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Based on review of the ED log, Family and Birth Center log, Medical Staff Rules and Regulations, policies and procedures, tour, staff interviews, observations, credential files, and personnel files, it was determined that the facility failed to comply with §489.24 for one ( Patient #1) of 23 sampled medical records when Patient #1 presented to the Obstetric (OB - related to childbirth) assessment area requesting services for a possible emergency medical condition.

Findings were:

1. Cross refer to A-2406, as it relates to failure to provide an appropriate medical screening examination for Patient #1.

Based on review of the ED log, Family and Birth Center log, policies and procedures, tour and staff interviews, it was determined that the facility failed to create a medical record for one (1) of 23 sampled medical records when Patient #1 presented to the Obstetric (OB - related to childbirth) assessment area requesting services for an evaluation of a possible emergency medical condition.

Findings were:

Cross refer to A-2405, as it relates to failure to enter Patient #1 into the OB log.

On 5/13/19 at 10:15 a.m. during a tour of the ED, the Assistant Vice President (AVP) GG confirmed that entering a patient into the ED central log automatically generates a medical record.

On 5/13/19 at 10:40 a.m. during a tour of the Family Birth Center, the Director DD of the Family Birth Center explained that entering a patient into the Family and Birth Center log automatically generates a medical record. Director DD stated Patient #1 was not entered into the Family and Birth Center log and therefore, there was no medical record generated for the patient.

The facility's failure to enter Patient #1 into the facility's Central Log resulted in the facility's failure to create a medial record for Patient #1 when she presented to the emergency department. The facility's policy does not adequately address CFR489.20(r).

Based on review of the ED log, Family and Birth Center log, policies and procedures, tour and staff interviews, it was determined that the facility failed to ensure that all patients who present requesting services were entered into the central log, when one (1) of 23 sampled medical records, Patient #1 presented to the Obstetric (OB - related to childbirth) assessment area requesting services for a possible emergency medical condition.

Findings were:

During the entrance conference on 5/13/19 at 10:00 a.m. with the System Director of Accreditation, System Manager of Accreditation and the Accreditation Improvement Consultant, a request for the Emergency Department (ED) central log and Family and Birth Center central logs were requested. A review of both logs revealed Patient #1 had not been entered into either of these logs as of 5/13/19 at 10:40 a.m.

Review of facility policies and procedures included but was not limited to the following:
I. ADMISSION PROCEDURE, no policy number, last revised 5/8/2018, revealed the purpose was to provide guidelines for admission procedures (within Mother Baby departments).
PROCEDURE:
1. Enter the patient into the online documentation system (OB log).
14. Complete documentation: assessments, communication with patient ' s primary care provider, interventions and patient teaching, patient response to teaching and understanding.

