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Based on review of hospital policies and procedures, hospital rules and regulations, medical records (MR), and interviews with staff, it was determined the hospital failed to:

1. Ensure the on-call physician performed a medical screening examination (MSE) on two of nineteen MRs reviewed who presented to the Obstetric Emergency Department (OBED) including Patient Identifier (PI) # 1 and PI # 2.

2. Provide an appropriate MSE within the capability of the hospital's OBED for two of nineteen MRs reviewed who presented to the OBED including PI # 1 and PI # 2.

These deficient findings had the potential to negatively affect all patients served by the hospital OBED.

Findings include:

Refer to A2404 and A2406 for findings.

Based on review of hospital policies and procedures, medical records (MR), and interviews with staff, it was determined the hospital failed to:

1. Ensure the on-call physician met the needs of the hospital's patients who were receiving services in accordance with the resources available to the hospital, which included on call physicians who were on call and available performed a medical screening examination (MSE) on two of nineteen MRs reviewed who presented to the Obstetric Emergency Department (OBED) including Patient Identifier (PI) # 1 and PI # 2.

Findings include:

Hospital Policy: Emergency Medical Treatment and Active Labor Act (EMTALA)
PolicyStat ID: 12492090
Effective Date: 10/6/2022

...On Call Coverage:

1. Each hospital maintains a list of physician specialists who are available for additional evaluation and stabilizing treatment of individuals with Emergency Medical Conditions...
2. When requested to make an in-person appearance...a physician who is on-call must do so.
3. On-call physicians must respond within the time period specified in applicable bylaws, rules, or policies after receiving communication indicating that their attendance is requested...

Policy: OBED/Maternity Emergency Care Center (MECC)
PolicyStat ID: 10140471
Effective Date: 5/7/2019
Revised Date: 7/20/2021

Purpose:
In keeping with the core values, this policy serves as an outline of the MECC/OBED processes for providing a MSE and stabilizing treatment for patients experiencing antepartum, intrapartum, and postpartum (up to six weeks) medical conditions such that the absence of immediate medical attention may place the patient or her fetus in serious jeopardy.

Policy:
It is the policy of the MECC/OBED to meet the requirements of the EMTALA...In addition, the MECC/OBED will follow the process, as noted:

...B. Pregnant patients presenting to the MECC/OBED:
1. All OB patients...will be provided such other assessments and stabilizing treatment as are deemed appropriate as a result of the initial MSE...
E. MSE and treatment provided by OB Hospitalist/Laborist.
F. Patient admitted or discharged as ordered by OB Hospitalist/Laborist...


An interview was conducted on 9/12/24 at 12:40 PM with Employee Identifier (EI) # 1, OB Nurse Manager. During the interview, EI # 1 stated "RNs have not provided MSEs since 2018 when the laborists were hired." EI # 1 was asked by the surveyor if everyone receives a MSE? EI # 1 stated, "I think it would be situational and up to the physician if they thought it was warranted."

A second interview was conducted on 9/12/24 at 2:30 PM with EI # 1. EI # 1 was asked by the surveyor if physicians could perform a MSE over the phone. EI # 1 stated, "I would think not. I would think it would require them to lay eyes on the patient." EI # 1 was also asked what was a "reasonable" amount of time to perform the MSE. EI # 1 stated, "If a laborist is in-house, 30 minutes is reasonable unless they are in an emergency surgery. If there is no laborist in-house it would depend on the situation and the chief complaint (CC) the patient presents with."

1. PI # 1 presented to the OBED on 9/7/24 at 7:45 PM with a chief complaint (CC) of nausea and vomiting. She was 35.3 weeks pregnant. Her treatment included electronic fetal monitoring (per Standing Physician Orders). She was contracting. Employee Identifier (EI) # 2, OBGYN, was not in the hospital but was notified via telephone at 8:29 PM and ordered a liter bolus of Lactated Ringers and then infuse at 125 milliliters per hour. A vaginal examination was performed by EI # 4, RN, due to the contractions.

