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.

SOUTHERN REGIONAL MEDICAL CENTER 11 UPPER RIVERDALE ROAD, SW RIVERDALE, GA 30274 Jan. 26, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
1. Based on observational tours of the ED, a review of ambulance trip report, Central Log, ED sign-In sheets, policies and procedures, Medical Staff Bylaws and Rules and Regulations, video recording, staff interviews, Police Officer interview, telephone call and interviews the facility failed to ensure that an appropriate medical screening examination was provided, that was within in the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed when a request was made by the mother of a 10 month old, presenting to the Emergency Department with a complaint of "Breathing" issues for 1 (#7) of 26 sampled patients. Additionally, the facility failed to ensure that their Medical Staff Bylaws or the Medical Staff Rules and Regulations determined who was qualified to conduct medical screening examinations. Cross refer to findings in tag A-2406.

2. Based on observations, review of medical records (sign-in sheets), policies and procedures and interview the facility failed ensure that their policy and procedure regarding leaving without treatment was followed as evidenced by failing to document that an individual was offered and/or provided information on the risks and benefits of further examination and treatment prior to triage or a medical screening examination for 1 (#7) of 26 sampled patients..
Cross refer to findings in tag A--2407.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of the Emergency Department (ED) registration sign-in sheets, the ED central Log, the Labor and Delivery (L&D) central log, and policies and procedures, and staff interviews it was determined that the facility failed to maintain a Central Log on each individual who "comes to the emergency department" seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for two (s) individuals, (Patient #7 and #21) out of twenty-six (26) sampled patients.


Findings were:


Policy and Procedure:

The facility's Policy and Procedure titled "Examination, Treatment and Transfer of Patients Presenting with Emergency Medical Conditions" Version 12, Revised Date: 02/05/2016 page 10 of 11 section G revealed in part, "Central Log-SRMC (Southern regional Medical Center) will maintain a Central Log on each individual who cones to SRMC emergency department or other departments, such as labor and delivery, providing Medical Screening Exam.
1. Each department where Medical Exams occur shall maintain a log of the following information...This policy shall apply if the individual presents to any part of SRMC (except _ _ _ Station).
b. Medical record number;
c. Date and time of arrived;
d. Time discharged ;
e. The name (s) of the clinician who performed the Medical Screening Exam;
f. The presenting complaint;
g. The level of acuity or triage documented; and
h. Whether the individual (a) was refused treatment; (b) was refused treatment; (c) was transferred; (d) was admitted and treated; (e; was stabilized and transferred;
Or (f) was stabilized and discharged ."

Review of the facility's ED registration sign-in sheet revealed that Patient #7, a [AGE]-year-old infant that (MDS) dated [DATE], with a complaint of "breathing". Review of the ED log failed to reveal that patient #7 was entered into the ED log.


Review of the facility's ED registration sign-in sheet revealed that Patient #21 was a [AGE]-year-old that (MDS) dated [DATE], with a complaint of "seizures". Review of the ED log failed to reveal that patient #21 was entered into the ED log.
During an interview on 01/25/17 at 3:30 p.m. in the conference room, Registrar #4 confirmed that he/she had been working at the registration desk on 01/17/17. Registrar #4 recalled a woman with a baby (Patient #7) and that the woman waited in line for less than five (5) minutes before coming to the registration window and handing Registrar #4 the sign-in paperwork. Registrar #4 stated that he/she normally entered patients into the electronic system.


During an interview on 01/26/17 at 12:30 p.m. in the Conference Room, the Director of Quality Services (Staff #9) confirmed that Patient #7 and Patient #21 were not registered into the electronic central log system. Staff #9 also explained that on 01/26/17 the facility had fixed the computer system so that patients who left prior to registration and/or triage could be identified


During an interview on 01/26/17 at 2:50 p.m. in the conference room, the patient access director (Staff #10) confirmed that registration clerks were responsible for taking the patient sign-in sheets and entering the patient into the facility's electronic system which in turn entered the patient into the ED Central Log and initiated a medical record. Staff #10 explained that all registration clerks had received EMTALA training.


