During EMTALA investigation of complaint number TN completed 8/7/18 - 8/9/18 at Starr Regional Medical Center, the facility was found to be out of compliance with Responsibilities of Medicare Participating Hospitals in Emergency Cases 42 CFR PART 482 for failing to provide an appropriate Medical Screening Examination (MSE) for one patient (#1) of 33 Emergency Department (ED) patients reviewed. The facility's failure resulted in Patient #1 presenting to the Emergency Department (ED) at the facility's satellite campus in Etowah on 7/13/18 at 5:32 PM with a complaint of low back pain, pelvic pain, and hematuria. Patient #1 was diagnosed with Pregnancy and UTI and was discharged home at 9:16 PM. Patient #1 presented approximately 9 hours later to the facility's main campus in Athens on 7/14/18 at 6:28 AM with a 42 week old, 6 pound 5 ounce male infant she delivered in her car just prior to arriving at the main campus. For documentation purposes: Hospital A is Starr Regional Medical Center's Main Campus, located at 1114 West Madison Ave, Athens TN . This facility has obstetric services with an obstetric physician on-call, a labor and delivery unit, and a neonatal nursery. Hospital B is Starr Regional Medical Center's Etowah Campus, a satellite facility of the Main Campus. The Etowah Campus is located at 866 Highway 411 North, Etowah TN , 10 miles from the main campus. The Etowah Campus does not have any obstetrical services, but is equipped for precipitous deliveries and has a physician present in the Emergency Department 24 hours each day. Refer to A-2406

Based on facility policy review, medical record review, and interviews, the facility failed to provide an appropriate medical screening examination (MSE) for 1 patient (#1) of 33 Emergency Department (ED) patients reviewed. The facility's failure to provide an appropriate MSE for Patient #1 resulted in the patient being discharged home from Hospital B on 7/13/18 at 9:16 PM with a diagnosis of pregnancy and urinary tract infection, and giving birth in her car on 7/14/18 at 6:15 AM (approximately 9 hours later) while on her way to Hospital A. The findings included: Review of facility policy "Emergency Screening Stabilization/Transfer/250 Yard Rule and EMTALA" effective date 5/2018, revealed "...Any individual who comes to the hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate medical screening examination by a physician or other qualified medical provider to determine whether or not an emergency medical condition exists...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 contraction is in true labor unless a physician, certified nurse-midwife, or qualified medical personnel acting within his or her scope of practice as defined in hospital staff medical by-laws and State Laws certifies, after a reasonable period of observation, the woman is in false labor...A Medical Screening Examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred...[Hospital B] campus does not provide obstetric services...Patients who present to the Emergency Department at [Hospital B], who are pregnant, will have a MSE by the ED physician or QMP [qualified medical professional] in the ED...If the chief complaint is pregnancy related and/or the patient is in labor, the ED physician or the QMP will consult the [Hospital A] campus on call obstetrician. A decision will then be made whether the patient can be safely transferred to the [Hospital A] Campus...If the patient cannot be safely transferred to [Hospital A]...the [Hospital B] campus is equipped for precipitous delivery. Both Mom and Baby will be transferred to [Hospital A] campus after delivery..." Medical record review from Hospital B's revealed Patient #1 (MDS) dated [DATE] at 5:32 PM with a complaint of low back pain, pelvic pain, and hematuria (blood in the urine). Medical record review of a nurse's notes from Hospital B dated 7/13/18 at 5:39 PM revealed "...low back pain, pelvic pain, hematuria starting today. Possibility of pregnancy/missed cycle...complains of pain in pelvis, low back...17:44 [5:44 PM] LMP [last menstrual period] 5/1/2018..." Further review revealed the patient was assessed with a pain level of 9 (on a 1-10 scale with 10 being extreme pain). Continued review revealed the patient's pain level at 6:56 PM was 8 and at 9:12 PM her pain level was 0. Further review revealed the patient was administered Zofran (medication for nausea) 4 milligrams (mg) by mouth (po) at 6:39 PM, Toradol (used to treat pain) 30 mg intravenously (IV) at 6:41 PM, Rocephin (antibiotic) 1 gram IV at 8:57 PM, and Tylenol 650 mg PO at 8:57 PM. Medical record review of a physician's notes from Hospital B dated 7/13/18 at 6:20 PM revealed "...patient presents with pain that is acute. The symptoms are located in the low back. The pain radiates to the pelvis...at their worse the symptoms were a 9 out of 10. The patient has not experienced similar episodes in the past. Denies h/o [history of] kidney stones but does have family h/o kidney stones...Patient asked about possibility of pregnancy and said that she missed her last menses...LMP 5/1/2018...the patient appears in obvious pain...sitting