HospitalInspections.org

Based on observations, interviews, and document review, it was determined the facility staff failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition exists for one (1) of twenty-one (21) patients.

The findings include:

On 10/17/2022 at 2:06 p.m. the surveyor conducted a tour of the emergency department (ED) and the facility's Family Birthing Center (FBC) with Staff Members (SMs) 1, 2, and 6 (Chairman of the ED). The surveyor conducted a second tour of the emergency department waiting room at 3:26 p.m. with SMs 1, 3, and 7, for clarification on how patients are received, directed, and screened in the waiting area.

During the facility tour on 10/17/2022 at 2:06 p.m., as per SM6, patients presenting to the ED, FBC, and outpatient services enter the facility through this same ED waiting room location. Patients are met by a greeter and directed to either outpatient services down the hall, or to the screening desk behind the greeter that is manned by a paramedic. The paramedic will screen patients presenting for emergency and labor and delivery services. The paramedic obtains the patient's name, date of birth (DOB), reason for coming to the facility, and is provided an identification band. Patients for the ED will be directed to the ED triage, performed by a nurse. Pregnant women less that twenty (20) weeks pregnant will also be referred to the ED triage. Pregnant women greater than twenty (20) weeks pregnant will be directed to the FBC, unless they present for a non-pregnancy related issue, then they will go to the ED triage. Pregnant women presenting to the FBC would be taken to a labor and delivery triage room for registration and input into the electronic medical record system called OBIX, and also triaged and assessed.

A review of the facility's FBC's non-electronic patient log provided evidence that Patient #2's name was handwritten on the log, where all other patient's names and DOBs were on a printed label placed on the log. The log also included Patient #2's reason for visit (34 w IUFD (intrauterine fetal demise)), time in (8:38 p.m.), and disposition (AMA).

A review of a printed version of the facility's FBC's patient encounter log from the OBIX fetal monitoring system (FMS) from about 9/17/2022 through 10/17/2022, provided evidence that Patient #2 was not documented on the patient encounter log in the facility's OBIX FMS. As per SM13, the OBIX FMS is a system that provides electronic fetal monitoring and integrates with the facility's EMR, Meditech. SM13 stated that if a patient is registered, their information would be found in the OBIX FMS.

On 10/18/2022, the surveyor reviewed twenty-one (21) patient medical records with SM12. There was no medical record for Patient #2 from their visit to the FBC on 9/23/2022. SM3 later provided the surveyor with the late entry documentation that was written by SM8 (Obstetrician), SM9 (L&D Nurse), and SM10 (L&D Nurse), recapping their accounts of the events that occurred with Patient #2 on 9/23/2022.

The medical record for Patient #2 contained the evidence that SM9 documented " ...This nurse gave a brief report that two other triages were here. One being 39wk and contracting, and the IUFD is also here. MD stated "I'm not going to do anything with her, why is she here. This is so confusing. How do we even know the baby is dead?" This nurse stated on [this nurse's] records its stated IUFD. Also stated this nurse can monitor PT [patient] and attempt to get FHT [fetal heart tones]. MD stated "Absolutely not. Don't you touch [the patient]. Don't put anything on [the patient]." This nurse stated "Then I need you to come in and talk to them." MD stated [MD] was coming in ...[Spouse] stated that this is a joke. Asked if they were going to be billed $2,000 for just sitting here. This nurse stated that officially they were still not admitted to unit that MD needs to give that order out ...This nurse, two other nurses and MD at nurses station, discussing happenings. MD asked if they could sign out AMA (against medical advice), reminded MD that [patient] was never admitted but this nurse can definitely have them sign ...MD stated "I don't understand why they left." Reminded MD that [MD] said [MD] wasn't going to treat. MD attempted to state, [MD] never said that. Asked if pt had vitals done. This nurse stated no, you said "Not to monitor [the patient] at all". MD stated, I did not. It was the baby not to monitor". It was discussed what occurred when the phytsician [sic] initially found out [the patient] was coming in and [MD's] response to the nurses ..."

