The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HALE COUNTY HOSPITAL 508 GREEN STREET GREENSBORO, AL 36744 June 5, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews, review of Emergency Medical Services (EMS) Pre-Hospital Patient Care Report, Emergency Department (ED) medical record (Hospital # 2), Quality Assurance Form, written statement by the registration clerk and Hospital 1's Policies and Procedures for Emergency Medical Treatment and Labor Act (EMTALA) and Examination and Treatment of Obstetrical Patients, Hospital # 1 failed to:

A. Create a medical record for Patient Identifier (PI) # 1, a pregnant female who presented to Hospital # 1's ED on 5/19/14.

B. Document in the ED log the presentation of PI # 1, a patient complaining of labor and contractions.

C. Provide an appropriate medical screening examination for PI # 1, a patient who presented to the ED with a complaint of labor and contractions on 5/19/2014.


Hospital # 1's deficient practice effected PI # 1, one of 21 sampled patients who presented to Hospital 1's ED and has the potential to negatively effect all patients who present to Hospital 1's ED for a Medical Screening Examination to determine if an Emergency Medical Condition exists.


Findings include:


Please refer to findings at A2403 - Medical Record, A2405 - emergency room Log and A 2406 - Medical Screening Examination.
VIOLATION: HOSPITAL MUST MAINTAIN RECORDS Tag No: A2403
Based on review of the Quality Assurance Form and interview, it was determined Hale County Hospital (Hospital # 1) failed to create a medical record for a pregnant female who presented to Hospital # 1's emergency room (ER) on 5/19/14 with complaints of being in labor and contractions. This affected Patient Identifier (PI) # 1, one of 21 sampled emergency room patients.

Findings include:

Review of Quality Assurance Form (Hospital # 1):

Occurrence Date: 5/19/14
Occurrence Time: "Unknown"
Name: (PI # 1)
Person Completing Form: First and last name of LPN (Licensed Practical Nurse) who was working in the emergency room when PI # 1 presented
Location: Administrative/Business Office
Type of Occurrence: LWBS (Left Without Being Seen) - Left prior to triage
Nurse Comments: "Approx (approximately) 12:15 was told by
(Adm. /Admission clerk) that patient said that she thinks she is in labor and don't have a ride to (Hospital # 2). I thought that patient was on the phone. Told her (Admission Clerk) to tell patient to call 911 and tell them that she is in labor and need to go to (Hospital # 2). Approx. 12:35 was told that patient was gone to HCEMS (Hale County EMS - Emergency Medical Services) Base. I never saw patient. Called EMS base was told by (EMT/Emergency Medical Technician) that patient was at base and was going to (Hospital # 2)."


During an interview on 6/4/14 at 10:37, the Director of Patient Care Services/Employee Identifier # 4, stated there is no sign-in form or any record to indicate PI # 1 presented to the hospital's ER on 5/19/14.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the emergency room (ER) Log Report dated 5/1914 and interview, Hospital # 1 failed to document the presentation of Patient Identifier (PI) # 1, a pregnant female with patient complaints of labor and contractions, in the ER log. This affected PI # 1, one of 21 sampled patients.

Findings include:


A review of the ER Log Report dated 5/19/14 beginning with the first entry at 00:17 through the last entry at 21:39 revealed no documentation to indicate PI # 1 (MDS) dated [DATE].

During an interview on 6/4/14 at 10:37, the Director of Patient Care Services/Employee Identifier # 4, stated there is no sign in form or any record to indicate the patient (PI # 1) presented to the hospital's ER on 5/19/14.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the Quality Assurance Form, written statement by the Registration Clerk, Emergency Medical Services (EMS) PreHospital Patient Care Report, ED Medical Record (Hospital # 2), Hospital # 1's Policies and Procedures related to EMTALA (Emergency Medical Treatment and Labor Act) and Examination and Treatment of Obstetrical Patients and interviews, Hospital # 1 failed to provide a medical screening examination for Patient Identifier (PI) # 1, a patient who (MDS) dated [DATE] with a chief complaint of labor and contractions. This deficient practice affected PI # 1, one of 21 sampled patients and has the potential to affect all patients who present to this hospital seeking emergency medical services.


