Piedmont Mountainside Hospital Inc.

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 42060 Based on review of video recording, medical record review, Observational tour, Medical Staff Rules and Regulations, policy and procedures, staff interviews, it was determined the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the facility’s emergency department, including ancillary services including Labor and Delivery (L&D) services to determine whether or not an emergency medical condition (EMC) existed for one patient (P #1) of 21 sampled patients. Specifically, P#1, a pregnant patient presented to the facility’s emergency department (ED) stating she was having abdominal and contractions on 4/12/25. The facility failed to provide a medical screening examination to determine if the patient was in labor. After being informed that the facility did not perform vaginal births after c-sections (VBAC), P #1 left the facility at 11:14 a.m. en route to facility (F) #2, where she delivered an infant boy by c-section. Findings: Cross refer to A-2406 as it relates to the facility’s failure to provide a medical screening examination to P#1.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), 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. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 42060 Based on review of the facility’s ED Central log, policy and procedures and staff interviews it was determined that the facility failed to maintain a central log on each individual who comes to the ED seeking medical 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 one (Pt.#1) of 21 sampled patients. Patient #1 presented to the hospital’s ED on 4/12/2025 pregnant with stated complaint of having complaints of contractions. Patient left the facility when she was told that the facility did not offer vaginal births to patients who had a previous c-section. Findings: A review of the facility’s ED Central Log failed to reveal an entry for P#1 on 4/12/25. Review of Policy Stat ID 17894219, originated 2/1/2012, Last revised 4/1/2025, titled “Emergency Medical Treatment and Active Labor (EMTALA)”, (a federal law that requires all facilities that received federal funds to treat all persons presented in the ED requesting medical treatment). The policy revealed in part, the following: “ ... 2. A central log that includes each individual who Comes to the Emergency Department (including OB emergency department) seeking medical assistance. The central log shall include: a. refused treatment b. was refused treatment. c. transferred to another hospital. d. was admitted and treated. e. was stabilized and transferred; and/or f. was discharged.” An interview was conducted with (RN)FF on 4/22/2025 at 10:00 a.m. RN FF said she also told P #1 she could check in, but she would need to sign AMA because they did not offer VBAC. RN FF said P #1 decided not to sign in and left the facility. An interview with Patient Access (Staff) GG took place on 4/22/25 at 11:00 a.m. in the conference room. Staff GG stated he remembered P #1 because she came in on a weekend. Staff GG said at first somebody came to the lobby and shouted someone was in labor. Staff GG said he went to the registration and asked P #1 about what was going on with her, i.e. what brought her to the facility. Staff GG said P #1 told him she was 41 weeks pregnant, and she was having contractions every five minutes. Staff GG said he asked P #1 about any liquid, she said she was having some light bleeding He said the person then approached Patient 1 at the registration window and said there was a patient in labor. Staff GG said when P #1 arrived, she was directed to the outpatient registration window. Staff GG said P #1 put her name, but the registration was canceled because it was determined that she was not going to stay. Staff GG said P #1 never made it to the ED window but rather she was redirected to the outpatient window and that was the reason she never appeared in the ED log. The facility failed to ensure that their own policy was followed as evidenced by failing to include patient #1 on the central log, when she presented to the hospital’s OBED seeking medical assistance on 4/12/2025.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 42060 Based on review of video recording, medical record review, Observational tour, Medical Staff Rules and Regulations, policy and procedures, staff interviews, it was determined the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the facility’s emergency department, including ancillary services including Labor and Delivery (L&D) services to determine whether or not an emergency medical condition (EMC) existed for one patient (P #1) of 21 sampled patients. Specifically, P#1, a pregnant patient presented to the facility’s emergency department (ED) stating she was having abdominal and contractions on 4/12/25. The facility failed to provide a medical screening examination to determine if the patient was in labor. Findings: 1. A review of a video recording of the facility’s emergency department dated 4/12/25 revealed the following: o at timestamp 10:57 a.m.