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Based upon record review and interview, the facility failed to ensure 1 (#1) of 30 patients' medical records reviewed had received an appropriate medical screening examination in the Emergency Department and failed to follow the facility policy.

Findings at Health Facility A on 09/04/2013:

Review of policy titled, "Medical Screening Exam and Referral in the Emergency Department; Reference #1202 a: DATE Effective: 10/2011" revealed:

"Purpose: The purpose of the medical screening examination (MSE) is to determine with reasonable clinical confidence and within the capability of the Emergency Department (and the ancillary services routinely available to the Emergency Department) whether or not an individual who comes to the Emergency Department has an emergency medical condition. The MSE will be performed in a non-discriminatory manner, by qualified medical personnel as detailed below.

Policy Statement: All individuals presenting to be seen in the Emergency Department will be provided an appropriate MSE by Qualified Medical Personnel (QMP). A QMP includes physicians and nurses who are members of the medical staff who practice within the guidelines established by the Board of Directors, Medical Staff, Texas Medical Board, and Texas Board of Nursing. This includes but is not limited to the scope of licensure, certification, education and experience of the QMP. Physician assistants, nurse practitioners, or Emergency Department registered nurses who have received specialized training, demonstrated appropriate competence for performing appropriate MSE's will function under standardized protocols approved by the Medical Staff Executive Committee.

Based on whether the patient meets any exclusion criteria and the results of this MSE, the patient may either be directed to the Rural Health Clinic or Emergency Department for further medical examination and treatment. If an emergency medical condition is determined to exist, the hospital will provide any necessary stabilizing treatment or an appropriate transfer.

The MSE must be the same MSE that would be performed on any individual coming to the Emergency Department, regardless of the individual's ability to pay. No information regarding the patients' payer status, HMO/PPO membership, or insurance shall be asked prior to the completion of the MSE.

After patients presenting to the ED will have a MSE completed by a QMP. This screening examination may be performed in the Emergency Department by a registered nurse who has been determined by the Chief Nursing Office and Emergency Department Nurse Manager to be qualified and experienced in emergency nursing and who is required to follow standardized protocols approved by the Medical Staff Executive Committee. In the event the registered nurse performing the screening examination is uncertain about the nature of the patient's condition or the existence of an emergency, the patient will be referred to the Emergency Department physician for further screening.

The nature of the MSE will depend on the patient's presenting symptoms, and may only a brief history and physical examination.

I. The medical screening examination consists of:
a. Assessment of the patient's chief complaint
b. Vital signs
c. General appearance of the patient
d. Mental status
e. Location and degree of pain based on both subjective and objective data
f. Skin-visual inspection and tactile assessment when indicated
g. Ability to walk/limits on ambulation or movement of affected extremity
h. A focused physical assessment-appropriate to the organ system related to the chief complaint
i. Exclusionary criteria questions

VI, Exclusionary Criteria Questions:
1. Is the patient's presenting complaint related to pregnancy?
2. Is the patient's presenting complaint related to a Psychiatric illness?
3. Is the patient four (4) years old or younger?
4. Is the patient sixty-five (65) years old or older?
5. Is the patient's presenting complaint a result of a Motor Vehicle Crash which has occurred within the past 7 days?
6. Is the patient's presenting complaint a work related injury?
7. Does the patient have VA benefits?

*If any of the answers are Yes, stop the MSE and admit patient to the ED. "

A review of the facility's record titled, "Triage Log" from 03/01/2013 thru 08/31/2013 revealed patient #1 was not on the triage log.

A review of the facility's record titled, "Elopement Log" for the month of August 2013 revealed patient #1 was not on the elopement log.

A review of the facility's record titled, "Transfer Log" for the month of August 2013 revealed patient #1 was not on the transfer log.

A review of twenty-nine medical records at Health Facility A revealed no medical record for patient #1.

Findings at Health Facility B on 09/05/2013 at 8:30 AM:

A review of patient #1's medical record at Health Facility B revealed patient was admitted to the emergency room on 08/18/2013 at 9:50 PM. Nurses notes revealed "After triage, this patient informed me that she had presented to triage at Health Facility A, and was told that "we can't help you here." States she was told they did not do OB (obstetrics), and could not do ultrasounds and that they were too busy to see her at all for several hours and that she should go to Mount Pleasant. She also states that as they were passing through Pittsburg, they called ahead to Pittsburg, and were told by the ER (Emergency Room) there that they too did not "do babies" and that she should go on to Mount Pleasant."