II. Medical Screening Exam (MSE) for patients presenting with OB complaints, no policy number, last revised 5/8/2018, revealed the purpose was to establish guidelines for medical screening and triage procedures for OB patients presenting to OB Assessment. Also included is the process referrals made by the ED of patients requesting an obstetrical MSE. These guidelines outline the appropriate medical examination/referral of OB patients with non-obstetrical chief complaint.
PROCEDURE:
1. Patients shall not be denied evaluation, treatment or stabilization on the basis of means to pay, race, creed, color, national origin, age, sex or actual or perceived disability. Patients shall not be denied evaluation, treatment or stabilization on the basis of their presenting complaint, condition, or lack of physician on the medical staff of this hospital.
2. All obstetrical patients 14 weeks or greater with an obstetrical problem who arrive in the ED will be directed to the OB Assessment Unit with the exception of pregnant trauma patients. If the patient is less than 14 weeks gestational age, presents with a non-obstetrical problem, or is a trauma patient, she will be cared for and receive the MSE as all other Emergency Service patients.
OB ASSESSMENT ADMISSION LOG PROCEDURE
1. Time In.
a. Log in the time the patient arrives at the OB Assessment window.
b. If the patient has been out to walk, log in the time they return to OB Assessment for further evaluation.
2. Time Out
a. Log in the time the patient leaves OB Assessment or Overflow Assessment rooms after the decision is made for their final disposition.
b. If the patient is being sent out to walk, log them out at the time they leave the room.
--Name - Include the patient ' s full name with last name first.
--Expected Date of Confinement (EDC) - Log in their due date - to be confirmed by their prenatal record.
--Estimated Gestation Age (EGA) - Log in their estimated gestational age in weeks- to be confirmed by their prenatal record.
--Chief Complaint/Reason for Admission.
a. Log in the reason they are presenting to OB Assessment.
b. If the patient was sent out to walk and is now returning, write in " return from walking " .
--Physician - Log in the physician they are seeing for prenatal care.
a. Faculty- write in Faculty, not the actual physician that may be following them.
b. Family Practice - write in FP and actual FP physician who is following them.
c. Health Department/Neighborhood Health Center - write in Faculty as these are the physicians that will be following these patients.
d. Private - write in the physician ' s name or the group ' s initials.
--Disposition on arrival - Log in the room that the patient is placed in on arrival to OB Assessment.
a. OB 1, OB 2, OB 3, OB 4.
b. Overflow rooms - 355, 357, 359.
c. L&D room (LDR) number/Recovery Room (RR) bed number.
--Disposition on transfer/discharge - Log in where the patient goes after their assessment time is complete.
a. LDR room number or RR bed number if admitted to L&D.
b. LDR POD room number if admitted to those rooms.
c. Room number on Perinatal floor if admitted to that area.
d. Home - if discharged home.
e. Other - be specific if sent to another area (lab, X-Ray, doctor's office, another floor, operating room, ED, etc.)
f. Out to walk - If patient is sent out to walk, write in " sent out to walk " .
g. Leave without treatment (LWOT).
h. Leave AMA. Counseling documented, and AMA forms signed by patient and witness.
MEDICAL SCREENING INFORMATION AND DOCUMENTATION TOOL:
All OB patients seeking medical treatment will be triaged immediately by the OB RN/ Qualified Medical Professional and findings documented on the Obstetric Triage/MSE Record. Triage criteria include the following parameters:
Class I and II = Emergent/Urgent - Patients who are actively laboring or present with conditions requiring immediate evaluation and therapeutic intervention.
Class III = Non-Urgent - Patients with presenting complaints, which do not require immediate evaluation and therapeutic intervention.
Examples of Class I and II complaints included:
i. Abdominal pain - unknown etiology.
All obstetrical patients triaged as class I or II will have an immediate obstetrical screening exam performed by the OB RN/ QMP.
PATIENTS LEAVING AGAINST MEDICAL ADVICE
If a pregnant patient decides to leave prior to receiving a medical screening or treatment, the OB RN/ QMP will counsel the patient regarding the risks of leaving without treatment. The OB RN/ QMP will document the counseling on the MSE Record along with having the patient sign the AMA forms.

On 5/13/19 at 10:15 a.m. during a tour of the ED, the Assistant Vice President (AVP) GG confirmed that entering a patient into the ED central log automatically generates a medical record.

On 5/13/19 at 10:40 a.m. during a tour of the Family Birth Center, the Director DD of the Family Birth Center explained that entering a patient into the Family and Birth Center log automatically generates a medical record. Director DD stated Patient #1 was not entered into the Family and Birth Center log and therefore, there was no medical record generated for the patient.

During an interview on 5/13/19 at 10:10 a.m. in the Quality Conference Room, RN EE explained that she has worked at the hospital for since January 2015 and has worked in the Family and Birth Center since July 2018. RN EE stated she began training to work OB assessment in March 2019. RN EE confirmed that on 4/30/19 she had the OB assessment phone and received a call from Triage Assistant/Emergency Medical Technician (TA/EMT) CC informing her that he was bringing a 34 weeks pregnant patient up. RN EE said that she asked the name of the patient's physician and after being informed of the physician's name she told TA/EMT CC that the patient's physician did not have privileges. RN EE said she told AT/EMT CC that typically that physician's patients are seen at another local hospital. RN EE said that she met the patient at the door to the OB assessment area and when the patient provided the name of her doctor I (RN EE) explained that the patient's doctor did not have privileges, and practiced at another local hospital. RN EE said Patient #1 asked if anyone else could see her and I (RN EE) said yes but it won't be your doctor and your doctor won't be involved with your care. RN EE said the patient said she would rather go to the other hospital and be treated by her doctor. RN EE said she did not try to get the patient to sign an AMA form. RN EE explained that the process for patients presenting to the OB assessment area include the following:
--registration,
--ask the chief complaint/reason for the visit,
--patient's doctor's name,
--due date,
--copy the patient's identification, and
--two (2) nurses or a nurse and technician help the patient put on a gown, obtain a urine sample, a nurse performs assessment/physical examination and obtains the medical history, if the patient is over 24 weeks pregnant a continuous fetal heart monitor is attached to the patient, if the patient is less than 24 weeks pregnant a nurse gets a fetal heart tone, these findings are reported to the physician who makes the determination as to whether to admit.