A late entry by SM8 on 10/9/2022 contained the documentation, "I introduced myself and noted they were leaving the room. [Spouse] said they had rights to be seen, over and over. I said I am here. The nurse repeated to them I was just in emergency situation. [Spouse] was speaking mostly and did yell loud enough over me, so I did not say much. I apologized to them for this wait and the sad news of fetal loss and said I am here now. However, [spouse] said [spouse] was waiting no longer and was leaving and had no confidence in me, saying that [three] 3 times. I did not understanding [sic] why [the spouse] said that and then [the spouse] said [the spouse] was reporting me to the CEO, CMO, several other places and the licensing board and left. [The spouse] told us [the spouse] was recording everything and pointed to [the spouse's] pocket. This encounter lasted less than a minute. I asked nurse to get a signature for AMA or I was going to write a note on the chart and no chart was created. I had no idea what was happening with this patient and why [the spouse] felt [the patient] was not getting care when [the spouse] was told I was in an emergency and I am the only doctor available ...Regardless, any patient was coming via the ED for urgent or medical care would be seen. Of course, anyone meeting criteria will be admitted and cared for. I did not have a chance to decide the status of patient once [the patient] arrived as stated above ...They left without being seen."

During an interview on 10/17/2022 at 4:05 p.m., SM3 stated that the facility is aware of the complaint the surveyor is investigating. The facility has met with the family of Patient #2 mentioned in the complaint. SM3 stated that Patient #2 should have been on the central log but was not. SM3 stated that staff should have registered Patient #2 and a Medical Screening Examination (MSE) should have been completed.

During an interview on 10/18/2022 at 9:00 a.m., SM8 relayed to the surveyor SM8's account of the encounter with Patient #2 and the patient's family on 9/23/2022. SM8 stated that a nurse notified SM8 that Patient #2 had presented to labor and delivery (L&D) with a fetal demise. L&D had received records for Patient #2 from the patient's obstetrician. At the same time, a pregnant patient presented with vaginal bleeding and SM8 tended to that patient first. The patient with vaginal bleeding required an emergency cesarean (c-section) delivery, and SM8 performed that procedure. About an hour or so later, after SM8 completed the c-section, nursing staff reminded SM8 about Patient #2. When SM8 entered Patient #2's room, Patient #2 and spouse were "standing and walking out the door". SM8 recalled the patient's spouse stating "I know my rights" and the spouse asked how the doctor would know if the patient was septic or not without an exam. SM8 stated to the spouse "I'm here now". SM8 recalled the spouse was requesting to see the physician's license and stating "I have no confidence in you", and the spouse was "tired of hearing about induction on Monday". SM8 did not respond to the spouse's comments and the spouse and patient left L&D. SM8 was "taken aback" by the spouse's response and later heard that the patient and spouse were waiting over two (2) hours. SM8 thought they should get Patient #2 and spouse to sign paperwork for leaving against medical advice (AMA), but the patient and spouse had already left. SM8 stated that SM8 was unable to document the encounter in the patient's chart because the nurse notified SM8 that Patient #2 was not registered "in the system". SM8 stated that earlier that day around 4:00 p.m. to 5:00 p.m., SM11 called SM8 and notified SM8 that Patient #2's spouse called and stated that no one would take the patient to do an induction that day, and that the patient's obstetrician (OB) did not have admitting privileges and could not induce the patient. SM8 stated that a fetal demise is not an emergency and many patients wait till they go in to labor to deliver with a fetal demise, but may not want to wait more than a week. SM8 stated that SM8 "could do lab work to ensure the patient is stable".

SM8 inquired from SM11 if Patient #2 was a transfer, because typically transfers are done through doctor to doctor communication. SM8 stated that SM11 sounded surprised that a fetal demise was not an emergency. SM8 then called SM15 (Obstetrics Medical Director) to notify SM15 about Patient #2. SM8 stated that SM15 stated the induction would not be done that day since SM8 was the only obstetrician available that weekend, and they discussed bringing the patient in on Monday for induction, although they had no real information on the patient at that time.

SM8 stated that SM8 triaged and cared for the most urgent patient at that time, and felt the nurse told Patient #2 and family that the doctor "was not going to induce" Patient #2 that night. SM8 recalled telling SM9 not to check for fetal heart tones since they had a documented ultrasound report from earlier that day that confirmed the patient had a fetal demise. SM8 stated that staffing goes down at this facility on the weekends and they have a book of timeslots to schedule inductions. SM8 stated that later SM8 spoke with Patient #2's obstetrician and the obstetrician stated that they planned to do the patient's induction the next week.

SM8 stated there has never been a time when a patient was not registered on L&D. SM8 was surprised that Patient #2 had not been registered. SM8 stated that SM8 never stated to the family that SM8 would not do the induction and SM8 never had a chance to assess Patient #2 because they were walking out of L&D. SM8 stated that at the time, SM8 was unaware that there was no screening or nursing assessment completed on Patient #2. SM8 stated that generally nursing staff would assess the patient and notify the physician if there were any issues or concerns noted during the assessment. SM8 stated that SM8 never told SM9 not to do a nursing assessment, only told SM9 not to assess or monitor for fetal heart tones. SM8 stated that this patient "should have been an emergency room patient".

