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.

REGIONAL ONE HEALTH 877 JEFFERSON AVENUE MEMPHIS, TN 38103 Oct. 25, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on medical by-laws, policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention received an appropriate Medical Screening Examination (MSE) to determine if an emergency medical condition existed for 1 of 20 (Patient #20) sampled DED patients, when a request for treatment was in his/her behalf by the mother.

Refer to findings in Tag A-2406.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on hospital policy, document review and interview, the hospital failed to maintain a central log that included each individual who presented to the dedicated emergency department (DED) seeking assistance for a medical condition for 1 of 20 (Patient #20) sampled patients.

The findings included:

1. Review of the hospital's "EMTALA [emergency medical treatment and labor act] policy revealed, "...[name of hospital #1] will maintain an EMTALA Central Log, which will capture all individuals presenting to any DED requesting medical assistance, regardless of if he/she departs...The log will contain at a minimum...Date and time of arrival...Name, age, and sex of the patient...presenting complaint...The EMTALA Central Log will be maintained for no less than 5 years..."

2. In a telephone interview on 10/25/17 at 1:00 PM the mother of Patient #20 confirmed that she brought her newborn baby to Hospital #1's DED to be seen related to potential complications and was told to take the baby to Hospital #2.

3. Review of the hospital's central DED log for 10/15/17 revealed Patient #20's name was not on the DED log.

4. In an in interview on 10/23/17 at 10:40 AM the Director of Quality verified the mother or baby was never placed on the DED log.

In an interview in the conference room on 10/24/17 at 11:10 AM, Emergency Department Clerk (EDC) #1 stated, "...On Sunday [10/15/17], the mother presented to the window [evaluation desk], the mother thought her baby was having complications...She [RN #1]said to tell the mom to take the baby to [name of Hospital #2]. I went back out...told the mom what she [name of RN #1] said, to take the baby to [name of Hospital #2]. The mother said, 'okay, are you sure'. I said yes ma'am...The dad picked up the baby in the carrier and they left..."
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical by-laws, policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention received an appropriate Medical Screening Examination (MSE) to determine if an emergency medical condition existed for 1 of 20 (Patient #20) sampled DED patients.

The findings included:

1. Review of the hospital's "Medical By-Laws" revealed, "A. Medical Screening Examinations (MSE) When a patient presents to the [Name of the Hospital #1] seeking treatment, a MSE will be done in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Any Medical Staff Member may perform the exam. In addition, specially trained non-physician Qualified Medical Personnel (QMP) may perform medical screening examinations. An Emergency Department Advanced Practice Nurse or Physician Assistant; a Trauma Department Advanced Practice Nurse or Physician Assistant; A Labor and Delivery Nurse may be designated as a Qualified Medical Person..."

2. Review of the hospital's "EMTALA Policy" revealed, "...Persons on [name of hospital] property requesting or appearing to need emergency medical treatment, will be treated in the following manner...If a person presents to a dedicated emergency department (DED), including Jefferson /Medicine, Trauma, L&D, OR Burn ED: A qualified medical person (QMP) will perform a medical screening exam (MSE) per Patient Triage Policy...Medical Screening Exam (MSE) An MSE consists of an assessment and any ancillary test (based on the patients chief complaint) necessary to determine if an emergency medical condition exists (EMC)...The MSE will be performed by qualified medical person (QMP)...to determine if an EMC exists on anyone, including children and newborns who present to [name of the hospital's] property requesting medical assistance..."

3. Medical record review for Patient #20 revealed the patient was born at Hospital #1 on 10/8/17 via Cesarean Section (C- section) and admitted to the hospital's Neonatal Intensive Care Unit (NICU).

Review of the 10/8/17 physician's progress note revealed, "...Baby...delivered by C-section due to active HSV [Herpes Simplex Virus] lesions. Review of the "Newborn Discharge Instructions" revealed the baby was discharged home with the mother on 10/12/17.

4. A telephone interview was conducted on 10/25/17 at 1:00 PM with Patient #20's mother. Patient #20's mother verified she and the patient/baby had an inpatient stay at Hospital #1 and were discharged on [DATE]. Patient #20's mother stated, "...I was told [at Hospital #1] to bring the baby back for any complications" when she and the patient/baby were discharged from Hospital #1 on 10/12/17.

This surveyor asked the patient's mother if she took the patient/baby to Hospital #1's DED on the afternoon of Sunday, 10/15/17. The mother stated, "Yes...I took the baby to the hospital to check for complications."
Patient #20's mother was then asked what she was told at Hospital #1's DED. The mother stated, "I had to take the baby to [name of Hospital #2] next door...They saw us at [name of Hospital #2] and we went home..."

