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Based on review of the facility policies and procedure, Medical Staff Bylaws and Rules and Regulations, facility registration log, Emergency Department (ED) log, Medical Records (MR), Hospital B Medical Records, EMS (Emergency Medical Services) Patient Care Reports (PCR), 911 call log, and staff interviews, it was determined Greene County Hospital (Hospital A) failed to ensure:

1. A physician was on duty and available to respond to an emergency.

2. All patients requesting emergency care had a Medical Screening Examination (MSE) performed.

3. Stabilizing treatment was performed prior to transfer to another hospital.

4. An appropriate transfer of two patients was arranged for two patients who were transferred to another hospital.

5. An EMTALA (Emergency Medical Treatment and Labor Act) policy was adopted and approved.

This deficient practice did affect Patient Identifier (PI) # 1 and PI # 2 and had the potential to affect all patients presenting to this hospitals ED.

Refer to Tags: A2404, A2406, A2407, and A2409.

Based on review of the facility policies, facility registration log, Hospital A Medical Records (MR), and staff interviews, it was determined Greene County Hospital (Hospital A) failed to ensure a MR was initiated and maintained on a patient presenting to hospital in active labor and on the newborn who was delivered while on hospital premises.

This deficient practice affected 2 of 2 patients presenting to the ED with no MR completed including Patient Identifier (PI) # 1 and PI # 2, and had the potential to affect all patients presenting to this hospital.

Findings include:

General Policy Statement
Policy # 100
Date reviewed: 5/15/2018

... 8. All nursing staff shall record the details and time of all relevant medical information history, observations, patient complaints, vital signs, tests ordered, medical orders, received and care or treatment rendered on the triage form or emergency department record for each patient. ...

ER (Emergency Room) Policies and Procedures Recording
Policy # 107
Date reviewed: 5/15/2018

1. The ER Record must be completely filled out and signed by the nurse.

2. It should include a brief history of what precipitated the ER visit...

6. Special points to record:

1. Patients time of arrival
2. Physician's time of arrival, and physicians time notified
3. Patient's condition on discharge
4. Time the patient left and disposition...

ER Registration Policy and Procedure
Policy # 101
Date reviewed: 5/15/2018

Registration information may be obtained from a patient or a family member at any time ...

1. Review of Hospital B ED Patient Notes dated 3/25/2021 at 8:33 AM revealed PI # 1 stated she began to have labor pains at home at approximately 5:00 AM on 3/25/2021. After attempts to obtain an ambulance for transport were unsuccessful, PI # 1 was taken by family members to Hospital A by private car and arrived at approximately 7:00 AM. PI # 1 stated she notified the staff at Hospital A she was labor and then had a spontaneous delivery of PI # 2 in the car in the hospital parking lot.

Copies of the MR of PI # 1 and PI # 2 were requested on 3/30/2021 at 4:00 PM but no medical record documentation could be provided to the surveyors.

An interview was conducted on 3/31/21 at 10:47 AM with Employee Identifier (EI) # 8, Registered Nurse (RN), day shift 7 AM to 7 PM. EI # 8 was asked was a chart completed on PI # 1 and PI # 2? EI # 8 replied by stating "no, we did not know her name. A chart should have been done but it was not."

An interview was conducted on 3/31/21 at 2:30 PM with EI # 9, RN, 7 AM to 7 PM
shift. EI # 9 was asked did you complete a medical record on (PI # 1 or PI # 2)? EI # 9 responded, "No, I did not."

In an interview conducted on 4/1/2021 at 3:30 PM EI # 1, Administrator, and EI # 2, Director of Nurses, confirmed PI # 1 arrived at approximately 7:00 AM on 3/25/2021 and the patient was not registered as being seen in the ED there was no medical record documentation of PI # 1 or PI # 2.

Based on review of the facility policies and procedure, Hospital B Medical Records (MR), and staff interviews, it was determined Greene County Hospital (Hospital A) failed to ensure a physician was on duty and available to respond to an emergency.

