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Based on tours/observations, staff interviews, review of medical records, and facility documents, the facility failed to comply with the Medicare provider agreement as defined in ?489.20 and ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

The facility failed to meet the following requirements under EMTALA regulations:

489.20(q) Tag A 2402 - Posting of Signs
The facility failed to post EMTALA signage in a place or places likely to be noticed by all individuals entering the emergency department or obstetrics unit as well as those waiting for treatment. Specifically, the facility failed to post EMTALA signage within the triage area and ambulance bay of the emergency department and within the labor/delivery unit. This failure did not ensure compliance with EMTALA regulations or compliance with the facility's own EMTALA policy/procedure.

489.20(r)(3) Tag A 2405 - Emergency Room Log
The facility failed to ensure it had one central log for the tracking of patients who present to the Emergency Department and Labor/Delivery unit seeking care.

489.24(a) Tag A 2406 - Medical Screening Exam
1. The facility failed to ensure bylaws or rules and regulations defined qualified medical personnel (QMP). Instead, the facility stated this designation within its EMTALA policy, however, the EMTALA policy also stated bylaws or rules and regulations would determine QMPs.
2. The facility failed to ensure medical screening exams (MSEs) were clearly evidenced within obstetric/ maternal/ labor & delivery documentation (L&D). Specifically, documentation within L&D patients charts revealed 1 of 4 (#1) sample medical records of obstetric patients whose medical screening exam (MSE) was conducted in L&D did not show evidence that the physician was notified and informed of the patient's status. Further, 4 of 4 sample medical records of obstetric patients treated in L&D did not show evidence of usage of the Obstetrical Medical Screening exam, per the facility's policy/procedure.

Based on observations during tour of the facility, staff interviews, and policy/procedure, the facility failed to ensure EMTALA signage was consistently posted throughout the facility. This failure did not ensure patients were fully informed of their rights and created the potential for a negative outcome.

Findings:

1. The facility failed to post EMTALA signage in a place or places likely to be noticed by all individuals entering the emergency department or maternal unit as well as those waiting for treatment. Specifically, the facility failed to post EMTALA signage within the triage area and ambulance bay of the emergency department and within the labor/delivery unit. This failure did not ensure compliance with EMTALA regulations or compliance with the facility's own EMTALA policy/procedure.

a. The facility's policy titled Emergency Medical Treatment and Active Labor Act, effective 08/08/2013, stated the following: "Posting Signs - 1. The Hospital will post conspicuously, in the dedicated emergency departments... and labor and delivery and psychiatric units as well as all areas defined about and all areas in which patients routinely present for treatment of an emergency medical conditions and wait prior to examination and treatment (such as entrance, admitting areas, waiting room or treatment room), signs in the format of Attachments C and D that specify rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions."

b.
i. Tour of the facility was conducted with the Director of Quality Resource Services (DQ) on 9/08/2013 at approximately 2:20 p.m.

Tour of the emergency department (ED) revealed EMTALA signage was posted in the ED waiting room in two locations: near the registration desk and near the entrance doors. The only triage area/room of the ED was without EMTALA signage. Immediately after passing through the triage area, signage was posted within the ED care area. No signage was present in the ambulance bay of the ED, but it was instead on the floor, leaning in a crevice between the blanket warmer and wall. EMTALA signage was posted within the separate entrance used only for correctional facility patients/ individuals. The DQ and Emergency Department Director confirmed these observations.

Tour of the Obstetrics/ Labor & Delivery unit was conducted at approximately 3:10 p.m. The facility had just opened a new L&D unit approximately five days prior to survey. There was no EMTALA signage posted within the new unit. Tour of the old unit, located across the hall, revealed EMTALA signage still posted on the wall. The DQ and Labor & Delivery Director confirmed these observations.

ii. An additional tour of the facility was conducted with the Director of Quality Resource Services on 9/09/2013 at approximately 9:30 a.m. Tour of the ED revealed signage had been posted within both the ambulance entrance and triage room/area. Tour of the L&D unit revealed signage had been placed on the wall of the new unit.

Based on review of facility documents, policy/procedure, and staff interview, the facility failed to ensure it had one central log for the tracking of patients who present to the Emergency Department and Labor/Delivery unit seeking care. The facility utilized four logs between the Emergency Department and L&D unit in order to comprehensively track each EMTALA patient. Despite that the facility was cited for this deficiency over a year prior, the facility failed to implement a correction which included one central log for EMTALA patients, including patients who present to the emergency department (via walk-in, ambulance, or with police/correctional officers) and the L&D department (via walk-in or otherwise). Specifically, 5 of 20 sample medical records (#s 1, 2, 3, 15, & 19) were not captured on the facility's new main central log: the handwritten triage log. Sample medical record #s 1-3 were obstetric patients who did not enter the facility via triage and sample medical record #s 15 and 19 were patients who came in through the ambulance bay or police/correctional entrance. This failure did not ensure one central log was maintained and did not afford prompt retrieval and identification of EMTALA patients.