SM8 explained that this facility's obstetrics unit was not "OB/ED designated", so the patient does not have to be screened within forty-five (45) minutes as they would in an emergency department. This unit operates under the "triage method", where the trained nurse can see the patient and the patient can be discharged home without being seen by a physician, if the patient doesn't meet the criteria to see the physician, for example, for false labor with no issues.

During an interview on 10/18/2022 at 11:52 a.m., SM13 explained how small community hospitals function using the triage method, and Qualified Medical Professionals (QMP) (nurses who complete specialized training) can do an initial obstetrical screening, and get the physician if necessary. SM13 stated that the QMP's must complete the Obstetrical Medical Screening form if the patient does not meet the criteria to be seen by the physician, for example, if the QMP is only monitoring a patient who might be in early labor. Even if the patient does not need to be seen by the provider, all patients require orders by the physician to be discharged.

SM13 stated that the screening paramedic in the ED waiting room will ask the patient upon arrival their chief complaint and how many weeks gestation. The paramedic will follow the triage tree and send the patient to the emergency department triage or the Family Birthing Center as appropriate. SM13 stated that the patient that presents to the FBC will be triaged there upon arrival. If a patient is not a patient of a provider at this facility, the nurses will determine the patient's OB provider, have the patient sign a medical release, and obtain the patient's records. SM13 noted that in the OB medical record, the triage time is the same as the arrival time.

SM13 confirmed that Patient #2 should have been registered and that it is "traditionally standard to complete the nursing assessment". SM13 stated that SM13 had scheduled EMTALA (Emergency Medical Treatment and Labor Act) training for L&D staff for 11/8/2022. The training would educate on what is required related to EMTALA "despite what the physician" requests or does. SM13 will be completing an online Maternal Fetal Triage conference on 10/26/2022.

During an interview on 10/18/2022 at 1:20 p.m., SM9 recalled having a conversation with a dayshift nurse about a patient with a fetal demise who planned to present at this facility. SM9 stated that on that evening there were three patients triaged "back to back" within fifteen (15) minutes of each other. SM9 had Patient #2 put on a gown. Then spoke with the on-call physician via phone to notify the physician about the two (2) of the three (3) patients that were triaged. The physician asked SM9 who approved the transfer for Patient #2, and SM9 advised that the patient was not a transfer but they had received the patient's medical record stating that a fetal demise was documented. SM9 stated SM9 "could put the patient on a fetal monitor", but was told by SM8 not to touch the patient and that they wouldn't be doing anything with the patient. When SM8 arrived on the unit, SM8 went to assess the patient with vaginal bleeding and SM9 overheard that SM8 called an unscheduled c-section. SM9 proceeded with their typical protocol and called the supervisor to get the operating room (OR) team to come in. SM9 stated that SM9 updated Patient #2 and spouse multiple times about what was going on. At one point, Patient #2's spouse was upset, so SM9 advised them that SM8 was currently in an emergency but would be in to see them after. SM9 told the patient and spouse that SM8 would come in to talk to them and that there was a possibility that they would need to follow up on Monday. SM9 told Patient #2 and spouse that the nursing staff was here to help them and for them to speak up if they were not happy with waiting till Monday.

SM9 stated that SM8, SM9, and another nurse went into Patient #2's room and the patient and spouse were up and ready to leave. The spouse was upset because they had been there for a while and had not been seen by a physician. SM9 stated that SM8 tried to explain to the patient and spouse that the fetal demise was not an emergency situation and that this was a small community hospital. The spouse was not happy with the response. The patient "didn't say a lot". The spouse was concerned that the patient would become "septic", so SM8 explained the statistics related to sepsis in pregnancy. The spouse asked how the physician would know that Patient #2 was not septic. SM9 stated that SM8 told the spouse that SM8 would do some lab work on Patient #2. SM9 stated that the spouse "was done" and wanted to leave. The spouse had requested the nursing supervisor's information, but left before SM9 could get it for them.

SM9 does not recall SM8 stating that SM8 would not perform the induction, but did explain that SM8 was just one physician. SM9 stated that SM8 offered to do lab work and would review the patient's record. SM9 stated that the patient's spouse said that they were told that the patient would get an induction. SM9 confirmed that SM9 did not register or assess Patient #2. SM9 stated that usually they will get the patient's information and register them, and registration is typically performed by a technician while the OB nurse does the assessment. SM9 stated that with all of the patients that had come in at the same time, SM9 did not call registration on any of them and just put each of them in a room. SM9 stated that it is not typical that a patient isn't registered, and a technician usually knows to go in to a room to register a patient, and can also see that there is a patient on the monitor in that room.