Review of the MR revealed at 9:49 PM, the following nursing documentation was noted, "MD states to overnight obs {observation} patient and he/she will see in the AM." At 10:00 PM the plan of care was explained with PI # 1 by EI # 4. The nurse documented the following patient statement, "Since my cervix is closed, I don't feel that I need to be here, so I want to go home."

Further review of the MR revealed PI # 1 signed an Against Medical Advice (AMA) form at 10:11 PM and departed the OBED at 10:15 PM.

EI # 2 did not present to the OBED during the 2.5 hours the patient was in the OBED to perform a MSE.

An interview was conducted on 9/12/24 at 5:25 PM with EI # 1, who confirmed the on-call OB did not complete a MSE on PI # 1.

2. PI # 2 presented to the OBED on 9/8/24 at 12:37 AM with a CC of abdominal pain, constipation, and possible spontaneous rupture of membranes. She was 20.4 weeks pregnant. She was also from out of state. Her treatment included fetal monitoring (per Standing Physician Orders). An order was also entered at 12:57 AM for a ROM (rupture of membranes) Test.

Review of the MR revealed at 1:30 AM, EI # 4 contacted EI # 3, OB physician on call for unattached patients (patients with no prenatal care or patients who receive care elsewhere). EI # 3 was not in the hospital. EI # 3 ordered a limited OB Ultrasound (US). EI # 3 was also notified the ROM Test was negative for ruptured membranes.

Further review of the MR revealed the following nursing documentation at 4:00 AM, "EI # 3 updated via telephone of the OB US results and that PI # 2 needed to make a 6:00 AM flight and would need to leave for the airport. EI # 3 stated he/she would be in to round in the AM."

Further review of the MR revealed the following nursing documentation at 4:05 AM, "EI # 4 called EI # 5, Family Medicine Physician, and informed EI # 5 of the OB US results. EI # 5 verbally informed PI # 2 of the results via phone. PI # 2 states she wants to sign out AMA to make flight."

Further review of the MR revealed PI # 2 signed an AMA form at 4:31 AM and departed the OBED at 4:34 AM.

EI # 3 did not present to the OBED during the three hours and 57 minutes the patient was in the OBED to perform a MSE.

An interview was conducted on 9/12/24 at 11:41 AM with EI # 4, RN. EI # 4 stated when the phone report was given to EI # 3 at 1:30 AM, it was reported to the physician PI # 2 was complaining of pressure and said she felt constipated. No contractions had been observed and her abdomen was soft and nontender. EI # 3 responded "I'm not coming in for constipation." EI # 4 responded "I do not know if it is constipation, that is what the patient said."

During the interview, EI # 4 stated EI # 3 instructed him/her to give PI # 2 her OB US results. EI # 4 responded "I can't, that is outside my scope of practice."

Also during the interview, EI # 4 stated EI # 5 was contacted about the OB US results because he/she knew that EI # 5 was sleeping in-house.

An interview was conducted on 9/12/24 at 1:29 PM with EI # 3, OBGYN. EI # 3 stated the OBED was occasionally ran as a triage unit and there had to be a laborist on-call to run as an OBED.

When asked who performs the MSE, EI # 3 stated, "the laborist does." "We (all OB physicians except the laborists) don't staff the OBED. I'm not an emergency physician."

When asked if a patient comes in at night, is it appropriate for them to wait all night to have a MSE completed, EI # 3 stated, "If someone comes in and it is non-emergent, it could wait until the morning."

An interview was conducted on 9/12/24 at 5:24 PM with EI # 1, who confirmed the on-call OB did not complete a MSE on PI # 2.

Based on review of hospital policies and procedures, Medical Staff Rules and Regulations, medical records (MR), and interviews with staff, it was determined the hospital failed to:

1. Provide an appropriate medical screening examination (MSE) within the capability of the hospital's Obstetrical Emergency Department (OBED) including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for two patients who presented to the OBED including Patient Identifier (PI) # 1 and PI # 2 requesting medical assistance.

Findings include:

Hospital Policy: Emergency Medical Treatment and Active Labor Act (EMTALA)
PolicyStat ID: 12492090
Effective Date: 10/6/2022

Standards for Medical Screening Examinations:

1. Patients who come to a Dedicated Emergency Department requesting examination and treatment will be Triaged and receive a Medical Screening Examination by a Qualified Medical Person (QMP).

