HospitalInspections.org

Based on record review and staff interview, the hospital failed to comply with its policy and procedure to provide a medical screening examination within its capabilities to determine whether an emergency medical condition was present for an individual that presented to the Emergency Department/Birthing Center Triage seeking care in one of twenty one sampled emergency/birthing center triage department patients (patient #1) from October to November 2014.


Findings include:


- The hospital's policy titled "Medical Screening Exam (MSE), Care of the Perinatal Patient Receiving" with an effective date of 2/14/2012 reviewed on 11/25/14 at 8:30 AM directed, "1. All pregnant patients presenting to Special Addition Birth Center requesting care will have a medical screening exam...Medical Screening Exam is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Emergency Medical Condition (EMC) means a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate attention could reasonably be expected to result in: 1) placing the health of the woman or her unborn child in serious jeopardy...Labor is defined by EMTALA as the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. a woman is in true labor unless a physician or qualified medical personnel certifies that, after a reasonable amount of time, the woman is in false labor. Under EMTALA guidelines, any pregnant woman with contractions present is legally defined as unstable. Under "Assessment" the policy directed, "Assess for contraindications to medical screening exam being performed by nurse including, but not limited to : a) judgment by nurse performing medical screening exam that physician's exam is necessary."


- Patient #1's closed medical record review on 11/24/14 and 11/25/14 revealed patient #1 presented to the birthing center on 11/5/14 at 2:32 AM complaining of cramping and vaginal bleeding. Patient # 1 remained in the labor and delivery triage area for observation until discharge. At 6:46 AM, Certified Nurse Midwife A (CNM A) diagnosed patient # 1 with false labor (irregular contractions occurring before true labor), questionable prolonged rupture of membranes, negative nitrazine and negative fern test, and planned to hold patient # 1 in labor and delivery triage for evaluation by OB physician staff E. CNM A documented, " Dr. [staff C] feels it best for Dr. [staff E] to see and evaluate this patient as Dr. [staff E] is coming to hospital for a 0730 C/S " (a 7:30 AM Caesarean Section). At 7:00 AM, the day shift OB nurse staff F assessed patient # 1 but did not perform any further vaginal exams. At 7:17 AM the OB nurse staff F documented she paged OB physician staff E and received orders to discharge patient # 1 prior to an examination. Review of a second medical record showed an ambulance trip report that indicated patient #1 delivered her baby in her home on 11/5/14 at 9:14 AM, approximately one hour and 45 minutes after discharge. Refer to tag A2406 for details.

Based on record review and staff interview, the hospital failed to provide an appropriate medical screening examination within its capabilities to determine whether an emergency medical condition was present for an individual that presented to the Emergency Department/Birthing Center Triage seeking care for one of twenty one sampled emergency/birthing center triage department patients (patient #1) from October to November 2014.


Findings include:


- The hospital's policy titled "Medical Screening Exam (MSE), Care of the Perinatal Patient Receiving" with an effective date of 2/14/2012 reviewed on 11/25/14 at 8:30 AM directed, "1. All pregnant patients presenting to Special Addition Birth Center requesting care will have a medical screening exam...Medical Screening Exam is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Emergency Medical Condition (EMC) means a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate attention could reasonably be expected to result in: 1) placing the health of the woman or her unborn child in serious jeopardy...Labor is defined by EMTALA as the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. a woman is in true labor unless a physician or qualified medical personnel certifies that, after a reasonable amount of time, the woman is in false labor. Under EMTALA guidelines, any pregnant woman with contractions present is legally defined as unstable. Under "Assessment" the policy directed, "Assess for contraindications to medical screening exam being performed by nurse including, but not limited to : a) judgment by nurse performing medical screening exam that physician's exam is necessary."



- Patient #1's closed medical record review on 11/24/25 and 11/26/25 revealed patient #1 presented to the birthing center on 11/5/14 at 2:32 AM complaining of cramping and vaginal bleeding. Documentation by Certified Nurse Midwife (CNM) staff A showed that patient #1 stated she possibly had food poisoning and reported bloody discharge when wiping with toilet tissue. Further documentation showed that patient # 1 was 36.2 weeks pregnant (full term pregnancy is 40 weeks).

Under "Progress Note" , page 25 of the medical record, Certified Nurse Midwife (CNM) A documented that patient # 1 stated she had been leaking large amounts of pinkish fluid since Thursday evening after her last OB appointment. Further documentation on page 26 showed, "wet pinkish fluid discharge present on glove following exam, perineum appears wet." On page 42 of the medical record under "Assessments" at 2:56 AM documentation showed that three sterile vaginal exams were performed due to difficulty finding patient # 1's cervix, "10 inch diameter of pinkish fluid present on chux (disposable absorbent bed pad) following exams." At 3:00 AM, CNM A performed a vaginal exam with a speculum and documented no pooling [of amniotic fluid] visualized. At 4:20 AM OB staff nurse D performed a vaginal exam and documented patient # 1 was dilated a fingertip (approximately 2 cm) with pink tinged vaginal bleeding. At 6:00 AM, CNM A performed the last vaginal exam and documented that patient # 1's cervix remained dilated a fingertip (full dilation is 10 cm) with pink tinged vaginal bleeding.