Review of Quality Assurance Form (Hospital # 1):

Occurrence Date: 5/19/14
Occurrence Time: "Unknown"
Name: (First and last name of PI # 1)
Person Completing Form: First and last name of LPN (Licensed Practical Nurse) who was working in the emergency room when PI # 1 presented
Location: Administrative/Business Office
Type of Occurrence: LWBS (Left Without Being Seen) - Left prior to triage
Nurse Comments: "Approx (approximately) 12:15 was told by (Adm. /Admission clerk) that patient said that she thinks she is in labor and don't have a ride to (Hospital # 2). I thought that patient was on the phone. Told her (Admission Clerk) to tell patient to call 911 and tell them that she is in labor and need to go to (Hospital # 2). Approx. 12:35 was told that patient was gone to HCEMS (Hale County EMS - Emergency Medical Services) Base. I never saw patient. Called EMS base was told by (EMT/Emergency Medical Technician) that patient was at base and was going to (Hospital # 2)."

Quality Assurance Description Investigation (This section must be completed): No documentation.


Review of the statement written by the Registration Clerk / Employee Identifier (EI) # 2 at Hospital # 1:

"On 5/19/14 about 12:14 PM (PI # 1) came to the emergency room (ER) and advised me that she needed to see a doctor and stated that she was in labor her contractions were 7 min (minutes) apart. I gave her the paper work to fill out. I went to the ER desk to inform the ER nurse that the patient said she was in labor and was not going to be able to make it to the hospital in Tusc (Tuscaloosa). Ms. (ER LPN) advised me to tell her to call 911 for a ambulance and they would take her. I told the patient what (ER LPN) said. The patient advised me that she has a family member who work at the ambulance base, and she would just go over there. Ms. (ER LPN) did not know the patient was in my office until she was gone. She thought that I was saying that she (PI # 1) was on the phone."

EMS Pre Hospital Patient Care Report Includes:

Patient Information:

Patient Name: First and last name of PI # 1
Type of Patient: OB Premature Threatened Labor
Date/Date of Onset: 5/19/2014 12:00
Receiving Hospital: Hospital # 2

Call Information:
Call Origin: Individual
Destination Reason: Most accessible receiving facility
Dispatch Scene: ...Base (located in close proximity to Hospital # 1)

Pertinent Findings: OB Labor Pains

History of Present Illness: "19 weeks gestation, Grav (Gravida: number of pregnancies) 5, Para ( number of deliveries leading to live births) 1.Water leakage sudden onset @ 12:00 noon. Severe lower abd (abdominal) pressure with some contractions. Fetus active then decreasing during transport. Denies bleeding. Put in Trendelenburg position. IV (Intravenous) NS (Normal Saline) 200 ML (milliliters) bolus 4 LTS (Liters), O2 (Oxygen), EKG (electrocardiogram) Stach (Sinus Tachycardia)."

13:10: Arrived at Destination (ED at Hospital # 2)


Review of Emergency Department Medical Record at Hospital # 2: Includes :

Triage: 5/19/14 at 1320

98.5 (Temperature); 87 (Pulse); 20 (Respirations); 116/87 (Blood Pressure)

Pain Intensity: 7 (0-10 scale)

Chief Complaint: "Woke up at 1200 with water in lap. Since then had lower abdominal/back/hip pain...States having constant pain and increase in pain every 7 minutes. G-5 (Gravida) P-1 (Para). Was 27 weeks with other child."

Physician Documentation:

Date: 5/19/14

Time seen by Provider: 1353

Triage History/Chief Complaint: "Woke up at 1200 with water in lap. Since then had lower abdominal/back/hip pain...having constant pain and increase in pain every 7 minutes." G -5 (Gravida: number of pregnancies); P-1 (Para: number of deliveries leading to live births) was 27 weeks with other child.

Context: This is a [AGE] year old G5 P1 female that presents to the ED (Emergency Department) for evaluation of waking up with water in her lap this morning. The patient states since that time she had had lower abdominal, back and hip pain. The patient also notes abdominal cramping, dizziness and burning behind neck...Patient denies fever, trauma, vomiting and diarrhea.

Severity: Moderate

History: Miscarriage x 3. Had one birth at 27 weeks gestation. High blood pressure during first pregnancy.

Physical Examination: The patient is in no acute distress and does not appear uncomfortable.

GI (Gastrointestinal)/Abdomen:
Mild suprapubic tenderness. No rebound or guarding. Nondistended. No masses.

Extremities: No pretibial edema
Medical Decision Making: Blood Pressure: 116/87; Heart Rate: 87; Respiratory Rate: 20.

