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Based on record review, staff interview, and review of facility documents, it was determined that the facility was not in compliance with §489.24 by failing to perform an appropriate Medical Screening Examination (MSE) (A2406).

Cross Reference:
489.24(a) & 489.24(c) Medical Screening Exam

Based on medical record review, staff interview and review of facility documents, it was determined the facility failed to maintain the Labor and Delivery log for each individual seeking care for an emergency medical condition.

Findings include:

Facility policy, titled, "Assessment Triage of OB Patients (OB/ER.39)", reviewed 11/07/2022, states, "... The emergency department logs and the L&D log must contain cross-references to each other in order to comply with EMTALA central log requirements ..."

Facility policy, titled, "Log, ED (ER.34)", reviewed 9/14/2022, states, "... The Emergency Department/S.E.D will keep a continuous log of all patients treated in the department. This should include: ... Date, Time and Mode of arrival ... Patient name, Date of Birth, Account number, Medical record number ... ER Doctor/APC Screening ... Doctor Treating or Admitting, if different from ER Doctor ... Chief Complaint ... Diagnosis ... Discharge/Admit time, Disposition ..."

The medical record of Patient (P) 24 was reviewed. On 12/29/2022 at 8:18 PM, P24 presented to the ED for complaints of syncope and feeling weak with noted decreased fetal movement after a fall. P24 was triaged at 8:36 PM with an ESI of 3H. Vital signs and an EKG (electrocardiogram) were completed and P24 was transferred to the OB (Obstetrics) ED. The OB Physician cleared the patient to return to the main ED to be treated for medical issues unrelated to pregnancy. P24 was brought back to the ED waiting room at 9:52 PM to wait to be seen by a physician. P24 was noted as left without treatment at 11:45 PM.

During a review of the Central log for 12/29/2022, it was noted that P24 had two central log entries. The first noted that P24 checked into the ED on 12/28/2022 at 8:17 PM. This log entry is missing information for the following: "MD seen date"; "Primary Practitioner"; "Diagnosis txt"; "Discharge Disposition"; and "Destination."

On 7/18/23, the Labor and Delivery Logs from December to the present date of 7/18/23 were requested from Staff (S)16. S16 provided the logs for December 2022 to June 2023 for review. Review of the December 2022 log noted that on 12/29/2022, P24 had a "Time In" of 8:40 PM. The L&D log for P24 was missing the following information: "Dr/CNM"; "Admit Reason"; "Time Out"; and "Disposition." Further review of the December 2022 L&D logs noted that the logs were incomplete with missing documentation for the disposition of 38 patients. Other incomplete log documentation for December 2022 included missing physician names, "Admit Reason" and "time out" for patients listed on the OB ED log. Review of subsequent months' logs up to June 2023 identified the same incomplete log documentation for multiple patients.

Per S16, the unit secretary, does the daily checks for accuracy and completeness of the Labor and Delivery Logs. On 7/18/23 at 1:47 PM, when asked who has oversight to monitor that logs are checked daily for completeness and accuracy, S16, S17, and S59 all confirmed that the logs had not been monitored or tracked for accuracy and completeness.

On 7/19/23 at 3:21 PM, S4 and S7, stated that they are responsible for monitoring the accuracy and completeness of the Emergency Department logs. S4 confirmed that the ED log is the central log for the facility. S4 stated that when a patient comes to the ED that needs to go to labor and delivery, it is noted on the central log and that what happens to the patient after, in the OB ED, is documented on the Labor and Delivery log. S4 stated that she is unsure if the two logs are reconciled with each other in order to maintain an accurate and complete central log.

Based on medical record review, staff interview, and review of facility documentation, it was determined the facility failed to ensure that a medical screening exam was conducted for 2 of 25 patients (#14 and #24) presenting to the Emergency Department (ED).

Findings include:

Facility policy, titled, "Assessment Triage of OB [Obstetrical] Patients", reviewed 11/07/2022, states, "... E. An OB patient greater than 20 weeks gestation, who presents with conditions unrelated to pregnancy and/or without abdominal trauma: 1. The patient will be evaluated by the Emergency physician and the OB/GYN Practitioner will be consulted by phone to agree on treatment and disposition. 2. FHR will be documented by Physician or Nurse..."

