Based on Medical Staff Rules and Regulations review, policy review, time line and record reviews and interviews the hospital failed to ensure that an adequate medical screening examination and stabilizing treatment was provided for a pregnant patient who presented to the hospital's DED for evaluation on 06/06/2018, and 1 of 20 sampled patients (Patient #2), a patient who was cleared of an Obstetric EMC, but needed evaluation for a respiratory condition. The findings include: 1. Based on Medical Staff Rules and Regulations review, policy review, time line and record reviews and interviews the hospital failed to ensure that an adequate medical screening examination was provided for a pregnant patient who presented to the hospital's Dedicated Emergency Department (DED) for evaluation on 06/06/2018 (#21), and Patient #2, a patient who was cleared of an Obstetric EMC, but needed evaluation for a respiratory condition on 03/23/2018.. ~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on review of the hospital's Emergency Department log and policy and procedure and procedure review it was determined the hospital failed to ensure that the hospital maintain a central log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 (#21) of 21 sampled patients medical records reviewed. Findings included: 1. Review of the hospital's policy titled, "Emergency Medical Treatment and Patient Transfer Policy" revision date 06/06/2017, revealed in part,..."6. Emergency Department Log. The Hospital shall maintain a Central Log on each individual who comes to the Emergency Department seeking assistance and indicate whether the individual refused treating (including leaving without notice prior to triage, medical screening and/or treatment), or was transferred, admitted and treated, stabilized and transferred, or discharged ...The Central log should include, directly or by reference, patient logs from other areas of the Hospital, such as pediatrics and labor and delivery where a patient might present for emergency services or receive a Medical Screening Examination instead of in the Emergency Department." Review of the Hospital A DED log for 06/06/2018 between the hours of the lookdown (2130 through 2335) revealed patients checked into the DED as follows: 2142, complaining of chest pain; 2152, complaining of chest pain, high blood pressure, headache; 2155, Assault (the gunshot wound patient); 2252, complaining of chest pain; and 2255, complaining of chest wall pain. The facility failed to ensure that their policy was followed as evidenced by failing to maintain a central log on Patient #21 who presented to the hospitals' emergency department on 6/6/2018 at 2130 seeking medical complaining of leaking of vaginal fluid and contraction. Patient #21 was 36.5 weeks pregnant.

Based on Medical Staff Rules and Regulations review, policy review, time line and record reviews and interviews the hospital failed to ensure that an adequate medical screening examination was provided for a pregnant patient who presented to the hospital's Dedicated Emergency Department (DED) for evaluation on 06/06/2018 (#21), and Patient #2, a patient who was cleared of an Obstetric EMC, but needed evaluation for a respiratory condition on 03/23/2018. Findings included: Review of "Medical Staff Rules and Regulations", effective 10/27/2018, revealed, "...Any individual who presents to the Emergency Department of this hospital for shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition ... All patients shall be examined by qualified medical personnel ..." Review of hospital policy titled "Building Lockdown Procedure" revision date: 05/12/2015 revealed, "...The House Supervisor has the overall authority for the hospital to initiate a building lockdown during an event ..." Review revealed no evidence of what patients are or are not allowed to register for treatment in the hospital's DED during a lockdown event. Review of hospital policy titled "Emergency Medical Treatment and Patient Transfer Policy" revision date 06/06/2017 revealed, "... Emergency Medical Condition means ... Labor means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician, certified nurse midwife, or Qualified Medical Personnel acting within his or her scope of practice certifies that, after a reasonable time of observation, the woman is in false