Based on interview, medical record review, transfer agreement review and transfer call log review, the facility (Hospital #2- (Munroe Regional Medical Center ) failed to ensure, that as a participating hospital that has specialized capabilities or facilities that include Neonatal Intensive Care Unit (NICU) and Labor/Delivery and has the capacity to treat the individual, that an appropriate transfer was accepted without delay from the transferring hospital (Hospital #1) for 1 of 24 patients reviewed (Patient #16). Hospital #2 initially refused the transfer of Patient #16, stating that they did not accept babies less than 32 weeks. The baby deceased while at the Free Standing Emergency Department (ED) at Hospital #1. Refer to tag A- 2411.

Based on interviews, medical record reviews, transfer agreement review , policy and procedure review, bed census review, Physician Core Privileges review, on call schedules review, and transfer audio call log review, the receiving hospital (Hospital #2) failed to ensure that an appropriate transfer was accepted without delay from the transferring hospital (Hospital #1) for 1 of 5 patients reviewed (Patient #16). Hospital #2 initially refused the transfer of Patient #16, stating that they did not accept babies less than 32 weeks. The baby deceased while at the Free Standing Emergency Department (ED) at Hospital #1. Policy and Procedure The facility's Policy and Procedure titled "Emergency Transfers Policy" Original Effective Date: 11/1/ 2003; Revision: 9/1/2013. The policy revealed in part, "7. Receiving or Recipient Hospital Responsibilities. A Hospital that has specialized capabilities or facilities (e.g., burn unit, psychiatric unit, cardiac catheterization units shock-trauma units, neonatal intensive care units, or with respect to rural areas, regional referral centers) may not refuse to accept from a referring Hospital. An appropriate Transfer of an individual requiring such specialized capabilities or facilities, if the receiving or recipient hospital has the capacity to treat the individual." Transfer Center Audio recordings: A review of Direct Patient Logistics transfer center's audio communication and call log, dated 7/20/2017, between Hospital #1 and #2 for Patient #16, showed the following: 2:47 AM: Patient arrived to free standing ED at Hospital #1. 3:05 AM: A transfer request was called to Hospital #2. 3:08 AM: Unit secretary at Hospital #2 took the call for information. 3:09 AM: Attending physician for the patient was paged. 3:17 AM: Transfer center was notified patient's water broke at Hospital #1. 3:18 AM: Second call to attending physician was made with no return call. 3:20 AM: Transfer center called Hospital #2 for urgency to accept the transfer. Transfer center advised to call on-call OB/GYN at Hospital #2. 3:23 AM: The OB/GYN on-call at Hospital #2 answered the transfer center and requested to have ED to ED transfer. (Total of 46 minutes) 3:24 AM: Transfer center called Hospital #2 to speak with ED, transfer center then sent to L&D. 3:27 AM: Transfer center called Hospital #2 back and spoke to charge nurse in the L&D (Labor and Delivery). The transfer center was advised to speak with house supervisor. 3:31 AM: Transfer center was advised that Hospital #2 does not take babies less than 32 weeks per the protocol and the NICU does not accept inbound transfers at this time. (7 minutes) 3:41 AM: Transfer unit called Hospital #2 back again to see if Hospital #2 has a NICU. 3:45 AM: House supervisor advised the transfer center that Hospital #2 does not take patients/babies at 28 weeks. 3:47 AM: Transfer center canceled the transfer request as Patient #16 is 28 weeks pregnant and cannot go to Hospital #2. 3:52 AM to 4:10 AM: The transfer center notes show disregard. 3:58 AM: Transfer center from Hospital #1 was advised by another facility, Hospital # 3 that it is inappropriate for Hospital #2 to refuse patient, as it is an EMTALA violation. 3:59 AM: Transfer center called Hospital #2 and advised them of what Hospital #3 stated. 4:04 AM: On-call OB/GYN at Hospital #2 stated had previously stated do ED to ED Transfer. 4:06 AM: The transfer center had a conference call with attending ED physician at Hospital #1, on-call OB/GYN at Hospital #2, and House Supervisor at Hospital #2. 4:08 AM: The on-call OB/GYN physician at Hospital #2 accepted Patient #16 to L&D at Hospital #2. 4:09 AM: Transfer center stated will be ground transport with Advanced Life Support (ALS). 4:29 AM: Transfer center advised Hospital #2 that Patient #16 delivered and now may not come to Hospital #2 and advised Hospital #2 that this was a long delay. 4:31 AM: House supervisor at Hospital #2 stated please keep up to date. 4:50 AM: House supervisor at Hospital #2 asked for update on this patient. House supervisor notified by transfer center that the mother (Patient #16) will be sent to this facility. They cannot fly the baby out of Hospital #1's ED due to weather. House Supervisor at Hospital #2 is aware of above concerns. House Supervisor at Hospital #2 advised that the county Emergency Medical Services (EMS) was sending equipment to help with mother/baby until they can be transported. 5:05 AM: House Supervisor at Hospital #2 advised transfer center they need to do an ED to ED Transfer. 5:23 AM: Hospital #2 accepted transfer of Patient #16 to ED. 5:28 AM: On-call OB/GYN at Hospital #2 notified of Patient #16's condition and that placenta had not been delivered at this time. 6:30 AM: House supervisor at Hospital #2 called for correct sheet to be faxed. 6:59 AM: Transfer center stated Patient #16 reroute to Hospital #2. 