Based on review of the ED log, Family and Birth Center log, Medical Staff Rules and Regulations, policies and procedures, tour, staff interviews, observations, credential files, and personnel files, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) to determine whether of not an emergency medical condition existed for one (1) of 23 sampled medical records when Patient #1 presented to the Obstetric (OB - related to childbirth) assessment area requesting services for evaluation of her medical condition.

Findings were:

During the entrance conference on 5/13/19 at 10:00 a.m. with the System Director of Accreditation, System Manager of Accreditation and Accreditation Improvement Consultant, a request for the Emergency Department (ED) central log and Family and Birth Center central log was requested. A review of the logs revealed Patient #1 had not been entered into either of these logs as of 5/13/19 at 10:40 a.m.

Review of the Medical Staff Rules and Regulations, Amended November 2016, adopted by the Medical Executive Committee and signed by the Chief of Staff 11/21/06, and approved by the Board and signed by the President/Chief Executive Officer 11/30/16 revealed the following:
EMERGENCY SERVICES
2. Medical Screening Exam (MSE) - All patients who arrive at the ED for evaluation or care are required under EMTALA law to have a MSE done and to have stabilizing treatment, if unstable. MSEs in the ED must be done by a physician, nurse practitioner (NP) or a physician assistant (PA) under the direct supervision of a physician. For medical screening exams related to Obstetrical (related to pregnancy and/or delivery) patients refer to "Obstetrics" (OB) section of these Rules and Regulations.
OBSTETRICS
Medical Screening Exams
All obstetrical patients presenting for evaluation or treatment through the ED or Obstetrical unit must receive a MSE to determine the patient's medical condition and/or labor status. The results of the MSE will indicate whether or not the patient's medical condition is stable or unstable. Those with an unstable condition will receive treatment to stabilize the medical condition to the extent the condition can be treated with available resources. The results of the MSE will indicate whether or not the patient is in active labor.
--MSEs Performed in ED
Patients who present to the ED in the process of imminent delivery or those who are unstable, will be seen and treated initially in the ED by the ED physician, NP or PA under the direct supervision of a physician.
OB patients in the first 14 weeks of pregnancy will be seen in the ED. The obstetrician/gynecology (OB/GYN - specialty dealing with pregnancy and delivery/female reproductive organs) resident on-call should be consulted, if/when deemed necessary by the ED physician.
OB patients who present to the ED after the first 14 weeks by history, with the exception of pregnant trauma patients, who have had their pregnancy confirmed by a positive urine or blood pregnancy test performed in the ED with a pregnancy related problem will be evaluated in OB Assessment.
Obstetrical patients who present to the ED as pregnant trauma patients will be evaluated by the ED physician, NP or PA regardless of weeks pregnant by history. (Refer to the ED OB Assessment Policy)
--MSEs Performed in OB Assessment
Patients who present to the ED in the process of eminent delivery or those who are unstable, regardless of gestational age (number of weeks pregnant), will be seen and treated initially in the ED by the ED physician, NP or PA under the direct supervision of a physician.
OB patients in the first 14 weeks of pregnancy will be seen in the ED. The OB/GYN resident on call should be consulted, if/when deemed necessary by the ED physician.
OB patients who present to the ED greater than 14 weeks pregnant by history, with the exception of pregnant trauma patients, who have had their pregnancy confirmed by a positive urine or blood pregnancy test performed in the ED with a pregnancy-related problem will be evaluated in OB Assessment.
Obstetrical patients who present to the Obstetrical Unit will be directed to the OB Assessment Area. These patients will be triaged and those who have a non-obstetrical problem, regardless of gestational age, will be directed to the ED as all other Emergency Services patients. Patients who remain in the OB assessment area who have a pregnancy related problem will have a MSE performed by a physician or qualified medical professional (QMP) qualified Registered Nurse using medical staff approved criteria. (Refer to Labor and Delivery Policy).