labor. Medical Screening Examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the Hospital's Capacity and Capability and available personnel ... Medical Screening Examinations shall be performed by an Emergency Department physician or another licensed practitioner as appointed and approved by the Hospital's Medical Staff and Board of Trustees ... If a pregnant woman presents to the Emergency Department in possible active labor, she can be sent to a contiguous or on-campus Obstetrics ("OB") Department that the Hospital deems appropriate to conduct or complete the initial Medical Screening Examination ... IF YOU HAVE AN EMERGENCY CONDITION OR ARE IN LABOR, YOU HAVE THE RIGHT TO RECEIVE, WITHIN THE CAPABILITIES OF THIS HOSPITAL'S STAFF AND FACILITIES ... AN APPROPRIATE MEDICAL SCREENING EXAMINATION ..." Review of hospital policy titled, "QHC Evaluation and Treatment of Pregnant Patients Presenting to the Emergency Department in a Facility with an OB Department" revision date: 06/23/2017 revealed, "...Any patient stating they are pregnant must be evaluated by a registered nurse ... Patients to be seen in Obstetrics (per ED RN triage decision) for their OB medical screening exam will then be triaged to OB ... Patients presenting with pregnancy 20 weeks or greater and an obstetrical complaint are to be transported to Labor and Delivery (L/D) via wheelchair or stretcher accompanied by clinical personnel as determined by the ED RN ..." 1. Review of a "Time Line of Events on June 6, 2018" related to Patient #21 revealed, "Time 2103 OB/GYN (Obstetrics and Gynecology Physician) answering service gets call from patient that she is having cramping and leaking-MD (Medical Doctor) advises patient to go to (Martin General Hospital - Hospital A) for evaluation. Time 2126 AOC (Administrator on Call) notified by house supervisor that rescue was bringing in a patient with GSW (Gunshot Wound) x (times) 4 and shooter had not been apprehended-was going to put the building on lockdown ... Time 2130 Security log indicates code lockdown called- 'had visitor with chest pain come in between 940-1030. Called (house supervisor). He told me to let them in if is (sic) heart related, so I did.' ... Time 2150 Security guard secures helicopter pad for (Named Air Ambulance Service) ... (Observations from security camera footage noted on time line) Time 2154 Woman enters vestibule and talks to security guard - leaves at about the same time as the staff member who was still in the vestibule. 2154 Per staff member who was in vestibule at this time, there were 2 or 3 people who were not let in. She passed a pregnant woman on her way out, and heard several people outside stating that they wouldn't get in building was on lockdown. She states she assumed the pregnant woman was allowed in, because we have to let them in, but she did not actually see the woman enter the ED (Emergency Department). Time 2208 OB/GYN answering service received another call from patient who stated (Named Hospital A) was on lockdown and she was going to (Named area city). MD called patient back and she confirmed she could not enter the hospital. She was already in route (sic) to (Named area city) and stated she was continuing to leak fluid and have contractions ... Time 2335 Security log 'Code lockdown off, all secure ..." 1. Closed medical record review revealed that patient #21 presented to Hospital B's L&D unit on 06/06/2018 at 2245. Review of a Triage History and Physical note written by MD #3 on 06/07/2018 at 1224 revealed, "Pt (patient) is a 26yrs (years) G1P0 (indicates 1st pregnancy-this is contradicted later in the medical record) at 36w5d (36 weeks 5 days) with an intrauterine pregnancy, dated by 8 week ultrasound, with EDD (Estimated Due Date) 6/30/2018. She receives prenatal care at (Named Office) in Williamston ... She presents to triage with low back/pelvic pain and LOF (leaking of fluids). States she had a prenatal care appointment this morning and was called 4 cm (centimeters) dilated and 90 effaced at about 10:30 am this morning. Since then, she has had lower back and pelvic pain that 'feels like back labor' that comes and goes every few minutes. She also reports a couple of 'trickles' of fluid but no big gush. She states she would have gone to the hospital in Williamston but it is 'on lock down' and was told by her