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Based on clinical record review, policy review and interview, it was determined the facility failed to have a policy in place to determine the stability of patients presenting to the Emergency Department when commonly required emergency services were not available for one of one (#1) patients. The failed practice placed the patients at risk of complications of pregnancy and had the likelihood to affect all obstetrical patients seen in the Emergency Department. Findings follow: See A-1104 for details.

Based on clinical record review, policy review and interview, it was determined the facility failed to have a policy in place to determine the stability of patients presenting to the Emergency Department when commonly required emergency services were not available for one of one (#1) patients. The failed practice placed the patients at risk of complications of pregnancy and had the likelihood to affect all obstetrical patients seen in the Emergency Department. Findings follow:

A. Review of the facility's policy titled, 'Protocol for Triage of the Obstetric Woman" with an approval date of 12/2024 showed, "Women who are at less than 20 weeks gestation or with a non-obstetric emergency will be triaged in the main emergency department unless the Obstetric (OB) Provider requests triage in the labor and delivery department for assessment and observation. Regardless of the presenting complaint, care of the pregnant woman includes assessment of the fetus."

B. Review of Patient #1's 05/25/2025 (Saturday) clinical record showed the following:
1) At 8:24 AM, Arrival complaint was "5 weeks, spotting, cramping."
2) At 8:48 AM, Physician #1 Medical Screening Exam showed, "I provided an appropriate medical screening exam to the patient: An emergency medical condition exists. This visit is: Emergent."
3) At 9:48 AM, Chief complaint updated showed, "Abdominal cramping, pregnancy."
4) At 9:49 AM, ED Triage Note showed, "Pt (patient) states that she has had some ongoing cramping and spotting, was told by fertility doctor that if cramping became too severe to be evaluated; pt states she would like her HCG levels checked, reports 5 weeks gestation."
5) At 9:50 AM, pain was documented as a "4-moderate pain."
6) At 10:04 AM, "Lab - hCG, quantitative, pregnancy" was ordered.
7) Physician #1 note at 10:04 AM showed, "Chief complaint: pregnancy, abdominal cramping. Vaginal bleeding during pregnancy. Quality: spotting. Severity: moderate. Onset quality: sudden. Duration: 1 day. Timing: constant. Progression: unchanged. Chronicity: new. Prior pregnancy: no. Pregnancy confirmed by ultrasound: no. Gestational age: 5.5 weeks. Prenatal care: no prenatal care. Number of pads used: 1. Number of tampons used: 0. Context: at rest and spontaneously. Not after bowel movement, not after intercourse, not after urination, not during bowel movement, not during intercourse not during urination and not genital trauma. Relieved by: nothing. Worsened by: nothing. Ineffective treatments: none tried. Associated symptoms: abdominal pain, no back pain, no dizziness, no dyspareunia, no dysuria, no fatigue, no fever, no nausea and no vaginal discharge. Abdominal pain: Location: L (left) flank and R (right) flank; Quality: cramping; Severity: mild; Onset quality: sudden; Duration: 1 day; Timing: constant; Progression: unchanged; Chronicity: new. Risk factors: no bleeding disorder, no gynecological surgery, no hx (history) of ectopic pregnancy, no hx of endometriosis, does not have multiple partners, no new sexual partner, no ovarian cysts, no ovarian torsion, no PID (pelvic inflammatory disease), no prior miscarriage, no STD (sexually transmitted disease), no STD exposure, no terminated pregnancy and no unprotected sex. Mr. (Ms.) (Patient #1) is an otherwise healthy 36-year-old female who arrives to the emergency room from home via POV (privately owned vehicle). Pt states that she has had some ongoing cramping and spotting, was told by fertility doctor that if cramping became too sever to be evaluated; pt states she would like her HCG levels checked, reports 5 weeks gestation. Past surgical history: cesarean section , classic 3; tubal ligation; wrist surgery. Gastrointestinal: abdominal cramping. Genitourinary: spotting on pads noted. Physical exam: Vitals: Patient is afebrile vitals signs are stable and within normal limits. General: She is not in acute distress. Appearance: Normal appearance. She is obese. She is not ill-appearing, toxic-appearing or diaphoretic. Procedures: none. ED Course: HCG quant: 989.5. HCG ranges 2 to 4 weeks gestational age. This is consistent with the patient's dates. Clinical Impression: Threatened abortion. Medical Decision Making: Patient presents with early term cramping and spotting at 5 weeks gestational age pregnancy. She was told by the nursing staff of her fertility doctor to come to the emergency room to get checked out. UA (urinalysis) and urine pregnancy test both were normal showing that the patient is still pregnant. A beta hCG test was performed on the serum and the value was 989 which indicates that the patient is between 2 and 4 weeks gestational age. The cutoff for 5 weeks being 1000. Patient is informed of the news and is told to follow-up with her fertility specialist and to establish care with an OB/GYN to follow the pregnancy. She is medically stable and is discharged home.
Problems addressed: Threatened abortion: undiagnosed new problem with uncertain prognosis.
Risk Details: Patient to follow-up with her fertility specialist or establish care with an OB/GYN, she is to return to the emergency room if her symptom persist or worsen. Assessment/Plan: Patient with a threatened abortion based upon history and presentation. UA and urine pregnancy test were both normal and the patient still showing as pregnant on the urine pregnancy test. A serum beta hCG was performed for comparison purposes with her fertility specialist. It was 989 which is consistent with a 2 to 4-week gestational age pregnancy. Patient is instructed to follow-up with her fertility specialist and establish care with an OB/GYN to follow the pregnancy. She is to return to the emergency room for symptoms persist or worsen. She is medically stable and is discharged home. (Physician #1) 05/25/24 1051 (10:51 AM). Discharge Instructions: Body in the early term of pregnancy is usually indicative of what we as physicians called a threatened abortion. This does not mean that you have miscarried the child in fact your urine test still shows that you are pregnant and a quantitative hCG shows that you are between 2 and 4 weeks gestational age. The value is 989. Typical pregnancy at 5 weeks should be 1000. Your urinalysis was negative for any infection. I recommended you follow-up with your fertility doctor for continued care. In addition you will need to get an OB/GYN who will be the doctor that will deliver the baby. If her condition worsens please feel free to return to the emergency room for further evaluation."
8) At 10:41 AM, hCG lab resulted of 989.5 mIU/mL (milli-international units per milliliter).
9) At 10:50 AM, Patient Discharged.
10) At 10:50 AM, "Departure Condition" showed, "Departure Condition: Good; Mobility at Departure: Ambulatory; Patient Teaching: Discharge instructions reviewed, follow-up care reviewed, patient verbalized understanding; Patient discharged to: Home."
11) There was no evidence of any ultrasound or imaging completed on Patient #1 for further assessment. There was no evidence that the medical decision making considered an ectopic pregnancy.

