HospitalInspections.org

Based on findings from interviews and document reviews, Patient #19 was not provided a medical screening examination in the emergency department (ED) to determine if an emergency medical condition (EMC) existed.

Findings include:

-- Review on 7/28/14 of the entries in the hospital's ED central log for 7/20/14 revealed it did not contain Patient #19's name.

-- During interview of Customer Receiving Specialist (CRS) #1 on 7/29/14 at 1:20 pm, the following information was obtained:

CRS #1 was on duty in the evening of 7/20/14; in the CRS role he/she checks patients in at the reception window in the ED.

On that evening a "young woman" and her 2 year old daughter (Patient #19) presented to the ED. The mother told CRS #1 that she thought her daughter may have been sexually assaulted.

CRS #1 discussed this with the day/evening ED Charge Nurse (CN). The day/evening ED CN told CRS #1 to tell the mother they were not refusing to see the child but it would be best if she took the child to another hospital.

The evening/night ED CN was present and overheard the guidance to CRS #1 to tell the mother it would be best to go to the other hospital.

-- Review of the MR for Patient #19's presentation to the ED at another hospital at 20:14 on 7/20/14 reveals she presented there via ambulance. A copy of the Prehospital Care Report (completed by ambulance service staff) in the MR indicates the ambulance service picked the patient up at 110 West 6th Street (Oswego Hospital address). It also notes the patient's mother said she brought the patient to the Oswego Hospital ED and "was advised by a nurse that she needed to go to Upstate."

Based on findings from document reviews and interview, in 1 of 22 medical records (MRs) reviewed for patients who presented to the Emergency Department(ED) for evaluation and stabilization of an emergency medical condition (Patient #18), the patient was not provided stabilizing treatment prior to discharge.

Findings include:

-- Review of Patient #18's MR reveals the following information:

On 6/12/14:

At 2048 this 19 year old female, presented to the ED with complaints of abdominal pain. She was 3 days post-partum having had a live birth on 6/9/14 with no reported complications. The patient complained of suprapubic pain radiating to kidneys, and vaginal bleeding that was "stringy" after giving birth but was now like regular menstruation. The patient also reported feet/calves losing color, and pain 7 out of 10. She was triaged at 2136 as a level 3 acuity out of 5, with 1 being life-threatening.

0400 pain medication given (Motrin 800 mg and Percocet 5/325 mg, 2 tabs, orally)

A CT of the abdomen and pelvis with contrast (time completed not noted) revealed impression of an enlarged uterus with possible retained products of conception or hemorrhage. An ultrasound was recommended to further determine diagnosis.

The MR indicates the attending ED physician reviewed the CT. No ultrasound was performed.

0404 - The patient was discharged with diagnosis of postpartum pain, in good condition and with pain medication (Lortab 5/325 tablets). Pain level at time of discharge not described. The MR indicates the patient had an appointment with OB/Gyn (obstetrician / gynecologist) physician on 6/18/14. There is no indication written discharge instructions were provided.

- - During review of this MR with the Chief Nursing Officer on 7/29/14 at 12:00 pm, he/she acknowledged these MR review findings.

-- Given the lack of response or intervention for the CT examination findings above, the patient was not stable for discharge.