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Based on document review and staff interview, the hospital obstetrical staff failed to provide an appropriate or sufficient medical screening exam for 1 obstetrical patient (patient #1), who presented to the obstetrical department requesting care, out of 10 cases selected for review from August 2010 to January 2011. The hospital emergency department staff also failed to provide an appropriate medical screening examination for 1 emergency department patient (patient #1), who presented to the emergency department requesting care, out of 40 cases selected for review from August 2010 to January 2011. The hospital administrative staff identified an average of 293 patients in the Maternal Treatment and Triage Unit (MTTU) per month and an average of 6,200 emergency department visits per month.

Failure to provide an appropriate medical screening exam resulted in a patient with an emergency medical condition not receiving appropriate care, potentially leading to disability, loss of limb, or death.

Findings include:

1. Review of the medical record revealed Patient #1, who was 31 weeks pregnant and had a history of gestational diabetes and previous bilateral adrenalectomy (which caused Patient #1 to have a high risk pregnancy and became immunocompromised) arrived at the MTTU on 9/26/10 at 12:56 PM. Registered Nurse (RN) A documented Patient #1 presented for "assessment of right sided 'bulging area' .... Raised bulge on [patient's] right side, possible baby part." RN A placed Patient #1 on fetal monitoring. RN A noted Patient #1 rated her pain 7 (severe) on a scale of 1 - 10 and documented "Pain Interventions: No need assessed / requested".

At 1:06 PM, RN A received orders from Physician B over the telephone, including "Diagnosis: Bulge on [Right] side..." Physician B also ordered RN A to continue to provide fetal monitoring to Patient #1. Physician B did not include any orders related to the bulge on Patient #1's right side, or Patient #1's pain.

At 2:05 PM, RN A documented they notified Physician B over the telephone about Patient #1, and the bulge on Patient #1's right side. Physician B gave orders for RN A to discharge Patient #1 home, and advised Patient #1 to use over-the-counter antacids. Physician B did not come to the hospital and physically examine Patient #1 prior to discharge.

At 2:15 PM, RN A discharged Patient #1 from the MTTU.

Review of Patient # 1 ' s medical record for inpatient admission on 9/26/10 at 7:19 PM showed Patient # 1 returned to the MTTU. RN C documented in the medical record Patient #1 "states pain has worsened, now has visible extruding lump in [upper right side of the abdomen]. [Patient] reports extreme tenderness. [Patient #1 is] asking to see the [doctor] this time."

At 7:25 PM, RN C received orders from Physician B over the telephone, including an abdominal ultrasound.

On 9/27/10 at 1:27 AM, Surgical Resident D diagnosed Patient #1 with an incarcerated incisional hernia, which required surgical repair on 9/28/10.

On 10/2/10, nursing staff discharged Patient #1 home.

2. During an interview on 1/13/10 at 9:20 AM, the Medical Director for the Emergency Department stated that the medical screening exam performed in the MTTU on 9/26/10 focused only on Patient #1's pregnancy and did not include further investigation into the cause of her abdominal pain.


3. Review of the policy, "EMTALA: The Treatment and Transfer of Individuals Who Request Emergency Medical Services", effective 8/09, revealed in part, "A woman who is not in true active labor may still have an emergency medical condition if the individual has a medical condition such that the absence of immediate medical attention will place her or her fetus in serious jeopardy." Further review of the policy revealed, "Stable for Discharge means: the physician has determined that the patient has reached the point where his continued medical treatment could reasonably be performed as an outpatient or later as an inpatient...". The hospital failed to follow this policy and discharged Patient # 1 on 9/26/10 at 2:15 PM prior to performing an examination sufficient to determine she did not have an emergency. On 12/24/10 at 10:15 PM Patient # 1 presented to emergency department by ambulance with complaints of severe abdominal pain and was again discharged without receiving an examination sufficient to determine she did not have an emergency. Refer to tag A2406 for further details.

Based on document review and interviews, the hospital obstetrical staff failed to provide an appropriate or sufficient medical screening exam for 1 obstetrical patient (patient #1), who presented to the obstetrical department requesting care, out of 10 cases selected for review from August 2010 to January 2011. The hospital emergency department staff also failed to provide an appropriate medical screening examination for 1 emergency department patient (patient #1), who presented to the emergency department requesting care, out of 40 cases selected for review from August 2010 to January 2011. The hospital administrative staff identified an average of 293 patients in the Maternal Treatment and Triage Unit (MTTU) per month and an average of 6,200 emergency department visits per month.