During a telephone interview on 10/19/2022 at 9:34 a.m., SM10 stated that on the evening of 9/23/2022, SM10 gave SM8 a "heads up" about a patient coming in with a "term fetal demise". SM10 stated that SM8 became defensive and said that SM8 did not accept the patient and that the patient can turn right back around and leave. SM10 stated feeling thrown "off guard". SM10 explained to SM8 that this was not a transfer. SM10 confirms being present in Patient #2's room when SM8 was in there with the patient. SM10 stated that the patient's spouse asked how the physician would know that this wasn't an emergency. SM10 stated that the patient and spouse were by the bathroom and looked as if they were leaving the facility, and they said that they hadn't been seen. SM10 stated that SM14 said that SM14 had offered for Patient #2 to be seen in the ED. SM10 was not aware of any other time when a patient was not registered in their system.

During an interview on 10/19/2022 at 9:43 a.m., SM14 recalled being called by one of the OB nurses for a c-section, so SM14 went to L&D. SM9 made SM14 aware that Patient #2 had come in with a fetal demise and had spoken with SM8, who said that SM8 would send the patient back home and see the patient on Monday. SM14 went into the room to see Patient #2 with SM8 and SM9. At that time, SM14 heard SM8 tell the patient and spouse that it was ok for the patient to see their obstetrician on Monday. SM14 recalled the spouse asked how the staff would know if the patient was ok, and SM8 did not think that the patient's situation was an emergency.

SM14 then called the director and the supervisor, but neither answered, so SM14 spoke the leadership person on-call. SM14 went to the ED lobby to speak with the spouse to see if they would allow the ED doctor to evaluate the patient in the ED, the wife was not present at this time. SM14 told the spouse that the ED could obtain labs. The spouse stated that if SM14 could guarantee that they would not be billed for their ED visit, then they would "forget about the L&D situation". SM14 spoke with the leadership on-call and was told they could not guarantee that the patient would not be billed for the ED visit. The spouse said that they knew the laws about refusal to treat, and they would only go to the ED if they would not get a bill. SM14 also explained that the patient would not be induced in the ED, but would be sent back to the FBC after being assessed in the ED. The spouse stated that if the patient goes back to FBC, SM8 would not admit the patient, so there was no point. The spouse asked SM14 to call another hospital for a bed for the patient, and SM14 explained that there is a process to transfer a patient which includes being seen by a physician. SM14 told the spouse to check the patient's temperature at home, and the spouse responded that they would see SM14 in court.

During an interview on 10/19/2022 at 10:08 a.m., SM11 stated that SM11 never met Patient #2, but SM11 spoke with the patient's spouse via phone, as the spouse called asking about the facility's induction schedule, and explained the patient's situation. SM11 asked the spouse to hold and SM11 called SM8 for guidance. SM8 was upset with SM11 and asked SM11 not to take the spouse's phone calls anymore, and SM8 said the patient needs to go through their doctor's office to get something set up. SM11 did not relay that information to the spouse, but told the spouse they could present to the hospital to "see what is going on". SM11 stated that Patient #2 was discussed during huddle, then SM11 called Patient #2 and explained that if Patient #2 came to the facility, they would be triaged and then seen by a physician. SM11 told the spouse that there was room available in the facility and explained that they could talk to the provider about their options.

SM11 stated that when a patient presents with a fetal demise, the physician will give them the option to be induced, and the staff don't have to follow the induction schedule for that. SM11 stated that usually all patients are triaged and labs and testing are performed. SM11 was not aware of any time when a patient was "turned away". SM11 stated that during orientation, SM11 had EMTALA training and was told that every patient that presents has to be seen.

A review of the facility's policy titled "Policy and Procedure Manual, Scope of Service, Emergency Department" states in part:
...All patients presenting to the Emergency Department seeking care will receive an appropriate medical screening examination as defined by current EMTALA regulations ...

A review of the facility's policy titled "Lippincott Procedures -Triage, emergency department" states in part:
...In1986, the federal government passed the Emergency Medical Treatment and Active Labor Act, which requires that all patients who come to the ED for treatment receive a medical screening to determine whether an emergency condition exists. The law seeks to prevent "dumping," the practice of unethically refusing to treat patients who may not have insurance or financial resources to cover their care ...
If the patient is pregnant or of childbearing age, inquire about the last menstrual period and the possibility of pregnancy. As determined by your facility, you may evaluate a pregnant patient in the ED or in the labor and delivery department. Ask a pregnant patient who is over [twelve] 12 weeks' gestation if the patient feels fetal movement. Other issues to ask about include urinary symptoms, lower back pain, hypertension, vaginal bleeding, edema, and seizures ...

