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.

ST FRANCIS HOSPITAL 2122 MANCHESTER EXPRESSWAY COLUMBUS, GA 31995 Aug. 2, 2018
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on review of the Emergency Department (ED) Central Log, 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 treated or admitted , treated and stabilized, and treated or discharged for 1(#2) of 20 sampled patients. The facility failed to ensure that the patient was entered into the ED Central Log.

Findings were:
Review of the facility's ED Central Log confirmed that patient #2 was not entered into the ED Central Log on 07/18/18.

Review of facility policies and procedures included but was not limited to the following:
I. ADMISSION AND DISCHARGE OF ER (emergency room ) PATIENTS, policy number 76, last approved 01/17, revealed staff were to follow these guidelines regarding the admission of all patients to the ED.
The policy stated in part, "7. Registration will occur either at the patient's bedside or in the registration area. Patients or their legal guardian will sign consent for permission to treat. If the patient is unable to sign for consent to treat the request for treatment will be implied until the next of kin can be notified. "

2. LL.026, EMTALA -Medical Screening and Treatment of Emergency Medical Conditions revealed in part, "Central Log is a log that that a Hospital is required to maintain on each individual who comes to its emergency department or any locations on the hospital property or Premises seeking assistance and that contains the disposition of each individual, whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged . The purpose of the Emergency Department log is to provide a listing of each individual who comes to the Dedicated Emergency Department seeking examination or treatment for a medical condition

Staff Interviews:
During an interview with the Registration Clerk (#8) on 07/31/18 at 8:50 a.m. at the ED registration desk, the Registration Clerk explained that when a patient presents to the ED the patient is asked to fill out the Check-In Form which includes the patient's name, date of birth, social security number, the patient's primary doctor's name, and the patient's chief complaint. The Registration Clerk stated the patient's information is then entered into the computer system which enters the patient into the ED Central Log and generates a medical record for the patient.

During an interview with the MT (#3) on 07/31/18 at 9:15 a.m. in the Administration Conference Room, the MT explained that it was his/her duty to register patients at night but that his/her immediate thought was to escalate the baby to be seen because he/she was worried that it was a breathing issue and he/she wanted to get a nurse to assess the baby. The MT explained that after the family left the baby was not entered into the ED Central Log because he/she did not have a name for the infant or any of the registration information.

During an interview with the RN (#5) on 07/31/18 at 10:30 a.m. in the Administration Conference Room, the nurse stated he/she did not know if the baby was put into the ED Central Log. .
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of medical records, review of the video recording, Medical Staff Bylaws and Rules and Regulations, Professional Services Agreement, policies and procedures, observational tours of the ED, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination within 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 for one (1) of 20 sampled medical records when patient #2 (a newborn baby) was brought into the ED on 07/18/18.

Findings were:

The CO provided a copy of the video recording dated 07/17/18. The video recording revealed the following:

--11:28 p.m., A female enters the ED, goes to the front desk, and places an infant carrier on the countertop. Multicare Technician (MT) #3 speaks with the female.
--11:29 p.m., A second female enters the ED and speaks with the MT. The MT goes into the main ED.
--11:30 p.m., Registered Nurse (RN) #4 comes out and looks at the infant. A male and a third female arrive.
--11:31 p.m., RN #4 goes back into the main ED.
--11:32 p.m., RN #5 (the ED Charge Nurse) comes out, looks at the infant and talks with the family.
--11:33 p.m., RN #5 takes his/her stethoscope and listens to the infant's chest.
--11:34 p.m., RN #5 talks with the three (3) females and one (1) male family members.
--11:35 p.m., one (1) of the females picks up the infant carrier while RN #5 continues to talk with the family members.
--11:38 p.m., RN #5 goes back into the main ED.
--11:40 p.m., RN #5 and physician #2 come out to the front desk and physician #2 looks at the infant. RN #5 picks the infant up and the physician uses his/her stethoscope to listen to the baby's chest. Physician #2 and RN #5 continue to talk with the family for a couple of minutes.
--11:43 p.m., One (1) of females picks up the infant carrier and is escorted out of the ED by RN #5. Physician #2 and RN #5 go back into the main ED.



Review of patient #2's birth medical record from St. Francis Hospital revealed the patient was a full-term baby delivered on 07/16/18 at 9:13 p.m. Nurses' notes indicated the baby weighed six (6) pounds and 13 ounces and was 19.49 inches long. Delivery notes revealed the baby was delivered by cesarean section. The mother's complications were noted as chorioamninotis (intra-amniotic infection caused by bacteria entering the uterus from the vagina) and arrest of decent (failure of the infant to continue through the birth canal despite uterine contractions and pushing efforts).

Apgar assessments were performed to evaluate the health of the infant. Apgar scores evaluate the following:
--evaluates breathing effort: zero [0] if the infant is not breathing, one [1] if breathing is slow or irregular, and two [2] if the infant cries well;
--heart rate: zero [0] if there is no heart rate, one [1] if the heart rate is less than 100 beats per minute, and two [2] if the heart rate is greater than 100 beats per minute;
--muscle tone: zero [0] if the muscles are loose and floppy, one [1] if there is some muscle tone, and two [2] if there is active movement;
--reflexes: zero [0] if there is no reaction, one [1] if there is grimacing, and two [2] if there is grimacing and a cough, sneeze, or cry, and
--skin color: zero [0] if the infant is pale or blue, one [1] if the body is pink but the extremities are blue, and two [2] if the entire body is pink.

Documentation revealed the baby's apgar score was: respirations two (2), heart rate two (2), muscle tone one (1), reflexes two (2), and color zero (0) for a total of seven (7) at one (1) minute. The nurse noted that tactile stimulation (rubbing the body) was initiated and the baby's apgar score was documented as: respirations two (2) heart rate two (2), muscle tone one (2), reflexes two (2), and color zero (1) for a total of nine (9) at five (5) minutes.

