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Based on a review of medical records (MR), hospital Medical Staff Bylaws, Rules and Regulations, hospital policies and procedures, Columbia Lighthouse Project Protocol, and interviews with the staff it was determined the hospital failed to ensure:

1. The hospital identified and approved individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Services in the hospital bylaws or rules and regulations.

2. An appropriate MSE within the capability of the hospital was provided to determine whether or not an emergency medical condition exists for all patients who presented for emergency services.

3. The risk and benefits of transfer to the individual's health was explained to the patient prior to transfer to another hospital.

Cross Refer to A 2406 and A 2409 for findings.

Based on a review of medical records (MR), hospital Medical Staff Bylaws, Rules and Regulations, hospital policies and procedures, Columbia Lighthouse Project Protocol, and interviews with the staff it was determined the hospital failed to ensure:

1. The hospital identified and approved individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Services in the hospital bylaws or rules and regulations.

2. An appropriate MSE within the capability of the hospital was provided to determine whether or not an emergency medical condition exists for all patients who presented for emergency services.

This did affect two of nine Obstetric (OB) patients reviewed, including Patient Identifier (PI) # 1 and PI #6, and had the potential to negatively affect all patients who present to the hospital for an emergency medical condition requiring a MSE.

Findings include:

Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening and Treatment of EMC.
Policy Number: BBH CLN.04.01
Reviewed Date: 7/29/2024

Purpose:

To ensure individuals presenting to... Facility's emergency departments receive an appropriate MSE...

Policy:

...An individual is deemed to have come to the Dedicated ED if the individual:

1. Presents at a Dedicated ED and requests examination or treatment for a medical condition...

Procedure:

A. The facility will provide an appropriate MSE within its capability to an individual coming to the Dedicated ED, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists.

Hospital Policy: Triage, Registration, and Treatment
Policy Number: BBH CLN.04.01.PR.01
Reviewed Date: 7/29/2024

I. Procedure:

...C. MSE

1. An MSE will be provided by Qualified Medical Personnel to any individual who comes to the Dedicated Emergency Department...

2. The MSE will be performed by a physician or other Qualified Medical Personnel. The examination should be specific to the patient's complaint and presenting symptoms.

Hospital Policy: Perinatal Services
Policy Number: BBH PS 03.01.PR.01
Effective Date: 1/31/2022

I. Definitions:

... Qualified Medical Person/Personnel (QMP): An individual or individuals determined qualified by Brookwood Baptist Health (BBH) bylaws or rules and regulations...to perform a MSE. In facility, QMP are limited to physicians, physician assistants, nurse practitioners (including nurse midwifes) and registered nurses (RN) who have been deemed qualified to conduct the patient assessment portion of the MSE in conjunction with the OB (Obstetrical) physician.

II Procedure:

...B. Medical Screening

1. BBH provides a MSE to all patients presenting for OB evaluation, testing or services within the capabilities of the OB Unit and the ancillary services routinely available to the OB Department (OBED), including the use of on-call physicians.

...b. Patients fewer than 20 weeks gestation will receive a MSE by a QMP in the ED or in the OBED for obstetrical presentations as appropriate.


1. Review of the hospital Medical Staff Bylaws and Rules and Regulations revealed no documentation to identify and approve the individual(s) qualified to perform the MSE for the hospital emergency services in the ED.

Further review of the hospital Rules and Regulations revealed documentation a RN may perform a MSE on OB outpatients if credentialed to do so.

Further review of the hospital Medical Staff Bylaws revealed the credentials committee reviews and evaluates the qualifications of each practitioner and health professional affiliate then recommends the appropriate services for the practitioner/health professional affiliate.

a. PI # 6 presented to the hospital ED on 6/3/25 at 2:49 PM with a chief complaint of Vaginal Bleeding and Contractions in pregnancy. A review of the MR revealed the MSE was performed on 6/3/25 at 3:23 PM by a RN and not a physician.

An interview was conducted with Employee Identifier (EI) # 1, Risk Manager, on 11/18/25 at 12:46 PM who confirmed there was no documentation in the hospital bylaws or rules and regulations to identify and approve individual(s) qualified to perform the MSE in the ED.