A review of the facility's policy titled "Policy & Procedure Manual: Emergency Medical Treatment & Active Labor Act "EMTALA" Policy" states in part:
Policy: EMTALA
I. Purpose
The purpose of this policy is to ensure compliance by Culpeper Medical Center (the "Hospital") with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) by establishing a process for (i) providing appropriate medical screening examinations for patients who come to the Hospital seeking treatment for emergency medical conditions and/or labor; (ii) providing necessary stabilizing treatment and; (iii) making appropriate transfers in cases where the Hospital does not have the capability or capacity to provide the treatment necessary to stabilize the emergency medical conditions ...
III. General Policies and Procedures
A. Provision of Appropriate Medical Screening Examination
Individuals coming to the Emergency Department or such other area of the Hospital's campus where patients may expect to receive emergency treatment (i.e., the Family Birth Center) must be provided with an appropriate medical screening examination. A medical screening examination is the process required to reach the point at which it can be determined, with reasonable clinical confidence, whether an emergency medical condition does or does not exist ...
2. Eligibility for Screening
An individual qualifies under EMTALA for a medical screening examination if that individual (or person on behalf of the individual) requests medical treatment or examination while that individual is physically located on the Hospital campus where that person could reasonably expect to receive emergency services. The request for treatment can either be made by the patient or can be made on the patient's behalf. The request may also be reasonable inferred by the patient's appearance/condition ...
4. Initiation of Medical Screening
A medical screening examination shall be initiated as soon as reasonably possible, in accordance with patient acuity, to determine whether an Emergency Medical Condition exists. If the presence of an Emergency Medical Condition is identified, efforts to provide stabilizing treatment should be immediately initiated.
5. Documentation of the Medical Screening Exam
The medical screening exam is an ongoing process. The medical record should reflect that the screening exam continued until the patient is either discharged or transferred. For example, the medical record should indicate that vital signs were taken and recorded throughout the entire period of screening. Results of all screening tests performed must be documented in the medical record. The medical record should document the findings of the medical screening exam, including but not limited to whether an emergency medical condition does or does not exist ...

A review of the facility's policy titled, "Care of the Patient in Obstetric Triage" states in part:
Policy: Obstetrical patients at [twenty] 20 weeks of gestation or more will be evaluated in the obstetric triage unit. In accordance with ACOG's Committee Opinion of Hospital-Based Triage of Obstetric Patients, they will receive a medical screening examination by a provider, or qualified medical personnel (QMP), determined by MSE competency, and stabilizing treatment or appropriate transfer as needed or necessary in accordance with Federal EMTALA guidelines. This examination should take into account the health of the woman and the fetus when determining if there is an emergency medical condition.
Process:
Admission of Obstetric Patients to Triage
A. Obstetric patients at [twenty] 20 weeks of gestation will be assessed in the triage unit with the following exceptions:
Patients scheduled for cesarean delivery, induction of labor, cerclage, version or dilation and curettage
Patients directly admitted by a physician
Patients in active labor who were evaluated by their attending physician within the past [two] 2 ours
Patients who give birth en route to the hospital
Patients who are in transition or second stage of labor
B. A QMP completes and signs an obstetric triage assessment record and an Obstetrical Medical Screening Form (MCH 075).
1. All patients at [twenty] 20 weeks of gestation should be admitted into OBIX for documentation
2. Prenatal records (if available) should be pulled and appropriate information documented on the obstetric triage record. If prenatal records are not available, attempt to obtain records.
3. Fetal heart tones should be assessed using a fetal monitor or Doppler ultrasonography. Findings should be documented.
4. All patients at [twenty-eight] 28 weeks of gestation or greater should undergo a non-stress test.
5. A QMP will initiate the obstetrical medical screening tool.
The RN will perform a head to toe assessment of the patient including vital signs, mental status, significant medical history, obstetrical history, and focused assessment based on the patient's complaint. The obstetrical assessment will include a pelvic exam (exceptions to a pelvic exam include pre-term ROM, Frank bleeding, documented previa [placenta previa is a problem during pregnancy when the placenta completely or partially covers the opening of the uterus (cervix)] and EFM. Information can also be obtained from the patient, family and the prenatal record ...
C. The attending physician should be notified after the initial assessment, unless earlier notification is warranted...