Nurses' notes indicated that the baby cried after being bulb suctioned and that thick meconium (stool passed by the infant while in the uterus) was noted at the time of delivery. Nurses' notes indicated that the baby was placed in the warming incubator by the delivering physician and was deep suctioned with a catheter (tube inserted into the airway) and bulb syringe multiple times. Nurses' notes also indicated that the baby continued to cry well and that the baby's color and tone gradually improved.

On 07/17/18 at 1:31 p.m., physician notes indicated the following:
--normal healthy newborn;
--vital signs (temperature, pulse, respirations, and oxygen saturation) appropriate;
--bonding appropriate;
--voiding and stooling;
--plan to continue newborn care;
--nursed or cried most of the night and consolable; and
--exclusive breast feeding.

On 07/18/18 at 11:41 a.m., physician notes indicated the following:
--normal healthy at term newborn;
--vital signs appropriate;
--bonding appropriately;
--voiding and stooling;
--feeding problems;
--plan to continue newborn care;
--second day baby doing well except fussy and gassy. Latches well but mother's milk not in yet. Physical exam normal. May try simethicone (Mylicon) drops with feeds. If obstetrician allows discharge baby with follow-up in office tomorrow.

Nurses' notes indicated that the infant's care plan and nursing interventions were initiated for the following:
--maintain a clear airway, this was documented as being met;
--maintain body temperature, this was documented as ongoing; and
--will be free of pain (post circumcision and heel sticks for bloodwork), this was documented as ongoing.

Discharge notes revealed the baby and mother were discharged home in stable condition on 07/18/18. Discharge documentation revealed the baby's discharge weight was six (6) pounds and 11 ounces.

Review of hospital B's medical record for patient #2 revealed the baby was admitted to hospital B's pediatric ED on 07/18/18 at 11:57 p.m. The chief complaint was documented as "resuscitation" (the action or process of reviving someone from unconsciousness or apparent death).

At 12:02 a.m., the ED physician noted that the baby's father reported one (1) episode where the baby became pale, went limp, but did not stop breathing. The physician further noted that the father reported that the family stimulated the baby and when the baby's color improved they drove the baby to St. Francis Hospital and were directed to bring the baby to hospital (B's) pediatric ED. The ED physician further noted that the family reported that the baby was a breast-fed baby and had been crying for 18 hours. The physician noted that the mother reported that the baby had been latching on well until about 1:30 p.m. and that she had been unable to get the baby to latch on appropriately since then. In addition, the physician noted that the mother reported that the family had tried to feed the baby with a syringe but were unable to get the baby to swallow. The physician noted that the family reported that the mother and baby had been discharged home from St. Francis Hospital after 8:00 p.m. on 07/18/18. The physician noted that upon arrival, the baby was very pale, limp, and had a weak cry. In addition, the physician noted the following:
--point of care (POC) glucose (blood sugar level) was low (too low for machine to show the value);
--bottle fed one (1) ounce;
--approximately 10 minutes later prior to rechecking POC glucose the baby became pale again and rapid response (emergency response team) was called;
--POC glucose was low again, bolus of intravenous (into a vein) fluids were administered;
--POC glucose increased to 50 and D10 (dextrose which is a form of glucose) drip was started;
--mother attempted to breastfeed and POC glucose dropped to 27;
--D10 drip rate increased.
Documentation further revealed that the father reported two (2) incidents where the baby turned gray and became unresponsive. The physician noted that the baby's legs were cyanotic (blue) and that the body was pale. The physician further noted that the baby appeared ill, pale, with mild respiratory distress and that the baby was hypoglycemic (low blood sugar).

The baby was triaged by a nurse as a level 1 priority (requires immediate treatment) at 12:07 a.m. Nurses' notes indicated the following:
--12:07 a.m., heart rate 132 (normal 100-160), respirations 56 (normal 20-60), temp 97.3 (normal rectal 96.8 to 100.4), blood pressure was not taken (normal 65/40-105/68), and oxygen saturation 98% (96-100%). The baby's vital signs (temperature, heart rate, respirations, blood pressure, and oxygen saturation) remained within normal limits from the time of admission through 07/23/18 at 10:00 a.m. (last recorded vital signs at the time the medical record was received) with the following exceptions: heart rate was 169 (high) on 07/20/18 at 2:00 a.m. and 161 (high) on 07/20/18 at 6:00 p.m., respirations were 76 (high) on 07/19/18 at 1:09 a.m. and 62 (high) on 07/19/18 at 1:30 a.m., blood pressure was 101/71 (high) on 07/19/18 at 12:15 a.m., and oxygen saturation was 95% (low) on 07/19/18 at 6:00 p.m. The baby's glucose level on 07/19/18 at 12:40 a.m. was less than 20 (normal newborn level 40-150) at 1:05 a.m. it was 50, at 1:26 a.m. it was 27, 2:03 a.m. it was 52, and at 2:42 a.m. it was 44.