This deficient practice affected 2 of 2 patients who presented to the ED requesting treatment when no physician was available for treatment including Patient Identifier (PI) # 1 and PI # 2, and had the potential to affect all patients presenting to this hospital.

Findings include:

Emergency Staffing Patterns
Policy # 123
Date reviewed 5/15/2018

A. Emergency staffing for 24 hour period: There is a registered nurse on duty 24 hours per day who is responsible for the immediate assessment and treatment of the ER (Emergency Room) patients until the on-call MD (Medical Doctor) arrives.

B. A physician is on-call 24 hours per day to provide immediate medical services to patients presenting to the ER. The physician's call list is posted at the nurses station. Unless otherwise indicated, the physician indicated as "on-call" will be notified.

C. Types of Emergencies treated at GCH (Greene County Hospital):..
14. Obstetrical patients...

1. Review of Hospital B Emergency Department (ED) Patient Notes dated 3/25/2021 at 8:33 AM revealed PI # 1 stated she began to have labor pains at home at approximately 5:00 AM on 3/25/2021. After attempts to obtain an ambulance for transport were unsuccessful, PI # 1 was taken by family members to Hospital A by private car and arrived at approximately 7:00 AM. PI # 1 stated she notified the staff at Hospital A she was labor and then had a spontaneous delivery of PI # 2 in the car in the hospital parking lot.

An interview was conducted on 3/30/21 at 10:20 AM with Employee Identifier (EI) # 5, Marketing Coordinator, who stated "I told them to get the patient out of the car and in a wheelchair and take her to the Emergency Room and call the doctor on call and 911."

An interview was conducted on 3/30/21 at 4:56 PM with EI # 4, physician, who stated when asked how are you notified of a patient requiring Emergency Treatment he/she stated "the nurse contacts me by phone and lets me know an ER patient is at the hospital." He/she then stated (EI # 8, RN, Registered Nurse) "called me and I told (him/her) I was sick and I called (EI # 3, physician). He/she came to the hospital in about 1 to 2 minutes. We usually call each other at the end of the shift and (EI # 3) did not call me that morning which was strange. I got dressed and came in."

An interview was conducted on 3/31/21 at 9:40 AM with EI # 3, physician, who stated "my shift was over and (EI # 4) called and asked me to see the patient. I came back and the ambulance people were here. EI # 3 was asked who treated the patient in the parking lot? EI # 3 responded by stating EMS was doing CPR on the baby and we were all there but we were waiting on a person to come to help with the mother. I told my nurse (EI # 7, RN) we needed to get them inside. There was myself, the EMS people and the nurses from the hospital." EI # 3 was asked did you or the hospital employees provide any treatment to the patient? EI # 3 responded "No, EMS was doing it." EI # 3 was then asked how long does it take you to get to the hospital? EI # 3 responded "It does not take me long."

An interview was conducted on 3/31/21 at 10:47 AM with EI # 8, RN, who stated "a man came in and said a lady was having a baby. I called (EI # 4, physician) and I told him."

An interview was conducted on 3/31/21 at 3:35 PM with EI # 7, RN who stated "I went and got a wheelchair and the man knocked on the door and I asked him when her water broke. He said 5:00 AM. He said he did not know why 911 did not come. I told him the other nurse is on the phone now with the doctor and we would be to the car in a minute."

PI # 1 and PI # 2 were transported by ambulance to Hospital B on 3/25/2021 at 7:54 AM.

In an interview conducted on 4/1/2021 at 3:30 PM, EI # 1, Administrator, and EI # 2, Director of Nurses, confirmed a physician was not immediately available when PI # 1 arrived at the hospital.

Based on review of the facility policies, facility registration log, Emergency Department (ED) log, Hospital B Medical Records, and staff interviews, it was determined Greene County Hospital (Hospital A) failed to ensure an accurate ED log was kept and all patients presenting to the ED for treatment were entered.

This deficient practice affected 2 of 2 patients who presented to the ED for treatment but were not entered into the ED log including Patient Identifier (PI) # 1 and PI # 2, and had the potential to affect all patients presenting to this hospital.