C. Review of Patient #1's 05/30/2025 (Thursday) clinical record showed the following:
1) At 5:52 PM, Arrival complaint: 5-6 weeks pregnant - bleeding
2) At 6:37 PM, Physician #3 Medical Screening Exam, "I provided an appropriate medical screening exam to the patient. An emergency medical condition exists. This visit is: Emergent."
3) At 6:37 PM, Chief Complaints Updated: Vaginal bleeding.
4) At 6:39 PM, pain was documented as "1-mild pain."
5) At 6:37 PM, ED Triage Note showed, "Patient states she is pregnant, started having vaginal bleeding-spotting since 05/24."
6) At 6:41 PM, Pregnancy last 6 weeks showed, "Are you having headaches unresolved by Over-the-Counter medications?: No Are you experiencing double vision, floaters, spots, decreased vision, or tunnel vision?: No Are you experiencing RUQ (right upper quadrant)/epigastric pain?: No. Postpartum Hemorrhage: Are you using one or more pads per hour?: No. Have you been pregnant in the last 6 weeks?: Yes."
7) Physician #2 note at 6:49 PM (electronically signed at 7:53 PM) showed, "Chief Complaint, Patient presents with: Vaginal bleeding. 36 - year-old female currently 5 to 6 weeks pregnant presents with complaint of vaginal bleeding. Moderate discomfort at the pelvic region. Bright red bleeding. Utilizes 1 pad today. 3 previous pregnancies. Throat (?) with a different partner. History of tubal reversal. Vaginal Bleeding: Quality: Bright red; Severity: Moderate; Onset quality: Gradual; Duration: 24 hours; Timing: Intermittent; Progression: Unchanged; Chronicity: New; Menstrual history: Regular; Number of pads used: 1; Possible pregnancy: yes; Context: spontaneously; Relieved by: Nothing; Worsened by: Nothing; Ineffective treatments: Rest; Associated symptoms: no dysuria, no fever, no nausea and no vaginal discharge; Risk factors: gynecological surgery (Tubal reversal) and new sexual partner; Risk factors: no bleeding disorder and no prior miscarriage.
Past surgical history: Procedure: Cesarean section, classic 3; Tubal ligation; wrist surgery.
Genitourinary: Positive for vaginal bleeding. Negative for dysuria and vaginal discharge.
Clinical Impression: Threatened abortion. Medical Decision Making: Suspected IUP at 5 to 6 weeks; Abnormal uterine bleeding; History of tubal ligation reversal; New partner; Afebrile; No vaginal discharge; No dysuria. Assessment/ Plan: (Patient #1) is a 36 y.o. (year-old) female diagnosed today with: Final diagnoses: Threatened abortion; Patient relatively asymptomatic, just wanted to recheck her quantitative hCG, last 1 done on 5/25, was 989. Last menstrual cycle was 4/20, which puts her at about 3 and half to 4 weeks prior. Patient was advised to follow up with (Named Physician). Schedule an appointment as soon as possible for a visit in 3 days as needed, if symptoms worsen, Post Hospitalization. Stuttgart ER, 1703 North Buerkle, Stuttgart Arkansas 72160 (Phone number provided) As needed, If symptoms worsen. (Physician #2) 05/30/24 1953."
8) At 7:49 PM, HCG result was 1,077.3 mIU/mL.
9) At 7:53 PM, Discharge Condition showed, "Departure Condition: Good; Mobility at Departure: Ambulatory; Patient Teaching: Discharge instructions reviewed; Patient verbalized understanding; Patient discharged to: Home; Form of transportation: Patient driving; Accompanied by: Alone."
10) At 7:54 PM, Patient #1 was discharged.
11) There was no evidenceof any ultrasound or imaging completed on Patient #1 for further assessment. There was no evidence that the medical decision making considered an ectopic pregnancy.