Review of facility policies and procedures included but was not limited to the following:
I. ADMISSION PROCEDURE, no policy number, last revised 5/8/2018, revealed the purpose was to provide guidelines for admission procedures (within Mother Baby departments).
PROCEDURE:
1. Enter the patient into the online documentation system (OB log).
2. Have the patient provide clean catch urine specimen and (perform) a dip stick (determines blood sugar and protein levels) test.
3. Obtain temperature, pulse, respirations and blood pressure.
4. Place patient on the external fetal monitor (evaluates unborn baby's heart rate) or obtain fetal heart rate with doppler (handheld ultrasound machine).
5. Review the prenatal record for pertinent history, including prenatal lab results, if available.
6. Complete OB initial assessment form.
7. If patient is less than 35 weeks gestation, notify physician to determine if patient is a candidate for fetal (unborn child) fibronectin test (fFN - used to determine if preterm labor is imminent) prior to vaginal exam.
8. Vaginal exam for patient ' s 35 weeks or greater gestation unless contraindicated (vaginal bleeding or history of placenta previa [placenta blocks the birth canal]).
9. If patient complains of possible leaking of fluid, RN is to complete amniotest (evaluates whether the amniotic fluid/water is leaking) swab and record results.
10. If patient is greater than 35 weeks estimated gestational age with no contraindications to vaginal exam (placenta previa, vaginal bleeding of unknown etiology), nurse performs a vaginal exam to determine: effacement (thinning of the cervix/bottom portion of the uterus), dilation (evaluates cervical opening), station (how the delivery is progressing), presenting part of the unborn child.
11. Notify physician of patient's status within ½ hour of beginning evaluation.
12. The physician determines, on the basis of the nurse ' s evaluation, whether or not the patient is in active labor and may: admit the patient to the unit, allow patient ambulation for a period of time ordered by physician and reevaluate, discharge the patient to home with discharge instructions.
13. Temperature, pulse, respirations and blood pressure T, P, R, and BP will be re-assessed at time of discharge.
14. Complete documentation: assessments, communication with patient ' s primary care provider, interventions and patient teaching, patient response to teaching and understanding.