Documentation revealed the baby was admitted to the Neonatal Intensive Care Unit and received the following:
--POC glucose testing every three (3) hours;
--D10W 250 milliliters (ml) intravenously (IV)at 6 ml;
--Complete blood cell count with differential;
--Basic Metabolic Panel (test kidney and electrolyte function);
--C-reactive protein level (test for any inflammation);
--Herpes simplex virus was negative;
--Hepatic function panel (test liver function);
--Chest x-ray revealed the lungs were clear;
--Strict intake and output;
--Xylocaine (local anesthetic that was used to perform the lumbar puncture - spinal tap to test for bacteria/infection);
--Consult neonatology and pharmacy (for neonate dosing);
--Lumbar puncture;
--Cerebral spinal fluid culture and gram stain was negative for bacteria/infection;
--Blood cultures that revealed no growth after three (3) days (negative for bacteria/infection);
--Gentamicin (antibiotic) 14 milligrams (mg) pediatric syringe IV every 24 hours;
--Gentamicin peak and trough level (evaluates effective levels);
--Ampicillin (antibiotic) 300 mg IV every 12 hours;
--Consult lactation specialist for poor feeding;
--On 07/20/18 at 2:53 p.m. orders were to do 6:00 p.m., 9:00 p.m. and 12:00 a.m. blood sugars and if results are acceptable may discontinue every three (3) hour blood sugars;
--On 07/22/18 at 12:04 p.m. orders were to transfer the patient to the Pediatric floor. Documentation revealed the patient was transferred in good condition;
--Lactation consult breast feeding difficulties
--Acyclovir (antiviral medication) 60 mg pediatric syringe IV every 8 hrs.
Documentation revealed the baby remained hospitalized at hospital (B) at the time the medical record was received by the Department.

Review of the Medical Staff Bylaws and Rules and Regulations, signed by the Medical Staff on 11/21/17, CEO 11/21/17, Board of Trustees on 11/27/17, approved by Legal Counsel 07/30/18, and by the COO 07/30/18, revealed the following:
APPENDIX "B' - RULES AND REGULATIONS
.
ARTICLE V - EMERGENCY MEDICAL SCREENING, TREATMENT, TRANSFER, and ON-CALL ROSTER POLICY
5.1 SCREENING TREATMENT & TRANSFER
5. I (a) Screening
(1) Any individual who presents to the ED of this hospital for care shall be provided with a medical screening examination (MSE) to determine whether that individual is experiencing an emergency medical condition (EMC). Generally, an EMC is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child.
(2) Examination and treatment of EMC shall not be delayed in order to inquire about the individual's method of payment or insurance status, nor denied because of the patient's inability to pay.
(3) All patients shall be examined by qualified medical personnel, which shall be defined as a physician, or in the case of a woman in labor, a registered nurse trained in obstetric nursing, where permitted under state law and Hospital policy, who may determine true, false or no labor but may not make a medical diagnosis.
(4) Services available to ED patients shall include all ancillary services routinely available to the ED, even if not directly located in the department.

Review of the Professional Services Agreement effective 01/01/16 and continued on a year to year basis, revealed the following:
Contractor (ED service) and Contractor's Representatives (ED practitioners) shall perform all services under this agreement in accordance with any and all regulatory and accreditation standards applicable to the hospital and the services, including, without limitation, those requirements imposed by the Medicare Conditions of Participation, The Joint Commission accreditation standards, the AMA Code of Ethics, the rules and regulations of the Board of Medicine in the State, the Emergency Medical Treatment and Active Labor Act ("EMTALA"), the Federal Anti-Kickback and Stark statutes and regulations, federal and state regulations governing the security and privacy of health information, and other applicable state and federal regulations, all as amended from time to time.

Review of the facility's policies and procedures included but was not limited to the following:
II. LL.026, EMTALA - MEDICAL SCREENING AND TREATMENT OF EMC, policy number 0, last 12/04/13, revealed that any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate MSE performed by a physician or other Qualified Medical Personnel to determine whether or not an EMC exists.

If an EMC is found to exist, the Hospital will (without regard for the patient's insurance coverage or ability to pay) provide: (a) stabilizing treatment within the capabilities of the Hospital and its staff (including on-call physicians and diagnostic services), and/or (b) an appropriate transfer to another medical facility (if required for the patient's treatment or requested by the patient).

PROCEDURE:

EMC means:
1. A medical condition manifesting itself by acute 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:
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part; or
2. With respect to a pregnant woman who is having contractions:
a. That there is inadequate time to effect a safe transfer to another Hospital before delivery; or
b. That transfer may pose a threat to the health or safety of the woman or the unborn child.

ii. MSE is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists, or a woman is in labor. Such screening must be done within the facility's capability and available personnel, including on-call physicians. The MSE must be performed by a Physician or other Qualified Medical Personnel. The MSE is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred. Triage does not constitute a MSE.


Qualified Medical Person or Personnel, or "QMP", means an individual other than a licensed physician who has demonstrated current competence in the performance of MSE and been approved by the main Hospital provider's governing board as qualified to administer one or more types of MSE and complete/sign a certification for transfer in consultation with a physician. The categories of non-physician practitioners who may be designated as QMPs is set forth in Medical Staff Bylaws or Rules and Regulations and approved by the governing body of the Hospital. Ad hoc QMP designations of other categories of non-physician practitioners are not permissible.

Stabilized with respect to an EMC means that no material deterioration of the condition IS likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta. A patient will be deemed stabilized if the treating physician of the individual with an EMC has determined, within reasonable clinical confidence, that the EMC has been resolved.

To Stabilize means, with respect to an EMC to either provide such medical treatment of the condition as may be 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 from a facility or, in the case of a woman in labor, that the woman has delivered the child and the placenta.

Stable for Discharge: A patient is considered stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions. For the purpose of discharging a patient with psychiatric condition(s), the patient is considered to be stable for discharge when he/she is no longer considered to be a threat to him/her or to others. Also, a psychiatric patient is considered stable when they are protected and prevented from injuring or harming him/herself or others. The administration of chemical or physical restraints for purposes of transferring an individual from one facility to another may stabilize a psychiatric patient for a period of time and remove the immediate EMC but the underlying medical condition may persist and if not treated for longevity the patient may experience exacerbation of the EMC. Therefore, practitioners should use great care when determining if the medical condition is in fact stable after administering chemical or physical restraints.

