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Based on documentation and interviews, the hospital failed to ensure compliance with requirements of 42 CFR 489.24, as evidenced by the deficient practice cited at 42 CFR 489.24 (a) and (c).

Based on documentation and interviews, the hospital failed to ensure that each patient, who presented to the ED for evaluation, received the necessary care and services by a physician or other qualified health professional, when the designated physician on-call did not come in to evaluate a patient with a potential emergency medical condition, in one of 23 records reviewed (Patient G). Findings include:

Medical record review indicated that Patient (G), whose estimated date of delivery is 12/06/10, presented to the hospital's emergency department at 12:45 a.m. on 05/10/10, for evaluation of spotting and cramping.

The progress notes, dated 05/10/10 at 12:45 a.m., indicated that Nurse (F)/RN assessed Patient (G) upon arrival. The patient had mild cramping and rated her pain as being 1.5 on a scale of 1 - 5, had 5 - 10 cc dark-pink vaginal discharge, and her blood pressure was 90/64.

The hospital's physician on-call schedule for the ED indicated that Physician Assistant (H) was the designated on-call provider for 05/10/10 and Physician (I) was the back-up on-call provider for 05/10/10.

Although the on-call schedule specified that Physician Assistant (H) and/or Physician (I) were the designated medical personnel for on-call duty to the ED, Nurse (F) contacted Nurse Midwife (E) regarding the patient's presentation and symptoms.

Nurse (F) was interviewed on 09/02/10 at 10:45 a.m. and stated the following: She was on duty on 05/10/10 when Patient (G) presented to the ED. She made a brief assessment of the patient's status and was unable to locate fetal heart tones with a doppler. She then reported her findings to Nurse Midwife (E), via telephone. Nurse (F) requested that Nurse Midwife (E) come to the ED at this time to evaluate the patient, which was declined by Nurse Midwife (E). Nurse Midwife (E) informed Nurse (F) that she did not have ED privileges and advised Nurse (F) to contact the designated physician on-call. Nurse (F) stated that Physician Assistant (H) was the designated on-call medical staff for 05/10/10; Physician (I) was the designated back-up on-call medical staff. Nurse (F) did not call Physician Assistant (H) because Physician Assistant (H) is not credentialed to evaluate obstetric patients. Rather, Nurse (F) contacted Physician (I) and updated him regarding the patient's symptoms of spotting, cramping, her inability to obtain fetal heart tones with a doppler, the patient's vital signs, and the patient's concerns and desire to be seen; Nurse (F) also told Physician (I) about her telephone conversation with Nurse Midwife (E).
Physician (I) declined to evaluate the patient and did not come in to the ED. Nurse (F) stated she was "uncomfortable" that neither Nurse Midwife (E) nor Physician (I) would come to the ED to evaluate the patient's condition. Nurse (F) discharged the patient from the ED at 1:10 a.m. The patient was not examined by a physician or other health professional who was qualified to conduct the medical screening examination, to determine whether or not an emergency medical condition existed..

After the patient was discharged, Nurse (F) completed an incident report, which indicated: "Patient presented with concerns about her pregnancy. Small amount of spotting and cramping noted at work. Patient evaluated by nurse. Regular OB provider and MD on-call did not come in to assess patient (when called to do so)."

Review of the physician on-call schedules from March 2010 through June 2010 verified that Nurse Midwife (E) is not assigned to on-call duty for the ED. Review of Nurse Midwife (E)'s personnel file verified that she does not possess the necessary credentials to function as an independent practitioner in the ED.

The hospital's policy regarding Notification of Practitioners indicated that "the registered nurse is responsible for obtaining physician services for those patients under his/her care who are assessed as actually or potentially requiring medical attention...the physician call schedule is posted at the nurses's station and in the Emergency Department...The First Care Medical Staff By-laws require a maximum of 20-minute response time...to ensure that the practitioner is available 24/7, follow the procedure outlined...Telephone the practitioner on call...if the telephone is busy, call the beeper...if there is no response within five minutes after calling the beeper, call the physician's telephone again and if busy, immediately repeat the beeper call...if unable to reach the practitioner by telephone and there is no response to the beeper, call the Chief of Staff...if unable to reach a physician, call the Director of Patient Care Services...the charge nurse for that shift will complete an Occurrence form and submit the form to the Director of Patient Care."

There was no evidence that Nurse (F) called the Chief of Staff, when Physician (I)/the designated physician on-call, declined to come in to the ED on 05/10/10, to evaluate Patient (G).

Physician (I) was interviewed on 09/09/10 at 1:10 p.m. He acknowledged that he was the physician on-call on 05/10/10. He stated that the ED nurse did call him on 05/10/10 when Patient (G) presented to the ED with symptoms of spotting and cramping. He instructed the ED nurse to call Nurse Midwife (E) about the patient because Nurse Midwife (E) was the patient's primary obstetric provider. Nurse Midwife (E) wants to be notified when one of her patients is having problems. He denied that the nurse asked him to come in to the ED to evaluate the patient. He stated he would never and has never refused to see a patient.

