CMS-Doctors-Hospital-of-Augusta

Based on review of the 4/10/2021 video recording, review of medical records, review of Medical Staff Rules and Regulations, review of policy and procedures and interviews, it was determined that the facility failed to provide an appropriate and ongoing medical screening exam for one of 20 patients (Patient #1) when Patient (P) #1 presented to the Emergency Department (ED) on 4/10/2021 for complaints of 'hearing voices'.

Findings:

A review of the ED video recordings for P#1 revealed the following:

First video: On 4/10/2021 (no time stamp), P#1 walked into the ED entrance alone and went to the registration desk. Per the time elapsed on the video recording, two minutes later a female family member entered, spoke with P#1 and sat down in the waiting room. RN AA spoke with P#1 at the registration desk and escorted him into triage room 1.

Second video: On 4/10/2021 (no time stamp) RN AA escorted P#1 to ED room 8. Per the time elapsed on the video recording, approximately one to two minutes later, RN AA exited ED room 8. At video elapsed time of 10 minutes 30 seconds, P#1's female family member entered ED room 8. At video elapsed time 13 minutes 15 seconds, a security officer walked down the hall. At video elapsed time 16 minutes 30 seconds, P#1's female family member exited ED room 8 and walked to the nurses' station across from ED room 8 and spoke with an unidentified nurse. A female family member paced in and out of ED room 8 at video elapsed time 17 minutes 30 seconds. At video elapsed time 17 minutes 50 seconds, P#1 exited ED room 8 and paced from the hallway to ED room 8 doorway continuously until he walked out of camera view at video elapsed time 20 minutes 52 seconds.

Third video: On 4/10/2021 (no time stamp) numerous staff members observed moving in and out of the trauma room. RN BB and other staff members are seen at the desk. At video elapsed time 2 minutes 30 seconds, P#1 walked down hallway and exited out the ambulance entrance. The ambulance entrance was adjacent to the trauma room.

A review of P#1's medical record revealed that he arrived at the facility's ED at 3:20 a.m. on 4/10/2021. Continued review of the record revealed that P#1's mother signed an acknowledgement of receipt of Patient Rights and Responsibilities at 3:33 a.m. Physician (MD) CC initiated the medical screening examination (MSE) at 3:30 a.m. A review of the MSE revealed that P#1's chief complaint was auditory hallucinations (hearing voices that were not there). P#1 denied having suicidal ideations (SI) (thoughts of harming self) or homicidal ideations (HI) (thoughts of harming others). P#1 denied that the hallucinations were commanding (instructing or demanding) and denied visual hallucinations. Continued review of the MSE revealed that P#1 denied additional medical concerns. P#1 informed MD CC that he heard voices in the past and acknowledged recent methamphetamine (illegal stimulant) use. MD CC performed a physical examination of P#1 that revealed P#1 was alert and oriented, cooperative and in no apparent distress. P#1's speech was normal, his affect was normal, judgement was normal, thought content was normal and cognitive function was normal. MD CC documented that P#1 did not have acute SI or HI and showed no signs of organic pathology (physical changes). At 3:35 a.m., MD CC ordered Lorazepam (Ativan) (used for anxiety) for P#1. MD CC documented a clinical impression of methamphetamine abuse and drug induced auditory hallucinations.

RN AA initiated the triage assessment at 3:39 a.m. P#1 reported that he started hearing voices about ten hours after using methamphetamines. P#1 denied suicidal ideations or homicidal ideations. P#1 denied using alcohol or other drug use. P#1 was assigned a triage level of 3.

A review of the Emergency Notes written at 3:45 a.m. by RN BB revealed that P#1 was not in ED room 8. RN BB documented that P#1 had not informed the staff that he was leaving. RN BB was unable to discuss the risks and benefits of treatment or have P#1 sign an AMA form. P#1 was discharged from the ED tracker with a disposition of AMA (against medical advice) at 3:55 a.m.

Review of the Medical Staff Bylaws, Policies, and Rules and Regulations, approved by the Medical Executive Committee on 10/8/2019, General Medical Staff on 11/20/2020, and the Board of Trustees on 12/10/2020 revealed the following:

ARTICLE X

EMERGENCY SERVICES

10.1 General - Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care.

10.2 Medical Screening Exams (MSE) - within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition (EMC). Qualified medical personnel (QMP) who can perform the MSE are defined as:

a) ED:

1. Members of the Medical Staff with clinical privileges in Emergency Medicine;

2. Other Active Staff members; and

3. Appropriately credentialed allied health professionals.

A review of the facility's policy, number 41, titled 'EMTALA- Georgia Medical Screening Examination and Stabilization Policy', last approved 03/2021, revealed that the purpose of the policy was to require, in conjunction with state specific policies, that an acute care or specialty hospital with an ED provide an appropriate medical screening examination (MSE) and any necessary stabilization treatment to an individual, including every infant born alive, at any stage of development, that came to the ED and requested such examination, as required by EMTALA and all Federal Regulations and interpretive guidelines thereafter. Continued review of the policy revealed that a hospital with an ED provided any individual and every infant who came to the ED, an appropriate MSE within the capabilities of the ED, including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition (EMC) existed, regardless of the individuals ability to pay. The EMTALA obligations were triggered when there had been a request for medical care by an individual within a dedicated emergency department (DED), or when a prudent layperson would recognize that an individual on hospital property required emergency care or examination, though no request for treatment was made. If an EMC was determined to exist, the hospital provided either (1) further medical examination and necessary stabilization within the capabilities of the staff and facilities available at the hospital or (2) an appropriate transfer to another medical facility. The CEO of the hospital, the executive officer responsible for the ED and the ED Director were responsible for implementation of the EMTALA policies outlined herein.

Definitions included but were not limited to:

Emergency Medical Condition (EMC) meant a medical condition that manifested itself by acute symptoms of enough severity (including severe pain, psychiatric disturbances or symptoms) such that in the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the health of the individual in serious jeopardy

b. Serious impairment to bodily functions

c. Serious dysfunction of any bodily organ or part

d. With respect to a pregnant woman who was having contractions

g. With respect to an individual with psychiatric symptoms;

h. That acute psychiatric or acute substance abuse symptoms were manifested; or

i. That the individual expressed suicidal or homicidal thoughts or gestures and was determined to be a danger to self or others.

Medical Screening Examination (MSE) was the process required to reach with reasonable clinical confidence, the point at which it was determined whether an EMC existed. Screening was conducted to the extent necessary, by physician's and/or other QMP to determine whether an EMC existed. With respect to an individual with behavioral symptoms, and MSE consisted of both a medical and behavioral health screening.

General requirements included: any hospital with an emergency department will provide to any individual who comes to the emergency department an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an EMC exists, regardless of the individual's ability to pay when a request is made by or on behalf of the individual for medical care, or a prudent layperson would observe that such care is needed, whether the individual is in the hospital's DED or elsewhere on the hospital's campus. EMTALA required the hospital to do the following:

Provide an appropriate MSE to the individual within the capability of the hospital's emergency department to determine whether an EMC existed.

Leaving DED after the MSE. For those individuals that indicated a desire to leave the DED against medical advice (AMA) after receiving an MSE, the facility used its best efforts to:

-Complete the registration process and open a medical record;

-Offer the individual further medical examination and treatment as may be required to identify and stabilize an EMC;

-Log the individual in the Central Log;

-Discuss with the individual the risks and benefits involved in leaving against medical advice and document same;

-Take all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the AMA Form, if possible;

-Describe, in the medical record, the examination and treatment that was refused or the request for treatment was withdrawn; and

-Sign, date and time the entry.

During the ED tour on 4/19/2021, an interview was conducted with Registrar EE at 1:20 p.m. at the registration desk. Registrar EE explained that when a patient presented to the ED, registration was limited to the patient's social security number, name, date of birth and chief complaint. She added if a patient's chief complaint was suicidal ideations, the triage nurse was notified. The patient was triaged and taken to a room. If a patient wanted to leave the ED, she attempted to get the patient to stay and talk with the provider. If the patient again refused, she would have the patient sign the Against Medical Advice (AMA) form.

During an interview with Registered Nurse (RN) BB on 4/19/2021 at 2:30 p.m. in the Azalea room, she stated she had worked in the facility's ED for two years. She confirmed that she was P#1's primary nurse. RN BB recalled that she received report from RN AA. RN BB noted that Lorazepam was ordered for P#1. RN BB went to prepare the ordered Lorazepam. When RN BB went into ED room 8, the only person in the room was P#1's mother. RN BB recalled that P#1's mother was upset and yelling and did not provide information about P#1's location. RN BB said that ED staff informed her that P#1 was out by the road up near the red light and security was trying to get the patient to come back into the ED. RN BB was unaware if the police were notified. RN BB explained that MD CC performed the MSE while P#1 was in triage, and she did not observe the MSE. RN BB explained that if there was no 1013 (Georgia's legal form that allows a patient to be held involuntarily when the patient is a threat to self or others) order, then a sitter was not provided. RN BB confirmed that P#1 did not have an order for a 1013, and RN AA reported that P#1 denied suicidal or homicidal ideations. When asked about the facility's general practice regarding patients' being placed in an ED Behavioral Health room, RN BB explained that patients were not placed in those rooms unless they had 1013.

During an interview with RN AA on 4/19/2021 at 2:55 p.m. in the Azalea room, he stated he had worked in the facility's ED for two years and had been a nurse for 12 years. RN AA confirmed that he was the triage nurse on 4/10/2020 when P#1 presented to the ED. RN AA explained that P#1 reported using methamphetamine several hours earlier and hearing voices. P#1 reported that he had similar symptoms previously after using methamphetamines. RN AA completed the suicide risk assessment and P#1 denied having any suicidal or homicidal ideations. RN AA recalled that MD CC came into triage and evaluated P#1 while P#1's family member remained in the waiting room. RN AA said P#1 was alert and aware that he was hearing voices, which was his only complaint. RN AA said he escorted P#1 to ED room 8 and he did not see him again. RN AA said that if a patient were suicidal or homicidal, they were placed in an ED Behavioral Health room, even if they were not a 1013.

During an interview with ED Physician (MD) CC on 4/19/2021 at 3:15 p.m. in the Azalea room, he confirmed that he remembered P#1. MD CC completed P#1's exam in the triage area. MD CC said P#1 reported recently used methamphetamine and heard voices. MD CC explained that P#1 was cooperative, a little 'antsy' and verbalized that he did not want to be here but his mother brought him into the ED. MD CC recalled that P#1 requested that he wanted medication to help him calm down because it helped in the past. MD CC said P#1's family member was not present during the evaluation. MD CC said he did not make P#1 a 1013 because the patient was not a threat to self or others, and P#1 was a nice, pleasant guy that reported hearing voices.

MD CC ordered Lorazepam for P#1 and prepared his discharge orders/instructions. MD CC learned from staff that P#1 left prior to receiving the medication. MD CC said he had not seen P#1 leave. MD CC explained psychiatric patients were evaluated in triage in case a 1013 order is required. After triage, patients are assigned an ED Behavioral Health bed as soon as possible.

The hospital failed to appropriately monitor Patient #1 enabling him to leave, delaying an appropriate continuing medical screening exam. The risks and benefits of leaving were not discussed, and his decision-making capacity was not assessed. Patient #1 was agitated and the physician wrote an order for Ativan to be administered.

Show Text of Violation

Based on review of the 4/10/2021 video recording, review of medical records, review of facility policy and procedures and interviews, it was determined that the facility failed to provide stabilizing treatment for one of 20 patients (Patient #1) when Patient #1 presented to the Emergency Department (ED) on 4/10/2021 for treatment of 'hearing voices'. P#1 was left unmonitored in an ED room and left the ED without notifying the staff.

Findings:

A review of the ED video recordings for P#1 revealed the following:

First video: On 4/10/2021 (no time stamp), P#1 walked into the ED entrance alone and went to the registration desk. Per the time elapsed on the video recording, two minutes later a female family member entered, spoke with P#1 and sat down in the waiting room. RN AA spoke with P#1 at the registration desk and escorted him into triage room 1.

Second video: On 4/10/2021 (no time stamp) RN AA escorted P#1 to ED room 8. Per the time elapsed on the video recording, approximately one to two minutes later, RN AA exited ED room 8. At video elapsed time of 10 minutes 30 seconds, P#1's female family member entered ED room 8. At video elapsed time 13 minutes 15 seconds, a security officer walked down the hall. At video elapsed time 16 minutes 30 seconds, P#1's female family member exited ED room 8 and walked to the nurses' station across from ED room 8 and spoke with an unidentified nurse. A female family member paced in and out of ED room 8 at video elapsed time 17 minutes 30 seconds. At video elapsed time 17 minutes 50 seconds, P#1 exited ED room 8 and paced from the hallway to ED room 8 doorway continuously until he walked out of camera view at video elapsed time 20 minutes 52 seconds.

Third video: On 4/10/2021 (no time stamp) numerous staff members observed moving in and out of the trauma room. RN BB and other staff members are seen at the desk. At video elapsed time 2 minutes 30 seconds, P#1 walked down hallway and exited out the ambulance entrance. The ambulance entrance was adjacent to the trauma room.

A review of P#1's medical record revealed that he arrived at the facility's ED at 3:20 a.m. on 4/10/2021. Continued review of the record revealed that P#1's mother signed an acknowledgement of receipt of Patient Rights and Responsibilities at 3:33 a.m. Physician (MD) CC initiated the medical screening examination (MSE) at 3:30 a.m. A review of the MSE revealed that P#1's chief complaint was auditory hallucinations (hearing voices that were not there). P#1 denied having suicidal ideations (SI) (thoughts of harming self) or homicidal ideations (HI) (thoughts of harming others). P#1 denied that the hallucinations were commanding (instructing or demanding) and denied visual hallucinations. Continued review of the MSE revealed that P#1 denied additional medical concerns. P#1 informed MD CC that he heard voices in the past and acknowledged recent methamphetamine (illegal stimulant) use. MD CC performed a physical examination of P#1 that revealed P#1 was alert and oriented, cooperative and in no apparent distress. P#1's speech was normal, his affect was normal, judgement was normal, thought content was normal and cognitive function was normal. MD CC documented that P#1 did not have acute SI or HI and showed no signs of organic pathology (physical changes). At 3:35 a.m., MD CC ordered Lorazepam (used for anxiety) for P#1. MD CC documented a clinical impression of methamphetamine abuse and drug induced auditory hallucinations.

RN AA initiated the triage assessment at 3:39 a.m. P#1 reported that he started hearing voices about ten hours after using methamphetamines. P#1 denied suicidal ideations or homicidal ideations. P#1 denied using alcohol or other drug use. P#1 was assigned a triage level of 3.

A review of the Emergency Notes written at 3:45 a.m. by RN BB revealed that P#1 was not in ED room 8. RN BB documented that P#1 had not informed the staff that he was leaving. RN BB was unable to discuss the risks and benefits of treatment or have P#1 sign an AMA form. P#1 was discharged from the ED tracker with a disposition of AMA (against medical advice) at 3:55 a.m.