Transfer means the movement of an individual outside a Hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the Hospital, but does not include such a movement of an individual who has been declared dead or who leaves the facility against medical advice or without being seen.

iii. Facility Policies
Each Hospital that provides emergency medical services must develop policies and procedures to insure compliance with EMTALA requirements. Such policies should contain the following provisions:
A. General Requirements: Registration, Triage, and MSE.
1. Registration and Log
Each such presenting individual must be listed in the Central Log. The MSE may not be delayed in order to secure the individual's insurance information or payment arrangements. Hospitals should request this information only after the MSE has begun.
3. MSE
A MSE may be performed by an ED physician, another physician, or a non-physician practitioner who is qualified to conduct such examination (QMP) and approved by the Hospital's governing board.

iv. Results of MSE; Additional Obligations; Stabilizing Treatment.
1. Results of MSE and Attendant Responsibilities
In general, if the physician or other QMP performing the MSE determines that the individual does not have an EMC, then the Hospital's EMTALA obligations to that individual cease. The Hospital may proceed to collect financial information and make financial arrangements for treatment.
If the MSE reveals an EMC, then the Hospital must provide stabilizing treatment within its capacity and capabilities (including on-call physician services and ancillary services) necessary to stabilize the patient or must appropriately transfer the patient to another facility. Admission as an inpatient may be required as part of the stabilizing treatment. Once a patient is admitted as an inpatient in good faith, EMTALA is satisfied; however, the Hospital continues to have responsibility to meet patient emergency needs in accordance with the Medicare Conditions of Participation.
2. Transfer Requirements
If the MSE reveals an EMC, the patient may only be transferred while the condition has not been stabilized if (a) the physician has certified that the medical benefits to be received at another Hospital outweigh the increased risks to the individual (and, as the case may be, to her unborn child) or (b) the patient, or a legally responsible person acting on the patient's behalf, requests the transfer, after being informed of the Hospital's obligations under EMTALA and of the risks and benefits of the transfer, among other requirements. Patients should not generally be transferred to a lower level of care (for example, patients should never be transferred to a physician office unless the office has specialized equipment which is generally limited to ophthalmologists). For a complete description of transfer requirements, please see EMTALA - Transfers policy.


Staff Interviews:

During a tour of the ED with the Assistant ED Director (#7) on 07/31/18 at 8:40 a.m., EMTALA signage was observed to be posted in the main ED waiting room, in the triage (assessment by a nurse to determine the order in which patients will be seen based on their chief complaint, signs, and symptoms) room, in the ED hallway, and at the ambulance entrance. All EMTALA signage was posted in English and Spanish. The Assistant ED Director explained that the ED has a Green Zone (fast track) that has seven (7) chairs/beds, a Red Zone (main ED) that has 22 beds and four (4) Behavioral Health beds, and a Yellow Zone that has 12 observation beds. The Assistant ED Director stated that the MSE is performed by a physician or mid-level (physician's assistant or a nurse practitioner) under the supervision of a physician. He/she explained that the ED has a registration clerk on duty until 10:00 p.m. and that after 10:00 p.m. the MT on duty registers ED patients. The Assistant ED Director explained that after 10:00 p.m. the MT is also responsible for reassessing patients waiting to be seen and performing any electrocardiograms (test that evaluates the heart rate and rhythm).

During an interview with the MT (#3) on 07/31/18 at 9:15 a.m. in the Administration Conference Room, the MT explained that he/she has worked for the facility for three (3) years and has been in the ED for two (2) of those years. He/she confirmed that EMTALA training is part of the ED's mandatory required annual training and that he/she received EMTALA training in April 2018. The MT stated he/she remembered the episode that occurred on 07/18/18. The MT said that he/she was stationed at the main ED desk when two (2) women approached with an infant. The MT said that the women were frantic and reported that the infant was lethargic (sluggish) and had experienced episodes of turning gray. The MT said the women asked, "is this normal". The MT said that the mother was pointed out and that she reported being discharged from the facility earlier in the evening (07/18/18). The MT said that his/her first thought was that the baby was having periods of apnea (not breathing). The MT said he/she looked at the baby to see if the baby needed to be taken immediately to the back. The MT said that the baby was pink in color and did not look to be in any distress. The MT said he/she went and asked his/her lead nurse (RN #4) to go out and check the baby. The MT said that he/she also informed the ED Charge Nurse (CN/RN #5) because the CN had more experience. The MT explained that he/she and the CN passed RN (#4) who was on his/her way to get the CN. The MT said that the CN listened to the baby's lung sounds, checked the baby's airway and extremities, and that the baby started to cry. The MT said that the family was encouraged multiple times to sign in to be seen and were informed that the facility did not have a pediatrician available to see the baby but that if the baby needed further care the baby would be transferred. The MT said that the CN (RN #5) had the ED physician (#2) come out and assess the baby. The MT said that after the ED physician (#2) assessed the baby the family decided to leave. The MT said that it was his/her duty to register patients at night but that his/her immediate thought was to escalate the baby to be seen because he/she was worried that it was a breathing issue and he/she wanted to get a nurse to assess the baby. The MT explained that after the family left the baby was not entered into the ED Central Log because he/she did not have a name for the infant or any of the registration information.

