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During EMTALA investigation of complaint number TN45036 completed 8/7/18 - 8/9/18 at Starr Regional Medical Center, the facility was found to be out of compliance with Responsibilities of Medicare Participating Hospitals in Emergency Cases 42 CFR PART 482 for failing to provide an appropriate Medical Screening Examination (MSE) for one patient (#1) of 33 Emergency Department (ED) patients reviewed. The facility's failure resulted in Patient #1 presenting to the Emergency Department (ED) at the facility's satellite campus in Etowah on 7/13/18 at 5:32 PM with a complaint of low back pain, pelvic pain, and hematuria. Patient #1 was diagnosed with Pregnancy and UTI and was discharged home at 9:16 PM. Patient #1 presented approximately 9 hours later to the facility's main campus in Athens on 7/14/18 at 6:28 AM with a 42 week old, 6 pound 5 ounce male infant she delivered in her car just prior to arriving at the main campus.

For documentation purposes:

Hospital A is Starr Regional Medical Center's Main Campus, located at 1114 West Madison Ave, Athens TN 37371. This facility has obstetric services with an obstetric physician on-call, a labor and delivery unit, and a neonatal nursery.

Hospital B is Starr Regional Medical Center's Etowah Campus, a satellite facility of the Main Campus. The Etowah Campus is located at 866 Highway 411 North, Etowah TN 37331, 10 miles from the main campus. The Etowah Campus does not have any obstetrical services, but is equipped for precipitous deliveries and has a physician present in the Emergency Department 24 hours each day.

Refer to A-2406

Based on facility policy review, medical record review, and interviews, the facility failed to provide an appropriate medical screening examination (MSE) for 1 patient (#1) of 33 Emergency Department (ED) patients reviewed. The facility's failure to provide an appropriate MSE for Patient #1 resulted in the patient being discharged home from Hospital B on 7/13/18 at 9:16 PM with a diagnosis of pregnancy and urinary tract infection, and giving birth in her car on 7/14/18 at 6:15 AM (approximately 9 hours later) while on her way to Hospital A.

The findings included:

Review of facility policy "Emergency Screening Stabilization/Transfer/250 Yard Rule and EMTALA" effective date 5/2018, revealed "...Any individual who comes to the hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate medical screening examination by a physician or other qualified medical provider to determine whether or not an emergency medical condition exists...Labor means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contraction is in true labor unless a physician, certified nurse-midwife, or qualified medical personnel acting within his or her scope of practice as defined in hospital staff medical by-laws and State Laws certifies, after a reasonable period of observation, the woman is in false labor...A Medical Screening Examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred...[Hospital B] campus does not provide obstetric services...Patients who present to the Emergency Department at [Hospital B], who are pregnant, will have a MSE by the ED physician or QMP [qualified medical professional] in the ED...If the chief complaint is pregnancy related and/or the patient is in labor, the ED physician or the QMP will consult the [Hospital A] campus on call obstetrician. A decision will then be made whether the patient can be safely transferred to the [Hospital A] Campus...If the patient cannot be safely transferred to [Hospital A]...the [Hospital B] campus is equipped for precipitous delivery. Both Mom and Baby will be transferred to [Hospital A] campus after delivery..."

Medical record review from Hospital B's revealed Patient #1 presented to the ED on 7/13/18 at 5:32 PM with a complaint of low back pain, pelvic pain, and hematuria (blood in the urine).

Medical record review of a nurse's notes from Hospital B dated 7/13/18 at 5:39 PM revealed "...low back pain, pelvic pain, hematuria starting today. Possibility of pregnancy/missed cycle...complains of pain in pelvis, low back...17:44 [5:44 PM] LMP [last menstrual period] 5/1/2018..." Further review revealed the patient was assessed with a pain level of 9 (on a 1-10 scale with 10 being extreme pain). Continued review revealed the patient's pain level at 6:56 PM was 8 and at 9:12 PM her pain level was 0. Further review revealed the patient was administered Zofran (medication for nausea) 4 milligrams (mg) by mouth (po) at 6:39 PM, Toradol (used to treat pain) 30 mg intravenously (IV) at 6:41 PM, Rocephin (antibiotic) 1 gram IV at 8:57 PM, and Tylenol 650 mg PO at 8:57 PM.