The facility failed to ensure that their Central Log policy and procedure was followed as evidenced by failing to maintain a central log for patient #7 and #21 when they presented to the hospital seeking assistance as to whether he or she was refused treatment, refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observational tours of the ED, a review of ambulance trip report, Central Log, ED sign-In sheets, policies and procedures, Medical Staff Bylaws and Rules and Regulations, video recording, staff interviews, Police Officer interview, telephone call and interviews the facility failed to ensure that an appropriate medical screening examination was provided, that was within in the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed when a request was made by the mother of a 10 month old, presenting to the Emergency Department with a complaint of "Breathing" issues for 1 (#7) of 26 sampled patients. Additionally, the facility failed to ensure that their Medical Staff Bylaws or the Medical Staff Rules and Regulations determined who was qualified to conduct medical screening examinations.

Findings were:


1. Review of the ED registration sign-in sheet revealed that Patient #7, a [AGE]-year-old infant (MDS) dated [DATE], with a complaint of "breathing". There was no documentation as to when the patient left the ED or that the patient left the ED without being registered or triaged (assessment by a nurse to determine patients' medical priority). The facility failed to ensure that their Triage policy an procedure was followed as evidenced by failing to ensure that the 10 moth old infant (Pt. #7) was triaged when he (MDS) dated [DATE] when the patient's mother documented on the sign-in the patient's complaint was "Breathing." There was no documented evidence that a medical screening examination was provided for patient #7 on 1/17/2017, when presented to the ED with his mother.


On 01/25/17 at 1:00 p.m., surveyor reviewed the video of Patient #7 being brought into the ED on 01/17/17, and observed as follows:

At 10:46:09 p.m., a female with a stroller was standing at the ED sign-in area and appeared to be waiting in line for registration;
At 10:47:09 p.m., the female gives papers to Registrar #4 and can be seen talking with the Registrar #4;
At 10:48:09 p.m., the female turns to leave and an infant can be seen in the stroller; and
At 10:48:15 p.m., the female pushes the stroller with inside the infant out of the ED. The infant appeared to be dressed appropriately for the weather and was observed to be resting, the infant did not appear to be in any observable distress at that time.


Review of the ED Central Log revealed that EMS brought Patient #7 back to the ED on 01/18/17 at 3:05 a.m. The ED central log and the Patient #7's medical record listed the reason for the visit as "unresponsive". The EMS trip report revealed that the ambulance attendants arrived at Patient #7's home at 2:48 a.m. and found Patient #7 in cardiac arrest (no heartbeat). The ambulance attendants noted that a county police officer (#11) was performing cardiopulmonary resuscitation (CPR - chest compressions and respirations) on Patient #7. The trip report further revealed that Patient #7 was transported to the hospital and care was turned over to the hospital staff. Physician #6 noted that the EMS had reported that Patient #7's parents found Patient #7 not breathing at 2:45 a.m. Physician #6 noted that the patient was pulseless for over 20 minutes prior to arrival in the ED. Physician #6 also noted that the Patient #7's pupils were fixed, dilated, and non-reactive to light (signifies severe brain injury and impending death). Physician #6 noted that standard pediatric resuscitation techniques were followed, but unfortunately resuscitation was unsuccessful. The patient was pronounced dead on 01/18/17 at 3:25 a.m.

During an interview and observational tour of the ED on 01/25/17 at 9:20 a.m. with the Interim ED Director (Staff #1), he/she confirmed that all individuals who present to the ED seeking treatment were to receive an MSE from either a physician, a Nurse Practitioner, or a Physician's Assistant. The Interim Director explained that patients present to the Quick Registration desk after filling out a form with their name and chief complaint.