-red car arrives-pulls to portico and visitor (identified by Quality Director BB as P #1) exits car o at timestamp 10:59 a.m.-P#1 enters building through ED doors o at timestamp 11:00 a.m.-P#1 approaches main check-in desk o at timestamp 11:01 a.m.-P#1 taken to registration room 1 o at timestamp 11:04 a.m.-a blonde woman (P#1’s driver) arrives and is sent to room 1 o at timestamp 11:08 a.m.-L&D nurse (RN FF) arrives and goes to room 1 o at timestamp 11:10 a.m.-L&D nurse leaves o at timestamp 11:10 a.m.-P#1 and driver leave room 1 and exit via the ED doors o at timestamp 11:14 a.m.-car seen leaving hospital parking. 2. A review of P#1 ’ s medical record from Facility (F) #2 revealed that P #1 was a 27-year-old female who presented to the emergency department on 4/12/25 at 12:19 p.m. with a chief complaint of 41 weeks and 5 days pregnancy with contractions every five minutes. P #1 was triaged at 12:21 p.m. ED nurse notified Labor and Delivery of P #1’s presence in the ED during triage. P #1 was taken to Labor and Delivery via wheelchair on 4/12/25 at 12:22 p.m. Further review of the medical record revealed P #1 was assessed in the L&D at 12:55 p.m. and 1:37 p.m. P #1 was admitted to inpatient care under physician’s order. P #1’s Obstetric history revealed she had a total of three pregnancies (Gravida 3), with her first pregnancy and delivery by C-Section (a surgical procedure where a baby is delivered through an incision in the mother’s abdomen and uterus) on 12/18/2018. On 2/16/2022 P #1 delivered a baby via vaginal method. On 4/12/25 P #1 had a C-section performed at facility #2 and delivered a single male infant. 3. A review of the facility’s Medical Staff, Rules, and Regulations Stat ID #: 14376645, adopted and approved on 18/9/23, revealed that the hospital provided emergency services and care to any person who came to the emergency department (ED) as defined in the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations where there are appropriate facilities and qualified personnel available to provide such services or care. A further review of the policy stated: (1) Medical screening exam, 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. A Qualified Medical Personnel (QMP) who can perform medical screening examinations within applicable Hospital policies and procedures defined as: (a) Emergency Department: (i) Members of the Medical Staff with clinical privileges in Emergency Medicine: (ii) other Active Staff members: and (iii) appropriately credentialed Advanced Practice Professionals. The results of the medical screening examination were documented before the patient left the Emergency Department. 4. Review of Policy Stat ID 17894219, title “Emergency Medical Treatment and Active Labor (EMTALA)”, Origination Date 2542/12/2021, Last Revised 4/1/2025. The policy revealed in part, “Medical Screening Examination (MSE) is the screening process that determines the presence or absence of an EMC or if a woman is in Labor. The MSE must be performed by a QMP and should not be delayed by any registration process. Appropriateness of the MSE depends on the presenting signs and symptoms as elicited in history. An MSE is a process and may involve multiple steps and reassessment overtime (including laboratory, radiology, CT, EKG, procedures, e.g. lumbar puncture and even consultation and exam by other staff specialty physicians). Policy: All PHC hospitals with a dedicated emergency department (DED) will ensure that all individuals requesting an examination for a possible Emergency Medical Condition (EMC), including women in Labor, are provided with an appropriate Medical Screening Examination (MSE).” 5. During a tour of the ED on 4/21/25 at 12:05 p.m., Triage Nurse (RN) AA explained that the facility tried to get patients into triage (as system of rapidly identifying and sorting patients according to the severity if their injuries, or illness) as soon as possible. RN AA stated that pregnant patients with pregnancy related complaints were triaged, and an OB nurse came down to evaluate these patients and for the most part, they took the patients to the L&D. 6. An interview with the Director of Quality (Director) BB took place on 4/21/25 at 3:00 p.m. in the conference room. Director BB said she was aware of the complaint because during a phone call with F #2’s administrator, they were made aware of a potential EMTALA violation involving their facility. Director BB said she had a chance to review the case regarding P #1, she stated the patient came to seek