7:01 AM: Patient #16 from Hospital #1 free standing ED transferred and has arrived at Hospital #2. Medical Record Review Hospital #1 (Transferring Hospital): Review of the Medical record revealed that patient #16 presented to Hospital (#1) emergency department on 7/20/2017 at 2:47 A.M., as walk-in. The patient was triaged as ESI (Emergency Severity Index) 2/Emergent. Further review of the Emergency Notes, noted revealed in part, "Patient is 28 weeks pregnant came in with what she refers to as cramping every 15 seconds since 1:15 AM. Refers that it comes and go. Patient states she had discharge for the past few days bur she thinks is just vaginal discharge normal, she has gone to her GYN (gynecological) physician did not evaluate her, they just weighed her and told her she is fine. Patient has a history of early births. " Review revealed the following medications and nursing procedures were administered by an RN as ordered by the ED physician on 07/20/2017: - 0315 Patient refers her water broke; - 0319- Fluids were started 1 liter on #20G (gauge) on left A.C. (antecubital) ; - 0320-Pt started with contractions and on average of every 30 seconds as referred by patient; - 0341 Morphine 4 mg were administered intravenously for pain; - 0405- Decadron 6 mg and Magnesium 1000 mg in 100 ml administered intravenously for contractions; According to medical record review, the patient was medically screened on 07/20/2017 at 2:55 AM. The patient's Chief complaint was Pelvic and Perineal pain, and gradually worsening. Physical Examination, revealed in part, "Genitourinary bleeding, there appears to be some effacement of the cervix, with crowning beginning and 2 cm dilation ... Re-evaluation and MDM (Medical Decision Making) ...at 3:28 am still waiting for one-step (transfer center) to call back with MD ...at 3:57 Monroe states they cannot accept the patient because she is only 28 weeks and they do not accept anybody under 32 weeks. At 3:58 (Hospital #3) contacted immediately state, the patient needs to go to the closest hospital, will attempt (Hospital #4) and will contact Hospital # 2 again, the patient was finally accepted by physician at 4:10 AM at hospital # 2. The baby was delivered with an Apgar score of zero and a heart rate of 79, and a weight of roughly 800 grams (1.7637 pounds), CPR (Cardiopulmonary Resuscitation) ...CPR continued and intensivist neonatologist consultation was obtained, who advised to give dextrose 10 (dextrose medication given for neonatal [DIAGNOSES REDACTED]{low blood sugars})as IV fluids at 5cc/hr. ....(MD name) the person who attempted initially never responded. The patient still has placenta in place. The patient was accepted for transfer by hospital # 2 and ED physician was informed. A review of the EMTALA Memorandum of Transfer form dated 7/20/2017 revealed at 5:56 AM, Patient #16 Vital Signs were Temperature 98.4; Pulse: 134 (normal 60-100); Blood Pressure: 133/79 and Oxygen saturation was 98%. Review of the ambulance report dated 7/20/2017 revealed that Patient #16 reason for transfer was the patient delivered prematurity, and need an Obstetrician. The ambulance patient care report revealed the patient left Hospital #1 at 6:03 AM and arrive at Hospital #2 at 6:41 AM. Baby #16 Medical Record review: Review of medical record from Hospital #1, dated 7/20/2017, documentation by the ED physician showed that Patient #16's baby delivered at 4:10 AM: Apgar (measures of physical condition of a newborn infant) 0, fasting sugar (fs) 61, heart rate 79, but then went down to 33, Cardiopulmonary Resuscitation (CPR) started immediately. Vascular access obtained epinephrine given total of 3 times, neonatologist consultation obtained, recommends dextrose 10 at 5 cc/hr., airway attempted but endotracheal tubes were too large to fit her trachea, bagging with oxygen (O2) continuously done and baby remained pink throughout the resuscitation. The neonatologist then advised to stop the resuscitation, parents informed and ultrasound of the heart revealed cardiac stand still. Further review of the medical record revealed a physical examination was performed baby #16 was unresponsive. The primary care physician (neonatologist intensivist) declared the baby expired at 5:48 AM. Documentation by the MD revealed in part, Clinical Impression: Cardiopulmonary Arrest; Second Impression: Prematurity of fetus." Hospital #2 On-Call Schedule Review of the hospital's call schedule (7/17/2017 -7/23 2017) was reviewed and verified that on 7/20/2/107 Hospital #2 had an Obstetrician on call, when Hospital #1 called requesting to transfer patient #16. Review of the on-call physician's Obstetrics and Gynecology Clinical privileges dated 5/30/2017 were reviewed. The Obstetrics Core Privileges revealed in part, "Yes (was checked) Admit, evaluation, diagnose, treat and provide consultation to female patient of all ages, and/or provide medical and surgical care of the female reproductive system and associated disorders, including major medical diseases that are complicating factors in pregnancy. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the techniques and skills ... Obstetrics: ... Management of high risk pregnancy inclusive of such conditions as pre-eclampsia, Third trimester pregnancy ...Manual removal of Placenta ..." On 7/20/2017 Hospital #2 had the capabilities and facilities to treat Patient #16. Bed Census Reports The bed Census report dated 7/20/2017 for the time 7:00 PM to 0300 am was reviewed. The labor and delivery unit total bed capacity is 12, as 3 beds were available. The Neonatal Intensive Care Unit total bed Capacity is 12, as 2 beds were available. On 7/20/2017 Hospital #2 had the bed capacity to treat patient #16. Transfer Agreement: A review at Hospital #1's ED transfer log showed that 4 patients were transferred to the Labor/Delivery (L&D) Unit at Hospital #2. A review of the transfer agreement between these two facilities (Hospital #1 and #2) showed that if Obstetrics and Labor/Delivery are needed, that a transfer is then conducted. The purpose of the agreement is that the transferring facility (Hospital #1) will accept patients meeting its admission criteria. The receiving facility (Hospital #2) will accept patients from Hospital #1 who are in need of acute obstetric care offered by Hospital #2 and not available at Hospital #1. This also includes NICU (Neonatal Intensive Care Unit) transfer. Interviews During an interview on 8/25/2017 at 9:15 AM, the Director of Risk Management for Hospital #2 stated Hospital #2 initially accepted the transfer of Patient #16 per the on-call