Findings include:

ER Policies and Procedures Recording
Policy # 107
Date reviewed: 5/15/2018

1. The ER Record must be completely filled out and signed by the nurse.

2. It should include a brief history of what precipitated the ER visit...

6. Special points to record:

1. Patients time of arrival
2. Physician's time of arrival, and physicians time notified
3. Patient's condition on discharge
4. Time the patient left and disposition...

ER Registration Policy and Procedure
Policy # 101
Date reviewed: 5/15/2018

Registration information may be obtained from a patient or a family member at any time ...

1. Review of Hospital B ED Patient Notes dated 3/25/2021 at 8:33 AM revealed PI # 1 stated she began to have labor pains at home at approximately 5:00 AM on 3/25/2021. After attempts to obtain an ambulance for transport were unsuccessful, PI # 1 was taken by family members to Hospital A by private car and arrived at approximately 7:00 AM. PI # 1 stated she notified the staff at Hospital A she was labor and then had a spontaneous delivery of PI # 2 in the car in the hospital parking lot.

Review of the ED Log and Registration Log at Hospital A revealed no documentation of PI # 1 or PI # 2 presented to the ED per hospital policy.

In an interview conducted on 4/1/2021 at 3:30 PM EI # 1, Administrator, and EI # 2, Director of Nurses, confirmed that PI # 1 arrived at approximately 7:00 AM on 3/25/2021 and the patient was not registered on the ED log as being seen in the ED.

Based on review of the facility policies and procedure, Hospital B Medical Records, EMS (Emergency Medical Services) Patient Care Reports (PCR), EMS Event Clinical Presentations, 911 call log, and staff interviews, it was determined Greene County Hospital (Hospital A) failed to ensure a Medical Screening Examination (MSE) was conducted on a patient presenting to the hospital in active labor or on the newborn who was delivered while on hospital premises and failed to develop and adopt an EMTALA policy to guide staff of their responsibilities.

This deficient practice did affect 2 of 2 patients who presented to the ED requiring emergency treatment and did not have a MSE including Patient Identifier (PI) # 1 and PI # 2 and had the potential to affect all patients presenting to this hospitals Emergency Department (ED).

Findings include:

Physician Procedures
Policy # 105
Date reviewed 5/15/2018

1. The on-duty emergency physician shall provide a medical screening examination to all patients presenting. ...

... 3. The physician providing the medical screening examination shall physically examine the patient and, where necessary to rule out any potential emergency medical condition ... The physician's observations, evaluation of differential diagnoses, testing ordered, and results of all testing shall be recorded in the medical record.

4. Necessary definitive care ... to stabilize the patient's condition shall be rendered in the hospital. ...

1. Review of Hospital B ED Patient Notes dated 3/25/2021 at 8:33 AM revealed PI # 1 stated she began to have labor pains at home at approximately 5:00 AM on 3/25/2021. After attempts to obtain an ambulance for transport were unsuccessful, PI # 1 was taken by family members to Hospital A by private car and arrived at approximately 7:00 AM. PI # 1 stated she notified the staff at Hospital A she was labor and then had a spontaneous delivery of PI # 2 in the car in the hospital parking lot.

The MR and documentation of a MSE examination on PI # 1 and PI # 2 was requested on 3/30/2021 at 4:00 PM but could not be provided to the surveyors.

Review of the 911 call log and phone recordings revealed PI # 1 called 911 on 3/25/2021 at 6:12 AM requesting an ambulance because she thought she was in labor. The 911 dispatcher informed PI # 1 that no ambulance was available at that time. At 6:44 AM PI # 1 called 911 again to advise the dispatcher to cancel the ambulance. At 7:34 AM the parent of PI # 1 called 911 stating "(his/her) daughter is in labor about to have a baby and they telling her they don't deliver babies out there and she is about to have the baby. Advised, they (are) at the front and a lady came out saying they don't deliver no babies and then went back in, guess she might come back out, not sure what they going to do." At 7:35 AM an ambulance was dispatched to Hospital A.