Ultrasound: 5/19/2014 at 1551

Findings: There is a single live intrauterine pregnancy at 18 weeks 5 days gestation. No complication noted...No evidence of premature rupture of membranes. Normal amniotic fluid volume. Fetal heart rate is 157 beats per minute.

ED Course:
1621: Spoke with (Obstetrician) concerning the patient...states patient should follow up at office on 5/21/14...

Condition: Stable
Disposition: Home/Self Care
Reason for Examinations: Wetness
Certified Medical Emergency: Yes
Clinical Impression: Intrauterine Pregnancy (Primary) and Urinary Incontinence (Secondary)


Interviews:

During an interview on 6/3/14 at 13:30, the Assistant Administrator Patient Care Services, Employee Identifier (EI) # 1, Hospital # 1, said the hospital self reported an incident that occurred on 5/19/14 to the state agency as a possible EMTALA violation when PI (Patient Identifier) # 1, a pregnant female, presented to the hospital and told the registration clerk that she came to the hospital to get a ride to Hospital # 2. The Assistant Administrator identified the name of the registration clerk and the Licensed Practical Nurse (LPN) involved in the incident on 5/19/14.

Because the clerk told the LPN that PI # 1 needed a ride to the hospital (Hospital # 2), the LPN thought PI # 1 was on the telephone. This is the reason the LPN advised the clerk to tell the patient to call 911 for transport. The Assistant Administration said Hospital # 1 does not provide Labor and Delivery services. According to the Assistant Administrator, the clerk never questioned the LPN's response. The Assistant Administrator identified the incident as a, "Communication error."

As soon as the LPN realized PI # 1 had actually been in the hospital (not on the telephone) and had told the registration clerk she was going to the EMS office after being told by the clerk to call 911, the LPN called EMS (Emergency Medical Services) staff and notified EMS of the incident.


During an interview on 6/3/14 at 14:40, the Registration Clerk, EI # 2, Hospital # 1, stated PI # 1 came to the hospital on [DATE] and said she was in labor and had a history of early delivery. The surveyor asked the clerk if she told the emergency room (ER) nurse about the patient's report of early delivery. The clerk said she did not recall if she reported this to the nurse. According to the clerk the patient was, "In my office and said she was unable to make it to Tuscaloosa (city approximately 38 miles from Hospital # 1 with a hospital that provides obstetrical services). I told Ms. (first name of ER LPN) the patient (PI # 1) presented to the hospital) the patient said her contractions were 7 minutes apart." The nurse said to tell the patient to call 911 for an ambulance. "I (clerk) did not understand that the nurse did not understand the patient was in the registration office in the emergency room ." According to the clerk, she was advised by the nurse to tell the patient to call 911 so an ambulance could get her to the hospital. "We (Hospital # 1) don't have delivery here. I went back to the office and told the patient to call 911. The patient said okay. I have a family member who works at ambulance company. I'm going over there. I went back and told Ms. (ER LPN) that the patient went to the EMS base and that's when she (LPN) realized the patient was here (in the hospital)... I went to the door (in the ER waiting room) to see if I could see the patient and looked in the parking lot (Hospital # 1). I did not see the patient...Ms. (ER LPN) called EMS and explained what happened..." The clerk was asked what she did when the patient presented to the emergency room and stated she thought she was in labor. The clerk said she gave the patient the initial paperwork, so she could begin signing in and immediately reported to the nurse.


During an interview on 6/3/14 at 15:15 the ER LPN, EI # 3, Hospital # 1, stated the admitting clerk said PI # 1 the patient reported she did not have a ride to (Hospital # 2) and thinks she might be in labor. The LPN stated she advised the clerk to tell the patient to call 911 and, "They will take her wherever she is supposed to go." The clerk said "okay" and returned to her office.

About ten minutes later, the clerk told the LPN, PI # 1 said she had a relative working at EMS and she was driving to the EMS base. The LPN said she asked the clerk why the patient would not just call 911. That is when the clerk told the nurse that the patient was in the registration office at the hospital when she made the statement about driving to EMS. The LPN said, "I thought the patient was at home because the clerk said the patient did not have a ride to the hospital." The LPN stated the clerk did not tell her the patient had been in the ER registration office. I (LPN) would never send a patient away (from the hospital) who was sick or in labor. I would keep the patient. I called the EMS base and spoke with (EMS staff) who said she's (PI # 1) already here. We will take to (Hospital # 2)..."