II. Medical Screening Exam for patients presenting with OB complaints, no policy number, last revised 5/8/2018, revealed the purpose was to establish guidelines for medical screening and triage procedures for OB patients presenting to OB Assessment. Also included is the process referrals made by the ED of patients requesting an obstetrical MSE. These guidelines outline the appropriate medical examination/referral of OB patients with non-obstetrical chief complaint.
PROCEDURE:
1. Patients shall not be denied evaluation, treatment or stabilization on the basis of means to pay, race, creed, color, national origin, age, sex or actual or perceived disability. Patients shall not be denied evaluation, treatment or stabilization on the basis of their presenting complaint, condition, or lack of physician on the medical staff of this hospital.
2. All obstetrical patients 14 weeks or greater with an obstetrical problem who arrive in the ED will be directed to the OB Assessment Unit with the exception of pregnant trauma patients. If the patient is less than 14 weeks gestational age, presents with a non-obstetrical problem, or is a trauma patient, she will be cared for and receive the MSE as all other Emergency Service patients.
3. OB RNs who are designated as a Qualified Medical Professional (QMP) may conduct the appropriate OB medical screening examination to determine that the patient is in labor or has an emergent obstetrical medical condition. The OB RN/QMP designation has been approved by the governing board of in the medical by-laws.
5. The OB RN/QMP will document on the Obstetric Triage Medical Screening Exam Record and communicate all assessment information to the MD/CNM prior to the patient dismissal. All orders received from the MD/CNM will be documented by the OB RN/ QMP on an order form and housed in the OB Assessment Prenatal file records.
6. The OB physician, CNM will be notified immediately of any patient presenting to OB Assessment with an emergency medical condition.
QUALIFIED MEDICAL PROFESSIONAL: QMP ' s WHO MAY PERFORM THE EMERGENCY MSE INCLUDE:
1. A licensed physician with medical staff privileges that includes obstetrical care or emergency care, OB Residents, and Family Practice Residents.
2. A licensed CNM with hospital privileges.
3. An RN with the following education and training and current Georgia RN license
a. Basic fetal monitoring class and completion of fetal monitoring written validation exam.
b. Satisfactory completion of Labor and Delivery (L&D) orientation.
c. Current Basic Life Support (certified to provide life saving measures for adults and children) and Neonatal Resuscitation Program (certified to provided life saving measures for newborns).
d. Ongoing evaluation of RN competency including annual evaluation by an L&D manager and satisfactory completion of fetal monitoring written validation exam.
TYPES OF PATIENTS APPROPRIATE FOR OB MSE BY AN OB, RN/QMP INCLUDE PREGNANT PATIENTS WITH COMPLAINTS OR CONDITIONS AS FOLLOWS:
1. Uterine contractions.
2. Rupture of membranes (water breaks or is leaking).
3. Decreased fetal (baby) movement.
4. Symptoms of urinary tract infection or pyelonephritis (kidney infection).
5. Symptoms consistent with pregnancy induced high blood pressure.
6. Abdominal pain.
7. Minimal vaginal bleeding.
8. OB patients presenting through the ED requiring an examination to rule out an OB problem or to establish fetal well-being.
CONDITIONS MANDATING PHYSICIAN RESPONSE IN PERSON FOR PATIENT ASSESSMENT, DIAGNOSIS AND MANAGEMENT INCLUDE:
1. Emergency condition requiring prompt medical intervention after initial stabilizing care has been initiated.
2. Acute decompensation of the patient and or fetus.
3. OB complication which is not resolving as anticipated.
4. Upon the request of the OB RN/ QMP.
OB ASSESSMENT ADMISSION LOG PROCEDURE
1. Time In.
a. Log in the time the patient arrives at the OB Assessment window.
b. If the patient has been out to walk, log in the time they return to OB Assessment for further evaluation.
2. Time Out
a. Log in the time the patient leaves OB Assessment or Overflow Assessment rooms after the decision is made for their final disposition.
b. If the patient is being sent out to walk, log them out at the time they leave the room.
--Name - Include the patient ' s full name with last name first.
--Expected Date of Confinement (EDC) - Log in their due date - to be confirmed by their prenatal record.
--Estimated Gestation Age (EGA) - Log in their estimated gestational age in weeks- to be confirmed by their prenatal record.
--Chief Complaint/Reason for Admission.
a. Log in the reason they are presenting to OB Assessment.
b. If the patient was sent out to walk and is now returning, write in " return from walking " .
--Physician - Log in the physician they are seeing for prenatal care.
a. Faculty- write in Faculty, not the actual physician that may be following them.
b. Family Practice - write in FP and actual FP physician who is following them.
c. Health Department/Neighborhood Health Center - write in Faculty as these are the physicians that will be following these patients.
d. Private - write in the physician ' s name or the group ' s initials.
--Disposition on arrival - Log in the room that the patient is placed in on arrival to OB Assessment.
a. OB 1, OB 2, OB 3, OB 4.
b. Overflow rooms - 355, 357, 359.
c. L&D room (LDR) number/Recovery Room (RR) bed number.
--Disposition on transfer/discharge - Log in where the patient goes after their assessment time is complete.
a. LDR room number or RR bed number if admitted to L&D.
b. LDR POD room number if admitted to those rooms.
c. Room number on Perinatal floor if admitted to that area.
d. Home - if discharged home.
e. Other - be specific if sent to another area (lab, X-Ray, doctor's office, another floor, operating room, ED, etc.)
f. Out to walk - If patient is sent out to walk, write in " sent out to walk " .
g. Leave without treatment (LWOT).
h. Leave AMA. Counseling documented, and AMA forms signed by patient and witness.
MEDICAL SCREENING INFORMATION AND DOCUMENTATION TOOL:
All OB patients seeking medical treatment will be triaged immediately by the OB RN/ QMP and findings documented on the Obstetric Triage/MSE Record. Triage criteria include the following parameters:
Class I and II = Emergent/Urgent - Patients who are actively laboring or present with conditions requiring immediate evaluation and therapeutic intervention.
Class III = Non-Urgent - Patients with presenting complaints, which do not require immediate evaluation and therapeutic intervention.
Examples of Class I and II complaints included:
i. Abdominal pain - unknown etiology.
All obstetrical patients triaged as class I or II will have an immediate obstetrical screening exam performed by the OB RN/ QMP.
PATIENTS LEAVING AGAINST MEDICAL ADVICE
If a pregnant patient decides to leave prior to receiving a medical screening or treatment, the OB RN/ QMP will counsel the patient regarding the risks of leaving without treatment. The OB RN/ QMP will document the counseling on the MSE Record along with having the patient sign the AMA forms.