information about vaginal delivery post C-section (VBAC: vaginal birth after c-section). Director BB said P #1 was not a patient of their OB group but came from another group. Director BB said from all the information she gathered about the case, a nurse from the L&D came down to see the patient when she presented to the ED. Director BB stated the nurse came down, met with the patient and educated P #1 about the VBAC. Director BB explained that the facility did not perform vaginal delivery on patients with history of C-section because of the high risk and lack of resources to treat these patients if things got complicated. Director BB further explained that the facility did not have a NICU (neonatal intensive care unit). Director BB said the procedure was high risk not only for the mother but for the baby as well. Director BB said the facility did not have in-house anesthesia (use of medication to prevent pain during surgery and other procedures) and they did not have an OR that was opened to serve patients 24/7. Director BB said they had these services 24/7 but as on-call and took half an hour or 30 minutes. Director BB explained that facilities that perform VBAC had OR staffed 24/7, including anesthesia, plus they had an entire neonatal team present at all times to handle very quickly if there were any complications such as a ruptured uterus or placenta broke. Director BB said they were a community hospital with limited resources; therefore, they offered limited services. Director BB said the nurse did offer P #1 to stay and they would take care of her if she decided to elect for C-section, but P #1 did not stay. Director BB said the surgeons and anesthesia were present Monday through Friday until around 4:30-5:00 p.m. for scheduled surgeries but were on call after hours and on weekend. 7. An interview with the ED Medical Director (Doctor) DD took place in the ED on 4/22/25 at 9:15 a.m. Doctor DD said all patients who came to the ED regardless of the chief complaint got a medical screening exam, including pregnant patients. Doctor DD said if the pregnancy was less than twenty weeks and the complaint was not related to the pregnancy, the ED providers examined the patient in the ED. Doctor DD said if the mother had signs and symptoms of active labor, the ED called labor and delivery to see the patient. Doctor DD said in either case, all patients presenting in the ED pregnant or not had a minimum a medical screening exam (MSE). Doctor DD explained that although the facility was not ideally suited for VBAC’s, if a patient presented with eminent delivery, the facility would still deliver the baby. Doctor DD further stated that he was not an expert in OB, but he understood they did not just accept a patient for VBAC. Doctor DD said if P #1 came to the registration desk and request to be seen, regardless, she should have at least an MSE. 8. An interview with the ED Nurse Director (RN) EE took place on 4/22/25 at 9:25 a.m. in his office in the ED. Director EE said he was not familiar with the case involving P #1; however, all patients who presented to the ED were entitled to have a medical exam regardless of complaint. Director EE said they accepted pregnant patients at all stages during pregnancy, and there were procedures regarding the gestational age. Director EE said if the patient came and was more than twenty weeks, the ED Charge Nurse called the Labor and Delivery department, and they would come down to bring the patient to the L&D. Director EE said the facility did not perform VBAC because of potential complication and their limited resources. Director EE said the main complication could be uncontrolled hemorrhage and they did not have a team in place to deal with major complications not only to the mother but to the baby as well. Director EE said if the pregnant patient came for a complaint not pregnancy related, they cared for the patient in the ED and still followed the protocol by calling OB to assess the baby in the ED. Director EE said that the facility had anesthesia service on-call for minor emergencies such as small trauma but nothing major. He explained that other cases they transfer to a major trauma facility that was equipped to handle potential complications. 