During an interview with the RN (#4) on 07/31/18 at 9:50 a.m. in the Administration Conference Room, the nurse explained that he/she has worked in the facility's ED since September 2017. The nurse said he/she had been a RN for three (3) years. The nurse confirmed that EMTALA training is required annually and that he/she completed the annual EMTALA training in June 2018. RN (#4) explained that on 07/18/18 the MT (#3) came an informed him/her that there was a baby that needed to be assessed. The RN said that he/she went out and assessed the baby. The nurse said that the baby was pink, warm and dry, and in no distress. The nurse said he/she consoled the mother and informed her that he/she (RN #4) was going to get a second opinion. The nurse said he/she went and got the CN (#5) who was already on his/her was to assess the baby. The nurse said he/she then went back to the Green Zone.

During an interview with the ED physician (#2) on 07/31/18 at 10:10 a.m. in the Administration Conference Room, the physician stated he/she recalled the event that occurred on 07/18/18. The physician explained that the CN (5) reported that there was a baby in the waiting room that was going to another hospital (B) and he/she (CN #5) wanted to be sure it was safe for the infant to leave. Physician #2 stated he/she told the family he/she would be happy to see the baby and that if the baby required additional treatment the baby would be transferred to another hospital (B). The physician (#2) stated he/she looked at the baby and examined the fontanels (soft spots) for any bulging. The physician (#2) said the baby was moving around in the car seat and did not require any immediate resuscitation. The physician (#2) stated he/she had not tried to coerce the family into staying because the family had already decided to go to another facility. The physician said that he/she was unable to document on the baby because the baby had not been registered as a patient.

During an interview with the RN (#5) on 07/31/18 at 10:30 a.m. in the Administration Conference Room, the nurse stated he/she has been a RN for three (3) years, has worked in the ED for 2.5 years, and that prior to that he/she was a flight medic for the Air Force for 11 years. RN #5 confirmed that he/she completed EMTALA training in April 2018. RN #5 said that on 07/18/18 he/she was the ED CN and was in the middle of caring for a patient when he/she was notified by the front desk staff (MT #3) that there was a patient at the desk that needed to be assessed by a nurse. RN #5 said he/she asked the team lead (RN #4) to go assess the patient and that after assessing the patient the team lead (RN #4) asked me (RN #5) to see the patient. RN #5 said that he/she assessed the baby and spoke with the family. RN #5 said that he/she was informed that the baby was born at this facility two (2) days ago and that the baby was sleeping a lot, was arousable, and was not eating as much as the family thought the baby should be eating. RN #5 stated that the family was offered several times to sign the baby in to be evaluated. RN #5 said that he/she was not sure if the family brought up the other hospital (B) but that he/she did inform them that there was no pediatrician in the ED and that the other hospital had a pediatric ED and would have pediatric physicians available.
The facility failed to ensure that an appropriate medical screening examination was provided that was with the capability of the hospital's capability to determine whether or not an emergency medical condition existed for a 2 day old infant (#2) who presented to the hospital's emergency department not feeding, and not acting or looking well on 7/18/18.

During a telephone interview with the pediatrician (#10) on 07/31/18 at 10:30 a.m. in the Administration Conference Room, the physician confirmed that he/she was familiar with the patient (#2) and that he/she had seen the patient prior to discharge from the Mother Baby Unit on 07/18/18. The physician explained that the baby was a fussy baby that was easily consolable. The physician said that he/she felt that the baby was fussy due to the mother's breast milk not being in fully. The physician explained that he/she saw the baby who was a second day cesarean delivered baby on 07/18/18 and gave the family the option of staying until the next day but the family chose to leave that evening. The physician said that the nurses reported that the baby was easily consolable and that he/she felt it was alright for the baby to be discharged that night. The physician said that in hind-sight the baby was probably not feeding well became dehydrated. The physician explained that he/she also saw the baby after the baby was admitted to the other hospital (B) with a low blood sugar. The physician said the baby was admitted to the other hospital (B) for about 72 hours until it was confirmed that the baby did not have and infections and that the baby is doing fine now. The physician said that a low blood sugar that is stabilized will not usually cause any permanent damage.

During a telephone interview with the RN (#11 nurse that was assigned care for the baby on 07/18/18 from 7:00 a.m. until 7:00 p.m. on the Mother Baby Unit) on 07/31/18 at 10:30 a.m. in the Administration Conference Room, the nurse explained he/she is an obstetric (delivery of infants) nurse and has been a RN and worked at the facility for four (4) years. The nurse said that he/she vaguely remembers the patient (#2). After review of his/her notes the nurse explained that prior to discharge the baby had been nursing frequently for 20 to 30 minutes intervals. The nurse said that the lactation consultant also saw the patient's mother during her admission. The nurse explained that breastfeeding mothers are required to document feedings and are encouraged to feed 8-12 times in a 24-hour period. The nurse said these recorded feedings are evaluated and if there are any lapses in feedings the nursing staff will encourage the mother to feed more often. RN #11 said that at the end of his/her shift on 07/18/18 the baby was stable and as far as he/she knew the baby was nursing without any difficulty. RN #11 stated the mother had not reported any problems with nursing the baby. RN #11 explained that the parents were given the option of staying another day, but the mother wanted to go home that night (07/18/18). RN #11 said that the mother had a lot of family present and that he/she overheard the mother in-law encourage the mother to give the baby some water.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on the entrance conference and review of the video recording, Emergency Department (ED) Central Log, patient #2's birth record from St. Francis Hospital, hospital B's medical record for patient #2, Medical Staff Bylaws and Rules and Regulations, Professional Services Agreement, policies and procedures, tour of the ED, observations, and staff interviews, it was determined that the facility failed to provide the following for one (1) of 20 sampled medical records when patient #2 (a 2 day old newborn baby) was brought into the ED on 07/18/18.

Findings were:


Cross refer to A-2406, as it relates to failure to provide an appropriate medical screening examination.

