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Based on review of medical records, Medical Staff Bylaws, policies and procedures, Emergency Department Central Log, and interviews , it was determined that the facility failed to ensure that a Medical Screening examination (MSE)was provided which was within the capability of the hospital 's emergency department including ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition exists for 3 (three) Patient (P1, P2, and P#11) of twenty sampled patients who presented to the emergency department with pregnancy related complaints.

Findings included:

Cross refer to A-2406 as it relates to the facility's failure to provide three patients (P#1, P# 2, and Pt#11) with an appropriate MSE.

ED Log Based on central log review, medical record reviews, a review of policy and procedures, and interviews, it was determined that the facility failed to enter one Patient (P) #1 of twenty sampled patients into the central log when she (P#1) arrived at the facility on 10/21/22 with a complaint of labor contractions.

Findings included:

A review of Facility #1's Emergency Department central log from 10/01 /22 to 3/31/23 failed to reveal that P#1's information was recorded on the log.

A review of the facility's policy titled "EMTALA-Compliance with the Emergency Medical Treatment and Active Labor Act," revised 12/09/2021, revealed the purpose was to provide consistent guidelines for the examination, treatment, and transfer of patients coming to and from the facility in accordance with federal Emergency Medical Treatment and Active Labor Act (EMTALA) anti-dumping requirements. Further review revealed the scope of EMTALA:
Central Log: Each department of the hospital that provided medical screening examinations (MSE) would maintain a central log recording the following:
a. Patient's Name
b. Date of Birth
c. Sex
d. Chief Complaint
e. Arrival Time
f. Triage Time
g. Registration Time
h. MSE Time
i. Medical Record/ Account Number
j. Mode of Arrival
k. Name of the provider who provided the MSE
l. If admitted, the name of admitting Licensed Independent Practitioner (LIP)
m. Disposition of patient, including refusal of treatments, transfer, admission, stabilization, and transferred or discharge.


A review of the facility's policy titled "Medical Screening Exam," last revised 10/19/2021, revealed the following:
1. Each individual presenting for an Emergency MSE would be registered.
a. Upon initial presentation, the person's name, the time of presentation, and the date would be entered into the Central Log. Additionally, whether the individual was treated, refused treatment, was transferred, admitted, and treated, stabilized, and transferred, or discharged, the hospital would maintain on record in the central log.
b. The following information would be collected at the earliest medically appropriate time by either the registration clerk or the triage nurse:
i. Name
ii. Address
iii. Presenting complaint
iv. Legally responsible person
v. Primary care/attending physician.

An interview took place with triage nurse, Registered Nurse (RN) AA, on 4/11/23 at 12:11 p.m. RN AA explained that staff were expected to complete a sign-in sheet when patients arrived seeking care. The information was entered into the electronic ED tracker.

RN AA explained that the nurse determined if the patient needed to be immediately assigned a bed or could wait in the waiting room based on the sign-in sheet information. RN AA further explained that a provider was immediately notified when a patient presented in active labor, regardless of diversion status. RN AA acknowledged that the facility recently began utilizing the electronic central log. RN AA explained that prior to use of the electronic log, patients completed a sign-in sheet on arrival. Staff then documented the information in a manual logbook. RN AA explained that she entered patient information into the logbook prior to taking patients to an assigned bed. Patients should be in the logbook even if they left without being seen.

An interview took place with L&D Nurse Manager (LDM) BB on 4/11/23 at 12:20 pm. LDM BB explained that previously, patients presented to the admission clerk, completed a sign-in sheet, and were assigned a bed if available or go to the waiting room. LDM BB explained that patients physically present on the unit and assigned a bed had their information documented in the logbook; however, those in the waiting room may not have their information in the logbook if they left before being seen. LDM BB stated that the staff should scan the sign-in sheet and include it in the patient's medical record (MR) A record of the sign-in sheet was not maintained. LDM BB said that the facility had recently improved its process by maintaining an electronic central log of all patients that presented to the unit.
A telephone interview took place with the certified midwife (CM) FF on 4/12/23 at 10:03 am. CM FF explained that she remembered the incident with P#1, it was on a Friday at around 6:45 pm; two nurses were supposed to work when they reached out to their supervisor and said they would not work. CM FF further explained the nurses said they were leaving, and the unit would be left with no nurses. CM FF said she had to step into the situation and tried to convince the nurses to stay back to talk with the unit director. CM FF said that while these were going on, she was informed that two patients were in the lobby and had been waiting for hours. CM FF said not knowing if those nurses would clock in that night, she had to approach both patients and inform them that they were welcome to stay but could also consider other options. CM FF said she told the patients they could stay, but she doesn't know how long they would be waiting. CM FF said her goal is patient care and safety. CM FF said she felt the patient needed more options and be informed that they could go to where they could be taken care of on time.