Facility policy, titled, "Vital Signs (ER.70)" states, "... A. All patients presenting to the Emergency Department/S.E.D will have vital signs taken as a part of the triage assessment. Additional vital signs will be taken for re-assessment at a minimum of four (4) hours and at the time of discharge ...F. Abnormal vital signs including pain level, will be rechecked at intervals appropriate to the abnormality and the patient condition as determined by the Triage/Primary nurse or the responsible physician. G. Complete vital signs will include temperature, pulse, respiration, blood pressure, pulse ox, and pain assessment ..."

Facility policy, titled, "Triage, Patient (ER.66)", states, "...Triage is a system for prioritizing patient care to facilitate prompt and appropriate treatment ... Every patient presenting to triage is considered an Emergency Department/Satellite Emergency Department (SED) patient by virtue of their request and will be placed in a treatment area and receive a medical screening exam by the physician/APC/resident on duty within four (4) hours ... The Pivot/Triage nurse/RN shall assign a Triage Level to each patient according to the Nationally recognized Emergency Severity Index (ESI) Guidelines and will be monitored consistent with the level assigned ... The Pivot/Triage Nurse is responsible for monitoring all patients remaining in the waiting area of the emergency department and reassessing acuity every four hours ... The Pivot/Triage nurse will update patients and families waiting for treatment regarding delays ... each patient shall be assigned an ESI Triage level of 1, 2, 3V, 3H, 4, or 5 based on the professional nursing triage and clinical assessment ... LEVEL 3 Vertical (can be initially treated in a chair) or Horizontal (requires and laydown space) ... Level 3 requires two or more resources ..."

The medical record of Patient (P)14 was reviewed. On 3/6/23 at 4:26 PM, P14 presented to the ED with complaints of right upper quadrant abdominal pain. P14 was triaged at 4:48 PM with an Emergency Severity Index (ESI) of 3V. A set of vital signs were taken in triage and the pain assessment noted, "Pain Present, Yes." Documentation in the medical record of P14 noted a patient disposition at 11:21 PM that stated, "... Left without being seen LWBS ... ED Reason for Leaving: Wait too long ... Waiting Room Patient: Waiting room checked, Patient called x3 ..." The medical record of P14 lacked evidence of a medical screening exam, a pain reassessment, and an evaluation by the Pivot/Triage nurse for reassessment of the patient's acuity. P14 was not called to be seen in the ED for six hours and 55 minutes. The medical record lacked evidence that the patient was informed of any delays in treatment.

The medical record of P24 was reviewed. On 12/29/2022 at 8:18 PM, P24 presented to the ED with complaints of syncope and feeling weak with noted decreased fetal movement after a fall. P24 was triaged at 8:36 PM with an ESI of 3H. Vital signs and an EKG (electrocardiogram) were completed and P24 was transferred to the OB (Obstetrics) - ED. The OB Physician cleared the patient to return to the main ED to be treated for medical issues unrelated to pregnancy. P24 was brought back to the ED waiting room at 9:52 PM to wait to be seen by a physician. P24 left the waiting room without being seen by an ED physician at 11:45 PM.

An interview with Staff S4, ED Director, stated that if a pregnant patient presents to the ED with complaints and is 20 weeks pregnant or greater, the patient will get a quick set of vital signs taken and then will be sent to the OB ED located on the Maternal Fetal Health Unit. Once the patient has been cleared by the OB Physician, the patient would then be sent back down to the ED waiting room. S4 stated that there is no set process for a patient coming from the OB ED to the Regular ED. S4 stated that maybe the patient might go straight to a bed, but the patient would go through the whole triage and registration process again. Upon review of P24's medical record for the date of 12/29/2022, P24 was cleared by the OB physician to be brought back to the main ED at 9:52 PM to wait to be seen by an ED physician. P24 left the waiting room without being seen by an ED physician at 11:45 PM, prior to a medical screening exam being completed by the ED Physician.