Cross refer to A-2407, as it relates to failure to take all reasonable steps to secure a written informed refusal from the individual acting on behalf of the 2 day old newborn, the risks and benefits of the examination or treatment or both to provide stabilizing treatment for an emergency medical condition.

Cross refer to A-2409, as it relates to failure to provide an appropriate transfer.
VIOLATION: HOSPITAL MUST MAINTAIN RECORDS Tag No: A2403
Based on the entrance conference and review of the video recording, Emergency Department (ED) Central Log, Medical Staff Bylaws and Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to generate a medical record for one (1) of 20 sampled medical records when patient #2 (a baby) was brought into the ED on 07/18/18.

Findings were:

An entrance conference was conducted on 07/31/18 at 10:00 a.m. in the Administration Conference Room with the Chief Operating Officer, ED Medical Director #1, Interim Chief Nursing Officer, Assistant ED Director #7, and the Compliance Officer (CO) #6. When informed that this was a possible Emergency Medical Treatment and Labor Act (EMTALA) investigation the CO said that the facility had been informed of an incident involving a baby that was brought to the ED on 07/18/18. The CO explained that after learning of this event he/she had reviewed the video recording and that the facility had initiated additional EMTALA training for all staff. The CO provided a copy of the video recording dated 07/17/18. The video recording revealed the following:

--11:28 p.m., A female enters the ED, goes to the front desk, and places an infant carrier on the countertop. Multicare Technician (MT) #3 speaks with the female.
--11:29 p.m., A second female enters the ED and speaks with the MT. The MT goes into the main ED.
--11:30 p.m., Registered Nurse (RN) #4 comes out and looks at the infant. A male and a third female arrive.
--11:31 p.m., RN #4 goes back into the main ED.
--11:32 p.m., RN #5 (the ED Charge Nurse) comes out, looks at the infant and talks with the family.
--11:33 p.m., RN #5 takes his/her stethoscope and listens to the infant's chest.
--11:34 p.m., RN #5 talks with the three (3) females and one (1) male family members.
--11:35 p.m., One (1) of the females picks up the infant carrier while RN #5 continues to talk with the family members.
--11:38 p.m., RN #5 goes back into the main ED.
--11:40 p.m., RN #5 and physician #2 come out to the front desk and physician #2 looks at the infant. RN #5 picks the infant up and the physician uses his/her stethoscope to listen to the baby's chest. Physician #2 and RN #5 continue to talk with the family for a couple of minutes.
--11:43 p.m., One (1) of females picks up the infant carrier and is escorted out of the ED by RN #5. Physician #2 and RN #5 go back into the main ED.

Review of the facility's ED Central Log confirmed that patient #2 was not entered into the ED Central Log on 07/18/18.

Review of the Medical Staff Bylaws and Rules and Regulations, signed by the Medical Staff on 11/21/17, CEO 11/21/17, Board of Trustees on 11/27/17, approved by Legal Counsel 07/30/18, and by the COO 07/30/18, revealed the following:
APPENDIX "B' - RULES AND REGULATIONS
ARTICLE II - MEDICAL RECORDS
2.1 PREPARATION/COMPLETION OF MEDICAL RECORDS
The medical record for inpatient or outpatient contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, promote continuity of care among health care providers and must be complete within 30 days from discharge date . When final laboratory or other essential reports are not received at the time of discharge, a notation shall be written or dictated that this information is pending. To facilitate consistency and continuity in patient care, the medical record must contain very specific data and information.

Review of facility policies and procedures included but was not limited to the following:
I. ADMISSION AND DISCHARGE OF ER (emergency room ) PATIENTS, policy number 76, last approved 01/17, revealed staff were to follow these guidelines regarding the admission of all patients to the ED.
A. Admission:
1. Patients seeking care will be admitted to the ED.
2. Patients will sign in at the front ED desk or EMS (ambulance entrance) desk. Do not delay patient care to obtain registration information.
3. Electronic medical record documentation system will maintain the following information:
a. Identification including name, age, and sex.
b. Date and time of arrival.
c. Means of arrival.
d. Nature of complaint.
e. Time of departure.
f. Disposition.
g. Name of all individuals dead on arrival.
h. Attending physician.
i. Those leaving AMA
5. An electronic medical record will be maintained on every patient seeking care or being cared for while awaiting hospital admission. The record is maintained in accordance with Medial Records Policies.
7. Registration will occur either at the patient's bedside or in the registration area. Patients or their legal guardian will sign consent for permission to treat. If the patient is unable to sign for consent to treat the request for treatment will be implied until the next of kin can be notified.

Staff Interviews:

During a tour of the ED with the Assistant ED Director (#7) on 07/31/18 at 8:40 a.m., h/she explained that the ED has a registration clerk on duty until 10:00 p.m. and that after 10:00 p.m. the MT on duty registers ED patients. The Assistant ED Director explained that after 10:00 p.m. the MT is also responsible for reassessing patients waiting to be seen and performing any electrocardiograms (test that evaluates the heart rate and rhythm).

During an interview with the Registration Clerk (#8) on 07/31/18 at 8:50 a.m. at the ED registration desk, the Registration Clerk explained that when a patient presents to the ED the patient is asked to fill out the Check-In Form which includes the patient's name, date of birth, social security number, the patient's primary doctor's name, and the patient's chief complaint. The Registration Clerk stated the patient's information is then entered into the computer system which enters the patient into the ED Central Log and generates a medical record for the patient.

The facility failed to ensure that the hospital Rules and Regulations and policy and procedure were followed as evidenced by failing to maintain a medical record for patient #2 when he/she was brought into the emergency department on 7/18/2018.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on review of facilities Medical Staff Bylaws and Rules and Regulations, and staff interviews the facility failed to ensure that their policy and procedure was followed as evidenced by failing to take all reasonable steps to secure a written informed refusal from the individual acting on behalf of an individual, the risks and benefits of the examination or treatment or both for one (1) of 20 sampled patients when patient #2 was brought to the ED on 7/18/2018.