Medical record review of a physician's notes from Hospital B dated 7/13/18 at 6:20 PM revealed "...patient presents with pain that is acute. The symptoms are located in the low back. The pain radiates to the pelvis...at their worse the symptoms were a 9 out of 10. The patient has not experienced similar episodes in the past. Denies h/o [history of] kidney stones but does have family h/o kidney stones...Patient asked about possibility of pregnancy and said that she missed her last menses...LMP 5/1/2018...the patient appears in obvious pain...sitting upright and rocking, unable to get comfortable...Exam...Abdomen/GI [gastrointestinal] Inspection: distension that is moderate...GU [genitourinary]: CVA [costovertebral angle/lower back area over the kidneys] tenderness, on the left..." Further review of a physician's note written at 7:10 PM revealed "...awaiting urine pregnancy test results prior to obtaining CT [computed tomography] Scan for suspected kidney stones..." Continued review of a physician's note written at 8:53 PM revealed "...Pt [patient] has a + [positive] pregnancy test and a UTI so she was given Rocephin IV and will f/u [follow up] with [Obstetrician] on Monday...beta quant [beta quantitative HCG, a blood pregnancy test] is pending and pt will call for results...I had a detailed discussion with the patient and/or guardian regarding: the need for outpatient follow up, an OB/Gyne [gynecologist] specialist..." Further review of a physician's notes at 9:02 PM revealed "...Discharge to home. Impression: pregnancy, UTI...Condition is stable..." Further review revealed no documentation a pelvic examination was completed.

Medical record review of a discharge note from Hospital B dated 7/13/18 at 9:16 PM revealed Patient #1 was discharged home in stable condition with diagnosis of "...pregnancy, UTI [urinary tract infection]..."

Medical record review from Hospital A of a labor and delivery (L&D) Flowsheet for Patient #1 dated 7/14/18 at 6:28 AM revealed "...PATIENT ARRIVED ON THE LABOR DECK AFTER DELIVERY OF INFANT IN CAR ON WAY TO HOSPITAL. PATIENT STATES SHE HAS HAD NO PRENATAL CARE AND DID NOT KNOW SHE WAS PREGNANT..."

Medical record review of an Admission History and Physical from Hospital A dated 7/14/18 at 6:45 AM revealed "...Pt delivered a baby in her car while driving to the hospital...The patient arrives to L&D with placenta still inside her. Pt was seen last night in ER [emergency room] at [Hospital B] campus and told had UTI pregnant but may be having a threatened SAB [spontaneous abortion/miscarriage] or kidney stone. She was then diagnosed with an UTI and sent home. Pt continued to have bladder spasms (ctx) [contractions] and then drove to our [Hospital A] campus when she delivered her baby boy in the car...she denies any ROM [rupture of membranes/water breaking] prior to delivery of baby..." Further review revealed the patient was discharged home on 7/16/18.

Medical record review of a Newborn Discharge Summary from Hospital A revealed Patient #1 delivered a baby boy on 7/14/18 at 6:15 PM with a gestational age determined by exam, of 42 weeks. Further review revealed the infant weighed 6 pounds and 4 ounces at birth and was a "...precip [unexpected/unprepared for] delivery in vehicle..." Continued review revealed "...Transfer to [named acute care hospital] NICU [neonatal intensive care unit] for NAS [neonatal abstinence syndrome/drug withdrawal] symptoms...7/16/18 time 0433 [4:33 AM]..."

Interview with Physician #1, in the ED Director's office at Hospital B, on 8/8/18 at 8:50 AM revealed he remembered examining Patient #1 on 7/13/18 and he was very surprised when he learned the patient had delivered a baby the next day. Continued interview revealed when he examined the patient she did not appear pregnant at that time, but appeared uncomfortable to him. Further interview revealed he did not suspect she was in labor, because the patient told him she had missed only her last menstrual period. Continued interview revealed he suspected a kidney stone and planned to have a CT Scan ordered if her pregnancy test was negative. Further interview revealed he turned the patient's care over to Physician #2 at the change of shift.

Telephone interview with Physician #2 at Hospital B on 8/8/18 at 10:20 AM revealed he remembered treating Patient #1 on 7/13/18 and he took over care of Patient #1 from Physician #2 at the change of shift on 7/13/18. Continued interview revealed he had no suspicion the patient might be in labor and the patient told him she had missed only one menstrual period. Further interview revealed he remembered telling the patient and her significant other (SO) of the positive pregnancy test and stated they were both very surprised and happy and wanted to know how far advanced the pregnancy was. Continued interview revealed Physician #2 ordered the beta quantitative HCG test to determine the stage of the patient's pregnancy, but the patient and SO wanted to leave prior to the test results because the SO needed to go to work. Further interview revealed the patient appeared in no distress or discomfort and desired to go home. Continued interview revealed there were no signs or symptoms of labor and he felt the patient had a UTI or possibly a kidney stone and believed she was in stable condition with no emergency medical conditions when he discharged her home.