The LPN said there is no obstetrical service at (Hospital # 1). If a patient presents to the ER, thinks they are in labor or is experiencing pain, our ER physician will evaluate the patient and usually consults with the patient's obstetrician. The patient is sent via ambulance to the appropriate hospital. The surveyor asked the LPN if a similar situation has occurred in the past and she replied, "No. Not that I know."

During an interview on 6/5/14 at 12:10, the Registration Clerk, EI # 2, Hospital # 1, was asked by the surveyor if she had ever been instructed by any ED staff member to call 911 for a patient who presented to the ER and she said, "No." The clerk was also asked if she thought the LPN's instruction to call 911 was out of the ordinary and she said, "I did not."


Policies and Procedures related to EMTALA (Emergency Medical Treatment and Labor Act) - Hospital # 1:

Subject: General Medical Screening
Issued: 9/97
Related to: Emergency Department, Outpatient Clinics, Admitting Policy: " ...all persons presenting for unscheduled...evaluations shall receive a medical screening examination within the capabilities of the emergency department and the ancillary services routine available to the emergency department, including the services of appropriate on-call physician...

Definitions:
Emergency Medical Condition (EMC): A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of prompt and appropriate medical attention could result in:
(a) Placing the health or safety of the patient or unborn child in serious jeopardy;
(b) Serious impairment to bodily functions;
(c) Serious dysfunction of any bodily organ or part.

Stabilize: With respect to an EMC...to provide that treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration is likely to result from (or occur during) the transfer of an individual; and with respect to a pregnant female experiencing contractions that the baby and placenta have been delivered.

Transfer: The movement of the patient, for any reason, including discharge...

Triage: The initial and on-going evaluation of presenting patients by the Triage Nurse or other designated Registered Nurse to determine the order in which they will be provided a medical screening examination...

Nursing Procedures:
1. ...all persons presenting at the Emergency Department (ED)...shall be provided a Medical Screening examination in the ED of this Hospital, including Obstetrics patients who are 26 weeks or more in estimated gestation...
2. The following conditions are declared to be emergency conditions by statue and regulation:
(a) Pregnancy with contractions present;
(b) Acute pain...
(c) Psychiatric disturbances;
(d) Symptoms of substance abuse...

Medical Screening Examination: The initial and on-going evaluation of the presenting patient conducted by a physician...to determine whether a patient has an emergency medical condition (emc)...or to ensure that the patient does not have an emc.

Necessary Definitive Care: ...medical care necessary to stabilize an emc within the discretion of the physician providing the medical screening examination...
5. No patient presenting shall be denied triage or medical screening examination...
11. Patients requesting transfer of their own volition, and without any suggestion or direction by an employee of this hospital or a physician member of the medical staff, shall be documented as indicated in the Patient Transfer Policy...

Physician Procedures:
1. The on-duty emergency physician shall provide a medical screening examination to all patients presenting. Except in the case of a documented refusal, AMA (Against Medical Advice),or instance of a patient leaving without being seen by a physician...

3. The physician providing the medical screening examination shall physically examine the patient and, where necessary to rule out any potential emergency medical condition in the range of differential diagnoses...shall order such testing and further examination by on-call physicians as is routinely available to the emergency department within the capabilities of this hospital. The physician's observation, evaluation of differential diagnoses, testing ordered and results...shall be recorded in the medical record.

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

8. When the existence of an emergency medical condition...has not been ruled out, any ambiguity in test results, examination, history or complaints shall be resolved by the physician in favor of an emergency medical condition and the patient treated accordingly. "

Subject: Examination and Treatment of Obstetrical (OB) Patients
Issued: 9/97
Policy: It is the policy of Hospital # 1 emergency room (ER) to assess all OB patients admitted to the ER...After MD (Medical Doctor) assessment, patient may be referred or transferred to OB/GYN (Gynecology) accordingly.

(1) ...patients with obvious OB complaints such as, but not limited to:
(a) Full term pregnancy stating, " I think I'm in labor. " ...

(2) ...patients, which after triage assessment and obtaining of history of complaint, leads to questionable complaint of OB versus medical problem will be examined by ER physician, and then phone consultation with patient's OB physician will be obtained. These complaints include, but are not limited to:
(a) Less than 20 week gestation with complaint of abdominal cramping and/or back pain, with/without bleeding...

There was no documentation that PI #1 was triaged or a Medical Screening Examination (MSE) was performed by a physician or Qualified Medical Personnel at Hospital #1. As result of Hospital # 1's failure to provide a MSE, PI # 1 left hospital property without a medical evaluation, presented to the EMS base and requested transfer to (Hospital # 2).