Findings:

1. The facility failed to maintain one central log to track EMTALA patients.

a. Document Review

i. Review of facility logs was conducted on 10/08/13. The facility provided three logs in order to identify EMTALA patients: (a.) the computerized emergency department log generated by the facility's electronic medical record, (b.) the handwritten book wherein infant deliveries were documented, and (c.) loose leaf papers which contained handwritten entries and patient labels of those patients treated and discharged on the L&D unit. Upon tour in the emergency department at approximately 2:20 p.m., the Emergency Department Director reported that another (d.) handwritten log was maintained within triage.

ii. The logs were reviewed and a sample of 20 patients was chosen. Sample #s 1 through 3 were obtained from the (c.) loose leaf papers which contained handwritten entries and patient labels of those patients treated and discharged on the L&D unit. Sample #4 was identified via the (c.) loose leaf papers which contained handwritten entries and patient labels of those patients treated and discharged on the L&D unit, (a.) the computerized emergency department log generated by the facility's electronic medical record, and (d.) the handwritten log maintained within triage. Sample #4 was later determined to have had two emergency room visits as well a L&D unit visit on the same day. All sample medical records #5 - 20 were on both (a.) the computerized emergency department log generated by the facility's electronic medical record and the (d.) handwritten log maintained within triage, except for sample medical records #s 12, 13, 15, and 19. Sample medical records #s 12 & 13 were only located on the (d.) handwritten log maintained within triage, as they were patients who were never registered or treated, however, presented to the emergency department seeking treatment and their representative consulted with the emergency department charge nurse, but sought treatment elsewhere. Sample medical records #s 15 & 19 were only located on the (a.) the computerized emergency department log generated by the facility's electronic medical record. Sample medical record #15 was a patient brought in by ambulance who, therefore, did not present through the triage unit but instead via the ambulance bay/entrance. Similarly, sample medical record #19 was a patient brought in by correctional or police officers who presented via the correctional facility patients'/individuals' entrance.

b. Interviews

i. An interview was conducted with the facility's Emergency Department Director on 10/08/13 at approximately 3:30 p.m. When asked what the facility's one central log was, s/he stated it was the computerized emergency department log generated by the facility's electronic medical record, as that tracked all admissions, however, s/he acknowledged that log did not track all patients who present to the emergency department.

ii. A joint interview was conducted with the facility's Director of Quality Resource Services (DQ) and Emergency Department Director (EDD) on 10/10/13 at approximately 2:30 p.m. Both the DQ and EDD reported the emergency department log was cited on an EMTALA survey conducted over sixteen months prior. As their electronic medical record log did not capture all patients who presented to seek care, but rather only those admitted, they stated their plan of correction for the previous citation was the handwritten triage log. Additionally, they stated this plan of correction was approved by CMS (Centers for Medicare/Medicaid) and implemented thereafter. The DQ and EDD reported this plan of correction was more achievable, as their electronic system did not allow entry and recording of patients unless they were registered and treated. Although this plan of correction afforded capture of all patients who presented to the emergency department waiting room, it did not afford capture of all patients who presented through the ambulance bay, correctional/police entrance, or obstetric unit. Therefore, neither the computerized emergency department log generated by the facility's electronic medical record nor the handwritten log maintained within triage were comprehensive of all patients who presented to the facility seeking emergency care.

Based on review of facility documents, policy/procedure, and staff interviews, the facility failed to ensure it defined who was designated as qualified medical personnel (QMP) and authorized to conduct a medical screening exam (MSE) within its bylaws or rules and regulations. Additionally, the facility failed to clearly document in each maternal record that a medical screening exam was conducted, a physician was notified, the patient was determined not to be in active labor, and safe for discharge. These failures did not clearly delineate facility processes and created the potential for a negative outcome.

Findings:

1. The facility failed to ensure Hospital bylaws or rules and regulations defined qualified medical personnel (QMP). Instead, the facility stated this designation within its EMTALA policy, however, the EMTALA policy also stated Hospital bylaws or rules and regulations would determine QMPs.

a. The facility's policy titled Emergency Medical Treatment and Active Labor Act, last effective 08/08/2013, stated the following: "The Hospital will provide an appropriate medical screening examination (MSE) within the capability of the Hospitals' dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists. The examination will be conducted by an individual(s) determined qualified by the Hospital Bylaws or rules and regulations."

b. An interview was conducted with the facility's Chief Medical Officer on 10/10/13 at approximately 12:30 p.m. When asked if designation of the QMPs was delineated within the facility's Bylaws or Rules/Regulations, s/he stated s/he was essentially the "keeper" of those documents and that QMP was not addressed within any.

c. The facility's Governing Body Bylaws, Medical Staff Bylaws, and Medical Staff Rules and Regulations were reviewed on 10/09/13. QMPs and which staff were designated to conduct a MSE was not defined in any of the three documents.