upright and rocking, unable to get comfortable...Exam...Abdomen/GI [gastrointestinal] Inspection: distension that is moderate...GU [genitourinary]: CVA [costovertebral angle/lower back area over the kidneys] tenderness, on the left..." Further review of a physician's note written at 7:10 PM revealed "...awaiting urine pregnancy test results prior to obtaining CT [computed tomography] Scan for suspected kidney stones..." Continued review of a physician's note written at 8:53 PM revealed "...Pt [patient] has a + [positive] pregnancy test and a UTI so she was given Rocephin IV and will f/u [follow up] with [Obstetrician] on Monday...beta quant [beta quantitative HCG, a blood pregnancy test] is pending and pt will call for results...I had a detailed discussion with the patient and/or guardian regarding: the need for outpatient follow up, an OB/Gyne [gynecologist] specialist..." Further review of a physician's notes at 9:02 PM revealed "...Discharge to home. Impression: pregnancy, UTI...Condition is stable..." Further review revealed no documentation a pelvic examination was completed. Medical record review of a discharge note from Hospital B dated 7/13/18 at 9:16 PM revealed Patient #1 was discharged home in stable condition with diagnosis of "...pregnancy, UTI [urinary tract infection]..." Medical record review from Hospital A of a labor and delivery (L&D) Flowsheet for Patient #1 dated 7/14/18 at 6:28 AM revealed "...PATIENT ARRIVED ON THE LABOR DECK AFTER DELIVERY OF INFANT IN CAR ON WAY TO HOSPITAL. PATIENT STATES SHE HAS HAD NO PRENATAL CARE AND DID NOT KNOW SHE WAS PREGNANT..." Medical record review of an Admission History and Physical from Hospital A dated 7/14/18 at 6:45 AM revealed "...Pt delivered a baby in her car while driving to the hospital...The patient arrives to L&D with placenta still inside her. Pt was seen last night in ER [emergency room ] at [Hospital B] campus and told had UTI pregnant but may be having a threatened SAB [spontaneous abortion/miscarriage] or kidney stone. She was then diagnosed with an UTI and sent home. Pt continued to have bladder spasms (ctx) [contractions] and then drove to our [Hospital A] campus when she delivered her baby boy in the car...she denies any ROM [rupture of membranes/water breaking] prior to delivery of baby..." Further review revealed the patient was discharged home on 7/16/18. Medical record review of a Newborn Discharge Summary from Hospital A revealed Patient #1 delivered a baby boy on 7/14/18 at 6:15 PM with a gestational age determined by exam, of 42 weeks. Further review revealed the infant weighed 6 pounds and 4 ounces at birth and was a "...precip [unexpected/unprepared for] delivery in vehicle..." Continued review revealed "...Transfer to [named acute care hospital] NICU [neonatal intensive care unit] for NAS [neonatal abstinence syndrome/drug withdrawal] symptoms...7/16/18 time 0433 [4:33 AM]..." Interview with Physician #1, in the ED Director's office at Hospital B, on 8/8/18 at 8:50 AM revealed he remembered examining Patient #1 on 7/13/18 and he was very surprised when he learned the patient had delivered a baby the next day. Continued interview revealed when he examined the patient she did not appear pregnant at that time, but appeared uncomfortable to him. Further interview revealed he did not suspect she was in labor, because the patient told him she had missed only her last menstrual period. Continued interview revealed he suspected a kidney stone and planned to have a CT Scan ordered if her pregnancy test was negative. Further interview revealed he turned the patient's care over to Physician #2 at the change of shift. Telephone interview with Physician #2 at Hospital B on 8/8/18 at 10:20 AM revealed he remembered treating Patient #1 on 7/13/18 and he took over care of Patient #1 from Physician #2 at the change of shift on 7/13/18. Continued interview revealed he had no suspicion the patient might be in labor and the patient told him she had missed only one menstrual period. Further interview revealed he remembered telling the patient and her significant other (SO) of the positive pregnancy test and stated they were both very surprised and happy and wanted to know how far advanced the pregnancy was. Continued interview revealed Physician #2 ordered the beta quantitative HCG test to determine the stage of the patient's pregnancy, but the patient and SO wanted to leave prior to the test results because the SO needed to go to work. Further interview revealed the patient appeared in no distress or discomfort and desired to go home. Continued interview revealed there were no signs or symptoms of labor and he felt the patient had a UTI or possibly a kidney stone and believed she was in stable condition with no emergency medical conditions when he discharged her home.

Based on review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), review of medical staff bylaws, review of facility policy, medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 2 patients (#29 and #30) of 30 Emergency Department (ED) patients reviewed. Refer to 2406 for failure to provide a medical screening examination.