Review of the Greene County EMS PCR dated 3/25/2021 revealed the ambulance arrived at Hospital A at 7:35 AM. Upon arrival they found a 23 year old female in the passenger seat of her car in the hospital parking lot who stated she started having contractions around 5 AM. The patient pointed to her groin and advised "I already had it". The paramedic documented he/she could visually see a bulge in her groin, patient fully clothed. The clothing was cut from PI # 1 and it was discovered PI # 2 was already delivered from the waist up.

Further review of the EMS Event Clinical Presentations revealed the paramedic documented "2 (persons) in blue scrubs were in the parking lot with us, it appeared there was no evidence of care rendered prior to EMS arrival."

EMS delivered the fetus and provided care to PI # 1 and Cardiopulmonary Resuscitation (CPR) to PI # 2. EMS transported both patients to Hospital B at 7:53 AM.

On 3/31/2021 at 8:00 AM a copy of the Internal Investigation Summary, Event Clinical Presentations dated 3/25/2021 conducted by Greene County EMS was provided to surveyors. Review of the Investigation summary interview with Paramedic revealed "Dr. (Employee Identifier (EI) # 3) approached the side ambulance door appearing nervous and asked (the Paramedic) ... if this could be an EMTALA (Emergency Medical Treatment and Labor Act) violation. Per (Paramedic) the Physician (EI # 3) stated 'should we take them inside? I think this may be an EMTALA violation...Yes, I think this is one.' Paramedic...responded, 'too late for that. They are in my care now'."

An interview was conducted on 3/31/21 at 9:40 AM with EI # 3, physician, who stated "I came back and the ambulance people were here. They were doing CPR on the baby. (EI # 8, RN), told me they tried to get the mom out of the car and she refused because she said the baby was in her pants. I told the ambulance people we needed to get them in the hospital because this would be an EMTALA. The ambulance people said they already have the mom and the baby loaded in the ambulance and they were just going to take them." EI # 3 was then asked who treated the patient in the parking lot? EI # 3 stated "EMS was doing CPR on the baby and we were all there but we were waiting on a person to come to help with the mother. I told my nurse (EI # 7), we needed to get them inside. There was myself, the EMS people and the nurses from the hospital." EI # 3 was asked did you or the hospital employees provide any treatment to the patient? EI # 3 stated "no EMS was doing it."

In an interview conducted on 4/1/2021 at 3:30 PM, EI # 1, Administrator, and EI # 2, Director of Nurses, confirmed there was no MSE performed on PI # 1 or PI # 2.

Based on review of the facility policies and procedure, Hospital B Medical Records, EMS (Emergency Medical Services) Patient Care Reports (PCR), EMS Event Clinic Presentations, and staff interviews, it was determined Greene County Hospital (Hospital A) failed to ensure Stabilizing treatment was performed on a patient presenting to the hospital in active labor or on the newborn who was delivered while on hospital premises.

This deficient practice affected 2 of 2 patients who did not received stabilizing treatment prior to transfer to another facility including Patient Identifier (PI) # 1 and PI # 2 and had the potential to affect all patients presenting to this hospitals Emergency Department (ED).

Findings include:

Physician Procedures
Policy # 105
Date reviewed 5/15/2018

1. The on-duty emergency physician shall provide a medical screening examination to all patients presenting. ...

... 3. The physician providing the medical screening examination shall physically examine the patient and, where necessary to rule out any potential emergency medical condition ... The physician's observations, evaluation of differential diagnoses, testing ordered, and results of all testing shall be recorded in the medical record.

4. Necessary definitive care ... to stabilize the patient's condition shall be rendered in the hospital. ...

Nursing ER Responsibility
Policy # 125
Reviewed 5/15/2018

The nurse is responsible for the following actions for each patient who presents to the ER.

1. For the patient requiring assistance with airway, the nurse will establish and maintain an airway.

2. For those in need the nurse will attempt to establish and support respiratory efforts...

3. For patients requiring a venous access, the nurse will establish and maintain this access...

4. The nurse will remove all clothing and visually examine each patient. Clothing may be cut away if necessary to allow visualization...

