HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient presenting at the hospital emergency department received an appropriate and complete medical screening examination according to hospital policy and current standards of care for 1 of 20 emergency department patients [Patient #1].

Findings were:

Facility policy entitled "ED-020 Gravid Patients Presenting to the Emergency Department," effective date 2/11/19, included the following:
"SCOPE
Applies to Women's Services Department (OB) and Emergency Department (ED) at Seton Medical Center Harker Heights.

PURPOSE
To ensure the highest quality care between the OB and ED for gravid patients. It is the shared intent of the Perinatal and Emergency Department to provide the highest level of care for all gravid patients.

POLICY
Ob/Gyn physicians are not staffed 24/7 on Labor and Delivery, but there is always an on-call OB/Gyn physician.

PROCEDURE
In order to better triage and provide optimal care for all gravid patients the following guidelines are to be followed ...
2. Patients 20 weeks or greater gestation who present to SMCHH (Seton Medical Center Harker Heights) with a non-obstetrical complaint should receive treatment in the ED. Non-obstetrical problems include but are not limited to chest pain, dyspnea, asthma attack, active seizure activity, unstable hemorrhaging (if vaginal bleeding, must be stable prior to transfer to L&D, keto-acidosis, or trauma ...
5. For all patients transferred between ED and OB units (a) a full report including the patients' chief complaint, gestational age, and vital shall be given verbally by ED staff to L&D staff. Doctor to doctor communication is preferable, but at times may be any doctor or nurse involved directly in the patients [sic] care; (b) the patient's problem must be manageable by OB - immediate life-threatening conditions such as chest pain, asthma exacerbation, active seizures, hemorrhaging, etc. should remain in the ED until the patient is stable for transfer ...
6. ...For patients greater that 28 weeks gestation, after being treated in the ED, and the plan of care is to discharge home, the patient may be transferred to OB Triage for Fetal Heart Rate Monitoring. Once a reactive strip is obtained, the OB physician may approve discharge of patient ..."

Facility policy entitled "EM004 Medical Screening Examination and Stabilization," effective date 3/29/19 included the following:
" ...PURPOSE
To ensure that all individuals who Come [sic] to the Emergency Department ... receive an appropriate Medical Screening Examination and further examination and Stabilizing [sic] treatment as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder.
1. POLICY
1.1 Any individual who comes to the Emergency Department will be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination to determine if the individual has an Emergency Medical Condition ...
2.3 Personnel who May Perform the Medical Screening Examination
2.3.1 The Medical Screening Examination may be performed by a Physician or Qualified Medical Person who is qualified to conduct such examination.
2.3.2 The Hospital and its Medical Staff will determine the categories of Qualified Medical Persons who may perform the Medical Screening Examinations ..."

Facility policy entitled "WOMEN'S-L&D-028 Medical Screening Examination for Labor Status by Qualified Medical Personnel," original approval date 12/31/12, included the following:
"SCOPE
To provide appropriate assessment and treatment for the obstetric patient at 20 weeks of gestation or greater who presents to Labor & Delivery as an unscheduled OB patient.

POLICY
A physician or qualified medical personnel (QMP) will perform the medical screening examination for all patients who present the [sic] Labor and Delivery Unit for emergency care ... the obstetric registered nurse with demonstrated competency can act as the QMP in Labor and Delivery, in order to perform a medical screening examination for labor status...

Primary OB Triage:
Initial contact with the patient to determine acuity. It includes: Name, Physician, Gravida/Parity, Gestational Age, Medical and Obstetrical history, Chief Complaint and Pain Assessment.

Secondary OB Triage:
Periodic Reassessment to be done within the time frame set for that acuity. It includes Maternal Vital Signs, Fetal Heart Tones, Pain reassessment and questions 'Any changes in condition/chief complaint?'

Medical Screening Exam (MSE):
Medical exam of sufficient scope as to reasonable [sic] be intended to determine whether an emergency medical condition exists, and includes all necessary testing and on-call services within the capability of the hospital to reach a diagnosis ..."


A review of the emergency department record of Patient #1 revealed she presented at the Seton Medical Center Harker Heights emergency department on 1/18/20 due to a motor vehicle accident. A local fire department responded to the accident, and the fire department patient care record included documentation of a full patient assessment with no abnormal findings with the exception of an entry entitled "General," which included the following:
"Pt is 30wks pregnant and would like to be seen for an ultra sound ..."
Additional documentation on the form included:
"Primary Impression: No complaints or Injury/Illness Noted...
Chief Complaint: I just want to be checked out ..."

Vital signs at 10:15 p.m. were as follows:
Blood pressure 165/91 (slightly elevated), Pulse 140 (rapid), 17 breaths/min (normal), oxygenation on room air 99%, no temperature noted.

Vital signs at 10:30 p.m. were as follows:
Blood pressure 160/90 (slightly elevated), Pulse 125 (rapid), 17 breaths/min, oxygenation on room air 98%, temperature 98.2

A fire department note read as follows:
"...dispatched to two vehicle accident on [intersection of two streets] ... one vehicle with minor damage to front passenger side bumper under the bridge facing southbound ... the driver of this vehicle is a 21 yof (year-old female) with no chief complaints was just wanting to have Vitals checked. EMS Checked vitals and the Pt was assessed with an unremarkable findings [sic] besides the obvious pregnancy. Pt states that she is fine and wanted some help to gather her belongings from the wrecked car and EMS did so ... After a few moments of staying onscene the 21 YOF walks up and states that she would like to be transported to the ER for further evaluation. EMS questions the Pt again and ask what is hurting or what is wrong? The Pt states she feels fine but her husband wants her to go to the ER for an ultrasound. EMS walk the Pt to the MICU (Medical Intensive Care Unit) and transport begins routine traffic to Seton ER. Pt report is given via Radio. Upon arrival to Seton ER Pt is taken by ER staff to L&D (labor and delivery) and Pt report is given to escort for L&D ..."