On 5/13/19 at 10:15 a.m. a tour of the ED was conducted with the Assistant Vice President (AVP) GG and the Manager of Patient Access Navigation HH. The ED was observed to have 60 beds, five (5) of which were fast track beds. There were two (2) triage (assessment by a nurse to determine the priority in which patients will be seen by a practitioner based on their chief complaint, presenting signs and symptoms). In addition, the AVP GG explained that the facility also has a Children's Hospital that has six (6) beds, seven (7) trauma rooms and 10 observation beds. AVP GG explained that physicians and/or midlevels (Nurse Practitioners or Physician Assistants) perform the medical screening examination (MSE) in the ED. AVP GG further explained that pregnant women who present to the ED who are less than 14 weeks pregnant or have a non-pregnancy related complaint are evaluated in the ED by ED staff, the Obstetric (OB - specialty that provides care for pregnancy and childbirth needs) Department is notified and an OB staff member comes to the ED to assist with the patient's care. AVP GG said pregnant women that are 14 weeks pregnant or greater or have any pregnancy related complaints are accompanied to the Family Birth Center for assessment by an OB assessment nurse. AVP GG confirmed that entering a patient into the ED central log automatically generates a medical record. EMTALA signage was observed in the ED entrance way between the outer and inner electronic doors, in the ED waiting room, in a second waiting room and in the ambulance entrance.

On 5/13/19 at 10:40 a.m. a tour of the Family Birth Center was conducted with the AVP GG and the Manager of Patient Access Navigation HH. The Director DD of the Family Birth Center explained that there are four (4) OB assessment rooms, 10 Labor and Delivery (L&D) rooms, 11 antepartum (before birth) rooms and 23 postpartum (after delivery) rooms. Director DD explained that OB assessment RNs who have completed OB assessment criteria/competency perform the MSE on the Family Birth Center unit. Director DD said that after the RN completes the MSE the on-call physician is notified with the results and for any necessary orders. Director DD explained that RN EE (the nurse who evaluated Patient #1) was being oriented to the OB assessment unit on 4/30/19. Director DD went on to explain that RN EE transferred to the Family Birth Center from another unit almost a year ago and was still in the process of being oriented to the OB assessment area on 4/30/19. The Director said all new Family and Birth Center staff must work on the unit for a period of time before being oriented to the OB assessment unit. Director DD explained that entering a patient into the Family and Birth Center log automatically generates a medical record, she confirmed that Patient #1 was not entered into the Family and Birth Center log and therefore, there was no medical record generated for the patient. EMTALA signage was noted right across from the elevator doors, in the Family and Birth Center waiting room, in the visitors' snack room and in the OB assessment waiting room.

On 5/13/19 at 7:00 p.m., a telephone interview was conducted with Triage Assistant/Emergency Medical Technician (TA/EMT) CC. TA/EMT CC confirmed he has worked in the facility's ED for 15 years. TA/EMT CC explained that OB patients present to the ED desk and inform the Registration Clerk that they are pregnant and how far along they are, if the patient is greater than 14 weeks the Registration Clerk will call and ask me to take the patient up to the OB assessment area. TA/EMT CC stated that he remembers being called to the registration desk to take Patient #1 up to the OB assessment area. TA/EMT CC said Patient #1 informed him that she was 34 weeks pregnant and was having pain in her lower abdomen and back. TA/EMT CC explained that he called the OB assessment area and informed the nurse (EE) that he was bringing a 34 weeks pregnant patient up. TA/EMT CC stated the OB assessment nurse (EE) asked for the patient's doctor's name and after being told the doctor's name the nurse replied, don't bring her (Patient #1) up she needs to go to the hospital where her doctor has privileges. TA/EMT CC said that by then he was on the elevator with the patient and when he arrived at the OB assessment area with Patient #1 a "nurse (EE) met us at the door and told the patient that she could not be seen here and that she would have to go to the hospital where her physician has privileges. TA/EMT CC confirmed that he has had EMTALA training and that it is required at least once a year. The facility failed to ensure that their policy and procedures were followed as evidenced by failing to ensure that an appropriate medical screening examination was provided to determine whether or not an emergency medical condition existed and/or the labor status for patient #1 when she presented to the L&D unit on April 30, 2019.