Based on review of facility policy, review of medical staff bylaws, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), medical record review, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 2 patients (#29 and #30) of 30 Emergency Department (ED) patients reviewed. The findings included: Review of the facility's "Initial Emergency Medical Screening" policy last reviewed 12/2016, revealed "...All patients presenting to...Emergency Department will receive an appropriate MSE...to determine whether or not an emergency medical condition [EMC] exists...The Initial Emergency Medical Screening will be provided by the Qualified Medical Personnel as approved by the Board of Trustees and Medical Staff..." Review of the facility's "Emergency Screening and Stabilization/Transfer/250 Yard Rule and EMTALA" policy last reviewed 4/2017, revealed "...must provide for an appropriate Medical Screening Examination conducted by a physician or other QMP...to determine whether or not an Emergency Medical Condition exists...or with respect to a pregnant woman having contractions, whether the woman is in labor..." Review of the facility's "Medical Screening of Obstetric Patients" policy last reviewed 12/2016, revealed "...Patients with Pregnancy of any gestational age who present to [name of hospital] will have a screening exam performed by a qualified provider...Patients < [less than] 20 weeks gestation are assessed through the Emergency Department...All patients > [greater than] 20 weeks gestation, presenting with OB related complaints will be directed to the Labor and Delivery area...The medical screening will take place in the Labor and Delivery area...A qualified Registered Nurse in Labor and Delivery...who has validated competency in Labor and Delivery skills and screening of OB [obstetric] patients may perform medical screening exams on an outpatient basis...Following assessment and examination of the patient, the RN will notify the patient's physician of the findings of her exam. Based on these findings the physician will determine disposition and give an appropriate order..." Review of the facility's "BYLAWS OF THE MEDICAL - DENTAL STAFF..." last reviewed/revised April 2016, revealed "...Qualified Medical Personnel which includes MDs [Medical Doctor], DOs [Doctor of Osteopathic Medicine], Nurse Practitioners...and Obstetric Registered Nurses [RN]..." Review of the Tennessee Code Annotated 63-7-103 revealed "...Title 63 Professions of the Healing Arts...Nursing...General Provisions..." dated 2016, revealed "...professional nursing includes...(A) Responsible supervision of a patient...(B) Promotion, restoration and maintenance of health or prevention of illness of others...(C) Counseling, managing, supervising and teaching of others...(D) Administration of medications and treatments as prescribed by a licensed physician...or nurse authorized to prescribe...(E) Application of such nursing procedures as involve understanding of cause and effect...(F) Nursing management of illness, injury or infirmity...(b) the practice of professional nursing does not include acts of medical diagnosis or the development of a medical plan or care..." Continued review did not specify Registered Nurses (RN) were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act. Medical record review revealed Patient #29 (MDS) dated [DATE] at 2:35 PM for complaint of "...PELVIC PRESSURE...UC [uterine contractions]..." and was 38.5 estimated gestational age (EGA). Further review revealed the patient was placed on a fetal monitor by the RN #1 at 3:40 PM (1 hour and 5 minutes after arrival). Continued review revealed the patient was provided a vaginal exam by the RN at 4:02 PM and the assessment was "...Dilatation...3.5 [centimeters]...Effacement...50 [%]...Station...-2..." Continued review revealed the patient was discharged home in stable condition on 9/20/17 at 4:28 PM. Further review revealed no documentation of the patient was provided a MSE by any QMP other than the RN. Medical record review revealed Patient #30 (MDS) dated [DATE] at 1:30 PM with complaint of "...sharp right lower abdomen pain..." and was 38.1 weeks EGA. Further review revealed the patient was placed on the fetal monitor by a RN #1 at 1:30 PM. Continued review revealed Patient #30's vital signs on arrival were: blood pressure 123/68 and heart rate 107. Further review revealed there was no documentation regarding dilatation, effacement, station, or presentation. Continued review revealed the triage assessment was charted by the RN at 9:28 PM (8 hours after arrival). Further review revealed the patient was discharged home in stable condition on 9/23/17 at 10:01 PM (8.5 hours after arrival). Further review revealed the patient's blood pressure was not reassessed between the time of arrival and the time of discharge. Continued review revealed no documentation the patient was provided a MSE by any QMP other than a RN. Review of the personnel file for RN #1 revealed the RN completed an Intermediate Fetal Monitoring Course on 9/23/15 and a labor and delivery core competency course in 2016 at the facility. Interview with RN #2 on 10/11/17 at 1:00 PM, in the Labor and Delivery Nurses Station, confirmed Patient #29 and Patient #30's MSE were provided by a RN and there was no documentation either patient was seen by a QMP other than RN#1. Interview with the Chief Nursing Officer (CNO) on 10/11/17 at 2:00 PM, in the CNO's office, confirmed Patient #29 and Patient #30's MSE was provided by a RN and there was no documentation either patient was seen by a QMP other than RN #1.