5. Measure vital signs and repeat as necessary...

6. Obtain adequate history from patient, family, ambulance attendants, friends...

7. Provide emotional support to patient and family or friends.

Protocol: Obstetrical Conditions
Policy # 131
Reviewed 5/15/2018

Patients admitted to the Emergency Room will have a complete set of Vital Signs taken by a member of the nursing staff. The nurse will make an assessment of the patient and will inform the physician of the patient's condition. Someone will remain with the patient at all time. ...

1. Obtain OB (Obstetrical) history and report to the Physician

2. Patient's chief complaint.

3. Estimated date of delivery.

4. Vital signs and Fetal Heart Rate.

5. Fundal Height and date of delivery according to pregnancy calculator wheel.

6. Onset, duration, frequency, and location of pain.

7. Symptoms associated with pain.

8. Status of membranes, intact, ruptured, or leaking.

9. Presence or absence of vaginal discharge.

10. Judgement regarding presence of or progress of active labor.

Note: the patient may be placed on the fetal monitor to determine the presence or absence of uterine contractions.

1. Review of Hospital B ED Patient Notes dated 3/25/2021 at 8:33 AM revealed PI # 1 stated she began to have labor pains at home at approximately 5:00 AM on 3/25/2021. After attempts to obtain an ambulance for transport were unsuccessful, PI # 1 was taken by family members to Hospital A by private car and arrived at approximately 7:00 AM. PI # 1 stated she notified the staff at Hospital A she was labor and then had a spontaneous delivery of PI # 2 in the car in the hospital parking lot.

The MR of PI # 1 and PI # 2 including documentation of stabilizing treatment was requested on 3/30/2021 at 4:00 PM from Employee Identifier (EI) # 2 Director of Nurses, but could not be provided to surveyors.

Review of the Greene County EMS PCR dated 3/25/2021 revealed the ambulance arrived at Hospital A at 7:35 AM. Upon arrival they found a 23 year old female who stated she started having contractions around 5 AM. The patient was in the passenger seat of a car in the hospital parking lot. The patient pointed to her groin and advised "I already had it". The paramedic documented he/she could visually see a bulge in her groin, patient fully clothed. The clothing was cut from PI # 1 and it was discovered PI # 2 was already delivered from the waist up.

Further review of the EMS Event Clinical Presentations dated 3/25/2021 revealed the paramedic documented "2 (persons) in blue scrubs are in the parking lot with us, it appeared there was no evidence of care rendered prior to EMS arrival."

EMS delivered the fetus and provided care to PI # 1 and Cardiopulmonary Resuscitation (CPR) to PI # 2. EMS transported both patients to Hospital B at 7:54 AM.

An interview was conducted on 3/30/21 at 4:56 PM with EI # 4, physician, who stated during the interview if a "patient is on campus we are responsible for them." EI # 4 stated, "We are supposed to do a medical screening. (EI # 3, physician) said he told them to bring the mom and baby into the hospital but I guess they didn't."

An interview was conducted on 3/31/21 at 9:40 AM with EI # 3, physician, was asked the question who treated the patient in the parking lot? EI # 3 responded stating "EMS was doing CPR on the baby and we were all there but we were waiting on a person to come to help with the mother." EI # 3 was then asked did you or the hospital employees provide any treatment to the patient? EI # 3 responded by stating "no EMS was doing it."

An interview was conducted on 3/31/21 at 10:47 AM with EI # 8, Registered Nurse, (RN) was asked what do you do if a pregnant patient comes in requesting treatment? EI # 8 responded by stating "I have not had that happen until last week. A (person) came in and said a lady was having a baby. I called (EI # 4) and I told him and called 911. There were only 2 nurses here myself and EI # 7. I called 911 for assistance to help get the patient out of the car. This happened between 7:25 AM and 7:35 AM. I went out to the car and the lady said she could not get up because she had the baby and it was in her pants." EI # 8 then stated "I went outside and asked the patient her name and age and if this was her first baby and she said no it was her second one. I told her to get into the wheelchair and she said she could not that the baby was in her pants already. I only touched the patients skin I did not do vital signs. I did feel the area and the baby was in her pants. I did not assess the baby because the baby was in her pants."