A review of the facility's policy, number 41, titled 'EMTALA- Georgia Medical Screening Examination and Stabilization Policy', last approved 03/2021, revealed that the purpose of the policy was to require, in conjunction with state specific policies, that an acute care or specialty hospital with an ED provide an appropriate medical screening examination (MSE) and any necessary stabilization treatment to an individual, including every infant born alive, at any stage of development, that came to the ED and requested such examination, as required by EMTALA and all Federal Regulations and interpretive guidelines thereafter. The EMTALA obligations were triggered when there had been a request for medical care by an individual within a dedicated emergency department (DED), or when a prudent layperson would recognize that an individual on hospital property required emergency care or examination, though no request for treatment was made. If an EMC was determined to exist, the hospital provided either (1) further medical examination and necessary stabilization within the capabilities of the staff and facilities available at the hospital or (2) an appropriate transfer to another medical facility.

Definitions included but were not limited to:

Emergency Medical Condition (EMC) meant a medical condition that manifested itself by acute symptoms of enough severity (including severe pain, psychiatric disturbances, or symptoms) such that in the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the health of the individual in serious jeopardy

b. Serious impairment to bodily functions

c. Serious dysfunction of any bodily organ or part

d. With respect to a pregnant woman who was having contractions

e. That there was inadequate time to effect a safe transfer to another hospital before delivery; or

f. That transfer may pose a threat to the health and safety of the woman or the unborn child; or

g. With respect to an individual with psychiatric symptoms;

h. That acute psychiatric or acute substance abuse symptoms were manifested; or

i. That the individual expressed suicidal or homicidal thoughts or gestures and was determined to be a danger to self or others.

Leaving DED after the MSE. For those individuals that indicated a desire to leave the DED against medical advice (AMA) after receiving an MSE, the facility used its best efforts to:

-Complete the registration process and open a medical record;

-Offer the individual further medical examination and treatment as may be required to identify and stabilize an EMC;

-Log the individual in the Central Log;

-Discuss with the individual the risks and benefits involved in leaving against medical advice and document same;

-Take all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the AMA Form, if possible;

-Describe, in the medical record, the examination and treatment that was refused or the request for treatment was withdrawn; and

-Sign, date, and time the entry.

A review of the facility's policy titled, 'Psychiatric Referral Plan', no date, revealed that the purpose was to provide a policy and procedure for the coordination of hospital services with the identified needs of the patient population served. It was the policy of the facility to provide hospital services based on identified needs of the patient. Since psychiatric services were not provided at this hospital, suicidal, emotionally ill, alcohol abuse, and drug abuse patients were referred for treatment once they are deemed medically stable. It was the duty of the primary nurse to report to the physician signs of emotional illness, alcohol abuse, or drug abuse when they are observed. The status of the patient must be determined, and observation of the patient must be constant as deemed by the physician. Restraints may be used according to hospital policy only if other methods of control fail. Observation for possible suicide attempts were made and the suicide precaution policy should be followed. The physician may utilize Social Services for assistance in making inpatient/outpatient referrals as deemed necessary. Patients may be referred to Psychologist/Psychiatrist for evaluation and assistance with transfer to Psychiatric facility. Referrals may be made for outpatients to private psychiatrists or psychologists or to community agencies for counseling or inpatient facilities.

If the patient was able to function on his/her own behalf, he/she may make a voluntary commitment to whichever type of hospital the doctor recommends. For those patients who are not able to function on their own behalf, an involuntary commitment to a psychiatric hospital was done. If an involuntary commitment is made, one doctor must certify that the patient is in need of commitment and must go through appropriate legal channels. All involuntary commitments will be followed by completion of a 1013 form and transfer for follow up as accepted by an appropriate psychiatric facility. Family members may or may not be involved. Emergency Department patients that have a psychiatric condition may be referred for a psychiatric consultation as ordered by the Emergency Department physician. The physician will make the final decision as to the disposition of the patient.

During the ED tour on 4/19/2021, an interview was conducted with Registrar EE at 1:20 p.m. at the registration desk. Registrar EE explained that when a patient presented to the ED, registration was limited to the patient's social security number, name, date of birth and chief complaint. She added if a patient's chief complaint was suicidal ideations, the triage nurse was notified. The patient was triaged and taken to a room. If a patient wanted to leave the ED, she attempted to get the patient to stay and talk with the provider. If the patient again refused, she would have the patient sign the Against Medical Advice (AMA) form.

During an interview with Registered Nurse (RN) BB on 4/19/2021 at 2:30 p.m. in the Azalea room, she stated she had worked in the facility's ED for two years. She confirmed that she was P#1's primary nurse. RN BB recalled that she received report from RN AA.

RN BB noted that Lorazepam was ordered for P#1. RN BB went to prepare the ordered Lorazepam. When RN BB went into ED room 8, the only person in the room was P#1's mother. RN BB recalled that P#1's mother was upset and yelling and did not provide information about P#1's location. RN BB said that ED staff informed her that P#1 was out by the road up near the red light and security was trying to get the patient to come back into the ED. RN BB was unaware if the police were notified. RN BB explained that MD CC performed the MSE while P#1 was in triage, and she did not observe the MSE. RN BB explained that if there was no 1013 (Georgia's legal form that allows a patient to be held involuntarily when the patient is a threat to self or others) order, then a sitter was not provided. RN BB confirmed that P#1 did not have an order for a 1013, and RN AA reported that P#1 denied suicidal or homicidal ideations. When asked about the facility's general practice regarding patients' being placed in an ED Behavioral Health room, RN BB explained that patients were not placed in those rooms unless they had 1013. RN BB confirmed that she received EMTALA training upon hire and annually thereafter. Crisis Prevention Intervention training was required every 2 years.

During an interview with RN AA on 4/19/2021 at 2:55 p.m. in the Azalea room, he stated he had worked in the facility's ED for two years and had been a nurse for 12 years. RN AA confirmed that he was the triage nurse on 4/10/2020 when P#1 presented to the ED. RN AA explained that P#1 reported using methamphetamine several hours earlier and hearing voices. P#1 reported that he had similar symptoms previously after using methamphetamines. RN AA completed the suicide risk assessment and P#1 denied having any suicidal or homicidal ideations. RN AA recalled that MD CC came into triage and evaluated P#1 while P#1's family member remained in the waiting room. RN AA said P#1 was alert and aware that he was hearing voices, which was his only complaint. RN AA said he escorted P#1 to ED room 8 and he did not see him again. RN AA said that if a patient were suicidal or homicidal, they were placed in an ED Behavioral Health room, even if they were not a 1013. RN AA confirmed that he had completed annual EMTALA training.

During an interview with ED Physician (MD) CC on 4/19/2021 at 3:15 p.m. in the Azalea room, he confirmed that he remembered P#1. MD CC completed P#1's exam in the triage area. MD CC said P#1 reported recently used methamphetamine and heard voices. MD CC explained that P#1 was cooperative, a little 'antsy' and verbalized that he did not want to be here but his mother brought him into the ED. MD CC recalled that P#1 requested that he wanted medication to help him calm down because it helped in the past. MD CC said P#1's family member was not present during the evaluation. MD CC said he did not make P#1 a 1013 because the patient was not a threat to self or others, and P#1 was a nice, pleasant guy that reported hearing voices.

MD CC ordered Lorazepam for P#1 and prepared his discharge orders/instructions. MD CC learned from staff that P#1 left prior to receiving the medication. MD CC said he had not seen P#1 leave. MD CC explained psychiatric patients were evaluated in triage in case a 1013 order is required. After triage, patients are assigned an ED Behavioral Health bed as soon as possible.

Patient #1 was hearing voices and was agitated for which the physician ordered Ativan to be administered. Patient # 1 was not monitored closely enough and was able to leave without having his condition stabilized.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that an appropriate medical screening exam was provided for one (1) of 20 sampled medical records (#1). Specifically, the facility failed to provide a medical screening exam for Patient #1 when the 29 week gestation pregnant patient presented to the Labor and Delivery Unit with an emergent medical condition.

Findings were:

Review of the Emergency Department (ED) medical record of Patient #1 revealed that the patient walked into the ED and (MDS) dated [DATE] at 1:31 p.m. Documentation by Greeter BB at 1:59 p.m. revealed that the patient came in with a chief complaint of a headache and denied any pregnancy complaints. The same notation revealed that the patient became angry and at 1:46 p.m. Patient # 1 left the facility. The note revealed that the patient was angry because she was not going directly to Labor and Delivery (L&D). The greeter documented that when it was explained to the patient that she would see the ED Doctor first, she became angry and left the facility. Further review revealed that Nurse Coordinator NN charted in the medical record at 4:57 p.m. that the patient had left the facility at 1:35 p.m. prior to triage.

There was no information available on Patient # 1 from her exit of the ED at 1:46 p.m. until the following medical record from Obstetrical (related to childbirth and the processes involved with it) Emergency Department (OBED).

Review of (L&D) medical record revealed Patient #1 arrived at 3:42 p.m. to the OBED (Obstetrical Emergency Department) on second floor of the facility. Registered Nurse (RN) MM documented she was a walk-in patient from home. Patient #1 reported that her reason for visit was headache, seeing spots, nausea and vomiting that morning, dizziness and mild cramping. The record revealed the patient has had some high blood pressure this pregnancy and is currently taking Labetalol (a medication used to treat high blood pressure). The patient ' s Obstetrician (doctor who specializes in the care of pregnant women and their unborn baby) was documented as her primary Dr. KK. The clinic summary revealed her estimated date of confinement (due date) was 4/22/19 and that she was at 29.5 weeks gestation (period of development, normal gestation or length of pregnancy is 40 weeks). Initial Vital Signs were documented at 3:59 p.m. as Pulse(P)-109 (normal Pulse 60-100 in adults) and Blood Pressure (BP)-138/87 (normal blood pressure in adults 120/80-140/90). Registered Nurse MM ' s assessment of Patient #1 at 3:59 p.m. revealed Patient #1 had swelling in both lower extremities (legs and feet), headache for several hours, and she was not currently in active labor.

Vital signs at 4:04 p.m. were P-103 and BP-151/94

Vital signs at 4:09 p.m. were P-103 and BP-156/104

Vital signs at 4:14 p.m. were P-100 and BP 153/84

Vital signs at 4:19 p.m. were P-102 and BP 155/83

Fetal Heart Monitoring revealed the fetal heart rate (rate at which the unborn baby ' s heart beats) baseline was 150 beats per minute (bpm). Normal fetal heart rate is between 120-160 bpm.

Further review of the medical record revealed at 4:29 p.m. that RN MM notified Dr. KK that his patient who was pregnant with her first child and at the time 29.5 weeks gestation was in L&D at the facility. The record reveals that Dr KK was told that Patient #1 had been seen in his office for symptoms of preeclampsia (preeclampsia is a condition that pregnant women develop that is marked by high blood pressure, elevated levels of protein in the urine, and often swelling in the feet, legs, and hands). Dr. KK was informed that the patient was taking Labetalol 100 milligrams twice a day. RN MM noted that she reported to Dr. KK that the triage assessment revealed Patient #1 ' s headache was rated 10 on a pain scale where 1 is mild and 10 is the most severe and was unrelieved by Tylenol, that she had been seeing spots before her eyes, dizziness, nausea and vomiting during the morning, and swelling and soreness in her lower extremities. RN MM report further revealed the blood pressure readings ranging from 130s/80s to 150s/100s were discussed. RN MM notified Dr. KK that the patient was due for her Labetalol at that time. Fetal monitor tracing was reviewed with Dr. KK. Dr. KK gave a phone order to discharge the patient with instructions not to go home but to report to another facility in town where he would see Patient #1. Patient #1 was discharged at 4:26 p.m. with instructions to go directly to the other acute care hospital per her own obstetrician ' s directions. Patient #1 left with her significant other in a personal vehicle. There was no record of the on-call OB physician being called.

At the time of the survey no records were available from the receiving facility.

Review of the Medical Staff Bylaws, Rules and Regulations of the facility, approved by the Medical Executive Committee 3/11/14, The General medical Staff 4/4/14, and the Board of Trustees 4/22/14, revealed the following:

ARTICLE X - Emergency Services

10.1. General:

Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care. Such emergency services and care will be provided without regard to the patient's race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing medical condition, physical or mental handicap, insurance status, economic status, sexual orientation or ability to pay for medical services, except to the extent such circumstance is medically significant to the provision of appropriate care to the patient.

10.2. Medical Screening Examinations:

Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified Medical personnel who can perform medical screening examinations within applicable Hospital policies and procedures are defined as:

(a) Emergency Department:

(1) members of the Medical Staff with clinical privileges in Emergency Medicine;

(2) other Active Staff members; and

(3) appropriately credentialed allied health professionals.

(b) Labor and Delivery:

(1) members of the Medical Staff with OB/GYN (gynecology - practitioner who specializes in the care/treatment of female reproductive organs) privileges;

(2) Certified Nurse Midwives with 0B privileges; and

(3) Registered Nurses who have achieved competency in Labor and Delivery and who have validated skills to provide fetal monitoring and labor assessment.

10.3. On-Call Responsibilities:

It is the responsibility of the scheduled on-call physician to respond to calls from the Emergency Department in accordance with Hospital policies and procedures.

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

I - OB Patients in The Emergency Department, Policy Number 33, last reviewed: 4/2016 revealed that the hospital provides available, appropriate emergency services to a woman who seeks hospital care for the safe delivery of her child.

GUIDELINES:

1. The evaluation and emergency medical care of any obstetrical patient presenting to the Emergency Department shall comply with the Georgia Emergency Medical Services to pregnant Women Act of 1984 and the Federal COBRA Act of 1986 and EMTALA (Emergency Medical and Labor Act) and they will be registered on the EMTALA log.

2. A gravid (pregnant) patient greater than 20 weeks, the Women's Center charge nurse should be notified and will respond promptly to assess the patient.

II - Policy EMTALA- Medical Screening Examination and Stabilization Policy, Policy Number 08, last revised 05/2017, revealed the purpose was to establish guidelines for providing appropriate medical screening exam (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA.

An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and:

1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or

2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition (EMC). Further, if a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists, or (ii) with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilization treatment shall be applied in a non-discriminatory manner (e.g., no different level of care because of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law).

Procedure:

1. When an MSE is Required

A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: (i) to any individual, including a pregnant woman having contractions, who requests such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior needs an MSE. An MSE shall be provided to determine whether the individual is experiencing an EMC or a pregnant woman is in labor. An MSE is required when:

a. The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition, including where:

i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition.

The MSE of the individual must be documented. This type of screening cannot be performed by the triage nurse. If an EMC is determined to exist and the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under EMTALA ceases.

Note: The MSE and other emergency services need not be provided in a location specifically identified as a DED. The hospital may use areas to deliver emergency services that are also used for other inpatient or outpatient services. MSEs or stabilization may require ancillary services available only in areas or facilities of the hospital outside of the DED.

b. The individual arrives on the hospital property other than a DED and makes a request or another makes a request on the individual's behalf for examination or treatment for an EMC.

i. Screening where the individual presented: If an individual is initially screened in a department or location on-campus other than the DED, the individual may be moved to another hospital department or facility on-campus to receive further screening or stabilizing treatment without such movement being a transfer. The hospital shall not move the individual to an off-campus facility or department (such as an urgent care center or satellite clinic) for an MSE.