Based on documentation and interviews, the hospital failed to maintain a central log in the emergency department (ED) that accurately tracked the care and disposition of each patient, in 6 of 23 patients reviewed (Patients G, K, L, M, N, and O). Findings include:

The ED log on 05/10/10 reflected that Patient (G) presented to the ED at 12:45 a.m. for evaluation of decreased fetal movement. The diagnosis/complaint section of the log indicated: "Patient not an ER, was an OPN (Outpatient Nursing)."

Administrative employee (B) was interviewed on 08/31/10. She acknowledged that Patient (G) presented to the ED for evaluation of an emergency medical condition. The nurse on duty in the ED contacted the patient's obstetric provider, as well as the physician on-call, regarding the patient's symptoms and concerns. Neither provider came in to the ED to evaluate the patient. The nurse assessed the patient and entered the information under "Outpatient Nursing." Employee (B) acknowledged that Patient (G) was an ED patient and did not meet the criteria for outpatient nursing.

The ED log on 05/15/10 reflected that Patient (K) presented to the ED at 11:31 a.m. The diagnosis/complaint section of the log indicated that the patient was "Not seen in ER, seen in clinic." There was no ED record for Patient (K), however, the clinic schedule revealed that Patient (K) had a pre-determined outpatient clinic appointment on 05/15/10 at 11:30 a.m. The patient was erroneously listed as an ED patient on the ED log.

The ED log on 06/12/10 reflected that Patient (L) presented to the ED at 10:12 a.m. The diagnosis/complaint section of the log indicated that the patient was "Seen at clinic." There was no ED record for Patient (L), however, the clinic schedule revealed that Patient (L) had a pre-determined outpatient clinic appointment on 06/12/10 at 10:15 a.m. The patient was erroneously listed as an ED patient on the ED log.

The ED log on 08/03/10 reflected that Patient (M) presented to the ED at 11:22 a.m. The diagnosis/complaint section of the log indicated that the patient was "Seen at clinic." There was no ED record for Patient (M), however, the clinic schedule revealed that Patient (M) had a pre-determined outpatient clinic appointment on 08/03/10 (time not identified). The patient was erroneously listed as an ED patient on the ED log.

Administrative employee (B) was interviewed on 08/31/10. The hospital is undergoing a major construction project, which involves a re-design of the hospital's main entrance, clinic entrance, and ED entrance. During this time, both ED patients and clinic patients initially present at the same location. ED patients are escorted to triage and clinic patients are directed to the clinic. The ED log entries for Patients (K, L, and M) were clerical errors.

The ED log on 06/17/10 reflected that Patient (N) presented to the ED at 9:12 p.m. and Patient (O) presented to the ED at 9:18 p.m. The diagnosis/complaint section of the log for both patients indicated they "refused to be seen." The disposition for both patients indicated they were discharged to home, which was inaccurate. Both patients were intoxicated and were transferred/discharged to a detoxification facility and/or jail.

Based on documentation and interviews, the hospital failed to ensure that each patient who presented to the emergency department received a medical screening examination, to determine whether or not an emergency medical condition existed, in one of 23 patients reviewed (Patient G). Findings include:

Medical record review indicated that Patient (G), whose estimated date of delivery is 12/06/10, presented to the hospital's emergency department at 12:45 a.m. on 05/10/10, for evaluation of decreased fetal movement.

The progress notes, dated 05/10/10 at 12:45 a.m., indicated that nurse (F)/RN assessed Patient (G) upon arrival. The patient had mild cramping and rated her pain as being 1.5 on a scale of 1 - 5, had 5 - 10 cc dark-pink vaginal discharge, and her blood pressure was 90/64. Nurse (F) contacted the patient's primary provider, Nurse Midwife (E), regarding the patient's symptoms.

The progress notes indicated that Patient (G) was "discharged to go home and rest. Call (Nurse Midwife E) in the morning for further plans. Patient instructed to return (to ED) if significant amount of bleeding occurs or if pain becomes very strong." Patient (G) was discharged from the ED at 1:10 a.m., without having been examined by a physician or other health professional who was qualified to conduct the medical screening examination.