9. An interview with L&D Nurse (RN) FF took place on 4/22/25 at 10:00 a.m. in the conference room. RN FF recalled getting a call from Patient Access (Staff) GG about a 41- week pregnant patient in the office with him who came to inquire about VBAC. RN FF said Staff GG told her P #1 was not a patient of the facility group, i.e., she did not have prenatal care here. RN FF said Staff GG told her that the patient reported she had a prior C-section and had a successful vaginal delivery after the C-section. RN FF said she told Staff GG to inform P #1 that VBAC was not performed at the facility, but they were still willing to take care of her here if she chose to have a C-section. RN FF said she then decided to come down to further explain to the patient the risk of having a VBAC. RN FF came to the registration room and spoke to P#1. RN FF recalled that P#1 asked about the type of anesthesia during a C-section and then requested information about other facility’s that perform VBAC’s. RN FF said she told P #1 she could stay here and that they could take care of her, but they were not going to perform VBAC as an option because they were not able to do it due to possible complications for the mother and the baby. RN FF said she followed up with the question and told P #1 she knew facility #2 did VBAC because they were a much larger facility. At the request of P#1’s driver, she (RN FF) explained to P#1 the complications that can be associated with VBAC’s. RN FF said for any VBAC, the facility must have anesthesia physically present the entire time the patient was admitted in case they needed to take the patient to the OR. RN FF further explained that she worked for many years in L&D, and she witnessed firsthand complications involving VBAC. RN FF said the facility did not have in-house anesthesia 24/7; she said after 5: p.m. and on the weekend, anesthesia and surgery services were on call. RN FF explained they could get to the facility within 30 minutes but when things got complicated, you needed to get that patient to the OR with a full team within seconds. RN FF said her goal was to make sure P #1 was educated and aware of her choices. RN FF said she did not take P #1 upstairs for an OB exam and found out she needed immediate delivery and was not able to have her deliver vaginally. RN FF said P #1 was not in any distress, she was just asking questions and wanted to get information about VBAC. RN FF said the person that came with P #1 said during her (P#1) last visit to her doctor, she was informed that the baby was breeched, and that VBAC was not an option. RN FF said P #1 asked her if they had a NICU at the facility and she said they did not have one. RN FF said the person that came with P #1 asked P #1 what she wanted to do, RN FF said, P #1 replied she wanted to go to the facility that RN FF told her performed VBAC. RN FF said P #1 told her she was having some contractions since earlier in the morning. 10. An interview with Doctor HH took place on 4/22/25 at 11:30 a.m. in the doctor’s office in his clinic. Doctor HH said he was aware of the case regarding P #1. Doctor HH said he was OB/GYN (Obstetrician/Gynecologist, medical doctor specializing in the care of women’s reproductive health, encompasses both pregnancy and childbirth, as well as the female reproductive system) took on-calls at the facility. He said P #1 refused the service they offered at the facility. He said this was a community facility with limited staff and resources. He said the facility did not have in-house anesthesia, they had anesthesia in the building Monday through Friday between 8:30 a.m. to 5:00 p.m.. He said the risk outweighed the benefits. Doctor HH said the practice saw all pregnant women but once they expressed the desire for VBAC, he referred them to other facilities because they did not do that at the facility. Doctor HH said we offered her to stay but P #1 declined. Doctor HH said we were willing to perform the C-section on her, but she chose to go somewhere else. 11. An interview with L&D Clinical Manager (Manager) II took place on 4/22/25 at 3:30 p.m. in the conference room. Manager II said she was working the day P #1 came to the facility. She was also aware when registration called the L&D to report about P #1. Manager II said she was aware that the phone call was about a patient who wanted to get information about having VBAC. Manager II said RN FF explained to the patient that the facility did not perform VBAC. Manager II said she was aware also that RN FF offered to P #1 to stay if she chose too but it was going to be a C-section. Manager II said when RN FF came up, she asked her if P #1 was in labor, and RN FF said P #1 did not appear to be in any distress. Clinical Manager II said they did not offer VBAC at the facility because they did not have the OR and anesthesia staff to support patients if they became complicated. Manager II said that during the evening and weekend, the OR was not staffed. Surgeons and anesthesia were on-call and thirty minutes away. Clinical Manager II said small facilities like theirs just did not have the resources to take the risks of VBAC. The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to ensure that a medical screening examination was provided by a QMP to determine if Patient #1 was in labor on 4/12/2025, who presented to the hospital’s ED complaining of abdominal pain and having contractions.”