3. Extent of the MSE

a. Determine if an EMC exists. The hospital must perform an MSE to determine if an EMC exists. It is not appropriate to merely

log in or triage an individual with a medical condition and not provide an MSE. Triage is not equivalent to an MSE. Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be screened by a physician or other QMP.

b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.

c. An on-going process. The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.

d. Judgment of physician or QMP. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP performing the examination function according to algorithms or protocols established and approved by the medical staff and governing board.

e. Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual's signs and symptoms:

i. Depending on the individual's presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures.

ii. Pregnant Women: The medical records should show evidence that the screening examination includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membranes (i.e., ruptured, leaking and intact), to document whether or not the woman is in labor. A woman experiencing contractions is in true labor unless a physician, certified nurse-midwife or other QMP acting within his or her scope of practice as defined by the hospital's medical staff bylaws and State medical practice acts, certifies in writing that after a reasonable time of observation, the woman is in false labor. The recommended timeframe for such physician certification of the QMP's determination of false labor should be within 24 hours of the MSE, however, the medical staff bylaws, rules and regulations can provide guidance on the timeframe.

4. Who May Perform the MSE

a. Only the following individuals may perform an MSE:

i. A qualified physician with appropriate privileges;

ii. Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges; or

iii. A qualified staff member who:

--is qualified to conduct such an examination through appropriate privileging and demonstrated competencies;

--is functioning within the scope of his or her license and in compliance with state law and applicable practice acts (e.g., Medical or Nurse Practice Acts);

-- is performing the screening examination based on medical staff approved guidelines, protocols or algorithms; and

-- is approved by the facility's governing board as set forth in a document such as the hospital bylaws or medical staff rules and regulations, which document has been approved by the facility's governing body and medical staff. It is not acceptable for the facility to allow informal personnel appointments that could change frequently.

b. Qualified Medical Personnel. QMPs may perform an MSE if licensed and certified, approved by the hospital's governing board through the hospital's by-laws, and only if the scope of the EMC is within the individual's scope of practice.

i. The designation of QMP is set forth in a document approved by the governing body of the hospital. Each individual QMP approved to provide an MSE under EMTALA must be appropriately credentialed and must meet the requirements for annual evaluations set forth in the protocol agreements with physicians and the State's medical practice act, nurse practice act or other similar practice acts established to govern health care practitioners. Only appropriately credentialed Advanced Practice Registered Nurses (APRN)s, Physician Assistants (PA)s and physicians may perform MSEs in the DED.

iii. Labor and Delivery QMP. QMPs in the labor and delivery DED may be appropriately-approved RNs and must communicate their findings as to whether or not a woman is in labor to the obstetrician on call, the laborist, or the ED physician.

iv. Limitations. The hospital has established a process to ensure that:

--a physician examines all individuals whose conditions or symptoms require physician examination;

--an ED physician on duty is responsible for the general care of all individuals presenting themselves to the emergency department; and

--the responsibility remains with the ED physician until the individual's private physician or an on-call specialist assumes that responsibility, or the individual is discharged .

III - Women's ' Center Policy Policy Medical Screening Exam, Policy # 21, last revised 03/2019 revealed the purpose to provide guidelines to insure a MSE is performed by QMP on patients presenting to the OB department requesting treatment.

PURPOSE:

To provide a Medical Screening Examination to any patient presenting to the L&D by qualified nursing personnel utilizing the Obstetrical Medical Screening Tab in the electronic medical record.

1. Notify the physician of patient arrival and obtain orders to assess the patient using the Medical Screening Tool found in Centricity Perinatal (CPN) medical record. Physician notification should be made within 30 minutes of the patient's arrival to the department. If the patient is not an established patient with an obstetrician at Doctors Hospital, she must be assigned to the obstetrician on call. The OB on-call list is available in Labor and Delivery, as well as the E.D.

2. Patients > 20 weeks pregnant may be evaluated in either the ED or L&D depending on the patient's presenting symptoms, unless the patient is unstable. Unstable patients will be evaluated and treated in the ED and stabilized prior to being transferred to L&D. The L&D RN will assist the ED staff as requested.

4. If the patient is discharged , complete another MSE with update of status of discharge disposition. The physician must certify the orders within 24 hours if Read back and verified is not documented, otherwise the orders may be verified within 30 days of patient discharge.

5. In the event of an emergency transfer to a higher level of care, and the physician is not physically present at the time of transfer, the QMP can sign the certification as long as the QMP is in consultation with the physician. Also, the physician must be in agreement with the certification and subsequently countersigns the certification. The date and time of such certification should closely match the date and time of transfer.

1. Obtain prenatal records if available and review. Notify physician of the patient's arrival. All OBED patients must have the Obstetrical Medical Screening Tool completed in CPN medical record found under the blue Admit tab. Results of medical screening will indicate if a provider must come in to examine the patient prior to discharge.

2. Documentation of patient assessment should be complete, thorough and recorded in the CPN electronic patient chart.

3. All fetal monitor strips are labeled or maintained and archived in the CPN system.

4. An initial MSE will be completed on ALL OBED patients, printed and placed on medical record...if OBED patient is stable and discharged undelivered, a reassessment MSE will be completed, printed and also placed on medical record. Please document required disposition on blue discharge tab.

During an interview on 4/08/19 at 11:10 a.m. Paramedic/Greeter BB said when pregnant patients arrive in the ED they are asked what is going on and what is their due date. If they are greater than 20 weeks and have any pregnancy related symptoms, they are immediately sent up to L&D for further evaluation. She expounded that pregnancy related symptoms might be nausea, vomiting, swelling, water leaking or even headache which could be a sign of preeclampsia. If symptoms are questionable for pregnancy related, the registrar is to immediately call the ED Physician Assistant or Nurse Practitioner to come and evaluate.

During the tour of the L&D unit on 4/8/19 at 11:30 a.m. an interview was conducted with L&D Clinical Director (EE). She confirmed that the facility has a Level II Neonatal (newborn)Intensive Care Unit that can care for babies born after 32 weeks gestation (developmental age of the unborn baby) without any complications. She said the L&D Unit will transfer a mother pending delivery prior to 32 weeks gestation to the hospital of her primary Obstetrician ' s choice.

During an interview on 4/9/19 at 9:50 a.m. in the Conference Room, Paramedic BB, confirmed that she was the ED Greeter on 2/8/19. The Paramedic explained that on 2/8/19 Patient #1 presented to the ED and reported that she was 29 weeks pregnant, had a headache and needed to go to L&D. The Paramedic said she asked the patient if she was having any pregnancy related issues such as: abdominal cramping, abdominal pain, back pain or pressure, pelvic pain, nausea or vomiting, if her water had broken or if her mucus plug (protective barrier that blocks bacteria from entering the uterus). The Paramedic said Patient #1 denied any pregnancy related symptoms and repeated that she had a headache and need to go to L&D because she was 29 weeks pregnant. The Paramedic said Patient #1 then went to the registration desk and told the Registrar that she was 29 weeks pregnant and needed to go to L&D because she had a headache. Paramedic BB said the Registrar tried to register the patient but the patient got angry and turned to leave the ED. Paramedic BB reported that Patient #1 stated I can't believe you aren't sending me to L&D, I'm 29 weeks pregnant, I have a headache, swelling and my blood pressure is high, just as the patient walked out the ED door. The Paramedic said she then documented her note in the electronic medical record. Paramedic BB said she did not try to bring the patient back into the ED because the patient was angry and there were about 14 patients at the desk. The Paramedic confirmed that she did not think about getting the Charge Nurse to speak with the patient. The Paramedic said she has worked in the facility's ED since August 2017 and has been a Paramedic since 2006. Paramedic BB stated that she receives EMTALA training annually and since this episode she has completed three (3) or four (4) OB related Healthstream courses.

During an interview on 4/9/19 at 10:35 a.m. in the Conference Room, RN MM confirmed that she was working L&D on 2/8/19 and that she remembers providing care for Patient #1. RN MM said she has been a RN since 2014, a L&D nurse since 2015, and has been working at the facility since February 2018. The RN said she remembers that the L&D Charge Nurse informed her that Patient #1 would be arriving and that the patient was experiencing a headache and pregnancy induced hypertension (high blood pressure). RN MM said she was setting up the room when Patient #1 arrived and that she helped the patient put on a gown and attached the fetal monitor (evaluates the baby's heartrate). RN MM said she asked the patient what brought her to the hospital and was informed that the patient was seen by the Dr. KK in his office and had lab work, I think that day to see if the patient was pre-eclamptic. RN MM reviewed her notes and said the patient's symptoms included: headache, dizziness, seeing spots, nausea, vomiting and mild cramping. RN MM explained that the patient was not admitted at this point and had only been triaged by RN MM. RN MM said she completed Patient #1's assessment and was informed by the patient that she was prescribed Labetalol but that she had forgotten to take her medication that day. RN MM said her first thought was to call Patient #1's Dr. KK to get orders. RN MM explained that she called the Patient's doctor KK and gave him an update of the patient's condition, the patient's blood pressure reading and informed the physician that the patient had missed taking her blood pressure medication. RN MM said she asked the physician what he wanted to do and he asked her to repeat the patient's blood pressure and then gave orders for the patient to be discharged with instructions for the patient to go directly to another local acute care hospital. RN MM said she thought this was odd and wondered whether this should be done. RN MM said she asked the physician KK if he wanted the patient transported (by ambulance) and the physician replied no, just tell the patient to come straight here and not to go anywhere else. RN MM said she asked the physician KK if he wanted her to give the patient the Labetatol and he replied no. RN MM said she discussed this with the L&D Charge Nurse and the L&D Charge Nurse asked about Patient #1's blood pressure and then told RN MM that the physician ordered the patient to be discharged so that's what we will do. RN MM added that after speaking with the patient's physician it never occurred to her that the on-call OB physician could be contacted. RN MM said that she received EMTALA training 4/7/19 but had also had EMTALA training in the past. RN MM confirmed that EMTALA training is required annually. RN MM explained that she has also completed the Obstetrical Medical Screening Tool Healthstream training.

During a phone interview on 4/9/19 at 12:30 p.m. with Dr. KK he reported that he remembered Patient #1. He confirmed he was her primary OB and had seen her earlier in the week of 2/8/19 in his office. He stated he had not sent her to the Emergency Department for evaluation. He reported that Patient #1 did have chronic (persisting for a long time or recurring) hypertension (high blood pressure) and had shown some protein (small molecules that play critical roles in the body) in her urine (if high amounts of protein are found in the urine late in a pregnancy, it may indicate kidney disease or preeclampsia). Dr. KK said he had sent labs off to be tested and sent the patient to see a urologist (physician who specializes in the treatment of the urinary tract {body 's drainage system for removing urine}) to rule out kidney (bean shaped organs that filter blood to remove wastes and make urine) damage and preeclampsia. Dr. KK reported he was at another acute care hospital in the local area when RN MM called to tell him his patient was at their facility. He confirmed that RN MM had provided him with her assessment of the patient and given him all the vital signs. He said he did not think the patient was that unstable. Dr. KK said he told RN MM where he was and asked that the patient not be admitted to her facility but be sent over to where he was for further evaluation. He explained that the facility where he was located at that time was not far and was able to provide specialized care if there were complications with the pregnancy. He confirmed that RN MM asked about emergency transport by ambulance, but he said he did not think Patient #1 ' s condition warranted emergency transport. He confirmed that Nurse MM asked if he wanted Patient #1 to get her Labetalol at that time and he told her no. Dr. KK said he assumed care when Patient #1 arrived at his location. He said he evaluated her and told her they would just watch her for a few days in the hospital. He said she was stable at that time. He said he left the hospital and was called back to the hospital in less than 30 minutes. When he arrived back at the hospital he found an emergency delivery was warranted and the baby was delivered by Cesarean-Section (surgery where the baby is taken out through the mother ' s abdomen).

Show Text of Violation

Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that stabilizing treatment was provided for one (1) of 20 sampled medical records (Patient #1). Specifically, the facility failed to provide stabilizing treatment to Patient #1 when the 29 week gestation pregnant patient presented to the Labor and Delivery Unit with an emergent medical condition.

Findings were:

Review of (L&D) medical record revealed Patient #1 arrived on 2/08/19 at 3:42 p.m. to the Obstetrical (related to childbirth and the processes involved with it) Emergency Department (OBED) on second floor of the facility. Registered Nurse (RN) MM documented she was a walk-in patient from home. Patient #1 reported that her reason for visit was headache, seeing spots, nausea and vomiting that morning, dizziness and mild cramping. The record revealed the patient has had some high blood pressure this pregnancy and is currently taking Labetalol (a medication used to treat high blood pressure). The patient ' s Obstetrician (OB - doctor who specializes in the care of pregnant women and their unborn baby) was documented as her primary Dr. KK. The clinic summary revealed her estimated date of confinement (due date) was 4/22/19 and that she was at 29.5 weeks gestation (period of development, normal gestation or length of pregnancy is 40 weeks). Initial Vital Signs were documented at 3:59 p.m. as Pulse(P)-109 (normal Pulse 60-100 in adults) and Blood Pressure (BP)-138/87 (normal blood pressure in adults 120/80-140/90). Registered Nurse MM ' s assessment of Patient #1 at 3:59 p.m. revealed Patient #1 had swelling in both lower extremities (legs and feet), headache for several hours, and she was not currently in active labor.

Vital signs at 4:04 p.m. were P-103 and BP-151/94

Vital signs at 4:09 p.m. were P-103 and BP-156/104

Vital signs at 4:14 p.m. were P-100 and BP 153/84

Vital signs at 4:19 p.m. were P-102 and BP 155/83

Fetal Heart Monitoring revealed the fetal heart rate (rate at which the unborn baby ' s heart beats) baseline was 150 beats per minute (bpm). Normal fetal heart rate is between 120-160 bpm. Further review of the medical record revealed at 4:29 p.m. that RN MM notified Dr. KK that his patient who was pregnant with her first child and at the time 29.5 weeks gestation was in L&D at the facility. The record reveals that Dr KK was told that Patient #1 had been seen in his office for symptoms of preeclampsia (preeclampsia is a condition that pregnant women develop that is marked by high blood pressure, elevated levels of protein in the urine, and often swelling in the feet, legs, and hands). Dr. KK was informed that the patient was taking Labetalol 100 milligrams twice a day. RN MM noted that she reported to Dr. KK that the triage assessment revealed Patient #1 ' s headache was rated 10 on a pain scale where 1 is mild and 10 is the most severe and was unrelieved by Tylenol, that she had been seeing spots before her eyes, dizziness, nausea and vomiting during the morning, and swelling and soreness in her lower extremities. RN MM report further revealed the blood pressure readings ranging from 130s/80s to 150s/100s were discussed. RN MM notified Dr. KK that the patient was due for her Labetalol at that time. Fetal monitor tracing was reviewed with Dr. KK. Dr. KK gave a phone order to discharge the patient with instructions not to go home but to report to another facility in town where he would see Patient #1. Patient #1 was discharged at 4:26 p.m. with instructions to go directly to the other acute care hospital per her own obstetrician ' s directions. Patient #1 left with her significant other in a personal vehicle. There was no record of the on-call OB physician being called.

At the time of the survey no records were available from the receiving facility.