D. During an interview with Physician #2 on 04/15/2025 at 12:00 PM showed the following when asked:
1) What is the process for treating a woman of child-bearing age presenting with abdominal pain and bleeding or spotting?
He stated he would obtain vital signs including pulse, blood pressure, oxygen saturation. He would determine if they were stable or unstable. He would find out how long it's been since their last ultrasound. He would determine the severity of bleeding along with their past medical history.
2) After reviewing Patient #1's clinical record, would you have treated Patient #1 any differently?
He stated the only thing different would have been to do an ultrasound, but the ultrasound tech isn't there 24 hours a day. The ultrasound tech isn't available on weekends or after normal business hours.

E. During an interview with Physician #1 on 04/15/2025 at 3:00 PM and on 04/16/2025 at 8:05 AM, showed the following when asked:
1) Do you utilize or follow any protocols or guidelines in the ED? Do you utilize any standing order sets in the ED for OB patients?
He stated he used ACOG (The American College of Obstetricians and Gynecologists) 2018 guidelines and stated he had access to them on his phone.
2) Do you utilize any standing order sets in the ED for OB patients?
He stated yes, but not in this (Patient #1) specific situation. Specific orders were placed in EPIC.
3) What is the process for treating a woman of child-bearing age presenting with abdominal pain and bleeding or spotting?
He stated he would establish the term of pregnancy, whether it's the first child or not, gather the patient's background and past OB history, and establish a rough estimate of gestational age then decide the next steps to take. He stated he did not have ultrasound available on the weekend or after normal working hours. He stated he can perform an HCG test. He stated he would have to establish whether there is a threatened abortion or ectopic pregnancy. If there might have been a threatened abortion, then let it take it's course. If the HCG was positive, then have the patient follow up with fertility doctor or OB/GYN. He would draw a baseline HCG. He stated per ACOG guidelines, if the HCG doubles in two days, then it's probably a normal intrauterine pregnancy. If it doesn't double, then it's a possible ectopic pregnancy.
4) After reviewing Patient #1's clinical record, would you have treated Patient #1 any differently?
He stated with Patient #1, her vital signs were normal and there was nothing on her exam that she was in any danger. He stated he told her she could always come back to the ER for further assessment. He stated ultrasound isn't available on weekends or after normal working hours. He stated he wasn't trained in performing ultrasounds on pregnant women due to the fact it required specialized training.

F. In an interview with the ER (Emergency Room) Manager on 04/15/2025 at 4:10 PM, when asked if ultrasound was available to the ER physicians she stated there was an ultrasound machine available in the ED. If the physician is comfortable to do the ultrasound then they can. Some physicians aren't comfortable doing ultrasounds. When asked if transvaginal ultrasound was available in the ER, she stated it wasn't available. She stated that if the patient was emergent, they could be transferred out, and if they weren't emergent, the patient could wait to receive an ultrasound the next morning. She stated it was determined by the physician.