5. An interview was conducted in the conference room on 10/23/17 at 10:40 AM with the Vice President (VP) of Risk, Director of Quality (DOQ) and the Labor and Delivery Manager (LDM). The VP of Risk stated during the daily safety call on Monday 10/16/17 a potential EMTALA violation was reported by the LDM.
The LDM stated she had received a message that a mother and her baby (Patient #20) had presented to the Labor and Delivery Evaluations emergency department (ED) on Sunday 10/15/17 at approximately 1:40 PM and informed ED clerk #1 that she was seeking care for her baby. The LDM reported ED Clerk #1 was informed by RN #1 to tell the mother to take the baby "...to [name of Hospital #2]..."

In an interview in the conference room on 10/23/17 at 1:10 PM, when asked about the 10/15/17 occurrence with Patient #20 and the mother, RN #2 stated, "...It was a Sunday [10/15/17]...I was the triage nurse...in a room came out. I heard [name of RN #1] talking to [another nurse name]... someone came to the window [name of RN #1] said if baby wanted to be seen we could see it or she could go to [name of Hospital #2]...I think it was in the afternoon, not sure..." RN #2 stated that she and RN #1 later went out to the waiting room to see if the mom and baby (Patient #20) were still there.

In a telephone interview on 10/23/17 at 2:00 PM, RN #1 was asked about the incident with Patient #20. RN #1 stated, "...Last Sunday [10/15/17] I was working in the evaluation triage area [in the DED]. The secretary [name of ED Clerk (EDC) #1] said a woman asked if this was where she should come to get treatment for her 4 day old newborn...told [name of EDC #1] if she wanted her child to be seen we had to see it, but [name of children's hospital] would be appropriate place to see a child...3 minutes later realized we needed to see her because she presented here. We talked to the charge nurse [name of Patient Care Coordinator]..." RN #1 stated when they went out to see if the mother and baby were still there, the security guard told us that "she [mother and Patient #20] had just left..."

In an interview in the conference room on 10/23/17 at 5:10 PM, the Risk Manager (RM) was asked about the 10/15/17 incident with Patient #20. The RM stated, "...On Monday morning while on a safety call, [name of Vice President (VP) of Risk] reported potential EMTALA ...touched base with [names of the LDM and EDC #1]. [Name of EDC #1] explained mom came to the [Labor and Delivery ED evaluation window] with a baby [Patient #20]... [Name of EDC #1] asked [name of RN #1] what to do with baby. [Name of RN #1] said to tell her [mom] to take the baby to [name Hospital #2]. She [EDC #1] said she did not write anything on log book. I interviewed [name of RN #1] via telephone. [Name of RN #1] stated she told [name of EDC #1] we can see baby here if she wants us to or she can take her baby to [Hospital #2]. [RN #1] thought the baby was 3 days old, that was her statement to the clerk..."

In an interview in the conference room on 10/24/17 at 11:10 AM with EDC #1, EDC #1 stated, "...On Sunday [10/15/17] the mother presented to the window [Labor and Delivery ED evaluation window], the mother thought her baby (Patient#20) was having complications, she didn't say what the complications were...I went to the nurses station, there were 2 nurses sitting at the desk doing something on the computer, [name of RN #1 and #2]. I told [name of RN #2] about the baby. She [RN #1] said to tell the mom to take the baby to [name of Hospital #2]. I went back out to the desk and told the mom what she [RN #1] said...The mother said 'okay, are you sure.' I said yes ma'am...I was the only one that saw the baby. The nurses never came out. The mom told me she had been discharged on Thursday [10/12/17]. The dad picked up the baby in the carrier and they left [Hospital #1]..."

5. Hospital #2's medical record for Patient #20 revealed the patient presented to the hospital's DED on 10/15/17 accompanied by the patient's mother.

Review of Hospital #2's ED Triage Assessment Form dated 10/15/17 revealed Patient #20 had presented to the DED with the chief complaint the mother was concerned about a blister on the baby's lip.

Review of the Hospital #2's Clinical Documents dated 10/15/17 revealed a MSE was performed on Patient #20 which documented, "...no lesions and specifically no lesions on upper lip. what they [parents] are concerned about is not a blister, but likely skin duplication and mild peeling of the lips, which is a normal finding..." The patient was discharged home from Hospital #2's DED on 10/15/17 at 4:04 PM.