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Based on record review, policy review, patient and staff interviews, the Hospital failed to perform an appropriate medical screening exam (MSE) within its capabilities to determine if an emergency medical condition (EMC) existed for 1 of 20 sampled patients (Patient 1) who presented to the hospital's emergency department seeking medical care. Failing to perform an appropriate MSE including assessing for cervical dilation and progression of labor in a patient complaining of contractions may place a patient at risk for premature delivery and poses a threat to the health and safety of the woman and unborn fetus.

Findings Include:

The hospital failed to perform an appropriate medical screening exam (MSE) within the hospital's capability to determine if an emergency medical condition (EMC) existed for 1 (Patient 1) of 20 patient records reviewed. (Refer to A2406 for details)

Based on record review, policy review, patient and staff interviews, the Hospital failed to perform an appropriate medical screening exam (MSE) within its capabilities to determine if an emergency medical condition (EMC) existed for 1 of 20 sampled patients (Patient 1) who presented to the hospital's emergency department seeking medical care. Failure to perform an appropriate MSE including assessing for cervical dilation and progression of labor in a patient complaining of contractions may place a patient at risk for premature delivery and poses a threat to the health and safety of the woman and unborn fetus.

Findings Include:

Review of "RULES AND REGULATIONS OF THE MEDICAL STAFF OF [ABOVE NAMED HOSPITAL]" Amended 10/15, showed " ...The hospital must provide for an appropriate medical screening examination, to determine if an emergency medical condition exists, on all patients presenting to the emergency room. The following individuals have been determined to be qualified medical personnel to perform the medical screening examination: registered nurses assigned the responsibilities and duties of the emergency department and obstetrics, physician assistants who are members of the McPherson Hospital Allied Health Care Staff and McPherson Hospital staff physicians."

Review of hospital policy titled "Care and Documentation of the Patient in Labor" last revised 11/2024 showed,

"POLICY: To define the care and documentation of patients in labor following an initial assessment upon admission.

When appropriate, documentation should be recorded on the patient and fetal monitor strip. Definitions: Active Phase of Labor- Dilation > 4 cm [centimeter] accompanied by uterine contractions.

...2. Uterine Activity

Spontaneous labor with absence of risk factors:

Assess and document uterine activity (frequency, duration, and intensity of contractions) every 30 minutes during the active phase of the first stage of labor and every 15 minutes during the active pushing phase of the second stage of labor.

Spontaneous labor with presence of risk factors and/or induced/augmented labor:

Assess using continuous electronic monitoring and document uterine activity (frequency, duration, and intensity of contractions) every 15 minutes during the active phase of the first stage of labor and every 15 minutes during the active pushing phase of the second stage of labor ...

...4. Sterile Vaginal Exams

Changes in dilation and effacement of the cervix, fetal station, and fetal presentation should be assessed and documented at intervals necessary to evaluate the progress of labor and fetal descent.

When membranes are ruptured, limit the number of vaginal exams to only those necessary or physician ordered for patient comfort and to decrease the possibility of infection ..."

Review of a hospital policy titled, "Standard of Care to be Provided to the Laboring Mother" last revised 07/2000 showed,

"Purpose: To establish a policy for the standard of care to be given to the laboring mother.

Implementation:

1. On admission, the admission nursing assessment will be completed. Admission documentation will include: vital signs, fetal heart tones, results of vaginal exam if patient is at least 36 weeks gestation, not actively bleeding or has intact membranes, frequency, duration, and intensity of contractions ...

...8. Repeat vaginal examinations will be done as necessary ...

...11. Other procedures and care as ordered by physician ..."

Review of the hospital medical staff on-call schedule showed OB on-call Physician, Staff F, was on call for obstetrics/labor and delivery (L&D) when Patient 1 presented to the OB department on 09/11/24 and 09/14/24.

Review of a hospital document titled, "2023/2024 Medical Staff Roster (As of 10/29/24)", showed, Staff F, Family Practice with OB, was a member of the medical staff.

Review of medical staff credential files showed, OB on-call physician, Staff F was reappointed to the medical staff on 12/19/22.