During an interview on 5/13/19 at 9:40 a.m. in the Quality Conference Room, RN FF explained that she has worked at the hospital for 11 years and has worked in the Family and Birth Center since 2013. RN FF said she has been working in the OB assessment area for at least two (2) years. RN FF said that the training for the OB assessment area includes the following:
--circulating in surgery for cesarean sections, tubal ligations, and hysterectomies,
--monitoring the unborn baby's heart rate, and
--checking the cervix (lower portion of the uterus) for dilation, effacement (thinning of the cervix for delivery) and station (progression of delivery).
RN FF went on to explain that the first steps for women that present to the OB assessment area is as follows:
--patient signs-in and states why she is here,
--patient states her gestation (how many weeks pregnant),
--patient is asked who her doctor is,
--a nurse does an assessment/physical examination and if the patient is having contractions and is at full-term the nurse will check the patient's cervix; the nurse will wait an hour and then re-check the patient and notify the physician. RN FF said the physician will then determine whether the patient is to be admitted. RN FF explained that on 4/30/19 RN EE had the OB assessment phone and RN EE would have received the call from the ED. RN FF said she was orienting RN EE and had not been notified that a patient was being brought up from the ED. RN FF stated she never saw Patient #1 and that she (RN FF) and the Charge nurse were informed by RN EE that Patient #1 decided to leave after being informed that her (Patient #1) doctor did not have privileges here. RN FF said that she and the Charge Nurse told RN EE that she had handled the situation correctly. RN FF said that she has since been informed not to tell a patient that her doctor does not have privileges until after the patient is signed in and then if the patient decides to leave the patient is asked to sign an Against Medical Advice (AMA) form. RN FF said that she has completed corporate compliance and that she believes EMTALA is part of it.

During an interview on 5/13/19 at 10:10 a.m. in the Quality Conference Room, RN EE explained that she has worked at the hospital for since January 2015 and has worked in the Family and Birth Center since July 2018. RN EE stated she began training to work OB assessment in March 2019. RN EE confirmed that on 4/30/19 she had the OB assessment phone and received a call from TA/EMT CC informing her that he was bringing a 34 weeks pregnant patient up. RN EE said that she asked the name of the patient's physician and after being informed of the physician's name she told TA/EMT CC that the patient's physician did not have privileges. RN EE said she told AT/EMT CC that typically that physician's patients are seen at another local hospital. RN EE said that she met the patient at the door to the OB assessment area and when the patient provided the name of her doctor I (RN EE) explained that the patient's doctor did not have privileges, and practices at another local hospital. RN EE said Patient #1 asked if anyone else could see her and I (RN EE) said yes but it won't be your doctor and your doctor won't be involved with your care. RN EE said the patient said she would rather go to the other hospital and be treated by her doctor. RN EE said she did not try to get the patient to sign an AMA form. RN EE explained that the process for patients presenting to the OB assessment area include the following:
--registration,
--ask the chief complaint/reason for the visit,
--patient's doctor's name,
--due date,
--copy the patient's identification, and
--two (2) nurses or a nurse and technician help the patient put on a gown, obtain a urine sample, a nurse performs assessment/physical examination and obtains the medical history, if the patient is over 24 weeks pregnant a continuous fetal heart monitor is attached to the patient, if the patient is less than 24 weeks pregnant a nurse gets a fetal heart tone, these findings are reported to the physician who makes the determination as to whether to admit.
RN EE confirmed that she has been educated on EMTALA.

Review of two (2) credential files (AA and BB) and three (3) personnel files (CC, EE and FF) revealed all five (5) staff members had received EMTALA training between 10/10/17 and 2/26/19. In addition, the OB RN FF's personnel file had documented evidence of completing the required competencies for working in the OB assessment area. At the time Patient #1 presented on 4/30/19 RN EE was in the process of the required orientation period to the OB assessment area.