physician for OB/GYN/Labor Delivery at Hospital #2. This happened on 7/20/2017. Patient #16 was 28 weeks pregnant and her water broke while at Hospital #1. Hospital #1 called stating that Patient #16 and her baby were coming to Hospital #2 and then later stated only Patient #16 was coming, not the baby. Patient #16 was transferred to Hospital #2 for the delivery of the placenta. During an interview on 8/25/2017 at 10:00 AM, the Director of Maternal Child Health for Hospital #2 stated that the on-call OB/GYN accepted the transfer of the patient to Hospital #2's Emergency Department (ED). Patient #16 presented to Hospital #2's ED and then transferred to Labor/Delivery at Hospital #2. Patient #16 stayed in Hospital #2 for 48 hours and discharged home. Director of Maternal Child Health for Hospital #2 stated if a baby had been sent with Patient #16, the neonatologist would have made the determination if the baby needed level 3 NICU. Hospital #1 facility initially refused to accept from a transferring Hospital #1 (did not have obstetrical services, or neonatal ICU services) Patient #16 on 7/20/2017; as facility #1 had specialized capabilities (Obstetrics) and/or facilities and the capacity initially to accept patient #16 on 7/20/2017. As this initial refusal resulted in a significant delay in the care and treatment of her emergency medical condition.

Based on interviews, review of medical records, and policy and procedures, the hospital failed to provide a Stabilizing Treatment within the capability of the hospital for 1 (Patient # 1) of 25 patients presenting to the hospital's Emergency Department. Findings: Review of the medical record revealed that Patient #1 (MDS) dated [DATE] at approximately 2:00 AM. The patient approached registration area and informed the staff in registration requesting medical treatment. The form signed by the midwife showed Patient #1 was sent by the midwife for a 3rd degree perineal tear following a home birth. Documentation by the ED Registered Nurse (RN) on 5/9/2017 at 2:00 AM revealed that an ED-OB (Emergency Department)-(Obstetrics) hand off sheet showed Patient #1 was sent to the ED for sutures following a home birth. Patient #1 was transported to the Labor/Delivery/Recovery (LDR) unit at 2:14 AM. There is no documentation in patient's medical record to indicate Patient #1 was medically screened in the ED by a physician/mid-level prior to being sent to the Labor/Delivery/Recovery unit. Documentation by the Labor/Delivery/Recovery unit nurse on 5/9/2017 at 2:15 AM revealed that the patient arrived to the unit after having a home birth by a mid-wife. At 2:16 AM a physical by the LDR RN was performed on Patient #1 that revealed the perineum appears to have a 3rd degree laceration from perineum extending in to the vagina. At 2:20 AM, a call/page was made to the on-call physician for walk-in's and was informed of need for repair of possible 3rd degree laceration following a vaginal home birth. The physician refused to come in and repair the laceration. The physician gave orders for the patient to follow up in the office in the morning. The Labor/Delivery/Recovery nurse stated again to the on-call physician that he was requested to come in to the facility to repair the laceration. The on-call physician stated again, no. The charge nurse of the LDR unit was aware of the situation. A call was placed to the hospital house supervisor regarding what the on-call physician had told the RN in the Labor/Delivery/Recovery Unit. At 5:02 AM, both verbal/written instructions were given to Patient #1 to go to the on-call physician's office in the morning for the laceration repair. Patient #1 stated she would not be seeing this physician. A repeat phone call was made to the on-call physician that Patient #1 was refusing to leave until the laceration was repaired. The physician was told that the ED was not willing to do the repair, as it was not their area of expertise. The on-call physician stated he had explained to the RN in the labor/delivery/recovery unit to send patient home and follow up in the morning in his office. The RN again explained that the patient was requesting the laceration be repaired. The physician stated that an episiotomy was not an emergency. Patient given information and discharged home. Continued record review showed Patient #1 was admitted for outpatient surgery on 05/09/2017 at 11:30 AM Munroe Regional Medical Center for repair of a third degree obstetric laceration. She was discharged home the same day with a follow up appointment with the same physician. During an interview on 5/22/2017 at 9:54 AM, Staff G stated that if a patient goes to LDR, the patient is usually over 20 weeks pregnant, a staff member will take the patient by wheelchair. If a patient presents to the ED and is under 20 weeks pregnant the patient will be seen in the ED. Patient #1 was not seen in the ED post delivery and this was found after Patient #1 went to the LDR Unit. Patient #1 should have been seen in the ED first, the ED physician/mid-level will communicate with on-call OB physician and a determination will be made to repair the laceration. During a telephone interview on 5/22/2017 at 3:25 PM, Staff V was asked why he did not come in and do the laceration repair on Patient #1. Staff V stated did not feel it was an emergency and that he had given the RN in Labor/Delivery/Recovery unit orders to discharge and he would do the repair in the morning at his office. Staff V did not feel that he needed to see the patient after given information from the RN. Staff V was aware from the RN that the ED did not feel comfortable doing the repair of the laceration. Staff V again stated he did not feel that this was life threatening. Staff V was asked, was he also the on-call physician for the ED that day and he stated yes. During a telephone interview on 5/22/2017 at 4:00 PM, Staff T (Registration clerk in the ED on 5/9/2017 at 2:00 AM for Labor and Delivery) also had never encountered a patient who had a baby somewhere other than the facility. This was something new and Staff T did not know where to send