EI # 8 further stated "the ambulance arrived and they opened the car door and cut the pants off the patient. I saw the baby was blue. The other ambulance person was in the back of the ambulance getting the supplies that were needed. They suctioned the baby and started CPR on the baby. EI # 7 came around with a blanket and the ambulance person put the baby in the blanket. The other ambulance person was with the mother. He cut and clamped the umbilical cord." EI # 8 was asked was the mother and baby brought into the hospital? EI # 8 responded stating "no. I was told EMS would not bring them in. The other EMS person and myself got the mom on the stretcher."

EI # 8 was asked how would you assist to get a patent out of a vehicle? EI # 8 stated "I would use a stretcher or a wheelchair and use who ever is available to help get the person out. We took a wheelchair out there but the patient refused to get up because the baby was in her pants. I called 911 to get some help to get her out of the car that's it I did not call them to take her anywhere. Also, the (parent) of the patient was there and the patient was alert and oriented and her skin was warm and dry."

An interview was conducted on 3/31/21 at 2:30 PM with EI # 9, RN. During the interview EI # 9 was asked are you familiar with the incident on 3/25/21? EI # 9 stated yes. EI # 9 was then asked how were you involved? EI # 9 replied "I was one of the day shift nurses. I got here about 7:49 AM that day. I had trouble getting here. Two nurses (EI # 7) and (EI # 8) and (EI # 3, physician) were here. (EI # 3) and (EI # 7) were at the ambulance. (EI # 8) was with the mother. I went out and the EMT had the baby and was using an ambu bag. (EI # 8) was assessing for bleeding. I did not do anything. They were trying to load the mom in the ambulance. Then (another) EMT arrived and then they got the mom in the ambulance."

An interview was conducted on 3/31/21 at 3:35 PM with EI # 7, RN, and was asked what do you do if a pregnant patient comes in requested treatment? EI # 7 replied by stating "we bring them in and stabilize them." EI # 7 was then asked are you familiar with the incident on 3/25/21? EI # 7 stated "yes, that was a few days ago. My shift was over and me and EI # 8 were giving report. I noticed there was a lot going on so I kind of tuned in to that. An employee was leaning on the counter and I asked her what was going on. She said a (person) said a woman was out in the car having a baby."

EI # 7 also stated "I went and got a wheelchair and the man knocked on the door and I asked him when her water broke. He said 5:00 AM. He said he did not know why 911 did not come. I told him the other nurse is on the phone now with the doctor and we would be to the car in a minute." Did you have any patient contact? "When I returned with the wheelchair one of the 911 people was inside the car with the baby. The mother was in the passenger side and the baby was on her lap. The first 911 person was suctioning the baby's nose and mouth. The second 911 person was ready to assist. I looked over and the back of the stretcher had sheets and a blanket. I folded the blanket to catch the baby. I then saw (EI # 3, physician), walk up to the ambulance. I saw the 911 person had put the 2 clamps on the cord and cut the cord. I handed him the blanket and he placed the baby in the blanket and placed the baby on the stretcher. I was rubbing the baby's leg trying to stimulate the baby."

EI # 7 was asked did you assess any part of the baby? "The baby was not breathing and was cold. I asked (EI # 8) if we had a baby ambu bag and the second 911 person went and got one out of the ambulance. The first 911 person started bagging the baby. I told (him/her) I could do the bagging so (he/she) let me. The second 911 person added oxygen on the ambu bag. It was obvious the baby was not breathing and had no heartbeat. I would say by the time EMS finished suctioning it had been 2-3 minutes. I said the baby was cold so one of the 911 people said we needed to take the baby to the ambulance. I offered to take the baby into the hospital but one of the 911 people said they have the baby in the ambulance already. When they were trying to get the mom on the stretcher she wouldn't move and I realized she had nothing on from the waist down so I shielded her with a sheet."