Under "Assessment", page 38 of the medical record, the night shift OB nurse staff B documented patient # 1 rated her pain a three (on a scale 1 - 10) at 3:18 AM and patient # 1 indicated her pain had increased to five at 6:00 AM.

Review of patient # 1's external monitoring strips (used to measure the baby's heartbeat and the strength and duration of contractions) revealed inability to see the mother's contractions from 6:04 AM to 6:47 AM (pages 26-31 of 46).

At 6:46 AM, near the end of the night shift, CNM A documented under "Impression and Plan", page 27 of the medical record, that they had reviewed all the documentation and discussed patient # 1's care with the on call OB physician staff C. CNM A diagnosed patient # 1 with false labor (irregular contractions occurring before true labor), questionable prolonged rupture of membranes, negative nitrazine and negative fern test, and planned to hold patient # 1 in labor and delivery triage for evaluation by OB physician staff E. CNM A documented, "Dr. [staff C] feels it best for Dr. [staff E] to see and evaluate this patient as Dr. [staff E] is coming to hospital for a 0730 C/S" (a 7:30 AM Caesarean Section).

At 7:00 AM, the day shift OB nurse staff F assessed patient #1 but performed no further vaginal exams. At 7:17 AM OB nurse staff F documented they paged OB physician staff E and received orders to discharge patient #1. OB nurse staff F documented they provided patient #1 with discharge instructions specific to False Labor and at 7:31 AM placed patient #1 in a wheel chair and took her to her car. The medical record indicated patient #1 was discharged at 7:38 AM (one and one-half hour after her last vaginal examination).

The medical record did not contain evidence that patient # 1 received a medical screening examination sufficient to determine the presence of an emergency medical condition including retesting of the pink tinged fluid, examination by the OB hospitalist due to patient # 1 ' s prolonged leaking of fluid and difficulty finding the cervix, or examination by OB physician staff E as agreed upon by CNM A and the on call OB physician C to determine further cervical dilation (progression of labor).


Review of a second medical record showed an ambulance trip report that indicated patient # 1 delivered a baby in her home on 11/5/14 at 9:14 AM, approximately one hour and 45 minutes after discharge from Shawnee Mission Medical Center's birthing center. At 9:29 AM the ambulance departed patient # 1's home and took her and her baby back to the hospital birthing center for further care.

In an interview on 11/24/14 at 2:42 PM, the Interim Birthing Center Director staff H stated that the birthing center has three triage rooms where patients stay until admitted or discharged, and that the triage area is staffed with a Certified Midwife and a Registered Nurse.

In an interview on 11/24/14 at 6:29 PM patient #1 stated that when she got to the hospital she was taken to a triage room. Two nurses did a vaginal exam and one said she was at nine and one wasn't sure. The head nurse then did a vaginal exam and said she wasn't dilated. She said that her pain had gotten worse at discharge, that she was still having contractions and bloody discharge. "I couldn't walk, my husband had to ask for a wheelchair."

In an interview on 11/26/14 at 9:35 AM CNM A stated that the patient was a high-risk patient due to chronic hypertension (high blood pressure), gestational diabetes, and advanced age. CNM A stated that it was difficult to find the opening of patient #1's cervix. CNM A stated that the OB charge nurse staff D found the opening of the patient's cervix and thought it was dilated only 2 cm (fingertip), another OB nurse staff B at one time thought patient # 1 was almost completely dilated (9 cm). CNM A stated patient #1 was 100% effaced (cervix is paper thin), -2 station (refers to the position of the baby's head in relation to the pelvis. A negative number (-5 to 0) means that the head isn't engaged in the pelvis), and dilated fingertip. CNM A stated that at first the patient did not say that she had fluid discharge since her last vaginal examination by her physician. CNM A had concerns that the patient might have ruptured membranes and CNM A thought to be on the safe side he/she would have the physician evaluate patient #1 because of the potential for rupture of the membranes. CNM A stated that he/she checked patient #1 several times during the night and there was no change in her cervix. CNM A further stated that he/she spoke to the on-call OB physician staff C several times during the night. CNM A stated that it was their understanding when they left their shift in the morning that OB physician staff E was coming to examine the patient.

In an interview on 11/25/14 at 7:50 AM, OB nurse staff B stated that sometime between 5:00 AM and 6:00 AM, CNM A contacted OB physician staff C and indicated that they wanted the patient kept until OB physician staff E could examine the patient in the morning.

In an interview on 11/25/14 at 8:10 AM, OB nurse staff F related that OB physician staff C wanted the patient's own physician (staff E) called. She called OB physican staff E and received an order to discharge patient #1. OB nurse staff F stated that Physician staff E did not come in to examine the patient.

In an interview on 11/25/14 at 8:30 AM, the Interim Labor and Delivery Manager staff indicated the hospital has an OB Hospitalist who is available for consults. The OB hospitalist ruptures membranes, attach internal monitors and see OB patients that had no prenatal care. The Interim Manager also stated the hospital has four OB hospitalists that rotate shifts and supervise the Midwives.

- Review of the November 2014 OB Hospitalist Call Schedule 11/24/14 at 4:00 PM revealed OB hospitalist staff G on call. Patient #1's medical record lacked evidence that OB hospitalist G examined patient #1.