Review of the Medical Staff Bylaws, Rules and Regulations of the facility, approved by the Medical Executive Committee 3/11/14, The General medical Staff 4/4/14, and the Board of Trustees 4/22/14, revealed the following:

ARTICLE X - Emergency Services

10.1. General:

Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care. Such emergency services and care will be provided without regard to the patient's race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing medical condition, physical or mental handicap, insurance status, economic status, sexual orientation or ability to pay for medical services, except to the extent such circumstance is medically significant to the provision of appropriate care to the patient.

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

I - Emergency Medical Treatment and Labor Act (EMTALA) - Provision of On-Call Coverage Policy, Policy Number 75, last reviewed: 07/2016

revealed the hospital must maintain a list of physicians on its medical staff who have privileges at the hospital or, if it participates in a community call plan, a list of all physicians who participate in such plan. Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with Emergency Medical Conditions (EMC) who are receiving services in accordance with the resources available to the hospital.

PROCEDURE: Maintain a List. Each hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC. The Medical Staff Bylaws or appropriate policy and procedures must define the responsibility of on-call physicians to respond, examine, and treat patients with an EMC.

II - OB Patients in The Emergency Department, Policy Number 33, last reviewed: 4/2016 revealed that the hospital provides available, appropriate emergency services to a woman who seeks hospital care for the safe delivery of her child.

GUIDELINES:

7. Stabilizing Treatment Within Hospital Capability

The determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED has determined, within reasonable clinical confidence, 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 a facility, or with respect to an EMC of a woman in labor, that the woman has delivered the child and placenta; or in the case of an individual with a psychiatric or behavioral condition, that the individual is protected and prevented from injuring himself/ herself or others.

a. Stable. The physician or QMP providing the medical screening and treating the emergency has determined within reasonable clinical confidence, that the EMC that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist. Once the individual is stable, EMTALA no longer applies. (The individual may still be transferred; however, the appropriate transfer requirement under EMTALA does not apply.)

c. Stabilizing Treatment and Individuals Whose EMC's Are Resolved. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. The EMC that caused the individual to present to the DED must be resolved, but the underlying medical condition may persist. Hospitals are expected within reason to assist/provide discharged individuals the necessary information to secure follow-up care to prevent relapse or worsening of the medical condition upon release from the hospital.

8. When EMTALA Obligations End

The hospital's EMTALA obligation ends when a physician or QMP has made a decision:

a. That no EMC exists (even though the underlying medical condition may persist);

b. That an EMC exists and the individual is appropriately transferred to another facility; or

c. That an EMC exists and the individual is admitted to the hospital for further stabilizing treatment; or

d. That an EMC exists and the individual is stabilized and discharged .

During the tour of the L&D unit on 4/8/19 at 11:30 a.m. an interview was conducted with L&D Clinical Director (EE). She confirmed that the facility has a Level II Neonatal (newborn)Intensive Care Unit that can care for babies born after 32 weeks gestation (developmental age of the unborn baby) without any complications. She said the L&D Unit will transfer a mother pending delivery prior to 32 weeks gestation to the hospital of her primary Obstetrician ' s choice.

During an interview on 4/9/19 at 10:35 a.m. in the Conference Room, RN MM confirmed that she was working L&D on 2/8/19 and that she remembers providing care for Patient #1. RN MM said she has been a RN since 2014, a L&D nurse since 2015, and has been working at the facility since February 2018. The RN said she remembers that the L&D Charge Nurse informed her that Patient #1 would be arriving and that the patient was experiencing a headache and pregnancy induced hypertension (high blood pressure). RN MM said she was setting up the room when Patient #1 arrived and that she helped the patient put on a gown and attached the fetal monitor (evaluates the baby's heartrate). RN MM said she asked the patient what brought her to the hospital and was informed that the patient was seen by the Dr. KK in his office and had lab work, I think that day to see if the patient was pre-eclamptic. RN MM reviewed her notes and said the patient's symptoms included: headache, dizziness, seeing spots, nausea, vomiting and mild cramping. RN MM explained that the patient was not admitted at this point and had only been triaged by RN MM. RN MM said she completed Patient #1's assessment and was informed by the patient that she was prescribed Labetalol but that she had forgotten to take her medication that day. RN MM said her first thought was to call Patient #1's Dr. KK to get orders. RN MM explained that she called the Patient's doctor KK and gave him an update of the patient's condition, the patient's blood pressure reading and informed the physician that the patient had missed taking her blood pressure medication. RN MM said she asked the physician what he wanted to do and he asked her to repeat the patient's blood pressure and then gave orders for the patient to be discharged with instructions for the patient to go directly to another local acute care hospital. RN MM said she thought this was odd and wondered whether this should be done. RN MM said she asked the physician KK if he wanted the patient transported (by ambulance) and the physician replied no, just tell the patient to come straight here and not to go anywhere else. RN MM said she asked the physician KK if he wanted her to give the patient the Labetalol and he replied no. RN MM said she discussed this with the L&D Charge Nurse and the L&D Charge Nurse asked about Patient #1's blood pressure and then told RN MM that the physician ordered the patient to be discharged so that's what we will do. RN MM added that after speaking with the patient's physician it never occurred to her that the on-call OB physician could be contacted.

During a phone interview on 4/9/19 at 12:30 p.m. with Dr. KK he reported that he remembered Patient #1. He confirmed he was her primary OB and had seen her earlier in the week of 2/8/19 in his office. He stated he had not sent her to the Emergency Department for evaluation. He reported that Patient #1 did have chronic (persisting for a long time or recurring) hypertension (high blood pressure) and had shown some protein (small molecules that play critical roles in the body) in her urine (if high amounts of protein are found in the urine late in a pregnancy, it may indicate kidney disease or preeclampsia). Dr. KK said he had sent labs off to be tested and sent the patient to see a urologist (physician who specializes in the treatment of the urinary tract {body ' s drainage system for removing urine}) to rule out kidney (bean shaped organs that filter blood to remove wastes and make urine) damage and preeclampsia. Dr. KK reported he was at another acute care hospital in the local area when RN MM called to tell him his patient was at their facility. He confirmed that RN MM had provided him with her assessment of the patient and given him all the vital signs. He said he did not think the patient was that unstable. Dr. KK said he told RN MM where he was and asked that the patient not be admitted to her facility but be sent over to where he was for further evaluation. He explained that the facility where he was located at that time was not far and was able to provide specialized care if there were complications with the pregnancy. He confirmed that RN MM asked about emergency transport by ambulance, but he said he did not think Patient #1 ' s condition warranted emergency transport. He confirmed that Nurse MM asked if he wanted Patient #1 to get her Labetalol at that time and he said told her no. Dr. KK said he assumed care when Patient #1 arrived at his location. He said he evaluated her and told her they would just watch her for a few days in the hospital. He said she was stable at that time. He said he left the hospital and was called back to the hospital in less than 30 minutes. When he arrived back at the hospital he found an emergency delivery was warranted and the baby was delivered by Cesarean-Section (surgery where the baby is taken out through the mother ' s abdomen).

Show Text of Violation

Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate discharge/transfer for one (1) of 20 sampled medical records (Patient #1). Specifically, the facility failed to appropriately transfer/discharge Patient #1 when the 29 week gestation pregnant patient presented to the Labor and Delivery Unit with an emergent medical condition.

Findings were:

Review of (L&D) medical record revealed Patient #1 arrived on 2/08/19 at 3:42 p.m. to the Obstetrical (related to childbirth and the processes involved with it) Emergency Department (OBED) on second floor of the facility. Registered Nurse (RN) MM documented she was a walk-in patient from home. Patient #1 reported that her reason for visit was headache, seeing spots, nausea and vomiting that morning, dizziness and mild cramping. The record revealed the patient has had some high blood pressure this pregnancy and is currently taking Labetalol (a medication used to treat high blood pressure). The patient ' s Obstetrician (doctor who specializes in the care of pregnant women and their unborn baby) was documented as her primary Dr. KK. The clinic summary revealed her estimated date of confinement (due date) was 4/22/19 and that she was at 29.5 weeks gestation (period of development, normal gestation or length of pregnancy is 40 weeks). Initial Vital Signs were documented at 3:59 p.m. as Pulse(P)-109 (normal Pulse 60-100 in adults) and Blood Pressure (BP)-138/87 (normal blood pressure in adults 120/80-140/90). Registered Nurse MM ' s assessment of Patient #1 at 3:59 p.m. revealed Patient #1 had swelling in both lower extremities (legs and feet), headache for several hours, and she was not currently in active labor.

Vital signs at 4:04 p.m. were P-103 and BP-151/94

Vital signs at 4:09 p.m. were P-103 and BP-156/104

Vital signs at 4:14 p.m. were P-100 and BP 153/84

Vital signs at 4:19 p.m. were P-102 and BP 155/83

Fetal Heart Monitoring revealed the fetal heart rate (rate at which the unborn baby ' s heart beats) baseline was 150 beats per minute (bpm). Normal fetal heart rate is between 120-160 bpm. Further review of the medical record revealed at 4:29 p.m. that RN MM notified Dr. KK that his patient who was pregnant with her first child and at the time 29.5 weeks gestation was in L&D at the facility. The record reveals that Dr KK was told that Patient #1 had been seen in his office for symptoms of preeclampsia (preeclampsia is a condition that pregnant women develop that is marked by high blood pressure, elevated levels of protein in the urine, and often swelling in the feet, legs, and hands). Dr. KK was informed that the patient was taking Labetalol 100 milligrams twice a day. RN MM noted that she reported to Dr. KK that the triage assessment revealed Patient #1 ' s headache was rated 10 on a pain scale where 1 is mild and 10 is the most severe and was unrelieved by Tylenol, that she had been seeing spots before her eyes, dizziness, nausea and vomiting during the morning, and swelling and soreness in her lower extremities. RN MM report further revealed the blood pressure readings ranging from 130s/80s to 150s/100s were discussed. RN MM notified Dr. KK that the patient was due for her Labetalol at that time. Fetal monitor tracing was reviewed with Dr. KK. Dr. KK gave a phone order to discharge the patient with instructions not to go home but to report to another facility in town where he would see Patient #1. Patient #1 was discharged at 4:26 p.m. with instructions to go directly to the other acute care hospital per her own obstetrician ' s directions. Patient #1 left with her significant other in a personal vehicle. There was no record of the on-call OB physician being called.

At the time of the survey no records were available from the receiving facility.

Review of the Medical Staff Bylaws, Rules and Regulations of the facility, approved by the Medical Executive Committee 3/11/14, The General medical Staff 4/4/14, and the Board of Trustees 4/22/14, revealed the following:

ARTICLE XII - Transfer to Another Hospital or Healthcare Facility

12.1. Transfer:

The process for providing appropriate care for a patient, during and after transfer from the Hospital to another facility, includes:

(a) assessing the reason(s) for transfer;

(b) establishing the conditions under which transfer can occur;

(c) evaluating the mode of transfer/transport to assure the patient's safety; and

(d) ensuring that the organization receiving the patient assumes responsibility for the patient's care after arrival at that facility.

12.2. Procedures:

(a) Patients will be transferred to another hospital or facility based on the patient's needs and the Hospital's capabilities. The attending physician will take the following steps as appropriate under the circumstances:

(1) identify the patient's need for continuing care in order to meet the patient's physical and psychosocial needs;

(2) inform patients and their family members (as appropriate), in a timely manner, of the need to plan for a transfer to another organization;

(3) involve the patient and all appropriate practitioners, Hospital staff, and family members involved in the patient's care, treatment, and services in the planning for transfer; and

(4) provide the following information to the patient whenever the patient is transferred:

(i) the reason for the transfer;

(ii) the risks and benefits of the transfer; and

(iii) available alternatives to the transfer.

(b) When patients are transferred, appropriate information will be provided to the accepting practitioner/facility, including:

(1) reason for transfer;

(2) significant findings;

(3) a summary of the procedures performed, and care, treatment and services provided;

(4) condition at discharge;

(5) information provided to the patient and family, as appropriate; and

(6) working diagnosis.

12.3. Emergency Medical Treatment and Labor Act (EMTALA) Transfers:

The transfer of a patient with an emergency medical condition from the ED to another hospital will be made in accordance with the Hospital's applicable EMTALA policy.

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

I- EMTALA-Transfer Policy 89, reviewed 7/2018 revealed the purpose was to establish guidelines for either accepting an appropriate transfer from another facility or providing an appropriate transfer to another facility of an individual with an EMC who requests or requires a transfer for further medical care. Any transfer of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual ' s behalf or by a physician order with the appropriate physician certification as required under EMTALA. EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC apply to any ED or dedicated emergency department (DED) of a hospital whether located on or off the hospital campus and all other departments of the hospital located on hospital property.

1. Transfer of Individuals Who Have Not Been Stabilized

a. If an individual who has come to the ED has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer and meets the following conditions:

i. The individual or a legally responsible person acting on the individual ' s behalf requests the transfer, after being informed of the hospital ' s obligations under EMTALA and of the risks and benefits of such transfer. The request must be in writing and indicate the reasons for the request as well as indicate that the individual is aware of the risks and benefits of transfer; or

ii. A physician has signed a certification that, based upon 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 the woman in labor, to the woman or the unborn child, from being transferred. The certificate must contain a written summary of the risks and benefits upon which it is based; or

iii. If a physician is not physically present in the DED at the time the individual is transferred, a qualified medical person (QMP) has signed a certification after a physician in consultation with the QMP, agrees with the certification and subsequently countersigns the certification. The certification must contain a written summary of the risks and benefits upon which it is based. Note: The date and time of the physician or QMP certification should match the date and time of the transfer.

b. A transfer will be an appropriate transfer if:

i. 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;

ii. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment;

iii. The transferring hospital sends the receiving hospital copies of all medical records related to the EMC for which the individual presented that are available at the time of transfer as well as the 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

iv. The transfer is effected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transport.

Hospitals that request transfers must recognize that the appropriate transfer of individuals with unstabilized EMCs that require specialized services should not routinely be made over great distances, bypassing closer hospitals with the necessary capability and capacity to care for the unstabilized EMC.

c. Higher Level of Care. A higher level of care should be the more likely reason to transfer an individual with an EMC that has not been stabilized.

2. Additional Transfer-Related Situations

d. Transfers for High Risk Deliveries. A hospital that is not capable of handling the delivery of a high-risk woman in labor must still provide an MSE and any necessary stabilizing treatment as well as meet the requirements of an appropriate transfer even if a transfer agreement is in place. In addition, a physician certification that the benefits of transfer outweigh the risks of transfer is required for the transfer of the woman in labor.

4. Authority to Conduct a Transfer

The transferring physician is responsible for determining the appropriate mode of transportation, equipment and attendants for the transfer in such a manner as to be able to effectively manage any reasonably foreseeable complication of the individual ' s condition that could arise during the transfer. Only qualified personnel, transportation and equipment, including those life support measures that may be required during transfer shall be employed in the transfer of an individual with an unstabilized EMC. If the individual refuses the appropriate form of transportation determined by the transferring physician and decides to be transported by another method, the transferring physician is to document that the individual was informed of the risks associated with this type of transport and the individual should sign a form indicating the risks have been explained and the individual acknowledges and accepts the risks. All additional requirements of an appropriate transfer are to be followed by the transferring hospital.