Failure to provide an appropriate medical screening exam resulted in a patient with an emergency medical condition not receiving appropriate care, potentially leading to disability, loss of limb, or death.

Findings include:

1. Review of the medical record revealed Patient #1, who was 31 weeks pregnant and had a history of gestational diabetes and previous bilateral adrenalectomy (which caused Patient #1 to have a high risk pregnancy and became immunocompromised) arrived at the MTTU on 9/26/10 at 12:56 PM. Registered Nurse (RN) A documented Patient #1 presented for "assessment of right sided 'bulging area' .... Raised bulge on [patient's] right side, possible baby part." RN A placed Patient #1 on fetal monitoring. RN A noted Patient #1 rated her pain 7 (severe) on a scale of 1 - 10 and documented "Pain Interventions: No need assessed / requested".

At 1:06 PM, RN A received orders from Physician B over the telephone, including "Diagnosis: Bulge on [Right] side..." Physician B also ordered RN A to continue to provide fetal monitoring to Patient #1. Physician B did not include any orders related to the bulge on Patient #1's right side, or Patient #1's pain.

At 2:05 PM, RN A documented they notified Physician B over the telephone about Patient #1, and the bulge on Patient #1's right side. Physician B gave orders for RN A to discharge Patient #1 home, and advised Patient #1 to use over-the-counter antacids. Physician B did not come to the hospital and physically examine Patient #1 prior to discharge.

At 2:15 PM, RN A discharged Patient #1 from the MTTU.

Review of Patient # 1 ' s medical record for inpatient admission on 9/26/10 at 7:19 PM showed Patient # 1 returned to the MTTU. RN C documented in the medical record Patient #1 "states pain has worsened, now has visible extruding lump in [upper right side of the abdomen]. [Patient] reports extreme tenderness. [Patient #1 is] asking to see the [doctor] this time."

At 7:25 PM, RN C received orders from Physician B over the telephone, including an abdominal ultrasound.

On 9/27/10 at 1:27 AM, Surgical Resident D diagnosed Patient #1 with an incarcerated incisional hernia, which required surgical repair on 9/28/10.

On 10/2/10, nursing staff discharged Patient #1 home.

2. Review of the policy, "EMTALA: The Treatment and Transfer of Individuals Who Request Emergency Medical Services", effective 8/09, revealed in part, "A woman who is not in true active labor may still have an emergency medical condition if the individual has a medical condition such that the absence of immediate medical attention will place her or her fetus in serious jeopardy." Further review of the policy revealed, "Stable for Discharge means: the physician has determined that the patient has reached the point where his continued medical treatment could reasonably be performed as an outpatient or later as an inpatient..."

3. During an interview on 1/12/11 at 10:15 AM Patient # 1 stated she had experienced increasing pressure all over her abdomen the morning of 9/26/10, so she called the on call Obstetrical physician. Patient # 1 stated she was instructed to take an antacid, but knew the problem required more treatment than an antacid. " The OB doctor told me to go to the OB department if I chose to go to the hospital. " Patient # 1 stated she had a sharp pain under her right rib, and there was a small bump about 4 inches long and about ? inch raised. Patient # 1 stated it hurt when she pushed into the bump, " the nurse thought it was the baby ' s foot. " Patient # 1 stated " I ' ve never had anything like [the bump before]. " Patient # 1 stated she tried to explain to the nurse how much it hurt. " I asked why they were discharging me in pain. The nurse said she didn ' t know what was going on with me. " " When I left the OB department, I asked if I came back, where should I go? " " The nurse said to come back to OB. " " When I returned to the hospital the OB doctor did not come in, however, they called the surgeons. " " I had an abdominal ultrasound and the tech said they thought it was a hernia. " " They got me admitted that night ... I had surgery on [9/28/10] at 7:30 PM. "
4. During an interview on 1/11/11 at 2:00 PM, RN A stated the nurses did not provide a medical screening exam to patients who presented to the MTTU. Instead, the nurses only focused on the pregnancy, and relayed their findings to a physician or nurse midwife. RN A stated s/he did not document if s/he examined the bulge in Patient #1's abdomen.

5. During an interview on 1/13/10 at 9:20 AM, the Medical Director for the Emergency Department stated that the medical screening exam performed in the MTTU on 9/26/10 focused only on Patient #1's pregnancy and did not include further investigation into the cause of her abdominal pain.

6. According to the statutorily mandated Quality Improvement Organization's physician peer review, Patient #1 did not receive an appropriate medical screening exam on 9/26/10 to determine the cause of Patient #1's abdominal pain.