Review of the Medical Staff Bylaws and Rules and Regulations, signed by the Medical Staff on 11/21/17, CEO 11/21/17, Board of Trustees on 11/27/17, approved by Legal Counsel 07/30/18, and by the COO 07/30/18, revealed the following:
APPENDIX "B' - RULES AND REGULATIONS
.
ARTICLE V - EMERGENCY MEDICAL SCREENING, TREATMENT, TRANSFER, and ON-CALL ROSTER POLICY

5. I (b) Stabilization
(5) If a patient refuses to accept the proposed stabilizing treatment, the ED physician, after informing the patient of the risks and benefits of the proposed treatment and the risks and benefits of the individual's refusal of the proposed treatment, shall take all reasonable steps to have the individual sign a form indicating that he/she has refused the treatment. The ED physician shall document the patient's refusal in the patient's chart, which refusal shall be witnessed by the ED RN. If the patient so desires, the patient will be offered assistance in finding a physician for outpatient follow-up care ....(4) All reasonable steps shall be taken to secure the written consent or refusal of the patient (or the patient's representative) with respect to the transfer. The ED Physician must inform the patient (or the patient's representative) of the risks and benefits of the proposed transfer.

The facility failed to provide documented evidence that all reasonable steps were taken to secure a
written informed refusal from the individuals acting on behalf of the infant on 7/18/2018 of the risks and benefits of the examination and or treatment or both.


Interviews
During an interview on 7/31/2018 at 8:40 a.m., the Assistant ED Director stated the ED does not have on-call pediatricians because the facility does not admit pediatric patients and that pediatric patients that need further treatment are stabilized and transferred.

. During an interview with the ED physician (#2) on 07/31/18 at 10:10 a.m. in the Administration Conference Room, the physician stated he/she recalled the event that occurred on 07/18/18. Physician #2 stated he/she told the family he/she would be happy to see the baby and that if the baby required additional treatment the baby would be transferred to another hospital (B). The physician said that he/she was unable to document on the baby because the baby had not been registered as a patient

An interview was conducted with the RN (#5) on 07/31/18 at 10:30 a.m. in the Administration Conference Room. Registered Nurse #5 said he/she then went to get the physician (#2) to assess the patient. RN #5 explained that after the physician (#2) assessed the baby the family decided to leave, and the father went to get the car. RN #5 said he/she put the baby back in the carrier and walked the family out. RN #5 said he/she did not know if the baby was put into the ED Central Log.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of facility Medical Staff Bylaws, Rules and Regulations, policies and procedures and staff interviews procedures the facility failed to appropriately transfer an acutely ill 2 day old new born to an acute care hospital by failing to: a.) provide an appropriate medical screening examination within it capacity to minimize the risk to the newborn's health; b.)Contact Hospital B to see if they had available space and qualified personnel; c.) Obtain acceptance from Hospital B to accept the newborn; d.)To effect an appropriate transfer through qualified personnel and transportation and equipment; and e.) To generate a medical record in order to send Hospital B all medical records related to the emergency medical condition for one (1) of twenty (20) sampled when patients (#2) ( an newborn) was brought to the ED on 7/187/2018.


Findings were:

Review of the Medical Staff Bylaws and Rules and Regulations, signed by the Medical Staff on 11/21/17, CEO 11/21/17, Board of Trustees on 11/27/17, approved by Legal Counsel 07/30/18, and by the COO 07/30/18, revealed the following:
APPENDIX "B' - RULES AND REGULATIONS
.
ARTICLE V - EMERGENCY MEDICAL SCREENING, TREATMENT, TRANSFER, and ON-CALL ROSTER POLICY
5.1(c) Transfer
(l) The ED Physician shall obtain the consent of the receiving hospital facility before the transfer of an individual. Said person shall also make arrangements for the patient transfer with the receiving hospital.
(2) The condition of each transferred individual shall be documented in the medical records by the physician responsible for providing the medical screening examination (MSE) and stabilizing treatment.
(3) Upon transfer, the ED shall provide a copy of appropriate medical records regarding its treatment of the individual including, but not limited to, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any test, informed written consent or transfer certification, and the name and address of any on-call physician who has refused or failed to appear within a reasonable period of time in order to provide stabilizing treatment.

Review of the facility's policies and procedures included but was not limited to the following:
II. LL.026, EMTALA - MEDICAL SCREENING AND TREATMENT OF EMC, policy number 0, last 12/04/13, specified in part, i. DEFINITIONS:
Appropriate transfer occurs (once a physician has certified the need for transfer or the patient has requested transfer after an explanation of the risks and the Hospital's obligation to provide stabilizing services) when:
1. The transferring Hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and in the case of a woman in labor, the health of the unborn child;
2. The receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment;
3. The transferring Hospital sends to the receiving Hospital all medical records (or copies thereof) related to the EMC for which the individual has presented, available at the time of transfer, including records related to the individual's EMC, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone reports of the studies, and the informed written consent or certification required, name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment, and that any other records that are not readily available at the time of transfer are sent as soon as practicable after the transfer; and
4. The transfer is effected through qualified personnel, transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. Campus means the physical area immediately adjacent to the main Hospital, other areas and structures that are not strictly contiguous to the main Hospital buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the main Hospital's campus.