5. Transfer Center Use

Hospitals may utilize a Transfer Center to facilitate the transfer of any individual from or to the ED of the transferring facility to the receiving facility. The transferring physician, after discussion with the individual patient or his or her legally authorized representative, determines the appropriate receiving facility for providing the care necessary to stabilize and treat the individual ' s emergent condition. The Transfer Center then facilitates the transfer from the transferring facility to the facility selected by the transferring physician and/or the patient.

At the ED Physician ' s request, the Transfer Center must facilitate a discussion between the ED Physician and the on-call physician of the receiving facility. The on-call physician does not have the authority to refuse an appropriate transfer on behalf of the facility.

The Transfer Center may, at the request of the transferring facility, provide information on the availability of Emergency Medical Services (EMS) or transport options for transfer of an individual.

PROCEDURE:

1. Transfers of Individuals Who Are Not Medically Stable

Requirements Prior to Transfer. After the hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC who is not medically stable, the hospital may arrange an appropriate transfer for the individual to another more appropriate or specialized facility. Evaluation and treatment shall be performed, and transfer shall be carried out as quickly as possible for an individual with an EMC which has not been stabilized or when stabilization of the individual's vital signs is not possible because the hospital does not have the appropriate equipment or personnel to correct the underlying process. The following requirements must be met for any transfer of an individual with an EMC that has not been stabilized:

a. Minimize the Risk. Before any transfer may occur, the transferring hospital must first provide, within its capacity and capability, medical treatment to minimize the risks to the health of the individual or unborn child.

b. Individual ' s Request or Physician ' s Order. Any transfer to another medical facility of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual ' s behalf or by a physician order with the appropriate physician or QMP and Physician certification as required under EMTALA. Any written request for a transfer to another medical facility from an individual with an EMC or the legally responsible person acting on the individual ' s behalf shall indicate the reasons for the request and that he or she is aware of the risks and benefits of the transfer.

c. Request to Transfer Made to Receiving Facility. The transferring hospital must call the receiving hospital or the Transfer Center if the facility is part of a Transfer Center network to verify the receiving hospital has available space and qualified personnel for the treatment of the individual. The receiving hospital must agree to accept the transfer and provide appropriate treatment. The transferring hospital must obtain permission from the receiving hospital to transfer an individual. This may be facilitated by a Transfer Center. Such permission should be documented on the medical record by the transferring hospital, including the date and time of the request and the name and title of the person accepting transfer. The transferring physician shall ensure that a receiving hospital has appropriate services and has accepted responsibility for the individual being transferred. If utilizing the services of a Transfer Center, the Transfer Center may assist in determining whether the receiving hospital has the appropriate services.

d. Document the Request. The transferring hospital must document its communication with the receiving hospital, including the request date and time and the name of the person accepting the transfer.

e. Send Medical Records. The transferring hospital must send to the receiving hospital copies of all medical records available at the time of transfer related to the EMC and continuing care of the individual. The transferring hospital may provide the Face Sheet with the appropriate information to the Transfer Center to assist Transfer Center in facilitating the transfer. But, the Transfer Center generally may not provide any information to, or respond to questions from, to the receiving facility or physician at the receiving facility, from the Face Sheet regarding whether or not the patient has insurance, or the type of insurance, or other information regarding the patient's ability to pay for services prior to acceptance of the patient except as required by a state or local plan for providing care to certain patient populations where insurance coverage is a determining factor in where the patient may receive care. Documentation sent to the receiving hospital must include:

--Copies of the available history, all records related to the individual ' s EMC, observations of signs or symptoms, patient ' s condition at the time of transfer, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests, monitoring and assessment data, any other pertinent information, and the informed written consent for transfer of the individual or the certification of a physician or QMP.

--The name and address of any on-call practitioner who refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; and

--The individual ' s vital signs which should be taken immediately prior to transfer and documented on the Memorandum of Transfer Form.

--Copies of available records must accompany the individual; and

--Copies of other records not available at the time of transfer must be sent to the receiving hospital as soon as practical after the transfer.

Medical and other records related to individuals transferred to or from the hospital must be retained in their original or legally reproduced form in hard copy, microfilm, or electronic media for a period of five years from the date of transfer.

f. Physician Certification of Risks and Benefits. A physician must sign an express written 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 should meet the following requirements:

--The certification must state the reason for transfer. The narrative rationale need not be a lengthy discussion of the individual ' s medical condition as this can be found in the medical record but should be specific to the condition of the patient upon transfer.

--The certification must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility and the risks associated with the transfer, including the time away from an acute care setting necessary to effect the transfer.

--The date and time of the physician certification should closely match the date and time of the transfer.

--Certifications may not be backdated.

g. QMP Certification. If a physician is not physically present at the time of the transfer, a QMP may sign the certification, after consultation with a physician, and transfer the individual as long as the medical benefits expected from transfer outweigh the risks. If a QMP signs the certification, a physician shall countersign it within 24 hours or a reasonable time period specified by the hospital bylaws, rules or regulations.

h. Send Memorandum of Transfer. A Memorandum of Transfer must be completed for every patient who is transferred to another separately licensed hospital. The Memorandum of Transfer and the patient ' s medical record must be sent with the patient at the time of the transfer. A copy of the Memorandum of Transfer shall be retained by the transferring hospital and incorporated into the patient's medical record.

During the tour of the L&D unit on 4/8/19 at 11:30 a.m. an interview was conducted with L&D Clinical Director (EE). She confirmed that the facility has a Level II Neonatal (newborn)Intensive Care Unit that can care for babies born after 32 weeks gestation (developmental age of the unborn baby) without any complications. She said the L&D Unit will transfer a mother pending delivery prior to 32 weeks gestation to the hospital of her primary obstetrician's choice.

During an interview on 4/9/19 at 10:35 a.m. in the Conference Room, RN MM confirmed that she was working L&D on 2/8/19 and that she remembers providing care for Patient #1. RN MM said she has been a RN since 2014, a L&D nurse since 2015, and has been working at the facility since February 2018. The RN said she remembers that the L&D Charge Nurse informed her that Patient #1 would be arriving and that the patient was experiencing a headache and pregnancy induced hypertension (high blood pressure). RN MM said she was setting up the room when Patient #1 arrived and that she helped the patient put on a gown and attached the fetal monitor (evaluates the baby's heartrate). RN MM said she asked the patient what brought her to the hospital and was informed that the patient was seen by the Dr. KK in his office and had lab work, I think that day to see if the patient was pre-eclamptic. RN MM reviewed her notes and said the patient's symptoms included: headache, dizziness, seeing spots, nausea, vomiting and mild cramping. RN MM explained that the patient was not admitted at this point and had only been triaged by RN MM. RN MM said she completed Patient #1's assessment and was informed by the patient that she was prescribed Labetalol but that she had forgotten to take her medication that day. RN MM said her first thought was to call Patient #1's Dr. KK to get orders. RN MM explained that she called the Patient's doctor KK and gave him an update of the patient's condition, the patient's blood pressure reading and informed the physician that the patient had missed taking her blood pressure medication. RN MM said she asked the physician what he wanted to do and he asked her to repeat the patient's blood pressure and then gave orders for the patient to be discharged with instructions for the patient to go directly to another local acute care hospital. RN MM said she thought this was odd and wondered whether this should be done. RN MM said she asked the physician KK if he wanted the patient transported (by ambulance) and the physician replied no, just tell the patient to come straight here and not to go anywhere else. RN MM said she asked the physician KK if he wanted her to give the patient the Labetalol and he replied no. RN MM said she discussed this with the L&D Charge Nurse and the L&D Charge Nurse asked about Patient #1's blood pressure and then told RN MM that the physician ordered the patient to be discharged so that's what we will do. RN MM added that after speaking with the patient's physician it never occurred to her that the on-call OB physician could be contacted.

During a phone interview on 4/9/19 at 12:30 p.m. with Dr. KK he reported that he remembered Patient #1. He confirmed he was her primary OB and had seen her earlier in the week of 2/8/19 in his office. He stated he had not sent her to the Emergency Department for evaluation. He reported that Patient #1 did have chronic (persisting for a long time or recurring) hypertension (high blood pressure) and had shown some protein (small molecules that play critical roles in the body) in her urine (if high amounts of protein are found in the urine late in a pregnancy, it may indicate kidney disease or preeclampsia). Dr. KK said he had sent labs off to be tested and sent the patient to see a urologist (physician who specializes in the treatment of the urinary tract {body ' s drainage system for removing urine}) to rule out kidney (bean shaped organs that filter blood to remove wastes and make urine) damage and preeclampsia. Dr. KK reported he was at another acute care hospital in the local area when RN MM called to tell him his patient was at their facility. He confirmed that RN MM had provided him with her assessment of the patient and given him all the vital signs. He said he did not think the patient was that unstable. Dr. KK said he told RN MM where he was and asked that the patient not be admitted to her facility but be sent over to where he was for further evaluation. He explained that the facility where he was located at that time was not far and was able to provide specialized care if there were complications with the pregnancy. He confirmed that RN MM asked about emergency transport by ambulance, but he said he did not think Patient #1 ' s condition warranted emergency transport. He confirmed that Nurse MM asked if he wanted Patient #1 to get her Labetalol at that time and he said told her no. Dr. KK said he assumed care when Patient #1 arrived at his location. He said he evaluated her and told her they would just watch her for a few days in the hospital. He said she was stable at that time. He said he left the hospital and was called back to the hospital in less than 30 minutes. When he arrived back at the hospital he found an emergency delivery was warranted and the baby was delivered by Cesarean-Section (surgery where the baby is taken out through the mother ' s abdomen).

Show Text of Violation

Based on review of medical records, policies and procedures, and interviews the facility failed to ensure that an appropriate medical screening examination was completed within the capability of the emergency department to include ancillary services routinely available at the hospital 's Emergency Department to determine whether or not an emergency medical condition existed as evidenced by failing to address the individual ' s pain and elevated blood pressure prior to leaving the hospital for 1 (#3) of 25 sampled patients medical records reviewed.

Findings:

The facility 's policy and procedure titled, EMTALA-Georgia Medical Screening Examination and Stabilization Policy , PolicyStat ID: 6, approved 2013 was reviewed. The policy revealed in part, Statement of Purpose: To establish guidelines for providing appropriate medical screening examinations ( MSE ) ...Policy Am EMTALA obligation is triggered when an individual comes to the dedicated emergency department ( DED ) and 1. The individual or a representative acting on the individual ' s behalf requests an examination or treatment for a medical condition ...Procedure: 1. When an MSE is Required A hospital must provide an appropriate MSE within the capability of the emergency department including ancillary services routinely available to the DED to determine whether or not an EMC exists.

The facility ' s policy and procedure entitled, Procedure for Emergency Registration & Admission and ESP (Emergency Services Protocol) Program, Page 8, EFFECTIVE DATE 01/01/2014 was reviewed. Emergency Department Medical Screening Exam (examination) for Qualified Medical Person. The non-emergent patient is identified by the Qualified Medical Person via facility specific designated (e.g. Blue Folders, Lavender Physician T-sheets, etc.). Following the medical screening exam, these patients are routed to registration for upfront collection and registration according to the ED Medical Screening Exam Flow, Scripting and troubleshooting process... The non-emergent patient required to pay the facility assigned QMP maximum deposit. Upon discharge, the ED Discharge Disposition must be HOME. ... Non-emergent patients who do not pay the required QMP maximum deposit at time of service may elect to leave the ED to receive care from a family physician or local resource ...Non-emergent patients who pay the required QMP maximum deposit are treated accordingly.

Review of the policy entitled Standards of Triage & Care in the Emergency Department, last reviewed 10/2014, revealed that level 4 acuity patients included minor back pain, Pulled something - muscle spasms; localized back pain (4-7/10). Possible extremity fracture, swollen, hot joint , tight cast-no neurovascular impairment.

Review of patient #3 ' s medical record revealed the patient was an uninsured patient who walked into the ED on 01/04/16 at 6:16 PM with complaints of back pain. The triage nurse #5 (a nurse who assessed a patient to determine in which a severity of the chief complaint and the priority in which a patient will be seen by the provider) noted that the patient was a level 4 (semi-urgent). Documentation the patient was initially with the provider at 6:19 PM and that the patient was placed in an ED room at 6:22 p.m. The triage nurse noted that the patient reported that his/her pain was a 4 on a pain scale of 1 (minimal pain) to 10 (severe pain) and that a level 3 was an acceptable pain level. The nurse noted that the pain was sharp and throbbing and that daily activities aggravated his/her back pain. In addition, the nurse noted that the symptoms had begun at 5:00 p.m. The nurse also noted that the patient had reported similar episodes that had never been evaluated and that the patient reported pain when walking. The nurse noted that the patient ' s temperature, pulse, respirations, and oxygen level were within normal limits. The patient ' s blood pressure was noted to be 157/101 ( Normal Blood Pressure 110-120/60-80). In addition, the nurse noted that the patient was alert and oriented to person place time and situation, moved all extremities, had no paralysis and ambulated independently. The Conditions of Admission and consent for Outpatient Care form was signed by patient #3 on 01/04/16 at 6:13 p.m. Further review revealed that at 7:07 p.m. the patient was discharged and the patient ' s pain intensity was still 4. Review revealed that patient #3 physically left the ED at 7:08 p.m. Documentation revealed that Discharge information was provided for patient #3 but the patient refused. Continued review of the medical record revealed that patient #3 was evaluated by a Physician ' s assistant (PA-#1) on 1/04/16 at 6:19 p.m. and that the PA completed the facility ' s electronic HPI (History of Present Illness)-Back pain 40 and Under forms. The PA noted that the patient complained of spontaneous low back pain that had started earlier that morning. The PA also noted that the quality of the pain was spasms with no radiation of pain. The PA noted that patient #3 reported that initially the pain had been a 7 on a scale of 1 to 10, but that the pain was now a 3 on a scale of, 1 to 10. The PA noted that the patient denied abdominal pain, fever, inability to walk, incontinence, neurological symptoms, numbness or tingling of the lower extremities. The PA notes indicated that the patient ' s pain increased with movement and was relieved by lying still. In addition, the PA noted that the patient reported that he/she had chronic back pain and that the episode felt like prior episodes. The PA noted that a review of the patient ' s systems were negative with the exception of the low back pain. The PA noted that the patient had no neck, upper back, extremity, or joint pain. The PA noted that the patient had a past history and that the patient ' s medications, allergies, and vital signs were reviewed. The PA noted that patient #3 ' s physical examination revealed the patient was alert and oriented to person, place and time, and that the patient was not in acute distress. In addition, the physical examination included the following: full range of motion of the neck, neurovascular (nerves and blood flow) intact, extremities have full range of motion with equal pulses, movement, and tendon reflexes, back has no vertebral or peri-spinal tenderness and no muscle spasms. In addition, the physical examination revealed that the patient was able to perform a straight leg raise with no findings and that cranial nerves II-XII were intact. The patient also had normal movement deficits and equal reflexes bilaterally. The PA noted that the ESP (Emergency Services Protocol) was complete and the patient was discharged . The PA ' s notes were electronically signed on 01/04/2016 at 7:15 p.m. and were also reviewed and electronically signed by the ED Physician #2 on 01/04/2016 at 8:47 p.m. The electronic record noted that at 6:39 p.m. the PA entered the patient as having a non-urgent medical condition. The Non-Urgent MSE Determination >5 <65 Years of Age was completed by the PA on 01/04/2016. The form noted that the MSE was completed and that immediate medical attention was not necessary because there was no acute symptoms of sufficient severity and no immediate serious impairment or dysfunction of body functions or organs is reasonably expected. This form was also signed by the Registrar #9 on 01/04/2016. The Registrar checked the box noting that the patient had received an MSE and that no Emergency Medical Condition (EMC) was found by the qualified medical personnel (the PA). This box noted that the patient declined further treatment and had left the facility. In addition, in this box the Registrar provided a listing of community resources to the patient for follow-up care for the patient ' s non-emergent medical condition. The triage nurse also signed this form, signifying that the patient received an MSE, was found to have no EMC, that the patient declined further treatment and had left the facility, and that the Registrar had provided a list of Community resources for follow-up of a non-emergent medical condition.