During an interview on 01/25/17 at 3:30 p.m. in the conference room, Registrar #4 confirmed that he/she had been working at the registration desk on 01/17/17. Registrar #4 recalled a woman with a baby (Patient #7) and that the woman waited in line for less than five (5) minutes before coming to the registration window and handing Registrar #4 the sign-in paperwork. Registrar #4 stated that the woman asked how long the wait would be and that he/she replied that "I can't give that information because many factors are involved". Registrar #4 further stated that the woman reported that the baby's chief complaint was "breathing". The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that on 1/17/2017 when Patient #7 presented to the ED for care with a documented complaint of "breathing" issues, he received a medical screening examination to determine whether or not an emergency medical condition was present.


During an interview on 01/26/2017 at 12:30 p.m., in the conference room, the Director of Quality Services (Staff #9) confirmed that patient #7 did not receive a medical screening examination, and did not receive stabilizing treatment, and that the facility staff had failed to follow their policies and procedures. Staff #9 further explained that the facility did not yet have patient #7's autopsy report because it takes up to 90 days to receive an autopsy report.


During a telephone call to the county police department on 01/26/17 at 12:45 p.m., the day officer on duty (Interview #11) explained that the police officer who had responded to Patient #7's home and performed CPR on Patient #7 was on leave and therefore unavailable for an interview.

During an interview on 01/26/17 at 3:30 p.m. in the conference room, the security manager confirmed that the facility had initiated an investigation into the incident and that the police were also investigating

Numerous attempts were made on 01/25/17 and 01/26/17 to speak with the ambulance attendants who responded to patient #7's home on 01/18/17. The EMT Chief refused to allow the ambulance attendants to be spoken with unless it was cleared by the county's legal department. A contact number was provided but the EMT Chief declined that the ambulance attendants speak with the surveyor.


Review of facility's policies and procedures included but were not limited to the following:

1. Examination, Treatment, and Transfer of Patients Presenting with Emergency Medical Conditions (EMC), no policy number, the policy was approved by the Interim CNO (Chief Nursing Officer), last revised 02/05/16, and defined the following:

a. MSE: a clinical evaluation that is to be performed by a physician or a mid-level provider (i.e., Physician's Assistant, Certified Nurse Practitioner, Certified Nurse Midwife), a registered nurse with training and experience in a specialized area (e.g., labor and delivery with demonstrated clinical competency in physical assessment of the obstetric (pregnant) patient, electronic fetal monitoring [infant heart rate] and obstetrical emergencies), psychiatry, or a master's prepared mental health professional (i.e., Licensed Clinical Social Worker, Licensed Professional Counselor, Master of Social Work, etc.) working under the supervision and direction of a physician, to determine if an EMC exists.

b. EMC: A medical condition manifesting itself by acute (sudden) symptoms of sufficient severity, (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of an individual or an unborn child in serious jeopardy, serious impairment to bodily function or serious dysfunction of any bodily organ or part.

c. Stabilize: To provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual. A patient is stable if the treating physician determines, within reasonable clinical confidence, that the EMC has been resolved.


2. Patient Assessment/Documentation in the ED, no policy number, last revised 08/27/13, revealed that the facility utilized a five (5) level triage system with one (1) being urgent conditions that require life-saving measures and five (5) being non-urgent conditions. This policy revealed how often patients were to be reassessed according to the patient's triage level and the patient's signs and symptoms. The policy also revealed in part, "PURPOSE: This policy is to be used as a guide for the nursing staff on the contents of the triage assessment, frequency of secondary assessments and vital signs, with special considerations of the pediatric ...population. POLICY: Each patient arriving to the Emergency Department will receive a Screening Assessment. The triage assessment, recorded on the Emergency Department Record, will include but no limited to: a. Patient complaint; b. Objective/Subjective assessment of injury /illness; c. Vital signs; d. Medical History ...This assessment must be completed in the exam area by a Registered Nurse."