doctor to come here. Patient has elevated blood pressures in triage and patient states she has not ever had issues with her blood pressure prior to or during any pregnancy ... OB History Gravida 4 Para 2 Preterm 2 AB 1 Living 2 ... BP 155/108 Pule 102 Temp 97°F Resp 20 ..." Review of a Discharge Summary written by MD #4 on 06/09/2018 at 0902 revealed, "Brief Hospital Course ... On 6/7/2018 at 7:08 PM she delivered a male infant via Normal Spontaneous Vaginal Birth, weighing 3.078 kg (kilograms), with Apgar scores of 8 at 1 minute and 9 at 5 minutes under None anesthesia (sic). The placenta delivered 6/7 7:14 PM ... On 6/9/2018 she met discharge criteria as noted above and was discharged in stable condition with follow-up as described ... Discharge Condition: Stable, ambulating and tolerating regular diet ... Discharge Disposition: Home ..." The patient's vital signs on 06/08/2018 at 2245 were BP 139/88, Pulse 91, Resp 18, Temp 98.1° F. The patient was discharged on [DATE] at 16:30. Review of the Hospital A DED log for 06/06/2018 between the hours of the lockdown (2130 through 2335) revealed patients checked into the DED as follows: 2142, complaining of chest pain; 2152, complaining of chest pain, high blood pressure, headache; 2155, Assault (the gunshot wound patient); 2252, complaining of chest pain; and 2255, complaining of chest wall pain. Interview was conducted with MD #1 on 09/04/2018 at 1615. Interview revealed he had recommended the patient (#21) present to Hospital A for evaluation. Interview revealed he later had a phone conversation with her that she (#21) was unable to enter Hospital A because the facility was on lockdown, and she was going to another facility. Telephone interview was conducted Security Officer (SO) #1 on 09/05/2018 at 0010. Interview revealed he had been told by a House Supervisor that the facility was on lockdown and only patients experiencing chest pain could enter. Interview revealed SO #1 vaguely remembered telling a patient the facility was on lockdown, but never explicitly telling any patient they could not come in. The House Supervisor no longer worked at Hospital A was not available for interview. 2. Closed medical record review revealed Patient #2 was a [AGE]-year-old female who presented to Hospital A's DED on 03/23/2018 at 1510, complaining of no fetal movement for 2 days, and wheezing. She was taken to the L&D department at 1512. Patient #2 was evaluated and cleared of any Obstetric EMC by MD #1. Review of a note written by Registered Nurse (RN) #1 on 03/23/2018 at 1604 revealed, " ...VSS (Vital Signs Stable) & (and) WNL (Within Normal Limits). + (positive) FETAL MVMT (movement). AUDIBLE WHEEZING. REASSURING EFM (Electronic Fetal Monitoring) TRACING ... INSTR (instructions) TO D/C (discharge) TO ED FOR EVALUATION OF WHEEZING." Review of a note written by Registered Nurse (RN) #1 on 03/23/2018 at 1610 revealed, "PT STABLE AND STATES FEELS BABY KICKING. TO ED VIA W/C (wheelchair) PER RN AND REPORT GIVEN TO (Named MD #2) IN ED." Review revealed no evidence of registration, triage, treatment, or stabilization provided to Patient #2 in the DED. Interview was conducted with RN #1 on 09/05/2018 at 1458. Interview revealed she did not recall Patient #2 or taking her to the DED on 03/23/2018. Interview revealed she did not recall talking to MD #2 or whether there was a nurse to nurse report or handoff. Interview revealed, "If that what was documented, that's what happened." Telephone interview was conducted with MD #2 on 09/06/2018 at 1135. Interview revealed he did not recall Patient #2 or receiving a report from RN #1 regarding Patient #2. Interview revealed, "Guess it might have been busy. Usually once in the ER we take care of them. Generally, there is a nurse to nurse sign off and if a room is available they would immediately be roomed and could have started nebs." Interview revealed MD #2 could not recall whether any report was given to him from MD #1 regarding Patient #2. The facility failed to ensure that their policy was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided for individuals who presented to the hospitals' ED to determine whether or not an emergency medical condition exists or woman in labor, that was within the capacity or capability and available personnel for patient #2 and #21 when they presented to the ED.