The medical record did not contain evidence that any medications or treatment had been administered for patient #3's complaint of pain on 1/4/2016;despite the patient reporting to the provider of prior episodes of pain that were never evaluated prior to this ER visit. The medical record did not contain evidence that the patient's elevated blood pressure had been addressed following triage, or prior to discharging patient #3 on 1/4/2016. The facility failed to ensure that a complete medical screening examination was provided for patient #3 on 1/4/2016.

During an interview on 01/13/16 at 4:30 p.m. in the Administrative Board Room, the PA (#1) said that he/she recalled caring for someone who had presented to the ED in a semi truck. The PA reviewed patient #3's medical record and stated the patient did not seem to be in severe pain and that the patient did not trigger any red flags for anything. The PA confirmed that the patient's physical examination had been negative and that the patient had reported that the back pain felt like previous episodes. The PA also confirmed that the nurse documented the patient's pain as a 4 on a scale of 1 to 10. The PA stated the patient told me that the initial pain was a 7 but the pain level was now a 3 on a scale of 1 to 10. The PA explained he/she had not ordered any diagnostic tests because none were needed. The PA stated that after ensuring that the patient did not have an EMC he/she clicked the non-urgent button on the computer which triggered the Registrar to come in and talk with the patient. After the Registrar talks with the patients I am notified if the patient decides to continue treatment. The PA stated no pain medications were ordered because the patient decided not to stay and left the ED voluntarily. The PA stated that if patients decide to stay and continue treatment they agree to pay any insurance co-payment or the hospital's fee.

During a telephone interview on 01/14/16 at 1:30 p.m. in the Administrative Board Room, ED physician (#2) stated that since patient #3 was determined by the QMP (Qualified Medical Person) as not having an EMC and declined further treatment that he/she would not have seen the patient. The physician explained that after being evaluated by the mid-level provider all patient's can request to be re-evaluated by a physician but that as far as he/she knew this patient had not asked to be re-valuated by a physician The physician stated he/she had reviewed the PA's (#1) documentation and signed off after determining that the documentation was appropriate.

During an interview on 01/14/16 at 8:30 a.m. in the Administrative Board Room, the ED Medical Director (#3) explained that once a provider has screened a patient and determined that the patient does not have an EMC, the provider hits the non-urgent button on the computer screen, and this notifies the Registrar staff that they can now talk with the patient. The Medical Director stated the providers have no way of knowing whether the patient has insurance or any other payer source. The Medical Director stated once the determination is made that the patient has no EMC the patient can elect to stay and pay any co-payment or the hospital's fee of $175.00. In addition, the Medical Director stated that if the patient decides to leave and go elsewhere, the patient has received a triage assessment, been placed in an ED room, and has had a MSE at no charge to the patient.

During a telephone interview on 01/14/16 at 1:45 p.m. in the Administrative Board Room, the PA (#4) confirmed that he/she had been in with the triage nurse on 01/04/16 when patient #3 presented to the ED. The PA confirmed that he/she vaguely remembered patient #3 because the patient was driving a semi truck. The PA stated the patient had been ambulatory upon arrival and appeared to have mild discomfort. The PA confirmed that he/she was unaware of the patient's payer source and did not ask the patient. The PA said the patient was triaged and placed in a room to be evaluated by another provider. The PA confirmed that after being seen by the QMP and determined to have no EMC that the Registrar would speak to the patient regarding the patient's options of whether they wished to stay and continue treatment after paying any co-payment or the hospital's fee or declined further treatment and wished to leave.

During an interview on 01/14/16 at 10:15 a.m. in the Administrative Board Room, the Registered Nurse (#5) confirmed that he/she was the triage nurse when the patient (#3) presented with complaints of back pain. The nurse explained that he/she remembered that the patient was a semi-truck driver who presented with complaints of back pain. The nurse said that the patient ambulated into the ED with a spouse and that when the patient walked he/she had a painful facial expression. The nurse confirmed that the patient was evaluated by a PA, was determined not to have a EMC, and then seen by a Registrar staff member. The nurse stated he/she observed the patient walk out of the ED and that the patient did look a little uncomfortable walking. The nurse said that about 50% of the patients who were determined not to have an EMC decided to stay and pay any required co-payments or the facility's require $175.00 for uninsured patients.

During an interview on 01/14/16 at 3:00 p.m. in the Administrative Board Room, the Director of the ED (#) confirmed that the facility followed the above QMP process. Medical records were audited to ensure patients who did not have an EMC, and were given the option to continue their treatment, and patients that decided to leave received a community resource list.

During interviews on 01/14/16 at 10:50 a.m. and 2:40 p.m. in the Administrative Board Room, the Registrar (#9) and the Director of Patient Access (#10), respectively, both interviewees confirmed that the facility's policy regarding the QMP patient was as follows:

--the provider evaluates the patient and determines that there is no EMC,

--the provider hits the computer button that signifies that there is no EMC,

--a Registrar staff member speaks with the patient and discusses the patient's options of continuing treatment which includes paying any required insurance co-payment or the facility's fee of $175.00 for non-insured patients, and

--if the patient decided to leave the patient was to be provided with a community resource list and would not accrue any charges.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based medical reviews and policies and procedures the facility failed to ensure that an appropriate medical screening examination was provided to the individual ' s presenting signs and symptoms that was within the capability and capacity of the hospital ' s emergency department, including ancillary services routinely available to the emergency department for 1 (#1) of 20 sampled patients medical records reviewed.

Findings:

The hospital ' s Policy and procedure titled EMTALA -Georgia Medical Screening Examination and Stabilization Policy Policy number PolicyStatID : 6, last revised 03/3013, specified in part, Statement of Purpose: To establish guidelines for providing appropriate medical screening examination (MSE) ...Policy: An EMTALA is triggered when an individual comes to a dedicated emergency department( DED ) ...Procedure: ...1. When an MSE is required: A hospital must provide an appropriate MSE within the capability of the hospital ' s emergency department including ancillary services routinely available to the DED, to determine whether or an EMC exists.(i)to any individuals ...who requires such an examination; (ii)an individual who has such a request made on h s or her behalf; or ...a The individual comes to the dedicated emergency department of a hospital and a request is made by the individual ...for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition .....Extent of MSE a. Determine if an EMC exists ...b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual ' s presenting signs and symptoms and the capability and capacity of the hospital.

The hospital s policy and procedure titled, Standards of Triage in the Emergency Department Original Date 12/96 revised Date: 10/15 was reviewed. The policy specified in part, Purpose: To provide assessment/reassessment guidelines for initial evaluation, continued monitoring, and/or changes in patient acuity levels according to severity of illness or injury ...Guidelines: All patients presenting to the emergency department room are assessed rapidly to determine the severity of the presenting chief complaint. Acuity is assigned to each patient during the rapid initial assessment ...Definitions: Triage Assessment-The dynamic process of sorting, prioritizing, and assessing the patient is performed by a qualified RN at the time of presentation and before registration ...C. The triage nurse will determine the status of the patient based on the following criteria ...b. Level 2 Triage Category: may include, but not limited to: ...CN (Central Nervous System) Serve headache with high blood pressure, ...altered LOC (Level of Conscious) ... headache ... c. Level 3 Triage Category ... CNS- Headache- severe (mild-moderate distress, pain scale 8-10/10), no LOC vomiting.... II Assessments: ... C. Focused Chief Complaint Assessment/Primary Assessment: 1.) Ongoing Vital signs 2) Ongoing pain Assessment 3) Data pertinent to the clinical presentation/chief complaint 4) documentation of any other complaints 5) Nurse Notes 6) Medications, treatments, and interventions performed on the patient ...III Reassessments/Vital Signs Guidelines A.) Reassessments/Vital Signs guidelines after initiation of the medical screening exam (MSE) are performed by nursing according to acuity ...3. Level (3) Urgent will be performed and documented every hour and more frequently if condition warrants.

The facilities Policy and Procedure titled Procedure for Emergency Registration & Admission and ESP Program reference Number: PARA.PP.PTAC.005 Effective 01/01/2014 was reviewed. The policy specified in part, Emergency Department Medical Screening Exam for Qualified Medical Person...The non-emergent patient by the Qualified Medical Person(QMP)...Non-Emergent patients who do not pay the required QMP maximum deposit at the time of service may elect to leave the ED to receive care from a family physician or local community resource...Non-emergent patients who pay the required QMP maximum deposit are treated accordingly.

The medical record for patient #1 was reviewed. Review of the form titled Emergency Patient Record, revealed that patient #1 (MDS) dated [DATE] at 9:18 p.m. Documentation by the Emergency Department (ED) Nurse specified Patient#1 stated and chief complaint was listed as Ingestion. Patient #1 ' s ESI (Emergency Severity Index) was listed as 3/Urgent. Further documentation by the ED nurse revealed in part in the section titled, Assessments revealed in part, Subjective Assessments: Pt. (patient) states a friend gave her what she thought was a goodie powder and a short time later she states she blacked out and could not remember things. The patient ' s Vital signs were listed as: Blood Pressure 180/110 (normal blood Pressure 120/80); Temperature: 98.0; Respirations: 18; and Oxygen saturation (measurement of oxygen the blood is carrying as a percentage)99%. Documentation by the ED nurse revealed in part,... 2158 (9:58 PM) Patient Tearful, had headache, states asked for goodie powder, given by roommate sister's boyfriend, Patient Anxious, asked to repeat tem (temperature), the same. C/O (complain/of) neck pain, headache, face, left shoulder, states sinus headache before med (medication). Believes she was given something else. . 10:00 p.m. ... Presenting Signs and Symptoms: HEADACHE, FACE PAIN, FEEL FUNNY ....2205 (10:05 PM) {ED physician name] stated has seen patient, no assault, sexual assault, ...Patient still crying and wants something for pain 2214 (10:14 PM) Patient vomited small amt (amount), food , not paying to be seen, asking for Tylenol for pain, ambulates well, steady gait, escorted to friends room. 22:15 PM (10:15 PM) ...Pain Scale: Numeric Intensity: 7(Pain scale 0-10 with 10 being the highest) ...physically leaves the ED ...22: 35 (10:35 PM) The ED physician documented in part, HPI (History of Present Illness) ... Context- related history: Took medication then left. Did drink some alcohol (1 shot) ...Phy (Physical) Exam (examination)- General Med ...General : Alert, oriented X3, cooperative, distress (Mild distress) ...Disposition- ...Clinical Impression ...Substance intoxication.

Review of the form in the medical record entitled, Doctor's Hospital MSE (Medical Screening Determination) dated 12/13/2015 revealed in part, QMP (Qualified Medical Personnel) ____MEDICAL SCREENING COMPLETE: Immediate medical attention not necessary, no acute symptoms of sufficient severity ....no immediate serious impairment or dysfunction of body functions or organs is reasonably expected ... Triage Nurse____ patient received medical screening exam. No emergency medical condition found per qualified medical personnel. Patient declined further medical treatment at the facility and has left. Registration provided a listing of community resources to the patient for follow-up care for the patient ' s non-emergent medical condition. Patient #1 left Doctor ' s Hospital and went to Hospital B, another acute care hospital, where the patient was appropriately treated and discharged .

The hospital failed to ensure that an appropriate medical screening examination was provided for patient #1 on 12/13/2015 that was within the capability and capacity of the hospital's ED. This was evidenced by the based on the patient's inability to pay for further treatment to include ancillary services (urine drug screen, laboratory test routinely available related to the patients presenting signs of ingestion of unknown powdery substance. The facility triaged patient #1 as a level 3 (Urgent). According to the facility's policy, levels four and five are non-emergent patient. According to the patient ' s complaints of ingestion of an unknown substance as well as loss of consciousness, there was no documentation in the medical record to indicate the patients VS were taken every hour, despite an elevated blood pressure initially, and no vital signs were completed upon discharge from the ED. The patients presenting signs and symptoms of ingestion of an unknown substance as well as reported loss of consciousness the patient should have been triaged as a level 2 as stated in the facility ' s triage policy. There was no re assessments of the patient complaint of pain and no treatment nor interventions were provided for patient #1 on 12/13/2015.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, transfer center recordings, transfer center log, bed census reports, policies and procedures and staff interviews, the facility failed to accept the transfer from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required such specialized services capabilities

or facilities if the receiving hospital has the capacity to treat 1 (#18) of twenty (#20) patients sampled patients medical records reviewed.

Findings include:

Review of PolicyStat 9, EMTALA- Transfer Policy, approved and revised 03/2013, revealed that a hospital with specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units or with respect to rural areas, regional referral centers) shall accept from a transferring hospital an appropriate transfer of an individual with an EMC who requires specialized capabilities if the receiving hospital has the capacity to treat the individual. The transferring hospital must be within the boundaries of the United States.

Review of recorded Transfer Center telephone calls from 12/13/15 revealed that physician (MD #9) was contacted by another facility's ER physician on 12/13/15 to request transfer of an [AGE]-year-old patient (#18) with high blood sugar of 696 - (normal range is less than 140 two [2] hours after eating), pneumonia and high blood sodium of 154 (normal range is 135-145) to this facility. After the ER physician provided details on the patient's condition and the treatment rendered, MD #9 (on call physician at Doctors Hospital ) could be heard stating can't you handle the glucose? and that he/she did not see a reason for him/her to admit the patient, and that he/she thought the patient could be managed over there. MD #9 could be heard further making treatment suggestions and instructed the ER MD to telephone him/her back if the patient did not improve. The MD further stated that he/she was not going to do anything differently than what the ER MD was doing over there and that was the only reason he/she did not want to take the patient.

Further review of the 12/13/15 Transfer Center telephone calls revealed that the transfer center contacted Doctors Hospital Bed Control Supervisor to advise of the physician's transfer request denial. The Bed Control Supervisor could be heard stating well, that's what we have to go with.

Further review of the 12/13/15 Transfer Center telephone calls revealed that the revealed that the transfer center contacted Doctors Hospital facility Administrator on Call to advise of the physician's transfer request denial. After the transfer center provided details of the situation, the Administrator on call could be heard asking how did they take it? After the transfer center's response, the Administrator on call stated that he/she thought that sounds appropriate, and okay, I agree (with the denial).