her, which is up to the ED nurse. During a telephone interview on 5/22/2017 at 4:25 PM, Staff X stated they had spoken to the nurse for Patient #1 several times through the early morning. Staff X also stated they had spoken with the administrator on-call that night and spoken with the on-call physician for labor/delivery/recovery unit. Staff X stated that Patient #1 could have stayed in the LDR and have the laceration repaired. Staff X does not know if this was told to the RN or to Patient #1. During a telephone interview on 5/22/2017 at 5:46 PM, Staff Z (Staff in the ED who had Patient #1 complete the ED- OB Handoff sheet) stated that there was no policy regarding a patient who has a home birth. During an interview on 5/22/2017 at 10:55 AM, Staff O stated that post partum patients should be seen in the ED before being sent to the LDR unit. When a patient needs a vaginal repair the patient would go to the operating room (OR) for the laceration repair. Most post partum patients are admitted through the ED and then go to the OR. During an interview on 5/22/2017 at 11:05 AM, Staff P stated that Patient #1 should have been seen in the ED before being sent to LDR Unit. Staff P stated they never had a patient from home present to either the ED or LDR before. During a telephone interview on 5/22/2017 at 2:55 PM, Staff S (The RN who was taking care of patient # 1 in the LDR) stated on 5/9/2017 at 2:15 AM, after Patient #1 was brought to the LDR after having a baby at home by a midwife, she had called the on-call physician and he stated he would not come in for the repair. The discharge instructions by the on-call physician was for Patient #1 to come to the office in the morning for repair of the laceration. Staff S stated she also called the house supervisor and was waiting for her to call back. Staff Z stated she called LDR regarding the patient. Patient #1 was not put on the emergency log or seen by a physician/mid-level before going to the LDR unit. During a telephone interview on 5/23/2017 at 11:30 AM, Staff U (Supervisor on -call 5/9/2017) stated they had a conversation with labor/delivery/recovery room charge nurse regarding Patient #1. Patient #1 can stay in the LDR Unit until morning and get the laceration repair. Staff U had spoken to the physician on-call, Staff V. Staff V still stated it was not an emergency and Patient #1 could be discharged home and seen in his office in AM for the laceration repair. Staff U stated to Staff V that LDR staff were uncomfortable and needed Patient #1 to be seen. The vital signs were with in normal parameters and drainage were minimal. Patient #1 decided to leave. During an interview on 5/22/2017 at 1:15 PM, Staff Y stated any post partum patient should be seen in the ED first. Patients who have any kind of vaginal tear need to have an evaluation in the ED first. All patients presenting to the ED are to have a medical screening exam, and if needed, the on-call physician for the specialty needed, is then called. Review of emergency room , Labor/Delivery/Recovery and Post partum Unit polices/procedures did not address a post partum patient as to how to register the patient or of the discharge process for a patient that had a birth at home.

Based on interview, review of patient records, policies and procedures, and the central log, the facility failed to maintain a log which included one (Patient #1) of 25 patients sampled seeking treatment in the hospital's Emergency Department. Findings: Review of the Emergency Department (ED) log from 5/7/2017 through 5/11/2017 revealed that Patient #1 was not in the Emergency Log. Review of the medical record revealed that Patient #1 (MDS) dated [DATE] at approximately 2:00 AM. The patient approached staff in the registration area and requested medical treatment. The form presented to the hospital and signed by the midwife showed Patient #1 was sent by the midwife for a 3rd degree perineal tear following a home birth. Documentation by the ED Registered Nurse (RN) on 5/9/2017 at 2:00 AM revealed that an ED-OB (Emergency Department)-(Obstetrics) hand off sheet showed Patient #1 was sent to the ED for sutures following a home birth. Patient #1 was transported to the Labor/Delivery/Recovery (LDR) unit at 2:14 AM without a medical screening in the ED. During a telephone interview on 5/22/2017 at 5:46 PM, Staff X (Staff in the ED who had Patient #1) stated there was no policy for a patient presenting to the ED after giving birth at home. During an interview on 5/22/2017 at 11:05 AM, Staff P stated that Patient #1 should have been seen in the ED before being sent to LDR Unit. Staff P stated they never had a patient from home present to either the ED or LDR after giving birth at home. During an interview on 5/22/2017 at 3:15 PM, Staff Z stated she called the LDR regarding the patient. Patient #1 was not put in the emergency log or seen by a physician/mid-level provider before going to the LDR unit. During an interview on 5/22/2017 at 1:15 PM, Staff Y stated that any post partum patient should be seen in the ED first. Patients who have any kind of vaginal tear need to have an evaluation in the ED first. All patients presenting to the ED are to have a medical screening exam and, if needed, the on-call physician for the specialty needed is then called. During an interview on 5/22/2017 at 10:55 AM, Staff O stated that a post partum patient should be seen in the ED before being sent to the LDR unit. When a patient needs a vaginal repair, the patient would go to the operating room for the laceration repair. Most post partum patients are admitted through the ED and then go to the operating room (OR). Review of the facility's Policy and Procedure, titled "Medical Screening and Treatment/Transfer Policy (EMTALA)" revealed Emergency Department Log, each hospital must maintain a central log to track the care provided to each individual who comes to the hospital seeking care for an emergency condition. The log entry must be made at the first point of contact and must contain the name of the patient, and the disposition of the patient as patient stabilized.