The fire department documentation indicated arrival at Seton Harker Heights at 10:32 p.m. on 1/18/20. A section entitled "Patient Transport Details" included the following:
"How was Patient Moved to Ambulance: Assisted/Walk
Patient Position During Transport: Sitting
How was Patient Moved From Ambulance: Assisted/Walk
Condition of Patient at Destination: Unchanged ..."

Patient #1 appeared on a "Women's Services Triage Log" for that date at 10:40 p.m. Her chief complaint was listed as "MVA (motor vehicle accident)" with an entry under the "Services" column as, "Vitals, NST (non stress test), monitor for 1 hr."

A non stress test (NST) is a way to check fetal health. It records fetal movement, heartbeat and contractions in the 3rd trimester to check that the fetus is getting enough oxygen. The following is included as reference from Medline:
(available at: https://medlineplus.gov/ency/patientinstructions/000485.htm)
"Non-stress Test (NST)
A healthy baby's heart rate will rise from time to time. During the non-stress test (NST), your provider will watch to see if the baby's heart rate goes faster while resting or moving. You will receive no medicines for this test.
If the baby's heart rate does not go up on its own, you may be asked to rub your hand over your belly. This may wake up a sleepy baby. A device may also be used to send a noise into your belly. It will not cause any pain.
You will be hooked up to a fetal monitor, which is a heart monitor for your baby. If the baby's heart rate goes up from time to time, the test results will most likely be normal. NST results that are reactive mean that the baby's heart rate went up normally.
Non-reactive results mean that the baby's heart rate did not go up enough. If the heart rate does not go up enough, you may need more tests.
Another term you might hear for this test result is a categorization of 1, 2, or 3.
* Category 1 means the result is normal ..."

An OB Triage nursing note on 1/18/20 at 10:56 p.m. included the following:
" ...Patient presents with
* Motor Vehicle Crash...Slow moving fender bender no other complaints or complaints of pain

Assessment

Vital Signs:
Vitals 1/18/20 2253
BP (blood pressure): 125/72
Pulse: (!) 116 (rapid)
Resp: 18
Temp: 37.1 ºC (98.7 ºF) ...

Cervical Exam: [blank] ...

Uterine Activity
Mode: Toco (tocodynamometer - records fetal heartbeat and uterine contractions in 3rd trimester of pregnancy) ...

Pt denies any leaking or bleeding or abdominal pain ...

2321 Report called to [physician name], Slow moving MVA at 2205, Pt denies any pain, leaking of fluid or bleeding, active fetal movement observed and heard on US (ultrasound) monitor Vitals WNL (within normal limits). No contractions tracing TOCO or palpated. Small seat belt mark to Pt sternum between collar bones. Verbalized understanding and stated to monitor for 1 hour and if no contractions or decelerations Pt can be DC (discharged), does not feel an ultrasound is indicated at this time Pt to follow up with provider. Repeated back and carried out ...

I have reviewed this information with [physician name]. Orders received to discharge patient home and to see patient's provider ...
1/18/20 10:56 PM ..."

Patient #1 was discharged home at 12:20 a.m. on 1/19/20.

A final nursing note on 1/19/20 at 12:15 a.m. included the following:
"Pt further denies any pain, leaking or bleeding and states baby is still actively moving.
Cat I strip (category 1 result on NST), no contractions traced/ palpated/ felt by patient. Monitors removed.
DC instructions given verbally and written, questions addressed and answered. Pt verbalized understanding. Pt changed into personal clothing and ambulated off unit with steady gait in stable condition to personal transportation home with parent ..."

In an interview with Staff #12, Director of Emergency Services, on the morning of 10/26/20 at approximately 9:50 a.m. in the hospital conference room, she stated, "This person would have been in a wheelchair and taken down to L&D ... She wouldn't be on the ED log because she was being seen in L&D. We wouldn't write her down on the ED log if that's the case." When asked if L&D kept a separate log of patients presenting there, she said she believed they did. In a subsequent interview with Staff #12 on the morning of 10/27/20 at approximately 10:15 a.m., she stated, " ...This patient probably should have been seen in the ED because of the MVA ..."

In a telephone interview with a relative of the patient on the evening of 10/26/20 at 8:01 p.m., he stated, "There were a couple of reasons for this complaint. First, no medical screening examination was done... And second, she was never seen by an MD, DO or NP (nurse practitioner). She arrived after an air bag had been deployed. It was determined she needed to go to the hospital by EMS. When she arrived at the ER, the nurse in the ER didn't even examine her. She didn't even get her blood pressure. The nurse had her get off the gurney without her even being examined. She walked herself over to the ER and to L&D without even knowing if it was safe for her to walk. They denied the ultrasound. It was never done. She asked that someone call her physician. That was denied. They said it wasn't a physician in Killeen who worked there ..."