The Transfer Center Pre-Admit Sheet dated 12/13/2015 for patient #18 was reviewed. The patient ' s diagnosis #1 was listed as pneumonia, hypernatremia (Elevated Sodium level); History of Present illness: ICU (Intensive Care Unit) Bed unresponsive. Review revealed that the Emergency Department physician from Hospital B called on 12/15/2015 at 10:34 Spoke to (MD NAME) - LOOKING TO TRANSFER TO HOSPITALIST. The section of this form titled Accepting Services and Provider Service: Pulmonary Critical Care Medicine ...Physician ' s Name (#9) ...Acceptance Status: Denied. Date and time of decision: 12//134/2015 11:04 Explanation: PHYSICIAN REFUSAL...Notes: ...12/13/2015 11:04 DR TO DR-84 YO (year old) NURSING HOME PATIENT HAS HYPERGLYCEMIA IS 698 ON ARRIVAL HYPERNATREMIC IS DNR (Do not resuscitate) IS UNRESPONSIVE ON FEEDING TUBE. PT COULD BE MANAGED OVER THERE HAS PNA (pneumonia), STATED ANTIBIOTICS DOES NOT REQUIRE ANY DIFFERENT CARE THAN ALREADY BEING DONE ...12/13/2015 11:09:CALLED LEFT MESSAGE FOR AOC (administrator on call) ...on denial of patient ...Notes: 12/13/2015 10:46 (House Supervisor) ...ICU GOOD ...12/1/3/2015 11:13:CALLED LEFT MESSAGE-FOR AOC ...ON DENIAL OF PATIENT AND CALLED HOUSE SUPERVISOR. House Supervisor AND ADVISED OF DENIAL OF PT (patient) WHO STATED WOULD STAND BY DRS (doctors) DECISION ...12/13/2015 11:39 AOC ...CALLED BACK. I ADVISED HER OF DENIAL AND THE DRS RESPONSES SHE STATED SHE AGREED WITH DECISION. PLACEMENT ...Placement ... Notes 12/13/2015 10:55: CHECKED ICU BEDS -OK.

Review of the hospital's bed census for the ICU dated 12/13/2015 revealed the hospital census for the unit was 13. The hospital's ICU Bed capacity is 24.

Interview with the ER Medical Director on 12/30/15 at 10:40 AM in the conference room revealed an acknowledgement of the transfer denial by MD #9 on patient #18. The ER Medical Director explained that MD #9 may not have believed that the patient needed to go to the ICU (Intensive Care Unit) or may not have known that he/she needed to accept the patient, even if the hospitals provided the same level of care. The ER Medical Director stated if we have a bed, we have to take them. Review of the hospital ' s bed census verified that on 12/13/2015 the hospital had a bed (capacity) to accept patient #18 on 12/13/2015 when the request was made by the ED physician from the referring hospital.

Telephone interview with MD #9 on 12/30/15 at 12:20 PM revealed that he/she recalled the telephone conversation with another facility's ER MD regarding their request to transfer patient #18 to this facility. The MD stated that he/she had not accepted the patient because the patient had pneumonia, high blood sugar, and high sodium, all of which could be managed on a medical floor. MD #9 further explained that the patient had already received antibiotics and intravenous fluids and that he/she would not have consulted with any specialist, such as a pulmonologist or a nephrologist. He/she stated that he/she believed the referring hospital had the capability to provide the necessary services to the patient. MD #9 further stated that he/she had worked as a Hospitalist at this facility for nearly one (1) year, and, believed that he/she had received EMTALA training on hire. Doctors Hospital had the capability to accept patient #18 on 12/13/2015 when the ED physician from Hospital A called and requested a transfer.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the facility's policies, computer query, and staff interviews, it was determined that the facility failed to maintain medical records and other records related to individuals transferred to or from the hospital when a request was made on the individuals behalf for an examination and treatment of a medical condition for one (1) individual (#11) of twenty (20) sampled patients presenting to the hospital's emergency department..

Findings:

Review of the facility's policy entitled General Policies - Emergency Department (ED) no policy number, last revised 01/2015, revealed medical records are maintained on all patients presented or presenting themselves for treatment.

On 10/06/2015, a computer query using the patient's name, date of birth, and date of event revealed there was no documented evidence that a medical record was generated for Patient (#11) who (MDS) dated [DATE].

During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with Patient #11,the patient to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with Patient (#11), the patient said that she did not have a ride to the other facility. The Manager also stated that the local Sheriff Officer from the ____________County Sheriff Office offered to give the patient a ride to the Veterans' Administration Hospital. The Manager confirmed that a medical record should have been generated for Patient #11 on 9/28/2015.

An interview was conducted on 10/06/2015 at 1:40 p.m. with the ED physician (#4) who was present in the ED when patient #11 arrived on 9/28/2015. The physician said he/she did not document the findings because the female was not entered into the system.

A telephone interview was conducted on 10/07/2015 at 12:10 p.m. in the Board Room, with the Chief Security Guard. The Chief stated that he/she asked the Nurse Manager if there was any information regarding the female and was told there was no information because the patient was never entered into the system.

Show Text of Violation

2406

Based on review of a medical records, Medical Staff Bylaws, Medical Staff Rules and Regulations, facility's policies, Sheriff's Office Case Report, physician's progress note statement, and On-call schedules, Physician credentialing file, staff and Sheriff's Officer interviews, it was determined that the facility failed to ensure one (1) individual (#11) of twenty (20) sampled patients received an appropriate Medical Screening Examination (MSE) that was within the capability of the hospital's emergency department to determine whether or an emergency medical condition existed for an individual (#11) who was found by 2 prudent laypersons walking the highway with an unsteady gait, twitching and carrying a young child.

Findings:

1. Review of the Medical Staff Bylaws, and Medical Staff Rules and Regulations, adopted by the Medical Staff and Approved by the Board on 04/22/2014, revealed MSE(s) within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition (EMC). Qualified medical personnel who can perform MSE(s) within applicable Hospital policies and procedures are defined as:

a. Emergency Department:

1. members of the Medical Staff with clinical privileges in Emergency Medicine;

2. other Active Staff members; and

3. appropriately credentialed allied health professionals.

2. Review of the facility's policy entitled EMTALA (Emergency Medical Treatment and Labor Act) - Georgia Medical Screening Examination and Stabilization Policy, number 6, last revised 03/2013, revealed an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and:

1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition, or

2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.

The Medical Screening Examination (MSE) must be completed by an individual (i) qualified to perform such an examination to determine whether an emergency medical condition (EMC) exists. The procedure was as follows:

1. An MSE is required when:

a. The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition. .. Extent of the MSE (Medical Screening Examination) a. Determine if an EMC exists. The hospital must perform am MSE to determine if an EMC exists ...Definition of MSE. An MSE is the process required to reach within clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The Medical Screening examination must be appropriate to the patients presenting signs and symptoms and the capability and capacity of the hospital.

2. The September : Doctor's Hospital Psychiatry on-call schedule was reviewed. The review revealed that an on-all psychiatrist was on-call on 09/28/2015 when Patient #11 presented to the ED, and a request was made on the patients behalf by two prudent laypersons for an examination.

3. Review of the ______ County Sheriff's Office case report dated 09/28/2015 revealed in part, the officers were dispatched to Doctors Hospital in reference to a disturbance/nuisance. The report noted that upon arrival, the officer spoke with the driver that drove the individual to the ED entrance and was informed that the driver observed the individual walking and carrying a small child. The report noted that the driver reportedly made the decision to take the individual to Doctors Hospital because the individual had an unsteady gate ({sic}-gait), was fidgeting, making jerking motions, and informing the driver that she had post-traumatic stress disorder and several other issues. The officer noted that upon arrival, the individual refused to exit the car but eventually entered the ED and was taken to a room for an assessment. The officer noted that the individual was advised by staff at Doctors that due to the individual's lack of insurance coverage the individual would be better served at the Veterans' Administration Hospital.

4. The medical record for Patient #11 was obtained from the Veteran's Administration Hospital for review. Review of the medical record revealed that the patient arrived at the VAH on 9/29/2015 at 1:48 p.m. The Emergency Department (ED) physician documented the patient's chief complain as Paranoid (Mental illness-being suspicious, irrational obsessive distrust of others). The section entitled History of Present illness the Physician documented in part, Pt (patient) was found wandering along a street reportedly hearing voices and responding to them. Per deputy pt was seen briefly at Doctors Hospital briefly and was sent here for eval (evaluation). Pt states that she is afraid that we are going to take out my heart and also take away her child which she is caring for currently ...Physical Exam (examination) Gen (general): agitated...Psychiatric: paranoid, pressured speech. No SI/HI (Suicidal Ideation- thoughts of wanting to kill oneself/Homicidal Ideation-thoughts of harming others), or AVH (auditory visual hallucinations). The Physician also documented that patient #11 attempted to elope from the VAH during workup. Patient #11 then required security restraint and was given Ativan (medication used to treat anxiety) intramuscularly. The patient was then placed on a 1013 ( a classification for a patient needing emergent in-patient mental health treatment) order. The physician further documented that Patient #11 was to be transferred to an outside facility for further care. The Social Worker documented that patient #11 attempted to elope from the Emergency Department with her baby in her arms. The VA(Veterans Administration ) police and 2 ED physicians, multiple nurses and the Social Worker were involved in patient #11's and her baby's safety. Documentation by the Social Worker revealed in part, Veteran stated Don't kill me , Please don't shoot me! the veteran was calmed down and brought back into the ED. Further documentation by the Social Worker revealed that after the patient was brought back into the ED a nurse took the baby to another part of the ED where she could be evaluated further. The Social Worker also documented that the Department of Family and Children Services (DFCS) was called and notified of the situation related to patient #11's child. The DFCS worker contacted the local courts and the child was placed in temporary custody of the court, until patient #11's mother could make arrangements to come in and care for the child. Patient #11 was accepted for in-patient psychiatric care at a Behavioral Health Center.

5. The Progress Notes dated 10/6/2015 and provided by physician (#4) on 10/06/15 revealed the female's (#11) 1350 (1:50 p.m.)Visit date 9/28/2015 The physician noted that the patient's history of present illness was as follows: female brought to hospital against her will by two (2) bystanders who picked the female up when she was observed walking to get to the Veterans' Administration Hospital. The female arrived at Doctors Hospital and was asked to come into a room for an evaluation. The female initially refused but eventually was brought into the ED. Female (#11) reported that she does not want to be here and wants to go to the Veterans' Administration Hospital. The female stated she needed a refill on her medications and denies complaints. Specifically, denies suicidal/homicidal ideations, hallucinations, or delusions. She denies fever, vomiting, diarrhea, headache, numbness, tingling, weakness, trauma, rashes, upper respiratory infections, or urinary tract infection symptoms. Review of systems was negative as stated above. Past medical history was reported as psychiatric issues. Past surgical history is unknown. Physical examination findings were within normal limits and vital signs were refused. Female was alert and oriented to person, place and time. The female's mood was normal. The physician documented the Action/Plan in part, Patient #11's last name of right refuses all care at Doctors Hospital. She (#11) had no sign of an EMC at this time. She refuses all care here and wishes to go to the Veterans' Administration Hospital. She agrees to go with the Sheriff's Officer for transport to the Veterans' Administration Hospital. She cannot be further treated at Doctors against her will. The physician documented patient #11's name and date of birth on the bottom of the progress note. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided for patient #11 on 9/28/2015 when 2 prudent laypersons observers concluded that patient #11's behavior walking along a highway with a child (unsteady gait and twitching) requested and needed an examination and treatment of an identified emergency medical condition. There was no documentation in the progress note to indicate with this patient s presenting signs and symptoms that the psychiatrist on-call was called to evaluate the patient. After Patient #11 was taken from Doctor's Hospital via the county police officer it was determined that she had an emergency psychiatric condition.

6. Review of two (2) of two (2) credential files revealed documented evidence of all required facility data. Physician #4 had EMTALA training in 08/2008 and physician #5 had EMTALA training in 03/2012.

INTERVIEWS

1. During a telephone interview on 10/07/2015 at 12:10 p.m. in the Board Room, the Chief Security Guard stated he remembered the episode regarding two (2) women driving up to the ED entrance with a female carrying a baby in the back seat. The Chief said that the driver's daughter informed him/her that they had observed the female walking down the road carrying a baby and that they offered the individual a ride. The Chief stated the two (2) ladies reported that they were concerned because the female was twitching and had informed them that she was a veteran. The Chief explained that the female refused to get out of the car and that the two (2) ladies wanted her out of their car and reported that they were not taking the female to another facility because they feared for their safety. The Chief said he/she was concerned for the baby and that the local Sheriff's Office was notified so that they could assist with getting the female out of the car. The Chief said that the ED Nurse Manager arrived, and that the Nurse Manager and the Sheriff's Officer got the female out of the car and took her into the ED. The Chief said that approximately five (5) to ten (10) minutes later, the female was escorted out of the hospital by the Sheriff's Officer, and they were taking her to the Veterans' Administration Hospital. The Chief stated he/she stayed outside talking with the driver and never went inside the hospital with the female.

2. During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager (#3) confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with the individual and that the individual continued to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with the individual the individual said she did not have a ride to the other facility and that the local Sheriff's Officer offered to give the patient a ride to the Veterans' Administration Hospital.

3. During an interview on 10/06/2015 at 1:40 p.m., the ED physician (#4) stated he/she had been asked to see a female who had been walking and was picked-up by two (2) ladies and brought to the ED entrance. The physician stated the individual did not want to be treated at Doctors Hospital and that the individual stated she wanted to go to the Veterans' Administration Hospital where she had received psychiatric treatment and her medications. The physician said the individual ended up in the ED and that he/she spoke with the individual and tried to offer her treatment. The physician confirmed that the individual was holding her baby at the time. The physician explained that he/she asked the female if he/she could examine her and that the female replied no, I want to go to the Veterans' Administration Hospital. The physician said the female finally got on the examination bed, and that he/she did a mental evaluation of the female. The physician said the female was adamant that she did not want to receive treatment at Doctors Hospital. The physician said the individual was alert to person and place and that the Sheriff's Officer offered to drive the patient to the Veterans' Administration Hospital so that the patient could get her medications refilled. The physician said he/she even offered to refill the female's medications and that the female had refused.

4. During an interview on 10/07/2015 at 9:15 a.m., the Corporal (#9) with the _______ County Sheriff's Office stated he/she had been informed by his/her supervisor not to talk with the surveyors. The officer did confirm that he/she and two (2) other officers were present when the ED physician examined patient #11.

The facility failed to ensure that their Medical Staff by Laws and Medical Staff Rules and Regulations and the facility ' s EMTALA policy and procedures were followed as evidenced by failing to provide an appropriate medical screening examination that was within the capability (medical clearance, psychiatric evaluation,1013'd, laboratory tests, and appropriate care of the child that presented with patient #11) of the hospital when requested by 2 prudent laypersons that observed and concluded from Patient #11's behavior on 9/28/2015 needed an examination to determine the presence of an emergency medical condition.

Show Text of Violation

Based on review of the facility's policies and procedures, on call schedules, Physician Progress note, medical record and staff interviews, it was determined that the facility failed to provide stabilizing treatment that was within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for an individual that was found wandering the highway with a child for one (1) individual (Patient #11) of twenty (20) sampled patients.