Based on interview, review of medical record, and policies and procedures, the hospital failed to provide a Medical Screening Examination for one (Patient #1) of 25 sampled patients presenting to the hospital's Emergency Department (ED) to determine if an emergency medical condition existed. This failure presented a substantial probability of adversely affecting the health and safety of all patients presenting to the Emergency Department. Findings: Review of the medical record revealed that Patient #1 (MDS) dated [DATE] at approximately 2:00 AM. The patient approached registration area and informed the Emergency Department staff requesting medical treatment. The form signed by the midwife showed Patient #1 was sent by the midwife for a 3rd degree perineal tear following a home birth. Documentation by the ED Registered Nurse (RN) on 5/9/2017 at 2:00 AM revealed that an ED-OB( Emergency Department)-(Obstetrics) hand off sheet showed Patient #1 included the birth of the baby at home and the need to have sutures. A form signed by a midwife stated the patient had a 3rd degree perineal tear, time of delivery 2245 on 5/8/17. Patient #1 was transported to the Labor/Delivery/Recovery (LDR) unit at 2:14 AM. There was no documentation in the patient's medical record to indicate Patient #1 was medically screened in the ED by a physician/mid-level prior to being sent to the Labor/Delivery/Recovery Unit. Documentation by the Labor/Delivery/Recovery Unit nurse on 5/9/2017 at 2:15 AM revealed that the patient arrived to the Unit after a home birth (assisted by a mid-wife). At 2:16 AM a physical by the LDR RN was performed on Patient #1 that revealed the perineum appears to have a 3rd degree laceration from perineum extending into the vagina. At 2:20 AM, a call/page was made to the on-call physician for walk-in's. The physician was informed of the need for repair of a possible 3rd degree laceration following a vaginal home birth. The physician refused to come in and repair the laceration. The physician gave orders for the patient to follow up in the office in the morning. The Labor/Delivery/Recovery nurse stated again to the on-call physician that he was requested to come in to the facility to repair the laceration. The on-call physician stated again no. The charge nurse of the LDR Unit was aware of the situation. A call was placed to the hospital house supervisor regarding what the on-call physician had told the RN in the Labor/Delivery/Recovery Unit. At 5:02 AM, both verbal/written instructions were given to Patient #1 to go to the on-call physician's office in the morning for the laceration repair. Patient #1 stated she would not be seeing this physician. A repeat phone call was made to the on-call physician that Patient #1 was refusing to leave until the laceration was repaired. The physician was told that the ED was not willing to do the repair, as it was not in their area of expertise. The on-call physician stated he had explained to the RN in the Labor/Delivery/Recovery Unit to send patient home and follow up in the morning in his office. The RN again explained that the patient was requesting the laceration be repaired. The physician stated that an episiotomy was not an emergency. Patient #1 was given information and discharged home. A review of the medical record showed: Review of symptoms: Drainage at perineum site small. Perineum revealed a 3rd degree laceration to perineum extending to the vaginal area. BP (Blood Pressure) 142/76, and pulse 110, shows small amount of drainage and no clots. Discharge vitals include BP 125/63 and pulse of 105. Review of post care instructions shows that the peripad was changed and had small amount of drainage. Further discharge instructions included patient to go the on-call physician's office to have laceration repaired and patient refused. Patient #1 followed up on 05/09/2017 with another obstetrician who took the patient to surgery and repaired the perineal tear in the Munroe Regional Medical Center operating room and discharged her home the same day. During an interview on 5/22/2017 at 11:05 AM, Staff P stated that Patient #1 should have been seen in the ED before being sent to LDR Unit. Staff P stated they never had a patient from home present to either the ED or LDR before. During a telephone interview on 5/22/2017 at 2:55 PM, Staff S (The RN who was taking care of Patient #1 in the LDR Unit) stated that on 5/9/2017 at 2:15 AM, after Patient #1 was brought to the LDR after having a baby at home by a midwife. She had called the on-call physician and he stated would not come in for the repair. The discharge instructions by the on-call physician was for Patient #1 to come to the office in morning for repair of the laceration. Staff S stated that she had also called the house supervisor and was waiting for her to call back. During a telephone interview on 5/23/2017 at 11:30 AM, Staff U (Supervisor on-call on 5/9/2017) stated that they had a conversation with Labor/Delivery/Recovery Unit charge nurse regarding Patient #1. Patient #1 could stay in the LDR Unit until morning and get the laceration repair. Staff U had spoken to the physician on-call. The physician on-call still stated it was not an emergency and the patient could be discharged home and seen in his office in the AM for the laceration repair. Staff U stated to the physician on-call that LDR staff were uncomfortable and needed Patient #1 to be seen. The vital signs were within normal parameters and drainage was minimal. Patient # 1 decided to leave. During an interview on 5/22/2017 at 1:15 PM, Staff Y stated that any post-partum patient should be seen in the ED first. Patients who have any kind of vaginal tear need to have an evaluation in the ED first. All patients presenting to the ED are to have a medical screening exam and, if needed, the on-call physician for the specialty needed, is then called. A review of the on-call physician for week of 5/8/2017 to 5/14/2017 and review of the on-call schedule for Labor/Delivery/Recovery and ED validated that on 5/9/2017 Staff V was the physician on-call for walk-in's. Review of the facility's Policy and Procedure, titled "Medical Screening and Treatment/Transfer Policy (EMTALA)" revealed Emergency Department Log: Each hospital must maintain a central log to track the care provided to each individual who comes to the hospital seeking care for an emergency condition. The log entry must be made at the first point of contact and must contain the name of the patient, and the disposition of the patient as patient stabilized.