In a second interview with Labor and Delivery Manager/RN BB on 5/30/23 at 12:10 p.m. in her office, L&D Manager BB said she became the Department Manager in March 2023. Manager BB said there has been changes made in the L&D department since March. Manager BB said that they did not have an OB/ED but now the department has an emergency service. Manager BB explained the new process in place now. Manager BB said patients with obstetrical emergency would go straight to the OB/ED department, got registered in Epic immediately. Manager BB said they did not have all patients on Epic before and now the department moved from paper to Epic. Manager BB explained that with that new process in place now, they were certain that all patients who arrived in the department were placed in the log. Manager BB said it was not like this before. Manager BB said before new changes were implemented, only patients that the doctors saw were registered in the log. Manager BB said they still maintained the previous log (a big book), but the patient was also in Epic. Manager BB described having a central log built in Epic as safer. Manager BB explained that once the patient was registered in Epic, the receptionist called the nurse and reported there was a patient. Manager BB said the nurse was to come or a Tech would go get the patient to the unit once a bed was available.

During a phone interview with P #1 on 5/30/23 at 1:43 p.m., P#1 stated that she arrived at the facility on 10/21/22 around 8:00 p.m. with complaints of labor contractions. P#1 explained that this was her second pregnancy and she had known that the baby was on her way because of the intense pain. P#1 said she arrived at the facility's Labor and Delivery (L&D) around 9:00 p.m., and the door was closed. P #1 said she had to wait for someone to come talk to her at the door. P#1 stated a nurse from L&D arrived and told her they did not have any beds and that they were full and would not be able to see her. P#1 said the nurse told her to go to another facility because there was nothing, they could do for her.

Based on review of medical records, Medical Staff Bylaws, policies and procedures, Emergency Department Central Log, and interviews , it was determined that the facility failed to ensure that a Medical Screening examination was provided which was within the capability of the hospital 's emergency department including ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition exists for 3 (three) Patient (P#1, P#2, and P#11) of twenty sampled patients who presented to the emergency department with pregnancy complaints.

Findings included:

A review of the Facility' #1s central log from 10/01/22 to 3/31/23 failed to reveal that P#1's information was recorded on the log.

A review of P#1's medical record (MR) from Facility #2 revealed that P#1 arrived on 10/21/22 at 10:09 p.m. A review of the record revealed that P#1 was a 29-year-old female at thirty-nine (39) weeks 3 days of gestation (developing inside the womb between conception and birth) who presented to the "Obstetric Emergency Department (OBED) complaining of contractions "all day." Patient reports + (positive) bloody show and questionable leaking of fluid. Fetal movement normal." P#1 was admitted to the facility for labor management and discharged home with her newborn on 10/23/22 at 2:10 p.m.

A review of the facility's central log from 1/1/23 to 2/28/23 revealed that P#2 arrived on 1/1/23 at 2:07 p.m. A review of P#2's MR revealed that P#2 arrived at the facility's labor and delivery (L&D) department on 1/1/23 at 2:07 p.m. complaining of shortness of breath and decreased fetal movement for two days. Continued review of the record revealed that fetal heart tones were documented at 2:54 p.m., 3:38 p.m. and 4:00 p.m. of 140 beats per minute, 130 beats per minute, and 140 beats per minute respectively. The medical record failed to reveal a medical screening exam (MSE) for P#2 in L&D. P#2 was discharged from L&D on 1/1/23 at 4:15 p.m. Continued review of the record revealed that P#2 presented to the ED on 1/1/23 at 5:24 p.m. A review of a nurses note revealed that P#2 was 25 weeks gestation and complained of shortness of breath. P#2 had initially been seen and cleared in L&D. P#2 disposition was left without being seen at 6:15 p.m. Patient #2 left the without being seen by the ED MD or the OBGYN MD.