2. The facility failed to ensure medical screening exams (MSEs) were clearly evidenced within obstetric/ maternal/ labor & delivery documentation (L&D). Specifically, documentation within L&D patients' charts revealed 1 of 4 (#1) sample medical records of obstetric patients whose medical screening exam (MSE) was conducted on L&D did not show evidence that the physician was notified and informed of the patient's status. Further, 4 of 4 sample medical records of obstetric patients treated in L&D did not show evidence of usage of the Obstetrical Medical Screening exam, per the facility's policy/procedure.

a. The facility's policy titled Obstetrical Medical Screening Exam, last reviewed 10/2010, stated the following:
"C. The L&D RN will notify the primary obstetric provider or attending/consulting obstetric provider on call promptly if any of the following high risk findings are present or suspected: 1. Vaginal bleeding 2. Acute abdominal pain 3. Temperature of 100.4 or higher 4. Preterm labor/threatened AB 5. Preterm rupture of membranes 6. Hypertension 7. Indeterminate or abnormal (Category II or III) fetal heart tracing
D. In the absence of the high risk factors above, the L&D RN will continue to assess and notify the primary obstetric provider or attending/consulting obstetric provider on call of patient status within 60 minutes of arrival.
E. The L&D RN will utilize the Obstetrical Medical Screening exam (see attached tool) to determine if the patient may be discharged after a minimum of a 60 minute evaluation. 1. If the score is 7 or less on the evaluation tool, the patient may be dismissed with a telephone order from the primary obstetric provider or attending/consulting obstetric provider on call. 2. If the score is 8 or greater on the evaluation tool, an obstetrical medical screening exam by an OB provider must be done prior to discharge ...
G. Discharge instructions shall state "the patient is certified to be medically stable or in false labor" and should include recommendations to return to the hospital if: 1. Contractions increase 2. Fetal movement decreases 3. Membranes rupture 4. Other warning signs occur (e.g. bleeding, fever)"

b.
i. Review of medical records was conducted on 10/09/13. Four maternal patients were evaluated and treated within the L&D unit. Review of sample medical records #2 through #4 revealed, within the nurses' documentation in the obstetric electronic medical record, that the obstetrician was notified of the patients' arrivals to the unit and status within 60 minutes of presentation, per the facility's policy/procedure. Sample medical record #1 contained no documentation that an obstetric physician (or midwife or other provider) was contacted. Although verbal orders were entered in the facility's general electronic medical record, no documentation existed within sample medical record #1 that the patient's obstetric provider was notified of the patient's status and that a consultation was conducted regarding the patient.

ii. Review of medical records revealed difficulty in determining that the patients' medical screening exams were conducted. The facility's policy, Obstetrical Medical Screening Exam, guides the staff to "utilize" the Obstetrical Medical Screening exam to determine if a patient may be discharged. The tool guides the staff member to evaluate up to 19 elements regarding the patient's labor, including but not limited to cervical change, effacement, membrane status, contractions, vaginal bleeding, vital signs, and pain. In sample medical records #s 1 through 4, no documentation existed which referenced this tool or score. Therefore, identification if an adequate MSE was conducted was cumbersome and unclear.

iii. Sample medical records #s 1 through 4 contained no physician documentation, discharge diagnoses, or clear identification of why the patients were treated. Each patient was evaluated, some treated, and then all discharged home without delivery of child. Physician communication was done via telephone only. Each patient's medical record contained a "OB Preterm Discharge Instructions" form, which contained four separately title sections: if you think you are in labor, urinary tract infection, preterm labor, and other instructions. Despite what the patients were treated for, none of the four sections were marked within any of the charts and, rather, the form was signed and dated.

c. On 10/10/13, and interview was conducted with the facility's L&D Director.

i. When asked about physician notification and documentation of such within the electronic medical record, specifically in sample medical record #1, s/he stated that in order to obtain the orders, the physician would have been notified, despite that it was not specifically documented.

ii. When asked if staff filled out and documented the results of the Obstetrical Medical Screening exam, s/he stated they did not. S/he continued, "They look at it and, if there is a question on it, they would tell the provider the score and that s/he needs to come in to see the patient. The numbers are kind of built into our heads."

iii. Finally, when asked about lack of discharge diagnoses and lack of delineation on the discharge instructions, s/he stated that staff go over each of the four categories with patients, regardless the reason the patients were treated/seen on the unit. Therefore, if a patient was evaluated for pre-term labor, she would still receive instructions on urinary tract infections. The L&D Director confirmed there was not a clearly defined discharge diagnosis within the patient's medical record.