EI # 7 was asked if CPR (Cardiopulmonary Resuscitation) started on the baby? EI # 7 stated "CPR was started on the baby after we got mom on the stretcher. The second 911 person started compressions as he was walking toward the ambulance. I went to the ambulance and asked if I could help and he said no I got this."

In an interview conducted on 4/1/2021 at 3:30 PM, EI # 1, Administrator, and EI # 2 confirmed no stabilizing treatment was performed by hospital staff for PI # 1 or PI # 2.

Based on review of the facility policies and procedure, Hospital B Medical Records, EMS (Emergency Medical Services) Patient Care Reports (PCR), 911 call log, and staff interviews, it was determined Greene County Hospital (Hospital A) failed to ensure an appropriate transfer was arranged for a transfer to Hospital B of a patient presenting to the hospital in active labor or on the newborn who was delivered while on hospital premises including:

1. No order for the transfer from the physician

2. No transfer form completed

3. No agreement from the patient authorizing the transfer

4. No agreement from the accepting Hospital B

5. No medical records of the patients sent with transfer

This deficient practice affected 2 of 8 records reviewed of patients transferred to another facility including Patient Identifier (PI) # 1, PI # 2, and had the potential to affect all patients presenting to this hospital.

Findings include:

Transferring a Patient
Policy # 103
Date reviewed: 5/15/2018

A patient can be transferred only by order from the physician and only after that patient has been properly evaluated and has been deemed stable for transfer, or when following the proper evaluation, the physician feels that the risk of transferring the patient outweigh the risk of keeping the patient in the facility. Arrangements for transfer must be made between the transferring physician and the accepting physician. Also there must be an agreement from the facility to which the patient is transferring to accept the patient. The appropriate department must be notified and given pertinent information such as vital signs, patient condition, medication or treatments that the patient has received, mode of transport and time of departure.

A. An order for transfer must be documented in the medical record.

B. A complete transfer form must accompany the patient and a copy must remain with the patient's medical record.

C. There should be an agreement from the patient or significant other authorizing the physician to seek and carry out the transfer...

D. Copies of all treatments, procedures, medications, and other pertinent information should accompany the patient to the accepting facility.

E. Services performed in the department...should also accompany the patient.

1. Review of Hospital B Emergency Department (ED) Patient Notes dated 3/25/2021 at 8:33 AM revealed PI # 1 stated she began to have labor pains at home at approximately 5:00 AM on 3/25/2021. After attempts to obtain an ambulance for transport were unsuccessful, PI # 1 was taken by family members to Hospital A by private car and arrived at approximately 7:00 AM. PI # 1 stated she notified the staff at Hospital A she was labor and then had a spontaneous delivery of PI # 2 in the car in the hospital parking lot.

A copy of the Medical Record of PI # 1 and PI # 2 was requested from Employee Identifier (EI) # 2, Director of Nurses, on 3/30/2021 at 4:00 PM but no MR or documentation the transfer was arranged by Hospital A could be provided.

Review of the Greene County EMS PCR dated 3/25/2021 revealed the ambulance arrived at Hospital A at 7:35 AM. Upon arrival they found a 23 year old female who stated she started having contractions around 5 AM. The patient was in the passenger seat of a car in the hospital parking lot. The patient pointed to her groin and advised "I already had it". The paramedic documented he/she could visually see a bulge in her groin, patient fully clothed. The clothing was cut from PI # 1 and it was discovered PI # 2 was already delivered from the waist up.

Further review of the EMS Event Clinical Presentations dated 3/25/2021 revealed the paramedic documented "2 females in blue scrubs are in the parking lot with us, it appeared there was no evidence of care rendered prior to EMS arrival."

EMS delivered the fetus and provided care to PI # 1 and Cardiopulmonary Resuscitation (CPR) to PI # 2. EMS transported both patients to Hospital B at 7:54 AM.