Patient 1

Review of a medical record showed Patient 1 who was gravida 2 (2 pregnancies) para 1 (1 live birth) at 35 weeks gestation presented to the hospital OB department (dedicated emergency department) on 9/11/24 at 8:16 AM with complaints of pelvic pain and contractions. The patient's medical screening examination included a sterile vaginal exam (SVE) performed by OB nurse G at approximately 9:17 AM. At 9:41 AM OB Physician F examined the patient and determined she was 1 cm dilated. Documentation by OB Physician F showed the patient remained 1 cm dilated on 3 checks. OB Nurse G provided OB Physician F with an update of Patient # 1's condition at 10:50 AM. OB Nurse G performed multiple antepartum assessments and documented observation of the patient's ongoing irregular contractions without progression to preterm labor. At 4:24 PM OB Nurse G documented a verbal order from OB Physician F to discharge Patient # 1. The patient's discharge diagnosis included a diagnosis of False labor.

Review of a second medical record showed Patient 1 returned to the hospital OB department on 9/14/24 at 3:40 PM to check on "contractions" and her blood pressure. Documentation by OB Nurse K under the "OB: Initial Interview" indicated Patient # 1 arrived at 3:40 PM to rule out "R/O" labor. Further documentation showed "Pt [patient] here to check on ctx [contractions] and BP d/t [due to] last check. Pt states she has a lot of anxiety about something being wrong with her or her baby ... She also states she is having a lot of pressure and feeling like she needs to poop." External fetal monitoring began at approximately 4:04 PM through approximately 5:01 PM. OB nurse K documented a phone order at 3:48 PM (countersigned by OB Physician F on 9/16/24 at 12:26 PM) which showed "If complaint of contractions or pelvic pressure, nurses to complete SVE if WGA (weeks gestational age) or greater. If less than 4 cm dilated, nurses may monitor and recheck SVE in 1 hour." However, despite the hospital's policy for "Care and Documentation of the Patient in Labor" and a physician's order for an SVE to be performed if complaint of contractions or pelvic pressure, an SVE was not performed nor were serial checks or medical decision-making documented as part of the MSE to rule out preterm labor prior to Patient 1's discharge at approximately 5:12 PM. Under "Patient Progress Notes", OB Nurse K documented at 4:52 PM provider (on-call OB Physician F) notified of the patient's condition and that "Provider ordered to DC [discharge] pt at this time." At 5:24 PM OB Nurse K documented "Uterine Activity Mode: External monitor" and "Uterine Activity: None."

In an interview on 11/12/24 at 9:44 AM, Staff B, Chief Operating Officer stated that patients 20 weeks gestation or greater bypass the Emergency Department (ED) and are triaged by trained Registered Nurses (RN) on the OB unit. The OB RN assesses fetal heart tones, signs of active labor like contractions and abnormalities like bleeding. Patients greater than 34 weeks gestation have a cervix check. The trained OB RN then consults the physician on call with the findings for every patient that presents, and the physician gives further direction for care.

During an interview on 11/13/24 at 11:50 AM, Staff K, RN stated that if the patient is 36 weeks or above, I would do a sterile cervical check. Monitoring time is a minimum of 20 minutes or longer of strip reports and it is recorded until delivery or until active labor is ruled out. If the patient is 36 weeks or less, I would call the provider to obtain an order to do a vaginal exam. Staff K remembered Patient 1. Staff K went on to say she would leave the patient on the monitor until after the provider is notified and it is ultimately up to the provider to determine if the patient needs to be admitted, transferred, or is stable for discharge.

In an interview on 11/13/24 at 2:52 PM, Patient 1 stated that she was having contractions on 09/11/24 and was dilated to 1 centimeter. She returned to the OB unit on 9/14/24 and denied any bleeding but stated she was having "pain." Patient 1 said she was told by the nurse that she was not having contractions but "according to the monitor, I was."

Despite the patient's recent history of uterine contractions, her anxiety about "something wrong with her baby" and having "a lot of pressure", the hospital failed to ensure the patient received an appropriate medical screening examination on 9/14/24 to evaluate whether or not the patient was experiencing a pregnancy related complication including preterm labor (an emergency medical condition) prior to affirming False labor and ordering the patient's discharge.