2. The MSE extends until the point the the QMP determines an Emergency Medical Condition (EMC) does or does not exist. A patient should continue to be monitored based on the patient's needs, and monitoring should continue until the individual is stabilized, admitted, or appropriately transferred...

4. If the MSE does not reveal the existence of an EMC, the patient may, if appropriate, be referred for further non-emergency treatment through the hospital's facilities or a private physician and/or may be discharged with appropriate follow-up instructions documented according to department procedures.

Policy: OBED/Maternity Emergency Care Center (MECC)
PolicyStat ID: 10140471
Effective Date: 5/7/2019
Revised Date: 7/20/2021

Purpose:
In keeping with the core values, this policy serves as an outline of the MECC/OBED processes for providing a MSE and stabilizing treatment for patients experiencing antepartum, intrapartum, and postpartum (up to six weeks) medical conditions such that the absence of immediate medical attention may place the patient or her fetus in serious jeopardy.

Policy:
It is the policy of the MECC/OBED to meet the requirements of the EMTALA...In addition, the MECC/OBED will follow the process, as noted:

...B. Pregnant patients presenting to the MECC/OBED:
1. All OB patients...will be provided such other assessments and stabilizing treatment as are deemed appropriate as a result of the initial MSE...
E. MSE and treatment provided by OB Hospitalist/Laborist...

Ascension St. Vincent's Birmingham Medical Staff Rules and Regulations:

...Emergency Medical Services:

...1. All individuals presenting to the Emergency Department (ED) and/or the Family Birth Place for treatment or examination, or arriving on hospital grounds requesting emergency care, will receive an appropriate MSE. The MSE is complete when enough information, to determine whether an EMC exists, has been obtained and this includes providing all necessary testing and on-call services within the capabilities and capacity of the hospital.

TRIAGE IS NOT A MEDICAL SCREENING EXAMINATION.

A MSE, as defined by the EMTALA (42 U.S.C. 1395dd), may be provided by a Physician or by the following individuals designated as a QMP, including a Nurse Practitioner, a Physician Assistant, a Certified Nurse Midwife, or a Registered Nurse (RN), with each QMP acting within the scope of his/her practice as defined by State Law and in accordance with Hospital's Rules and Regulations. An RN designated as a QMP is limited to only qualified RNs practicing in the Hospital's Labor and Delivery Department and performing a MSE for a pregnant patient with such qualifications established and approved by the Department of Obstetrics and Gynecology (OBGYN).

Designated QMPs are limited to providing MSEs in accordance with written protocols developed in collaboration with Nursing Leadership and the Medical Staff practicing in either the Department of Emergency Medicine or the Department of Obstetrics and Gynecology may develop their own protocols.

Written training programs, written protocols, written and demonstrated competency validation criteria and any competency validation of QMPs by non-physicians shall be approved by the Department of Obstetrics and Gynecology...

An interview was conducted on 9/12/24 at 12:40 PM with Employee Identifier (EI) # 1, OB Nurse Manager. During the interview, EI # 1 stated "RNs have not provided MSEs since 2018 when the laborists were hired." EI # 1 was asked by the surveyor if everyone receives a MSE? EI # 1 stated, "I think it would be situational and up to the physician if they thought it was warranted."

A second interview was conducted on 9/12/24 at 2:30 PM with EI # 1. EI # 1 was asked by the surveyor if physicians could perform a MSE over the phone. EI # 1 stated, "I would think not. I would think it would require them to lay eyes on the patient." EI # 1 was also asked what was a "reasonable" amount of time to perform the MSE. EI # 1 stated, "If a laborist is in-house, 30 minutes is reasonable unless they are in an emergency surgery. If there is no laborist in-house it would depend on the situation and the chief complaint (CC) the patient presents with."

1. PI # 1 presented to the OBED on 9/7/24 at 7:45 PM with a CC of nausea and vomiting. She was 35.3 weeks pregnant. Her treatment included electronic fetal monitoring (per Standing Physician Orders). She was contracting. EI # 2, OBGYN, was not in the hospital but was notified via telephone at 8:29 PM and ordered a liter bolus of Lactated Ringers and then infuse at 125 milliliters per hour. A vaginal examination was performed by EI # 4, RN, due to the contractions.