Review of Facility #1's Labor and Delivery Log revealed that patient #11 arrived at 10:37 a.m. A review of the medical record revealed that Patient #11 presented to Facility #1 on March 6, 2023, at 10:37 a.m. Review of the Flowsheet and MAR (Medication Administration Record) dated March 6, 2023, revealed the patient was placed on an external Ultrasound (most often used to examine the heart of an unborn baby in the wound). The patient's uterine activity was being monitored via toco (an indirect measure of the intrauterine pressure, provides contraction frequency and approximate duration of labor contractions). Further review of the record revealed that on March 6, 2023, at 2:10 p.m., an ultrasound was ordered by the attending physician. The US was ordered to check the well-being of the fetus. Documentation by the Licensed Vocational Practical Nurse (LPN) dated March 6, 2023, at 3:02 P.M. revealed in part, "Pt. (patient) off unit for US (Ultrasound)/ labs. At 5:28 p.pm the LPN documented the patient returned from Ultrasound and the attending MD was made aware, the patient was escorted to the laboratory for bloodwork, and was discharged from labor and delivery. There was no documentation in the medical record to indicate that a physical examination was done by the attending ED physician for patient P#11 on 3/6/23, when she presented to the ED.



A review of the facility's Medical Staff Bylaws and Rules & Regulations, last approved on 4/20/2020 by Medical Executive Committee and 10/14/2021 by General Medical Staff revealed under section 1.9 (f) a Medical Screening Examination (MSE) to determine if an emergency medical condition (EMC) existed may be performed by 1) a physician, 2) an advanced practice provider (i.e. Physician's Assistant, certified Nurse Practitioner, certified Nurse Midwife), who was working under the supervision of a physician, within the scope of their practice under Georgia law, and were credentialed by the hospital, or 3) a Registered Nurse (RN) with training and experience in obstetrical nursing , which would include demonstrated clinical competency in physical assessment of the obstetrical patient, electronic fetal monitoring and obstetrical emergencies. The screening shall be within the capabilities of the hospital, including available ancillary services.


A review of the facility's policy titled "Medical Screening Exam," last revised 10/19/2021, revealed it was the policy of the hospital to:
a. Examine patients (whether eligible for insurance benefits and regardless of ability to pay) to determine if the individual has an EMC; and
b. If it was determined that the individual had an EMC, to provide such further medical examination and treatment necessary to stabilize the medical condition, within the capability of the hospital, or to arrange for transfer of the individual to another medical facility in accordance with Emergency Medical Treatment and Active Labor Act (EMTALA) and the procedures set forth in the transfer policy.
1.) This policy applies to all individuals presenting anywhere on the Hospital property, even if they presented at a location other than the emergency department (ED).
2.) A determination of the patient's presenting condition (i.e. emergent or non-emergent) would be made for each patient. This initial determination, by the Qualified Medical Screening Officer, would not alter the appropriate clinical course of treatment for the patient. In addition, the designation of a patient's condition, throughout the course of stay, may change according to clinical symptoms, subjective and objective information collected from the patient and the evaluation of any diagnostic rest or treatment.

Procedure:
1. Each individual presenting for an emergency MSE would be registered.
a. Upon initial presentation the person's name, the time of presentation and the date will be entered into the Central Log. Additionally, whether the individual was treated, refused treatment, was transferred, admitted, and treated, stabilized, and transferred, or discharged, the hospital would maintain on record in the central log.
b. The following information will be collected at the earliest medically appropriate time by either the registration clerk or the triage nurse:
i. Name
ii. Address
iii. Presenting complaint
iv. Legally responsible person
v. Primary care/attending physician
2. MSE
a. The Hospital would provide a screening examination for every person who came to the ED making a request for examination and treatment. Each patient may be triaged to determine priority for medical screening.
b. The MSE would be based on the patient's condition and prior history, and would include at least the following:
i. Patient chief complaint, age, sex, age, duration of onset of chief complaint, date and time, level of distress, allergies, current medication, tetanus status, last menstrual period, private physician, and any other pertinent medical history.
ii. Vital signs, general observation, and localized examination
iii. Initiation and documentation of any necessary testing, treatments and /or procedures.
c. The scope of the examination was tailored to the patient's presenting symptoms and the medical history of the patient. The MSE was an ongoing monitoring process, which continued until a medical emergency condition (MEC) was found not to exist or until appropriate steps to stabilize the presenting EMC begin.

An interview took place with triage nurse, Registered Nurse (RN) AA, on 4/11/23 at 12:11 p.m. RN AA explained that the nurse determined if the patient needed to be immediately assigned a bed or could wait in the waiting room based on the sign-in sheet information. RN AA further explained that a provider was immediately notified when a patient presented in active labor, regardless of diversion status.

An interview took place with RN GG on 4/11/23 at 4:02 p.m. RN GG acknowledged she was aware of the incident with P#1. RN GG said Certified Midwife (CM) FF came to the nursing station on the day of the incident and informed the staff that she (CM FF) told patients in the waiting room that they had the option to stay or go because the facility would not be able to see them early.

