He/she went on stating that an elevated blood pressure on admission had not met the definition of HELLP; that the patient was stable enough for continued care by her OB physician, and that the patient's OB physician had instructed him/her of where he/she wanted that to happen. MD #1 explained that he/she would not have discharged Patient #3 if he/she had felt the patient was unstable. He/she further stated that he/she had routinely taken care of high risk patients, patients with a multitude of diagnosis, and other provider's patients; and, took pride in being able to do so. MD #1 stated that he/she had not instructed the nurse to provide discharge instructions on eclampsia/pre-eclampsia, adding that it may have been routine for high blood pressure. MD #1 also stated that he/she was not aware of the nursing discharge process regarding obtaining vital signs, and was unsure of whether there was a delay in discharging the patient. A blood pressure of 139/94 was only a mild elevation, and could be considered acceptable.+
A telephone interview with RN #7 on 12/13/2017 at 2:45 PM. RN #7 explained that he/she spoke to MD #1, who gave him/her discharge instructions for the patient. Although the patient had an appointment with her primary OB physician, MD #1 wanted her to receive follow up that day. RN #7 stated that Patient #3 had telephoned her primary OB physician's office to request an earlier appointment, but was unsuccessful. The RN stated that he/she had also provided information to the office while the patient was on speaker phone, and the office had said they would get back to the patient regarding being seen. RN #7 stated that he/she had left the patient's room to prepare the discharge, when the patient's primary OB physician had telephoned the nurse ' s station asking for him/her. The primary OB physician had stated that he/she had reviewed the patient's chart via EPIC (electronic medical record system), and asked questions about the patient's vital signs. The primary OB physician stated that he/she wanted the patient to go to the hospital. RN #7 stated that he/she informed the physician that would be a MD to MD request, and provided the physician with MD #1's phone number. MD #1 had telephoned later stating that he/she had spoken to the primary OB physician, they had discussed discharge, and, that the patient was stable, and fine to be discharged. MD #1 also stated that the primary OB physician wanted Patient #3 to go to Facility B, and asked if the patient had transportation. RN #7 stated that he/she asked Patient #3 if she had transportation, and she said that her brother was in the car napping. MD #1 then instructed RN #7 to ask the patient if she felt comfortable going to Facility B with her brother, as her primary OB physician had requested. Patient #3 answered "yes". RN #7 then had asked the patient if she had any further symptoms or pain, to which the patient answered "no", she was fine. After exiting the room to prepare the discharge paperwork, RN #7 received a telephone call from the (undischarged) patient. The patient had stated that her primary OB physician had telephoned her, requesting that she be transported to Facility B by ambulance. RN #7 stated that he/she had told the patient that he/she would speak to the manager about the process, which might take a little time, and get back to the patient. RN #7 stated that he/she asked the patient the reason for the request, and the patient had stated that it was what her physician wanted, confirming that she had no further symptoms. RN #7 stated that he/she had spoken to the charge nurse, who spoke to the manager, and they had kept following up until they received an answer, which was: Did the physician (#1) consider the patient to be stable, and order discharge? RN #7 stated that he/she answered "yes". The case manager had told the RN, that given the circumstances, the mode of transportation and cost would be the patient's choice. The case manager had spoken to the patient at her bedside, informing her of the situation. The patient had stated "no, my brother will take me". The RN stated that the patient had no further symptoms, and that he/she had discharged the patient. The RN stated that he/she usually obtained vital signs every couple of hours, but it depended on the patient's condition. He/she did not recall the patient's blood pressure going back up to 139/94, and stated that he/she may have taken vital signs again if he/she had seen the blood pressure was rising. He/she explained that the patient was sitting up making and receiving phone calls prior to discharge.

Policies and Procedures / Medical Staff, Podiatry/Dentist, Allied Health Professional
Review of facility policy #3608858, Transfers from the Emergency Department, originated 10/1/2008, version effective 1/1/2017, revealed the Emergency Department would arrange transfer of patients when it is in the best interest of the patient, or per the patient ' s request.

Review of facility policy #3663432, Transfer Activities in Accordance with EMTALA Requirements, originated 2/1/2012, last reviewed 4/1/2014, version effective 5/30/2017, revealed:
3. Definitions
a. 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;
b. The receiving facility:
- Has available space and qualified personnel for the treatment of the individual, and
- Has agreed to accept transfer of the individual and to provide appropriate medical treatment;
c. The transferring hospital sends to the receiving facility all medical records (or copies) related to the emergency condition which the individual has presented that are available at the time of the transfer.
d. 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 transfer. Private vehicles
do not meet these requirements, however a patient or guardian who is legally and mentally capable of
making decisions on behalf of the patient, may sign a refusal of ambulance transport which clearly
outlines the risks of such refusal.
In Labor and Delivery:
- Any RN or Certified Nurse Midwife in the L&D Department may perform the medical screening in
consultation with a physician.
- The RN, after a reasonable time of observation, will consult with the physician who will determine whether
the patient is in "false labor" as well as whether the patient should be discharged or admitted.
4. Policy
It is the policy of Piedmont Healthcare that Piedmont Healthcare Hospitals shall abide by the requirements set
forth in EMTALA regulations for patients presenting to the hospital seeking emergency treatment by:
- Providing an appropriate transfer if the hospital does not have the capability or capacity to provide the
treatment necessary to stabilize the emergency medical condition.

Review of Piedmont Henry Hospital, Henry County, Stockbridge, GA, Medical Staff, Podiatry/Dentist, Allied Health Professional, Rules and Regulations, current version - revised - Revised January 2012, revealed:
Article III. Transfer:
Patients transferred or discharged to other facilities require the physician and hospital to do the following:
F. Ensure that the transfer of an unstable individual is effected through qualified personnel and transportation equipment, including the use of medically appropriate life support measures;
G. A physician member of the medical staff, or a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) in consultation with a physician shall perform medical screening examinations on patients being considered for discharge/transfer from this facility. The risk/benefits of transfer will be documented on a certification form and signed by the physician

The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure he transfer of patient #3 on 12/1/2017, 23 weeks pregnant with preeclampsia, was effected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures; instead Patient #3 was transported to Facility B in a POV driven by her brother. The facility also failed to ensure that copies of all medical records related to Patient #3's emergency medical condition was sent with the patient on 12/1/2017.