III. LL.027, EMTALA - TRANSFER POLICY, policy number 2, last approved 12/05/13, revealed the purpose of the policy was to ensure that a patient requesting or requiring a transfer for further medical care and follow-up in connection with treatment for an EMC is transferred appropriately.
Procedure:
1. The hospital must have written guidelines in place for transferring a patient to another facility in accordance with federal and state laws.
2. If a patient that comes to the ED or seeks emergency care on Hospital Property or Premises is determined through a MSE to have an EMC, the hospital must provide either: (a) further medical examination and treatment, including hospitalization , if necessary, as required to stabilize the medical condition within the capabilities of the staff and facilities available at the hospital; or (b) a transfer to another more appropriate or specialized facility.
3. The four requirements of an appropriate transfer must be met before a patient can be transferred to a second facility:
a. The transferring hospital must, within its capability, provide treatment to minimize the risks to the health of the individual or unborn child;
b. The receiving hospital must have available space and qualified personnel for the treatment of the individual, and must have agreed to accept the transfer and provide appropriate treatment;
c. The transferring hospital must send copies of all available medical records pertaining to the individual's emergency condition to the hospital where the patient is being transferred.
i. These documents include copies of the available history, records related to the individual's EMC, observation of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or written certification of the physician.
ii. Documentation must also include the name and address of any on-call practitioner who refused or failed to appear within a reasonable time to provide necessary stabilizing treatment after being requested to do so by the emergency physician.
iii. Copies of other records not available at the time of transfer should be sent as soon as practical after the transfer.
iv. Copies of records must accompany the patient whether or not the patient's EMC is stabilized; and
d. The transfer must be carried out through the use of qualified personnel and transportation equipment, including those life support measures that may be required during transfer. The physician at the sending hospital has the responsibility of determining the appropriate mode, equipment and attendants for the transfer. Patients should not be transferred by private vehicle, for risk management purposes. If a patient (or the legal representative of a patient) insists on a private vehicle transfer, hospital personnel shall document the risks explained to the patient/ legal representative and the patient/LR shall be asked to sign that the private vehicle transfer is against medical advice.
4. If the hospital offers to transfer a patient to another hospital for services the hospital does not offer and informs the patient or the legally responsible person of the risks and benefits to the person of the transfer but the patient or the person acting on the patient's behalf refuses to consent to the transfer, the facility must provide all reasonable steps to secure a written refusal from the patient or the person acting on the patient's behalf. The written refusal should indicate the person has been informed of the risks and benefits of the transfer and state the reasons for such refusal. The patient's medical record must contain a description of the proposed transfer that was refused by the patient or the person acting on the patient's behalf.
5. The hospital may not transfer a patient with an Emergency Medical Condition that has not been stabilized unless: (a) the physician has certified that the medical benefits to be received at another hospital outweigh the increased risks to the individual (and, as the case may be, to her unborn child) or (b) the patient, or a legally responsible person acting on the patient's behalf, requests the transfer, after being informed of the hospital's obligations under EMTALA and of the risks and benefits of the transfer.
a. For transfer with physician certification. For a patient who has not been stabilized, a physician must have signed a certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based.
i. If a physician is not physically present at the time of the transfer, a qualified medical person, in consultation with a physician may transfer the patient if the medical benefits expected from transfer outweigh the risks.
ii. An express written certification is required. Physician certification cannot be implied from the findings in the patient medical record and the fact that the patient was transferred.
iii. If certification is signed by a Qualified Medical Person, it shall be countersigned by a physician within 24 hours or a reasonable time period specified by the hospital bylaws, rules or regulations.
iv. The certification must state the reason(s) for transfer.
v. This rationale may be documented on the certification form or elsewhere in the medical record.
vi. The physician certification that the benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the risk of the transfer is not required for transfers of individuals who no longer have an Emergency Medical Condition, unless otherwise required by state law.
vii. The certification form must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility and risks associated with the transfer, including the time away from an acute care setting necessary to effect the transfer.

Staff Interviews
During an interview on 7/31/2018 at 8:40 a.m., the Assistant ED Director stated the ED does not have on-call pediatricians because the facility does not admit pediatric patients and that pediatric patients that need further treatment are stabilized and transferred.

During an interview with the ED physician (#2) on 07/31/18 at 10:10 a.m. in the Administration Conference Room, the physician stated he/she recalled the event that occurred on 07/18/18. The physician explained that the CN (5) reported that there was a baby in the waiting room that was going to another hospital (B) and he/she (CN #5) wanted to be sure it was safe for the infant to leave. The physician (#2) stated he/she had not tried to coerce the family into staying because the family had already decided to go to another facility.
During an interview with the RN (#9 nurse that discharged the baby from the Mother Baby Unit) on 07/31/18 at 11:00 a.m. in the Administration Conference Room, the nurse explained that he/she is has been an obstetric (delivery of infants) for four (4) years and at this facility since October 2017. The nurse said he/she did not actually care for the patient (#2) that he/she only wheeled the patient out on 07/18/18. The nurse said the patient and mother were discharged home in stable condition. The nurse confirmed that the mother did not report any concerns at the time of discharge.

The facility failed to follow their own Medical Staff Bylaws, Rules and Regulations, policies and procedures as evidenced by failing to provide the following for patient #2 on 7/18/2018:
a.) Failing to provide an appropriate medical screening examination within the ED capacity that minimized the risk to the newborn's health; b.) Failing to notify Hospital B to see if they available space and qualified personnel for the treatment of the newborn c.) Failing to call Hospital B to obtain an agreement and acceptance for the newborn and provide appropriate medical treatment; d.) Failing to effect an appropriate transfer of the individual via Advanced Life Support ambulance. The newborn was brought to Hospital B via privately owned vehicle after being told by staff to go to Hospital B; and e.) Failing to enter the newborn on the ED log therefore no medical record was generated to send Hospital B a copy of a medical record.