An interview was conducted with EI # 1 and EI # 7, Nursing Operations Director of Labor and Delivery, on 11/18/25 at 1:21 PM. EI # 1 verbalized the hospital did not have a policy for the credentialing of an OB RN. EI # 7 verbalized an OB RN was able to complete the MSE on a patient after a competency evaluation was completed on the OB RN. The competency evaluation for the RN stays in the OB department and is not provided to anyone outside of the OB department for credentialing. EI # 1 and EI # 7 verbalized there was no documentation of the OB RN's credentialed to perform the MSE for an OB patient.

An interview was conducted with EI # 1 on 11/20/25 from 2:15 PM to 2:19 PM who confirmed the MSE was performed by a RN and not a physician for PI # 6.

2. PI # 1 presented to the ED on 10/31/25 at 11:43 PM with complaint of 18 weeks Pregnant and Vaginal Bleeding.

Review of the MR dated 10/31/24 revealed there was no documentation a vaginal examination was conducted, no documentation an ultrasound was ordered or performed, and no documentation the on-call OB physician was contacted for consultation.

Review of the ED Nurse note dated 11/2/25 at 7:57 AM revealed the patient presented to Labor and Delivery (L&D) via ambulance stretcher after delivering Intrauterine Fetal Demise at home at 7:28 AM. The patient delivered the placenta in ambulance at 7:50 AM.

Review of the physician's note dated 11/2/25 at 7:05 PM revealed the patient was 18 and 6/7 weeks gestation who was admitted for miscarriage. The patient came to the ED late Friday night with complaint of large gush of blood. There was no exam performed.

An interview was conducted on 11/19/25 at 5:00 PM with EI # 1, who confirmed there was no documentation a vaginal examination was conducted, no documentation an ultrasound was ordered or performed, and no documentation the on-call OB physician was contacted for consultation on 10/31/25.

An interview was conducted on 11/20/25 at 8:35 AM with EI # 3, OB Physician on-call 10/31/25, who verbalized the patient said she/he had presented to the ED on 10/31/25 and was told the on-call OB had been contacted. EI # 3 confirmed she/he had not been contacted on 10/31/25 about the patient. EI # 3 verbalized he/she reviewed the patient's ED medical record from 10/31/25 and there was no documentation of a vaginal exam, no documentation of a OB consult, and no documentation an ultrasound was conducted. EI # 3 verbalized a vaginal exam should have been completed and if ED physician felt uncomfortable doing a vaginal exam, then the OB on call should have been consulted.




46290

Based on review of Medical Record (MR), hospital policy and procedure, and staff interviews, it was determined the hospital failed to ensure the risk and benefits of transfer to the individual's health was explained to the patient prior to transfer to another hospital.

This deficient practice did affect one of four patients who was transferred from the hospital, including Patient Identifier (PI) # 3 and had the potential to affect all patients presenting to the hospital Emergency Department (ED) who require a transfer to another hospital.

Findings include:

Hospital Policy: Refusal of Treatment and Transfers
Policy Number: BBH CLN.04.01.PR.02
Reviewed Date: 7/29/24

Procedure:

...B. Transfer of Individual with an Emergency Medical Condition...

1. Transfer Upon Individual Request

a. Facility may transfer a medically unstable individual if a physician or Qualified Medical Personnel fully inform the individual or the person acting on the individual's behalf of the risks of the transfer...



40119

1. PI # 3 presented to the hospital ED on 10/31/25 at 4:57 PM with a chief complaint vaginal bleeding since 4 PM. The patient was 8 weeks postpartum.

Review of the ED Provider note dated 10/31/25 at 8:00 PM revealed the patient was 7 weeks postpartum after a cesarean section, had massive amounts of bleeding using 1 pad every 45 minutes, and the patient's cervix was unable to be visualized on examination. Further review revealed the patient was discussed with the OB/GYN (Obstetrics/Gynecology) at the hospital and it was agreed upon the patient would need to be transferred to OB/GYN services. The patient requested to be transferred to another hospital for the OB/GYN service.

Review of the Interhospital Transfer Form dated 10/31/25 at 8:05 PM revealed no documentation the risk and benefits of transfer to the individual's health was explained to the patient prior to transfer to another hospital.

An interview was conducted on 11/20/25 at 2:11 PM with Employee Identifier (EI) # 1, Risk Manager, and EI # 7, Nursing Operations Director of Labor and Delivery, who confirmed there was no documentation the risk and benefits of transfer to the individual's health was explained to the patient prior to transfer to another hospital.