A telephone interview took place with CM FF on 4/12/23 at 10:03 a.m. CM FF recalled the incident with P#1. CM FF recalled that it was a Friday, around 6:45 p.m. when two nurses informed their supervisor that they would not be coming in for the night shift. CM FF further explained that the off going nurses said they were leaving which meant the unit would be left with no nurses. CM FF stepped into the situation and tried to convince the nurses to stay and talk with the unit director. CM FF stated that while this was happening, she was informed that two patients were in the lobby and had been waiting for hours. CM FF explained that she approached both patients and informed them that they were welcome to stay but could also consider other options as it was unclear if there would be any nurses coming in for night shift CM FF said she told the patients they could stay but did not know how long they would be waiting. CM FF said her goal was patient care and safety. CM FF recalled that she had not been sure if there would be a nurse to cover triage or labor and delivery that night. CM FF said the unit director had to come in to work all night. CM FF said such incidents often happened between October and December of 2022. CM FF stated staffing was terrible with the unit experiencing a high employee turnover. CM FF said the unit director subsequently resigned in December 2022. CM FF explained that she had been made aware of a potential EMTALA violation around the incident a couple of weeks later. CM FF said the incident had been discussed with risk management and the director. CM FF stated after the incident, the facility had made a lot of improvement with staffing and had also started the Obstetric Emergency Department (OBED).

An interview took place with the Women's Center Manager (WM) EE on 4/12/23 at 2:38 p.m. WM EE explained that she had never witnessed any patient being told they could not be seen at the facility. WM EE said she heard an allegation of a potential EMTALA violation which the facility self-reported; however, she was not present when the incident occurred and was not aware of who the patient was. WM EE said she was aware that the facility had staffing issues which were similar problems across every hospital within the country. WM EE said whenever the facility had staffing issues, they requested diversion, which was approved; however, if a patient was present, even when the facility was on diversion, the patient would be seen. WM EE said staffing had improved and increased since the incident, and the current staff was more invested. WM EE further explained that the hospital initiated an OBED with their providers, who would perform MSEs for the patient. WM EE said the facility had also created a maternal-fetal triage index (MFTI) score similar to the Emergency Severity Index (ESI) (triage system) score for patients presenting to the OBED. WM EE explained that previously, nurses had to assess patients and decide, based on clinical judgment, which was higher acuity. WM EE said prior to the improvement they may have two to three RNs in the labor and delivery unit, and on average, they may need about six nurses. WM EE said that currently, they have an average of four to five nurses working on each shift.

An interview took place with the Obstetrics and Gynecology ED Medical Director (DIR) DD on 4/12/23 at 3:04 p.m. DIR DD explained that she was unaware of P#1 and P#2's incidence until yesterday (4/11/23) when she was informed that CM FF advised a patient to consider other options at other facilities to expedite care. DIR DD explained that previously the community doctor relied on the nurses to communicate the MSE to them, and they would decide to come to see the patient. However, since April 10th every patient was seen by a provider who would perform the MSE and determine if they have an emergency condition.

An interview with the Chief Nursing Officer (CNO) HH took place on 4/13/23 at 10:55 a.m. CNO acknowledged she was aware of an allegation regarding a potential EMTALA violation involving a midwife who was helping the hospital out. CNO HH further explained that the hospital immediately reported the allegation to the state agency and started investigating the complaint. CNO HH said staff and providers were provided education, and it was also discussed during meeting minutes. The facility decided to create an OBED department. CNO HH said during that period from October to December 2022, staff was calling out on multiple occasions. The women's centers had about 100 calls out, 40 in December alone. CNO HH said she took it upon herself to meet with each of the nurses on the unit and CNO HH realized many of the issues revolved around staffing and the need to hold people responsible. CNO HH said they had some staff who were encouraging stage calls out, so those staff were terminated, and new people were hired. CNO HH said for instance on Christmas day she was working on the unit because all of the staff on the night shift except one called out. CNO HH explained that they also extended the sessional program to retain more nurses. She acknowledged that P#2's L&D record did not include a MSE on 1/1/23.

CNO HH explained that they had also designed work instructions similar to the ED whereby all patients that presented to the OBED had their information recorded in the central log, and the patient was assessed at triage and assigned a triage index score (MFTI). Based on the score, patients were either made to wait in the waiting room or provided a bed immediately. CNO HH explained that the staffing situation had been resolved because she also had seven agency nurses, brought in LPN's, also three PRN (as needed) transitional nurses, and had a new L&D Nurse Manager who was a good leader and dedicated to teambuilding.