REFERENCE A 2405 Based on interview, review of patient records, and review of the Central Log, the facility failed to maintain a log which included one (Patient # 1) of 25 sampled patients presenting to the hospital emergency department. REFERENCE A 2406 Based on interview, review of medical records, and policies and procedures, the hospital failed to provide a Medical Screening Examination for one (Patient #1) of 25 patients presenting to the hospital's Emergency Department to determine if an emergency medical condition existed. REFERENCE A 2407 Based on interview, record review, and review of policies and procedures, the hospital failed to provide a Stabilizing Treatment within the capability of the hospital for one (Patient #1 ) of 25 patients presenting to the hospital's Emergency Department. Munroe Regional Medical Center presented a credible allegation of compliance: An initial investigation conducted promptly by the hospital on the morning of 5/9/2017. 05/09/2017 the Chief Medical Officer and Chief Nursing Officer reviewed the situation with the on-call obstetrician and emphasized the on-call physician's EMTALA and contractual obligation to come to the Hospital when specifically requested to provide further examination and, if a patient has an emergency medical condition, treatment to stabilize the emergency condition. The RN (Registered Nurse) Director of Maternal/child Services reviewed the L & D (Labor and Delivery) policy on the screening process for walk-in patients who have delivered. the policy was revised on 6/2/2017 to include: Weekly review of the L & D logs to review any returning post-partum patient to determine a medical screening exam was completed times 3 months 5/10/2017 through 8/10/2017. The RN Director of Emergency Services reviewed the ED (Emergency Department) policy with respect to obstetric patients who have delivered. Policy revision dated 6/2/2017 includes post partum patients should receive the medical screening examination in the ED; and The ED physician and staff are responsible for contacting the on-call obstetrician/gynecologist if needed for further examination and treatment of a post partum patient. On 6/2/2017, the RN Director of Maternal/Child Services provided education to L & D nursing staff on the following: The process clarification and policy, emphasizing that in post partum patient should be sent by the ED to L & D for a medical screening examination; post partum patients must receive the medical screening examination in the ED prior to proceeding to any other department of the Hospital; and The Chain of command and expectations for documenting actions taken. The RN Director of Emergency Services provided education to the ED nursing staff on the process clarification policy that no post partum patient should be sent by the ED to L & D for a medical screening examination; post partum patients must receive the medical screening examination in the ED prior to proceeding to any other department of the Hospital. The Medical Director of Emergency Services provided education to the ED physician on the process clarification that no post partum patient should be sent by the ED to L & D for a medical screening examination/ post partum patients must receive the medical screening examination in the ED prior to proceeding to any other department of the Hospital. The Chief Nursing Officer was provided re-education on EMTALA and on the Chain of Command in a meeting with the Nursing Directors and House Supervisors on 6/11/2017. The Chief Medical Officer provided re-education on the EMTALA obligations of on-call physicians in the OB/GYN department meeting with obstetricians on staff at the Hospital. the Chief Medical Officer emphasized it is never permissible for an on-call physician to recommend that the patient be discharged and follow up in a physician office unless there has been an appropriate medical screening examination by qualified medical personnel and a medical determination made and documented that no emergency medical condition exists. This re-education occurred on 5/24/2017. All L & D staff and House Supervisors completed an EMTALA education module that covers all of the EMTALA obligations on 5/10/2017. The RN Director of of Maternal/Child Services and the Director responsible for House Supervisors are tracking completion of education by staff members. Any staff who miss the scheduled sessions will receive the education upon their return to the Hospital and prior to the start of their next scheduled shift. The RN Director of Maternal/child Services established an audit process for reviewing the L & D logs each week for the next three months to track that: Any patients who come to the hospital post partum receive the medical screening examination in the ED: and Variances are placed in the incident-reporting system when L & D staff have difficulty reaching an on-call obstetrician. The RN Director of Maternal/child Services is responsible for following up on issues or concerns with the appropriate L & D staff member or on-call physician. The Director of Maternal/child Services will analyze and aggregate the audit data and report it to the Patient Safety Committee, Quality Council, Medical Executive committee, and the Board.

Based on review of videos medical records, emergency department logs, policies and procedures and staff interviews, the facility failed to follow their own policies/procedures for performing a medical screening exam on 1(patient #1) of 16 sampled patient, to determine if an emergency medical condition existed. This failure presents a substantial probability to adversely affect all patient ' s health and safety. Findings: Review of video # 1 shows that on 04/08/15 at 4:13:13 PM ( 4:00 PM, 23 minutes and 13 seconds) patient # 1 and a man entering the emergency Department ( ED). Review of the video shows that patient # 1 was in the waiting room and started having distress at: 4:18:16 Women identified as patient # 1, sitting in wheelchair grabbed man ' s arm, it is noted that patient # 1 having problem breathing. 4:19:12 Patient ' s hand goes to chest. 4:19:51 Patient ' s hand on face and having hard time breathing. 4:20:45 Looks at desk (Not able to see who the man is talking to) and points to patient # 1 needs help. 4:23:51 Patient # 1 slumped on couch. 4:23:53 Man walks out of video view. Visitor at patient ' s # 1 side. 4:24:56 ED Staff ( Unable to see staff's badges for identification) at patient"s # 1 side. 4:25:34 Two ED staff members and man (That was with patient # 1) tried to transfer the patient onto the stretcher times 2 tries. 4:25:48 The two ED staff and the man still trying to transfer patient # 1 on to the stretcher. 