An interview was conducted on 3/31/21 at 9:40 AM with EI # 3, physician, who was asked the following questions. Can you tell me what you understand about the EMTALA (Emergency Medical Treatment and Labor Act) laws? EI # 3 responded by stating "its about medical transfer and Labor Act. We have to treat anyone who comes to the hospital with no questions asked. We show no discrimination at all." Can you tell me what kind of EMTALA training you have had here? EI # 3 replied "I have not had any training here at this hospital."

EI # 3 was then was asked how are you notified of a patient requiring Emergency Treatment? EI # 3 stated "they call me after the nurse triages the patient. If the patient is severe they call me right away." How long does it take you to get to the hospital? "It does not take me long." For after hours do you stay in the house across the street from the hospital? EI # 3 stated "yes". EI # 3 was asked does the hospital own the property? He/she responded by stating "yes".

When asked what do you do if a pregnant patient comes in requested treatment? EI # 3 stated "depending on how far along she is. We do not deliver the baby. I see what is going on by assessing the situation, I do a medical screening first. I then contact an OB (Obstetrical) physician and usually transfer the patient."

EI # 3 was then asked have you ever had any pregnant patients present for emergency care? EI # 3 stated "yes, and the last time was last week." EI # 3 continued by stating"my shift was over and (EI # 4. physician) called and asked me to see the patient. I came back and the ambulance people were here. They were doing CPR on the baby. (EI # 8. Registered Nurse (RN) told me they tried to get the mom out of the car and she refused because she said the baby was in her pants. I told the ambulance people we needed to get them in the hospital because this would be an EMTALA. The ambulance people said they already have the mom and the baby loaded in the ambulance and they were just going to take them." The following question was asked of EI # 3, who treated the patient in the parking lot? EI # 3 replied "EMS was doing CPR on the baby and we were all there, but we were waiting on a person to come to help with the mother. I told my nurse (EI # 7, RN), we needed to get them inside. There was myself, the EMS people and the nurses from the hospital."

The surveyor then asked did you or the hospital employees provide any treatment to the patient? EI # 3 stated "no EMS was doing it. Ambulance people said they were transferring to Tuscaloosa.) EI # 3 was asked so, was the transfer arranged by you/hospital? His/her response was (no).

The surveyor then asked was a report called to Tuscaloosa? EI # 3 responded by stating "yes, the nurse called to tell them what happened at 7:37 AM and she made the call at 7:50 AM. (EI # 8) called Tuscaloosa to inform what had happened." EI # 3 was asked if this was documented somewhere and EI # 3 stated "I told her to make a note and I think she did I am not sure."

The surveyor then asked EI # 3 if any other patients deliver here and he/she responded by stating "about a month to a month and a half ago EMS brought a patient here. The baby was cyanotic. We stabilized both the mother and the baby and then we transferred both of them."

During the interview EI # 3 was asked the question were you on diversion during these incidents. EI # 3 replied by stating "we usually only have one nurse and we try not to divert. If we do it's usually only a few hours during the night time. Day time we are ok its night time that we divert. I think last week there was only one nurse on days and I think we were on diversion." EI # 3 was asked when you go on diversion its is due to staffing or bed availability. EI # 3 stated "its always because of staffing." The surveyor then asked do you have a record of when you were on diversion and EI # 3 stated "not to my knowledge but I will check." EI # 3 was then asked by the surveyor do you have a policy to follow for diversion? EI # 3 stated "no, we do not." The surveyor asked EI # 3 for clarification and asked so, if you only have one nurse you go on diversion and EI # 3 replied "yes". The surveyor asked where is it documented? EI # 3 stated "I am not sure I will check." Who do you notify you are on diversion? EI # 3 stated "we call 911".

A copy of the Diversion Policy was requested from EI # 2, Director of Nurses on 4/1/2021 at 2:00 PM. EI # 2 stated the hospital did not have a policy for diversion. EI # 2 stated if they only have one nurse on duty they will notify 911 they are on diversion.

In an interview conducted on 4/1/2021 at 3:30 PM, EI # 1, Administrator, and EI # 2, Director of Nurses, confirmed the transfer of PI # 1 and PI # 2 was not arranged by hospital staff.