7. Review of Patient # 1 ' s medical record for inpatient admission on 12/16/10 revealed Patient # 1 returned to the hospital for admission and surgery to replace an infected mesh used to repair the hernia on 9/28/10.

8. Review of Patient # 1 ' s emergency room medical record 8 days after the surgery to replace the infected mesh, showed Patient # 1 presented via ambulance on 12/24/10 at 10:15 PM. The ambulance crew documented patient # 1 was at home and began having " severe abdominal pain. " The ambulance crew administered 50 micrograms of Fentanyl (a potent medication to control pain) IV push (administration of a medication directly into a vein to quickly deliver medication into the body) and waited several minutes, reassessed patient #1, and documented " Again the [patient] was given 50 micrograms Fentanyl IV Push. " " The pt was having only minimal relief of her pain. "

At 10:15 PM the ambulance arrived at the ED. Review of the ED record revealed RN E documented Patient # 1 complained of sharp abdominal pain " all over. " The ED physician documented that Patient # 1 had hypoactive bowel sounds; " sharp, " crampy " type pain " located in the right lower quadrant and that Patient # 1 rated her pain a 9-10 (severe to most intense pain) out of 10. The ED physician ordered lab work, an abdominal x-ray and consultation with the surgical resident.

At 11:15 PM Surgical Resident F examined Patient # 1 and documented that " should her pain get worse or she becomes febrile that she return to the Emergency Department and she can be further evaluated. " Surgical Resident F documented on the discharge instruction sheet that Patient # 1 ' s discharge diagnosis was " abdominal pain, urinary tract infection " , and that Patient # 1 " should call [name of surgical group] on Monday and make an appointment to see Dr. [name of surgeon]. " " Take antibiotics as directed and pain medication as prescribed. "

At 11:15 PM, RN E documented in the " Interdisciplinary Record Page 2 " that Patient # 1 rated her pain a 10 (most intense pain) out of 10 and administered 1 mg of Ativan (a medication to control anxiety) IV push.

At 11:18 PM, RN E administered 1 mg of Dilaudid (a potent medication to control pain) IV push to Patient #1.

At 12:25 AM on 12/25/10 (approximately 2 hours after arriving in the Emergency Department), RN E documented Patient #1 rated her pain an 8 (severe pain) out of 10 and administered 1 mg of Dilaudid IV push.

At 1:00 AM RN E documented Patient # 1 ' s pain had decreased and that she rated her pain a 4 (moderate) out of 10.

At 2:30 AM , RN E documented that Patient # 1 ' s pain had increased to an 8 (severe pain) out of 10 and that she "request[s] more pain med[ication]." RN E documented contact with Surgical Resident F for additional orders on treating Patient #1's pain. The documentation in the medical record does not indicate Surgical Resident F re-examined Patient # 1 prior to discharge.

At 2:35 AM (5 minutes after paging Surgical Resident F about Patient #1's pain), RN E provided discharge instructions and teaching to Patient #1.

At 2:50 AM, RN E documented that Patient # 1 received 1 mg Dilaudid IV push but did not document Patient # 1 ' s level of pain or whether she had any pain relief.

At 3:10 AM (15 minutes after Patient #1 received the last dose of Dilaudid (a potent medication to control pain), RN E documented "[patient discharged] in stable condition [with significant other] for ride home."

Review of Patient # 1 ' s 12/25/10 medical record showed Patient # 1 presented to the ED approximately 7 ? hours after discharge (10:48 AM on 12/25/10) complaining of "abdominal pain - worse than this [morning]". The ED physician documented that Patient # 1 had " Frank Peritonitis " in all 4 quadrants of her abdomen, and ordered a stat surgical consult. Patient # 1 was subsequently admitted to the hospital for emergency surgery to repair a perforated bowel.

9. During an interview on 1/12/11 at 10:15 AM, Patient # 1 stated she developed excruciating pain in the evening on 12/24/10. Patient # 1 stated Surgical Resident F told her the pain was probably due to a stitch that had come loose. Patient # 1 stated that she knew something was wrong. Patient # 1 stated she returned to the ED a second time because of the pain, when a team of doctors and nurses evaluated her, and quickly decided to do surgery.

10. During an interview on 1/12/11 at 3:10 PM, Surgeon K, Surgical Resident F ' s supervising physician stated s/he did not know Patient #1 required additional intravenous pain medication shortly before discharge.

11. According to the statutorily mandated Quality Improvement Organization's physician peer review for patient #1's 12/24/10 Emergency Department visit, Patient #1 did not receive an appropriate or sufficient medical screening examination.