An interview took place with RN MM on 5/31/23 at 12:35 p.m. RN MM stated she frequently worked in triage and was very familiar with the triage process. She stated the process prior to the opening of the OB-ED was patients would sign in with reception. Reception would then call the triage nurse to alert them a patient is signed in. The triage nurse would then come to the front and take the patient directly to a room if one is available. The triage nurse would then assess the patient and call the provider if one is not in the facility. RN MM acknowledged that receiving verbal orders over the phone without the physician coming to physically see the patient had been a standard within the facility, especially if the patient was stable. RN MM confirmed that some patients did not receive proper medical screening examinations (MSE) because of this practice. She further explained that the current triage process is like the old process, however the difference was a provider remained onsite 24 hours a day and once the triage nurse assessed the patient, the patient was immediately seen by the provider.

During a phone interview on 5/31/23 at 1:10 p.m. with Obstetrics and Gynecology (OB/GYN) Doctor NN, she explained that in January, there the protocol was that trained nurses examined patients and provided the doctor a report via telephone. The doctor did not have to physically present to the facility and could give orders over the phone. The process has since changed, and the provider was required to examine patients.

During an interview with the facility's Chief Executive Officer (CEO) OO in the conference room on 5/31/23 at 1:30 p.m., CEO OO explained that the Obstetric Emergency Department (OBED) current policy and the provision of care in the main ED was the same since the opening of the OBED. In other words, the main ED EMTALA policies covered OBED. CEO OO said starting over a month ago, they required and ensured the OBED had a qualified provider 24 hours a day, seven days a week, on shift and on-call. CEO OO said this change ensured all patients who presented in the OBED were triaged and had an MSE by a doctor or a nurse midwife with no delay. CEO OO said it was the right thing to do for the community. CEO OO confirmed the change was effective since the opening of the OBED over a month ago.

During a phone interview with P #2 on 5/30/23 at 1:10 p.m., P #2 recalled that she went to the Emergency Department (ED) on 1/1/23. She was then transported to L&D from the ED. P #2 was put on a monitor to monitor the baby's heart. P #2 said she was in the L&D for about two hours. P #2 said they told her everything was okay to follow up with her doctor in a week. P #2 stated she saw a nurse but did not see a doctor.

During a phone interview with P #1 on 5/30/23 at 1:43 p.m., P#1 stated that she arrived at facility #1 on 10/21/22 around 8:00 p.m. with complaints of labor contractions. P#1 explained that this was her second pregnancy and she had known that the baby was on her way because of the intense pain. P#1 said she arrived at the facility's Labor and Delivery (L&D) around 9:00 p.m., and the door was closed. P #1 said she had to wait for someone to come talk to her at the door. P#1 recalled that a nurse from L&D told her they did not have any bed s and that they were full and would not be able to see her. P#1 said the nurse told her to go to another facility because there was nothing, they could do for her. P#1 explained that she was in active labor, and the facility did not provide her with a name for an alternate hospital, nor did they call an ambulance to transport her to another hospital. P #1 said she was scared to get on the highway and asked her husband to use the back roads to go to facility #2. P #1 stated she got to facility #2, and they did not have time to register her because the baby was coming out. P#1 said they took her straight to the operating room (OR) and within about half hour of P #1's arrival at facility #2, she delivered the baby around 10:30 p.m.

A telephone interview with RN KK took place on 5/31/23 at 10:02 am. RN KK explained he was a new nurse and has been employed with the facility since September 2022. He stated he did not remember P#2 coming in on 1/1/23 because he was not the triage nurse. RN KK stated he was not familiar with the entire triage process because he was a new nurse and only nurses who have been on the unit for 2-3 years can triage patients. RN KK stated the triage process prior to the OB-ED was that patients would sign in with reception, reception would then call a triage nurse to advise that there was a patient that needed to be seen. Depending on the acuity and the availability of rooms, the patient would be escorted to a room or sent to the waiting room. RN KK could not confirm what the current triage process was but acknowledged that a provider physically sees every patient now that the facility has an OB-ED.

During an interview on 7/7/23 at 3:15 p.m. via telephone, MD NN explained that P#2 had presented to the OB triage area and did not recall the specific complaint. She explained that at that time, it was practice for the nurse to phone the patients provider or the provider on call. The nurse conducted the OB MSE and followed the providers orders per telephone orders. The nurse called the provider with status updates and to determine disposition. MD NN recalled that the nurse had phoned her back about the status of the patient and the patient later left the facility. MD NN was not aware of the documentation practices of the nurses.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided that was in the capability of the hospital emergency department to include ancillary services routinely available in the ED to determine whether or not and emergency medical condition existed for P#1, P#2 and P#11 with pregnancy related complaints.