4:26:23 Patient # 1 on stretcher, on her side. 4:26:48 Patient # 1 on stretcher and out of sight of video. A total of 13 minutes and 33 seconds till patient # 1 out of view of video. Review of the video # 1 shows that there was no triage, no medical screening evaluation of patient #1 (Who was unresponsive) while she was in the ED waiting area, until the man with the patient walked out of view of video. The video did not reveal any resuscitative measures initiated by the ED staff, when patient was found non- responsive in the waiting room. Review of the video shows that there was no rise/fall of patient ' s #1 chest. Medical Record and Emergency Department(ED) Log review: Review of the ED registration log provided by the Charge nurse on 02/10/16 at 12:10 PM revealed Patient # 1 was logged in on 04/08/15 at 4:17 PM. This time did not match the time on the Video. Review of the Medical Record for patient #1: Review of the ED sign in sheet provided by risk manager for Patient # 1 medical records on 02/02/16 at 3:33 PM revealed a completed sheet that was clocked as received on 04/08/15 at 4:17 PM. The sheet included the patient's name, address,phone number, social security number, date of birth and a " primary Complaint: Difficulty Breathing. Review of the ED nurses notes dated 4/08/2015 reads, transferred from ambulance stretcher to bed # 4 on 04/08/15 at 4:17 PM. Called to waiting room by spouse who states his wife is having a seizure and having trouble breathing. Patient in waiting room, slumped on couch and non-responsive. There was no pulse or spontaneous breathing noted. Unit coordinator brought out gurney, patient placed on stretcher and taken back to room 4. Cardiopulmonary Resuscitation (CPR) initiated and Physician Assistant (PA) at bedside. Cardiac monitor applied and shows asystole (No heart beat) and non-spontaneous respiration noted. Staff assisted patient with breathing. The patient's time of death was documented at 4:47 PM. Review of ED Physician clinical history notes of present illness dated 04/08/15 at 4:17 PM, Examination started at 4:17 PM, and history was discussed with patient # 1 husband. The physician reviewed and agreed with the RN note. Presenting problem started minutes ago and was a witnessed arrest. Estimated down time was 3 minutes before resuscitative measures were began. No known precipitating cause and the patient was not viable on initial exam and there is no significant history available. Presenting cardiac rhythm - Asystole and had complained of chest pain prior to this event. Review of the CPR log dated 04/08/15 revealed that CPR was initiated at 4:20 PM. Review of the video # 1 shows that patient was still in the waiting room at that time. Patient # 1 time of death was 4:47 PM. Review of policies and Procedures: Review of facility ' s policy titled " Emergency Services Policy " effective date of 12/30/14 states all patients presenting to the ED will receive an initial triage and classification by a Registered Nurse(RN) using the emergency severity index. All patients will then receive an initial focused nursing assessment, and a full body assessment if admitted to the facility. Review of policy/procedure titled "ED- triage: initial Laboratory, X-ray and Medication order Protocols" Last review date of 4/3/13 reads: Only an RN on duty in the ED, who has been educated in basic triage guidelines and patients assessment including recognizing signs, symptoms and risk factors for acute coronary symptoms (ACS), may initiate the following triage orders before a physician or mid-level practitioner evaluates the patient in order to expedite care and treatment. Further review of the facility's policy titled "Emergency Department (ED) Triage: Initial Laboratory, X-ray and medication" dated 04/03/13, revealed that ED registration staff and ED EMT( Emergency Medical Technician) / Paramedic/Greeter/ PCT( Patient Care Technician) receive focused training and education on recognition of symptoms of Acute Coronary Symptoms (ACS) in ED patient. Procedure: Following is a list of procedures or treatments that may be initiated, based on the chief complaint, history, and nursing assessment. The Nurse triaging the patient initiates an electronic order sheet set based on patient chief complaint such as " ED Triage Chest pain. " Review of the facility ' s policy titled " The ESI Project " revised 2012 shows the triage process involves using the Emergency Severity Index(ESI) classification system. Appropriate assigning of the ESI level at time of triage is essential to safe and timely patient care resulting in more positive patient outcomes as well as a more positive patient experience. The ESI starts with triage, the process involves categorizing patients into different triage acuity levels based on preliminary assessment done by the triage RN. A ESI level 1 shows that resuscitation/life saving measures are needed. The facility failed to ensure that patient # 1 was triaged by a Registered Nurse(RN) on duty in the ED as stated in the facilities policy when patient # 1 presented with a complaint of difficulty breathing. Review of the facility ' s policy titled " Complaints such as ED chest pain " . Patient ' s entering the ED with a chief complaint that includes Chest Pain and or Shortness of Breath. Patient may present with syncope, nausea, vomiting, and shortness of breath. Other symptoms can be epigastric pain, shoulder, back and neck pain. Orders to be initiated include: 1. Transport to a monitored bed if available. 2. Undress patient, attach cardiac monitor, put oxygen on and a blood pressure cuff. 3. Oxygen at 2 liters by nasal cannula, keep oxygen over 92 %. 4. Obtain a 12 lead electrocardiogram within 10 minutes of arrival. Review of the facility ' s policy titled " Volunteer Services Policies and Procedures " dated 05/20/14 states that a volunteer is assigned to assist the facility ' s ED staff by visiting patients and families for reassurance and helping with non-medical needs. In addition to assist by performing tasks which do not require a medical/non-license and does not require actual patient treatment. Review of the facility ' s policy titled " Emergency Center Information Desk Volunteer " dated 05/20/14 shows that the volunteer makes copies of patient ' s paperwork/orders to give this information to the admission clerk. The volunteer notes date of birth on paperwork. If patient new to the ED, the volunteer will ask for photo identification and insurance cards to be copied. The volunteer puts the information in a folder in the order it was received. Interviews: During an interview on 02/10/16 at 4:03 PM, the volunteer in the ED stated that she was the volunteer in question when patient # 1 came into the ED. When asked what are her responsibilities as a volunteer in the ED. The volunteer stated that " I work