Nurse (F) was interviewed on 09/02/10 at 10:45 a.m. and stated the following: She was on duty on 05/10/10 when Patient (G) presented to the ED. She made a brief assessment of the patient's status and was unable to locate fetal heart tones with a doppler. She then reported her findings to Nurse Midwife (E), via telephone. Nurse Midwife (E) informed her that she had seen Patient (G) in the clinic earlier that day and Patient (G) had already spontaneously aborted the fetus. Nurse Midwife (E) instructed Nurse (F) to provide reassurance to Patient (G), that she would see Patient (G) in the clinic the next morning. Nurse (F) requested that Nurse Midwife (E) come to the ED at this time to evaluate the patient, which was declined by Nurse Midwife (E). Nurse Midwife (E) informed Nurse (F) that she did not have ED privileges and advised Nurse (F) to contact the designated physician on-call. Nurse (F) stated that Physician Assistant (H) was the designated on-call medical staff for 05/10/10; Physician (I) was the designated back-up on-call medical staff. Nurse (F) did not call Physician Assistant (H) because Physician Assistant (H) is not credentialed to evaluate obstetric patients. Rather, Nurse (F) contacted Physician (I) and updated him regarding the patient's symptoms of spotting, cramping, her inability to obtain fetal heart tones with a doppler, the patient's vital signs, and the patient's concerns and desire to be seen; Nurse (F) also told Physician (I) about her telephone conversation with Nurse Midwife (E). Physician (I) informed Nurse (F) that there was nothing more that could be done for the patient, if Nurse Midwife (E) had already determined that the patient had spontaneously aborted the fetus. Physician (I) declined to evaluate the patient and did not come in to the ED. Nurse (F) stated the patient was concerned because she had cramping and spotting. Nurse (F) stated she was "uncomfortable" that neither Nurse Midwife (E) nor Physician (I) would come to the ED to evaluate the patient's condition. Nurse (F) discharged the patient from the ED with the instructions provided by Nurse Midwife (E). Nurse (F) then completed an incident report, which indicated: "Patient presented with concerns about her pregnancy. Small amount of spotting and cramping noted at work. Patient evaluated by nurse. Regular OB provider and MD on-call did not come in to assess patient (when called to do so)."

Nurse Midwife (E) was interviewed on 09/02/10 at 9:27 a.m. She acknowledged that she is Patient (G)'s obstetric provider. She stated that she prefers to receive a courtesy call when one of her obstetric patients presents to the ED so she is aware of any problems the patient is experiencing. However, she does not have ED privileges and as a result, she is never on-call to the ED. On 05/10/10, she received a call from Nurse (F), sometime after midnight, that Patient (G) had presented to the ED for evaluation of cramping, spotting, and decreased fetal movement. Nurse Midwife (E) described Nurse (F) as "clinically competent"and when she received this call from Nurse (F), she instructed Nurse (F) to contact the physician on-call for evaluation of Patient (G)'s condition. Nurse Midwife (E) denied that she told Nurse (F) that the patient had already spontaneously aborted the fetus. Nurse Midwife (E) stated that the patient's pregnancy (to date) "is going just fine." Nurse Midwife (E) acknowledged that she is no longer on staff at the hospital, as of 06/30/10.

Physician (I) was interviewed on 09/09/10 at 1:10 p.m. He acknowledged that he was the physician on-call on 05/10/10. He stated that the ED nurse did call him on 05/10/10 when Patient (G) presented to the ED with symptoms of spotting and cramping. He instructed the ED nurse to call Nurse Midwife (E) about the patient because Nurse Midwife (E) was the patient's primary obstetric provider. Nurse Midwife (E) wants to be notified when one of her patients is having problems. He denied that the nurse asked him to come in to the ED to evaluate the patient. He stated he would never and has never refused to see a patient.

Patient (G) was interviewed on 09/02/10 at 1:05 p.m. She stated that she presented to the ED on 05/10/10 with symptoms of spotting and abdominal pain. She wanted to be evaluated to "make sure I wasn't going to lose the baby." She was examined by Nurse (F), who was unable to obtain any fetal heart tones. Nurse (F) then called her primary provider, Nurse Midwife (E), who indicated that nothing could be done at this point, if she was going to lose the baby. Nurse Midwife (E) never came in to evaluate her. Nurse (F) sent her home. She underwent an ultrasound the following day in Nurse Midwife (E)'s clinic. The ultrasound revealed she had a subchorionic bleed (abnormal bleeding within the layers of the placenta or within the outer fetal membrane next to the placenta). Nurse Midwife (E) told her that the subchorionic bleed was the cause of her spotting and that this problem would most likely resolve itself as her uterus grew. Patient (G) stated she has not had any further problems during her pregnancy. She is presently scheduled for a C-section in November 2010.

The hospital's physician on-call schedule for the ED indicated that Physician Assistant (H) was the designated on-call provider for 05/10/10 and Physician (I) was the back-up on-call provider for 05/10/10. Review of the physician on-call schedules from March 2010 through June 2010 verified that Nurse Midwife (E) is not assigned to on-call duty for the ED.

Review of Nurse Midwife (E)'s personnel file verified that she does not possess the necessary credentials to function as an independent practitioner in the ED.

The hospital's Medical Staff Rules and Regulations specified that "credentialed practitioners may perform a medical screening exam...patients considered 'emergent' shall be seen by a physician in accordance with hospital policy...the on-call physician will be immediately available to the hospital."

The hospital's policy on Medical Screening Exam (MSE) indicated that the purpose of the exam was to "provide a standardized process to determine whether a medical emergency does or does not exist." The policy specified that "a physician or qualified medical person shall complete the Medical Screening Examination for any individual that presents on hospital property and requests examination or treatment for what may be an emergency medical condition. When contacted, the Physician will appear within a reasonable time as per by-laws (within 20 minutes) and complete a medical screening exam."

Review of Physician (I)'s personnel file indicated that he does possess the necessary credentials to function as an independent practitioner in the ED. Moreover, Physician (I)'s personnel file reflected that he is the supervising physician for Nurse Midwife (E)'s practice.