Findings:

1. Review of the facility's policy entitled EMTALA (Emergency Medical Treatment and Labor Act) - Georgia Medical Screening Examination and Stabilization Policy, number 6, last revised 03/2013, revealed an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) ...1. An MSE is required when: a. the individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition. This policy noted that if an emergency medical condition (EMC) is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA.

2. The September : Doctor's Hospital Psychiatry on-call schedule was reviewed. The review revealed that an on-all psychiatrist was on-call on 09/28/2015 when Patient #11 presented to the ED, and a request was made on her behalf by 2 prudent laypersons for treatment of a medical examination.

3. The medical record for Patient #11 was obtained from the Veteran ' s Administration Hospital for review. Review of the medical record revealed that the patient arrived at the VAH on 9/28/2015 at 1:48 p.m. The Emergency Department (ED) physician documented the patient s chief complain as Paranoid (Mental illness-being suspicious, irrational obsessive distrust of others). The section entitled History of Present illness the Physician documented in part, Pt (patient) was found wandering along a street reportedly hearing voices and responding to them. Per deputy pt was seen briefly at Doctors Hospital briefly and was sent here for eval (evaluation). Pt states that she is afraid that we are going to take out my heart and also take away her child which she is caring for currently ...Physical Exam (examination) Gen (general): agitated...Psychiatric: paranoid, pressured speech. No SI/HI (Suicidal Ideations/Homicidal Ideations), or AVH (auditory visual hallucinations). The Physician also documented that patient #11 attempted to elope from the VAH during workup. Patient #11 then required security restraint and was given Ativan (medication used to treat anxiety) intramuscularly. The patient was then placed on a 1013 order. The physician further documented that Patient #11 was to be transferred to an outside facility for further care. The Social Worker documented that patient #11 attempted to elope from the Emergency Department with her baby in her arms. The VA(Veterans Administration ) police and 2 ED physicians, multiple nurses and the Social Worker were involved in patient #11's and her baby's safety. Documentation by the Social Worker revealed in part, Veteran stated Don't kill me, Please don't shoot me! the veteran was calmed down and brought back into the ED. Further documentation by the Social Worker revealed that after the patient was brought back into the ED a nurse took the baby to another part of the ED where she could be evaluated further. The Social Worker also documented that the Department of Family and Children Services (DFCS) was called and notified of the situation related to patient #11's child. The DFCS worker contacted the local courts and the child was placed in temporary custody of the court,until patient #11'++---s mother could make arrangements to come in and care for the child. Patient #11 was accepted for in-patient psychiatric care at a Behavioral Health Center.

4. The Progress Notes dated 10/6/2015 and provided by physician (#4) on 10/06/15 revealed the female's (#11) 1350 Visit date 9/28/2015. The physician noted that the patient's history of present illness was as follows: female brought to hospital against her will by two (2) bystanders who picked the female up when she was observed walking to get to the Veterans' Administration Hospital. The female arrived at Doctors Hospital and was asked to come into a room for an evaluation. The female initially refused but eventually was brought into the ED. Female (#11) reported that she does not want to be here and wants to go to the Veterans' Administration Hospital. The female stated she needed a refill on her medications and denies complaints. Specifically, denies suicidal/homicidal ideations, hallucinations, or delusions. She denies fever, vomiting, diarrhea, headache, numbness, tingling, weakness, trauma, rashes, upper respiratory infections, or urinary tract infection symptoms. Review of systems was negative as stated above. Past medical history was reported as psychiatric issues. Past surgical history is unknown. Physical examination findings were within normal limits and vital signs were refused. Female was alert and oriented to person, place and time. The female's mood was normal. The physician documented the Action/Plan in part, Patient #11's last name of right refuses all care at Doctors Hospital She (#11) had no sign of an EMC at this time. She refuses all care here and wishes to go to the Veterans' Administration Hospital. She agrees to go with the Sheriff's Officer for transport to the Veterans' Administration Hospital. She cannot be further treated at Doctors against her will.

INTERVIEWS

1. During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager (#3) confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with the individual and that the individual continued to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with the individual the individual said she did not have a ride to the other facility and that the local Sheriff's Officer offered to give the patient a ride to the Veterans' Administration Hospital.

2. During an interview on 10/06/2015 at 1:40 p.m., the ED physician (#4) stated he/she had been asked to see a female who had been walking and was picked-up by two (2) ladies and brought to the ED entrance. The physician stated the individual did not want to be treated at Doctors Hospital and that the individual stated she wanted to go to the Veterans' Administration Hospital where she had received psychiatric treatment and her medications. The physician said the individual ended up in the ED and that he/she spoke with the individual and tried to offer her treatment. The physician confirmed that the individual was holding her baby at the time. The physician said the female finally got on the examination bed and that he/she did a mental evaluation of the female. The physician said he/she did not document the findings because the female was not entered into the system. The physician said the female was adamant that she did not want to receive treatment at Doctors Hospital. The physician said the individual was alert to person and place and that the Sheriff's Officer offered to drive the patient to the Veterans' Administration Hospital so that the patient could get her medications refilled. The physician said he/she even offered to refill the female's medications and that the female had refused.

The facility failed to ensure that their stabilization policy and procedure was followed as evidenced by failing to provide stabilizing treatment as required to patient #11 when she and her were brought to Doctor's Hospital's on 9/28/2015 by 2 prudent laypersons seeking treatment for a medical condition.

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Based on review of the facility's policies and procedures, Hospital incident report, Police Officer Case Report, and staff interviews it was determined that the facility failed to follow their policy and procedure by failing to appropriately transfer an individual to another medical facility for 1 (one) individual (#11) of twenty (20) sampled patients who presented to the hospital's emergency department with a psychiatric emergency medical condition.

Findings:

1. Review of facility policy entitled EMTALA (Emergency Medical Treatment and Labor Act) - Transfer Policy, number 9, last revised 03/2013, revealed any transfer of an individual with an Emergency Medical Condition (EMC) must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual's behalf or by a physician order with the appropriate physician certification as required under EMTALA. The policy also revealed the receiving hospital has agreed to accept the individual to provide appropriate medical treatment and that the receiving hospital has available space and qualified personnel for the treatment of an individual. Review of the Physician Certification form revealed an appropriate transfer included but was not limited to the following: --Medical Condition/diagnosis, --Reason for transfer,--Risks and benefits of the transfer, --Mode/support during transfer as determined by physician, --Receiving facility and individual, --Accompanying documentation,--Patient consent to medically indicated transfer or patient request for transfer.

3. The facility's incident report regarding patient #11 was reviewed. The incident report created on 10/7/2015 at 2:15 p.m. revealed in part, At approximately 1243. Chief_____ and myself responded to an assistance call to ER (emergency room ) Canopy. Once on the scene I observed an unknown_______ female with small child refusing to exit two visitors vehicle stating that she wanted to go to the VA hospital for her treatment. After continued attempts to get the unknown female out of the vehicle. ____ County Officer was called to assist with dealing with (Patient #11).______County Officer arrived on the scene to speak with (Patient #11) at 1250, getting her to exit the vehicle. (Patient #11) was transported by ____ County Officer to the VA as requested.

4. Review of the ________ County Sheriff's Office case report dated 09/28/2015 revealed the officers were dispatched to Doctors Hospital in reference to a disturbance/nuisance. The officer noted that he/she transported the individual and her baby to the Veterans' Administration Hospital and advised the receiving hospital staff that during transport the individual said that the voices in her head were saying they were going to kill her.

INTERVIEWS

1. During an interview on 10/06/2015 at 3:40 p.m. in the Board Room, the Security Lieutenant (#8) stated he/she remembered the episode on 09/28/2015 and that the female had been holding her baby. The Lieutenant explained that the individual was in the back seat of a car at the ED entrance. The Lieutenant said he/she spoke with the driver and was informed that the driver had picked the individual up when the individual was observed walking down the road. The Lieutenant stated the driver informed him/her that although the individual (Patient #11) wanted to go to the Veterans' Hospital the driver had brought the individual to Doctors Hospital. The Lieutenant explained that the individual did not want to get out of the car and that the ______ County Sheriff's Office was notified. The Lieutenant said that once the Sheriff's Officer and nurse arrived that he/she had left the scene and did not know where the individual went.

2. During a telephone interview on 10/07/2015 at 12:10 p.m. in the Board Room, the Chief Security Guard stated he remembered the episode regarding two (2) women driving up to the ED entrance with a female carrying a baby in the back seat. The Chief said that the driver's daughter informed him/her that they had observed the female walking down the road carrying a baby and that they offered the individual a ride. The Chief stated the two (2) ladies reported that they were concerned because the female was twitching and had informed them that she was a veteran. The Chief explained that the female refused to get out of the car and that the two (2) ladies wanted her out of their car and reported that they were not taking the female to another facility because they feared for their safety. The Chief said he/she was concerned for the baby and that the local Sheriff's Office was notified so that they could assist with getting the female out of the car. The Chief said that the ED Nurse Manager arrived and that the Nurse Manager and the Sheriff's Officer got the female out of the car and took her into the ED. The Chief said that approximately five (5) to ten (10) minutes later the female was escorted out of the hospital by the Sheriff's Officer and they were taking her to the Veterans' Administration Hospital. The Chief stated he/she stayed outside talking with the driver and never went inside the hospital with the female.

3. During an interview on 10/06/2015 at 1:25 p.m. in the Board Room, the ED Nurse Manager (#3) confirmed that on 09/28/2015 a female (patient #11) was brought to the ED entrance by two ladies. The Manager explained that the facility's Security Guards responded and that the female did not want to get out of the car. The Manager said that the local police department was then notified. The Manager stated the female finally got out of the car and entered the ED. The Manager said he/she asked the female if she had any medical problems or needed to be seen in the ED and that the female stated no. The Manager further explained that the female reported that she wanted to go to the Veterans' Administration Hospital. The Manager explained that the ED physician (#4) talked with the individual and that the individual continued to refuse treatment and was requesting to go to the Veterans' Administration Hospital. The Manager said that after the physician spoke with the individual the individual said she did not have a ride to the other facility and that the local Sheriff's Officer offered to give the patient a ride to the Veterans' Administration Hospital.

4. During an interview on 10/06/2015 at 1:40 p.m., the ED physician (#4) stated he/she had been asked to see a female who had been walking and was picked-up by two (2) ladies and brought to the ED entrance. The physician stated the individual did not want to be treated at Doctors Hospital and that the individual stated she wanted to go to the Veterans' Administration Hospital where she had received psychiatric treatment and her medications. The physician said the individual ended up in the ED and that he/she spoke with the individual and tried to offer her treatment. The physician confirmed that the individual was holding her baby at the time. The physician said the female was adamant that she did not want to receive treatment at Doctors Hospital. The physician said the individual was alert to person and place and that the Sheriff's Officer offered to drive the patient to the Veterans' Administration Hospital.

The facility staff was well aware that patient #11 was being transferred to VAH on 9/28/2015 and failed to notify the receiving hospital to obtain agreement and acceptance of the patient in order to provide appropriate medical treatment, and failing to ensure the receiving hospital (VAH) had available space and qualified personnel for treatment of the patient. The facility also failed to provide documentation that a written certification for transfer form was completed by the ED physician for patient #11. As this resulted in an inappropriate transfer for patient #11 on 9/28/2015.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records and the hospital's policies and procedures the hospital failed to explain the risks and benefits of refusal for further treatment for 1 (#2) of (twenty) 20 sampled patients who presented to the emergency department.

Findings:

The facility's EMTALA policy and procedure, PolicyStat ID: 20, Original: 08/2008, Approved: 05/2015 was reviewed. Review of the section of the policy titled Refusal to Consent to Treatment page 11 of 13 revealed in part, a. Written Refusal-Partial Refusal of Care or Against Medical Advice. If a Physician or QMP (Qualified Medical Personnel) has begun the medical screening examination or any stabilizing treatment and an individual refuses to consent to a test, examination or treatment or refuses any further care and is determined to leave against medical advice, after being informed of the risks and benefits and the hospital's obligation under EMTALA (Emergency Medical Treatment and Labor Act), reasonable attempts shall be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individual's refusal to sign the Partial Refusal of Care or the Against Medical Advice Form ...The medical record must contain a description of the screening and the examination, treatment , or both if applicable, that was refused by or on behalf of the individual.

Review of the Emergency Patient Record revealed that Patient #2 (MDS) dated [DATE] at 3:10 a.m. The emergency department (ED) documented theSubjective Assessment: Pt (patient) punched wall. WENT TO____ (acute care hospital name) DX (diagnosed ) WITH OPEN FX (fracture) R (right) HAND. ____ (acute care hospital name) WANTED TO TRANSFER PT. PT WALKED OUT AND CAME HERE. The patient ' s Chief Complaint was Extremity Pain/Injury . Patient #2 ' s Triage level was ESI (Emergency severity Level) 3/Urgent. Documentation by the ED nurse revealed the extremity assessment included the mechanism of injury was blunt trauma, the presenting signs and symptoms was edema at injury, extremity discomfort, and decreased range of motion of the left hand. The patient's onset of symptoms was 6/14/2015 at 10:00 p.m. Further review revealed that on 6/15/2015 at 3:38 a.m., an x-ray of the left had was ordered by the ED physician. The disposition of the patient was documented by the ED nurse as, Disposition Category: [Refused Treatment] discharged ....Emergency Notes ...6/15/2015 0351 ...THE PATIENT VOLUNTARILY DEPARTS AT THIS TIME. THE PATIENT WAS MAKING COPULATORY REMARKS AND EXTENDING THE THIRD DIGIT OF HIS RIGHT HAND TOWARD THE NURSING STAFF AS HE WALKED PAST THE NURSING STATION.

The Emergency Provider Report dated 6/15/2015 was reviewed. Documentation by the Physician Assistant (PA) revealed that patient #2 -was seen at 3: 20 a.m. The PA documented the patient ' s chief complaint was hand injury. The Physical Examination revealed in part, Hand: Normal pulse, no [DIAGNOSES REDACTED], normal tendon function, swelling (DISTAL 5TH METACARPAL), abrasion ....Neurologic: No motor deficits, no sensory deficits. Disposition: Extremity Inj (injury) Upper Clinical Impression: HAND CONTUSION/HAND PAIN) (Disposition ...Screened and discharged .

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure there was documentation in the medical record to indicate a discussion of the risks and benefits of further treatment (x-ray) and/or a description of the treatment that was refused by patient #2 on 6/15/2015.

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Doctors Hospital of Augusta

23 CMS Violations since 2015-03-20

Non Immediate Jeopardy Violations

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: STABILIZING TREATMENT(A-2407)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: STABILIZING TREATMENT(A-2407)

Violation Name: APPROPRIATE TRANSFER(A-2409)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: RECIPIENT HOSPITAL RESPONSIBILITIES(A-2411)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: HOSPITAL MUST MAINTAIN RECORDS(A-2403)

Violation Name: EMERGENCY ROOM LOG(A-2405)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: STABILIZING TREATMENT(A-2407)

Violation Name: APPROPRIATE TRANSFER(A-2409)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: STABILIZING TREATMENT(A-2407)

Violation Name: PATIENT RIGHTS: GRIEVANCES(A-0118)

Violation Name: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS(A-0146)

Violation Name: Means of Egress - General(K-0211)