According to the labor and delivery admission assessment for patient #1, the assessment stated, "pt (patient) admitted to ldr1 (labor room #1) with c/o (complaints) of contractions, states receives prenatal care in Longview. Pt crying and restless with contractions, strong contractions palpated, sve (sterile vaginal examination) reveals bulging membranes and almost completely dilated. Patient's boyfriend and his mother arrived with pt. They are visibly upset and crying about inevitable, nonviable delivery and being "turned away from Gilmer." Mother states they stopped at Health Facility A (ER) first and were turned away. When questioned further the mother states that when they signed in to the ER they were told that the hospital does not delivery babies and that the ER was very busy trying "to save someone's life" and it would be "hours and hours" before the patient would be able to be seen. The patient was advised to go to either Longview or Mount Pleasant hospital to be seen by a hospital that delivers babies. The patient, her boyfriend and his mother then left and started on their way to Mount Pleasant. En route to Mount Pleasant the mother called Pittsburg ER via mobile phone and inquired about whether they should stop there. They were told the best place would be Mount Pleasant since they were already on their way and Mount Pleasant delivered babies. Due to patient's condition, this information was obtained by the paternal grandmother of the fetus to which the patient agrees."

Patient delivered spontaneous vaginal delivery 20 week fetal demise on August 19, 2013 at 6:17 AM. Patient discharged home from Health Facility B on 08/21/2013 at 9:41 AM.

A phone interview with family member #16 on 09/05/2013 at 10:30 AM stated, "My son called and said we are on our way to the emergency room in Gilmer my girlfriend is having bad cramps. I told him I was on my way, and when I drove up to the emergency room in Gilmer, my son and his girlfriend were coming out the door of the emergency room. They told me this emergency room doesn't deliver babies and we would have to go to Longview or Mount Pleasant. I chose Mount Pleasant because it's a better road and it's a straight shot. On the way I called Pittsburg emergency room because it's on the way to Mount Pleasant and my son's girlfriend was hurting so bad. They informed me they don't deliver babies either and I need to go on to Mount Pleasant. So we went to Mount Pleasant Hospital."

A phone interview with patient #1 on 09/05/2013 at 11:10 AM stated, "I went to the Gilmer emergency room on Sunday August 18th around 8:00 PM with my boyfriend. I was having bad cramping. I sat down where you register for an emergency room visit. I signed a piece of paper. The clerk told me "I didn't tell you this, but it will be hours before someone sees you because the emergency room is busy and they are trying "to save someone's life." We don't take care of babies here." The clerk told me Mount Pleasant or Longview is the closest place. My boyfriend and I left. My boyfriend's mother drove us to Mount Pleasant. Patient #1 was questioned did you see a nurse or physician before you left? She stated, "No."

On a return visit back to Health Facility A on 09/05/2013 at 12:00 PM requested the emergency room clerk schedule. Staff member #17 was the admitting clerk working the evening of August 18th, date in question.

A phone interview with staff #17 on 09/05/2013 at 12:10 PM stated, "I remember patient #1 because she left her social security card that night. It is in the top drawer where I sit in the second registration desk area. Staff member #17 was questioned did patient #1 sign into the emergency room. Staff #17 stated, she signed the piece of paper that asks for name, date of birth, social security#, and reason for visit. I remember there was patient behind her saying why are you checking into this hospital they don't deliver babies. I had to leave the area and take papers to the nurses in the emergency room. When I came back the patient asked me if this hospital delivers babies? I am not supposed to give out any information, but when patient asks a direct question I can answer. So I told her, "no we don't deliver babies here, the closest places are Longview and Mount Pleasant." They got up and left. Staff member #17 was questioned as to what happened to the piece of paper the patient signed? She stated, "I put it in the shred box when they left." Staff #17 was questioned as to whether patient saw a nurse or a physician? She stated, "No."

An interview with the Director of the Emergency Department on 09/05/2013 at 12:30 PM confirmed, if any patient had presented to the emergency room the patient would have been registered by the clerk and the patient would have signed the paper that request name, date of birth, social security #, and reason for visit.

On 09/05/2013 at 12:35 PM the Emergency Room Manager and I went to the emergency room registration area. We found the patient's original social security card in the top drawer of the second registration desk, where staff member #17 told me she had placed it.

An interview with the Administrator, Chief Nursing Officer, and the Emergency Room Manager, confirmed the patient #1 original social security card was left at the registration desk. Patient #1 had not received a medical screening, nor was the patient on the triage log, elopement log, and transfer log. Also the facility policy for medical screening examinations had not been followed.