HospitalInspections.org

Based on a interviews with staff, review of hospital policy Medical Screening Exam for Labor Status by Qualified Medical Personnel (QMP) (MSELSQMP) (revised 2/28/2019), the Emergency Department Central log; The Mother Infant Care (MIC) log, and patient #1's record, it was determined that; 1) 12 of a sample of 14 obstetrical (OB) patients who presented to the emergency department were logged only on the MIC log and not the central ED log; and 2) patient #1 (P1) disposition left before being seen was not captured on either MIC or ED log.

Review of the OB MSE policy identified the following statements: "Any obstetric patient who presents to the hospital (Emergency Department Labor & Delivery) unannounced, unplanned, or unanticipated. (sic) Regardless of whether the patient has an attending physician or a preregistration account, or whether the physician has notified Labor and Delivery that the patient is coming, the hospital will provide a medical screening exam and any necessary stabilizing treatment. These patients will be listed on the triage log."

It is not clear to what log the policy referred. However, the MIC unit kept a log of all presenting and treated patients. Unless an OB patient presented in the ED with complaints outside the OB status, OB patients were not placed on the ED central log. Review of select days of the ED central log compared to the MIC log revealed only 2 of 14 sampled OB patients appeared on the MIC log and also appeared on the ED central log.

Findings include:

Patient #1 (P1) was an over 35 year old OB patient in the third trimester who presented to the main ED in July 2019 with complaints of headache and high blood pressure. P1 was sent to the MIC triage for assessment by the OB RN. P1 received bloodwork and a non-stress test as well as serial vital signs, including blood pressure. The RN conducting the assessments was in contact with a physician by phone who gave orders to discharge home.

P1 presented again to the emergency department (ED) two days later. A RN in the main ED filled out an "Emergency Department OB Evaluation" form with "Headache, High BP" noted under "Special Considerations." No blood pressure or other vitals were taken in the main ED. P1 was sent to the MIC for evaluation.

Evaluation by the MIC triage RN found no concerns specific to high blood pressure or the pregnancy. P1 had a non-stress test to assess fetal viability and was given some IV fluids. A RN note stated in part, "Instructed to transfer pt to ED for medical evaluation." P1's headache continued at a level 8/10 where 10 is the worst pain. A report was called to the ED Charge RN. However, when P1 arrived in the ED, P1 left the ED per the hospital within 45 seconds, and without being seen by a physician.

P1's presentation had not been captured on the ED central log prior to going to the MIC, and so P1 leaving before being seen was also not captured. Further, P1 was not captured on the MIC log as having left before being seen.

Therefore, both the ED central log and the MIC log were inaccurate. Further, the hospital log process limited accurate tracking of care and disposition, and skewed look-back information for oversight of emergency care and retroactive quality assurance activities

Based on a review of the hospital Admissions/Discharge Policy (Revised 1/2018), and 10 BH referrals where 9 referrals were from emergency departments (ED), it was revealed that no determination could be made as to why referrals were declined for patients #15, 16, 18, and 20 who had accompanying clinical information, and 4 BH referrals without clinical information.

The Behavioral Health Unit (BHU) has a total of 10 beds and accepts both voluntary and involuntary patients for treatment.

Hospital referrals forms were titled, "Behavioral Health Referral Tracker (BHRT)." A request for 3 months of the referral log revealed separate BHRT forms which were gathered together by month. Review of 10 BHRT forms revealed 9 referrals from outside EDs. A request for the clinical information accompanying the referrals yielded clinical information for 6 of 9 where one referral was from an inpatient hospital unit. Further review identified no documented rationale for 4 denied referrals which had clinical information, or for 5 without clinical information. A sample of the BHRT forms were as follows:

1. Patient #15 was an adult who was referred by another Emergency Department (ED) to the hospital BHU in May 2019 for involuntary admission. The BHRT revealed the BHU had 7 of 10 beds occupied. Patient #15 was denied admission without a documented explanation though 3 beds were available.

2. Patient #16 was an adult who was referred by another ED to the hospital BHU in May 2019 for voluntary admission. The BHRT revealed the BHU had 5 of 10 beds occupied. Patient #16 was denied admission for unit acuity though 5 beds were available and no explanation regarding acuity was documented.

3. Patient #18 was an adult who was referred by another ED to the hospital BHU in July 2019 for voluntary admission. The unit had 7 of 10 beds occupied. Patient #18 was denied for acuity, though 3 beds were available and no explanation regarding acuity was documented.

4. Patient #20 was an adult who was referred by another ED to the hospital BHU in July 2019 for voluntary admission. The unit had 3 of 10 beds occupied. Patient #20 was denied for capacity though no explanation regarding a lack of bed capacity was documented where 7 beds remained available.

5. Patient #5 was an adult who was referred by another ED to the hospital behavioral health unit in July 2019. The unit had 3 of 10 beds occupied. Patient #5 was denied for "capacity" on the BHRT with no explanation documented as to why the unit was at capacity when 7 beds remained empty.

BHRT denials for 4 other patients had no accompanying clinical information, though these were also denied without documented explanation while between 3-6 open beds existed on the BHU. Review of staffing for the referral days revealed that staffing remained consistent for RN coverage of 2 RNs per shift which would effectively give a ratio of 1 RN to every 5 patients if every bed were utilized.