the front desk. I am first person to meet the people when they came into the ED. I make them complete a sign in sheet. I then stamp the form. I give a copy to the charge nurse and one to the financial staff. I get it stamped within 30 seconds. " The volunteer was asked what the volunteer ' s limitation and if ask for patient ' s ability to pay. " I cannot do any medical things and I do not ask them about payment. " When asked what she can recall the day patient # 1 came to the ED. The volunteer stated that she did remember the incident, husband came into the waiting area with his wife. They both sat on a love seat. There were no other patients/family in the waiting area. The husband went to the vending machine to get some snacks. I asked the husband to fill out the sign in sheet. The volunteer was asked if she remembered the husband telling her his wife was having chest pains or shortness of breath. " No, he did not say a word to me at all. I did see her standing up from the wheelchair and then sitting in the love seat. The husband did not say anything to me about his wife ' s complaints. I stamped the sheet as soon as it was completed. I gave a copy to the RN and financial. " During an interview on 02/10/16 at 12:10 PM, paramedic stated he has worked in the ED and usually works the desk area of the waiting area. We do have volunteers at the front desk area of the waiting room. If a patient comes in with chest pains, the patient is then assessed by an RN immediately. The volunteers are to tell the RN ' s if a patient has chest pains. If with family, I have the family sign them in. During an interview on 02/10/16 at 2:10 PM, clinical manager stated when asked about the discrepancy with the documentation indicating the patient was transferred from ambulance stretcher. (Patient # 1 walked into waiting area of the ED with a man according to Video # 1). The clinical manager stated there are glitches in the computer soft wear that when you click " Stretcher " for some reason the word ambulance pre-populates in the notes. The clinical manager and Risk manager confirmed that patient # 1 was came into the waiting area of the ED by wheelchair. During an interview on 02/22/16 at 9:15 AM, RN Manager stated that the expectations is that within 10 minutes of arrival of any patient stating that they have either chest pain or shortness of breath that the patient is to brought back to a room and electrocardiogram is to be done. The volunteer will tell the RN if there is a patient having chest pain or shortness of breath. The RN manager stated she felt that staff did what was needed. The RN Manager also stated that at no time did family member of Patient #1 say that wife was having either chest pain or shortness of breath. The videos verified that on 04/08/15 that between 4:18:16 and 4:19:51 patient # 1 was in distress in the ED waiting area. Patient's # 1 ED sign in sheet was stamped by the volunteer at 4:17 PM. with chief complaint listed as " Difficulty Breathing." Review of the hospitals ED video # 1 dated 04/08/15 and the sign in sheet verified that on 04/08/15 while patient # 1 was in the waiting area of the ED that the patient was experiencing severe shortness of breath/Cardiac distress while in the waiting room. During an interview on 02/22/16 at 11:34 AM, Staff RN B stated when a patient comes into the waiting area, the volunteer signs them in. The registration will pop up on a screen in the ED or can view the monitors in the waiting area. Volunteers will tell staff if the patient has chest pain or shortness of breath. The volunteer can bring the patient to a room if available. The RN stated that the staff receive training each year on chest pain protocol. During an interview on 02/22/16 at 11:59 AM, the Medical Director stated that due to the proximity of the rooms to the waiting rooms, expectation is that staff can get the patient into the treatment rooms if something happens in the waiting rooms. The patient would be brought back to a room and cardiac workup would then be done. The Medical Director stated that this might help. During an interview on 02/22/16 at 12:27 PM, the registration clerk states that when a patient signs in on the triage sheet, the volunteer makes a copy and gives it to the triage RN. The volunteer also will make a copy of identification and gives it to the registration staff. If there is a problem in the waiting area the volunteer/registration staff will call for the RN to check the patient. As a registration clerk, I can go get a wheelchair if needed. During an interview on 02/22/16 at 12:39 PM, Volunteer in the waiting room at this time states that if a patient states having either chest pain/shortness of breath will go get the RN to check the patient in the waiting area. There is a room off the waiting area that can be used by the RN to triage the patient. During an interview on 02/22/16 at 1:30 PM, Clinical RN Manager of the ED states that there are cameras in the waiting area and that these cameras can be viewed in the main ED. The clinical RN manager was asked if someone ' s watches them at all times, was told " No " . Inquired on 04/08/15 what had happened and no answer was given. Further review of patient ' s # 1 medical chart, video ' s, policy/procedures and interviews the facility failed properly triage and initiate a medical screening examination. Review of the video # 1 shows that there was no triage, initiated and that 13 minutes went by before patient # 1 had been seen by staff. The facility failed to ensure that their policy and procedure regarding Chest pain and Shortness of Breath was followed as evidenced by when patient # 1 (MDS) dated [DATE] with a complaint of shortness of breath, failed to administer oxygen, failed to complete an EKG( Electrocardiogram) within 10 minutes; and failed to transport the patient to a monitored bed. The facility also failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that trained ( RN, PCT, Greeter, EMT and PMG) medical staff were in the ED waiting area to recognize acute coronary symptoms, when patient # 1 (MDS) dated [DATE].

Based on review of videos, medical records, emergency department logs, policies and procedures and staff interviews, the facility failed to ensure that an individual who presents to the Emergency Department with complaints of shortness of breath was provided an appropriate medical screening examination that was within the capability of the hospital's Emergency department to determine that an emergency medical condition existed for 1( patient #1) of 16 sampled patients reviewed. The facility also failed to ensure that policies and procedures regarding triage for chest pain/shortness of breath protocols were followed for Patient #1. Refer to findings in tag A-2406.