3. Responsibility for Patient Evaluation and Treatment, no policy number, policy was approved by the CNO, and revised 01/12/15, revealed that all patients arriving at the facility's ED were to receive an MSE by a physician, Nurse Practitioner, or Physician's Assistant.

4. The ED Statement of Care, no policy number, policy approved by the interim CNO, last revised 06/01/12, revealed that in accordance with EMTALA, "all patients presenting to the ED for care will receive a medical screening to determine if there is a medical emergency condition present."


Review of the facility's Medical Staff Bylaws and Rules and Regulations, approved by the Governing Board on 09/13/16, revealed no indication of who had been determined qualified to perform an MSE (Medical Screening Examination. During an interview on 1/26/2017 at 12:30 p.m. in the Conference Room the Director of Quality (Staff #9) confirmed that the facility had updated the Medical Staff Bylaws and Rules and Regulations to identify who had been approved to provide the MSE and that the corrective version was scheduled to be approved by the Medical Executive Committee later in the day on 1/26/17.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, review of medical records (sign-in sheets), policies and procedures and interview the facility failed ensure that their policy and procedure regarding leaving without treatment was followed as evidenced by failing to document that an individual was offered and/or provided information on the risks and benefits of further examination and treatment prior to triage or a medical screening examination for 1 (#7) of 26 sampled patients.


Findings were:

The facility's Policy and procedure titled "Patient Elopement, Left without referral, and Against Medical Advice, Version 6, Effective Date: 10/18/2013 was reviewed. The policy revealed in part, "POLICY: Definitions: 1. Left without Treatment (LWT) - A patient that leaves the facility prior to receiving a medical screening examination by the physician/healthcare provider or having the any protocols started, regardless of whether or not the triage and registration process has been completed ...PROCEDURES: LWT: Documentation of reason for leaving and time will be placed. Information will be provided regarding the risks of leaving and documented in the medical record."



Review of the ED registration sign-in sheet revealed that Patient #7, a [AGE]-year-old infant (MDS) dated [DATE], with a complaint of "breathing". There was no documentation as to when the patient left the ED or that the patient left the ED without being registered or triaged. There was also no documentation that any risks and benefits were explained to Patient #7's mother.


During an interview on 01/25/17 at 9:20 a.m. at the ED Registration desk, Registrar #2 was observed registering a patient. The registrar entered the patient's name, date of birth, and chief complaint into the facility's electronic system and scanned the patient's identification and placed an armband on the patient. The interview continued at 9:45 a.m., at which time Registrar #2 explained that if a patient decided to leave prior to receiving the MSE that he/she would document the time the patient left and enter the patient ' s information into the electronic system. Registrar #2 further stated that the registration staff were to inform the nurse in order that the nurse attempt to persuade the patient to remain and complete the MSE. Registrar #2 confirmed that he/she had received EMTALA training.

An interview was conducted with Registrar #4 on 3/25/2017 in the Conference room at 3:30 p.m. Registrar #4 stated that the woman (Patient #7's mother) stated there were many people waiting to be seen and asked where she could take her child to be seen faster. Registrar #4 stated that he/she informed the woman that there was a children's hospital in downtown Atlanta. Registrar #4 stated that the woman told Registrar #4 to throw away the sign-in sheet because she was not going to wait. Registrar #4 explained that he/she put the sign-in sheet away and the woman turned and left with the baby. Registrar #4 confirmed that he/she had received EMTALA training. Additionally, there was no documentation of a description of the communication between Registrar #4, and patient #7's mother (legal representative) of the risks and benefits of further examination and treatment after Patient #7's mother told the registrar #4 told the mother the location of another hospital , and that she was not going to wait.

There was no documented evidence that the nurse was notified to persuade patient#7's mother to remain in the ED until a MSE was completed, as stated in the facility's policy and procedure. The facility failed to follow their own policy as evidenced by failing to document on 1/17/2017 of Patient #7's mother (acting on his behalf) of informed refusal to consent to a medical screening examination and /or treatment.