Review of the MR revealed the following nursing documentation at 9:49 PM, "MD states to overnight obs {observation} patient and he/she will see in the AM."

Further review of the MR revealed EI # 4 explained the plan of care to PI # 1 at 10:00 PM. PI # 1 then stated, "since my cervix is closed, I don't feel that I need to be here, so I want to go home."

Further review of the MR revealed PI # 1 signed an Against Medical Advice (AMA) form at 10:11 PM and departed the OBED at 10:15 PM.

EI # 2 did not present to the OBED during the 2.5 hours the patient was in the OBED to perform a MSE.

An interview was conducted on 9/12/24 at 5:25 PM with EI # 1, who confirmed EI # 2 did not complete a MSE on PI # 1.

2. PI # 2 presented to the OBED on 9/8/24 at 12:37 AM with a CC of abdominal pain, constipation, and possible spontaneous rupture of membranes. She was 20.4 weeks pregnant. She was also from out of state. Her treatment included fetal monitoring (per Standing Physician Orders). An order was also entered at 12:57 AM for a ROM (rupture of membranes) Test.

Review of the MR revealed on 9/8/24 at 1:30 AM, EI # 4 contacted EI # 3, OB physician on call for unattached patients (patients with no prenatal care or patients who receive care elsewhere). EI # 3 was not in the hospital. EI # 3 ordered a limited OB Ultrasound (US). EI # 3 was also notified the ROM Test was negative for ruptured membranes.

Further review of the MR revealed the following nursing documentation at 4:00 AM, "EI # 3 updated via telephone of the OB US results and that PI # 2 needed to make a 6:00 AM flight and would need to leave for the airport soon. EI # 3 stated he/she would be in to round in the AM."

Further review of the MR revealed the following nursing documentation at 4:05 AM, "EI # 4 called EI # 5, Family Medicine Physician, and informed EI # 5 of the OB US results. EI # 5 verbally informed PI # 2 of the results via phone. PI # 2 states she wants to sign out AMA to make flight."

Further review of the MR revealed PI # 2 signed an AMA form at 4:31 AM and departed the OBED at 4:34 AM.

EI # 3 did not present to the OBED during the three hours and 57 minutes the patient was in the OBED to perform a MSE.

An interview was conducted on 9/12/24 at 11:41 AM with EI # 4. EI # 4 stated when the phone report was given to EI # 3 at 1:30 AM, it was reported to the physician PI # 2 was complaining of pressure and said she felt constipated. No contractions had been observed and her abdomen was soft and nontender. EI # 3 responded "I'm not coming in for constipation." EI # 4 responded "I do not know if it is constipation, that is what the patient said."

During the interview, EI # 4 stated EI # 3 instructed him/her to give PI # 2 her OB US results. EI # 4 responded "I can't, that is outside my scope of practice."

Also during the interview, EI # 4 stated EI # 5 was contacted about the OB US results because he/she knew that EI # 5 was sleeping in-house.

An interview was conducted on 9/12/24 at 1:29 PM with EI # 3, OBGYN. EI # 3 stated the OBED was occasionally ran as a triage unit and there had to be a laborist on-call to run as an OBED.

When asked who performs the MSE, EI # 3 stated, "the laborist does." "We (all OB physicians except the laborists) don't staff the OBED. I'm not an emergency physician."

When asked if a patient comes in at night, is it appropriate for them to wait all night to have a MSE completed, EI # 3 stated, "If someone comes in and it is non-emergent, it could wait until the morning."

An interview was conducted on 9/12/24 at 5:24 PM with EI # 1, who confirmed EI # 3 did not complete a MSE on PI # 2.


The facility failed to ensure that their own Policy and Procedure, and Medical Staff Rules and Regulations were followed as evidenced by failing to ensure that PI #1 and PI#2 received an appropriate medical screening examination when they presented to the hospital's OBED seeking medical assistance for pregnancy related complaints.