HospitalInspections.org

Based on review of the medical record from the receiving hospital, review of the hospital policies/procedures, hospital internal document, observation on tour, hospital logs, other documents, and interviews, it was determined the hospital failed to maintain documentation on their central log that included patients who entered through a dedicated emergency department (DED) doors seeking help for 1 of 1 patients. (Patient # 1)

Findings include:

Patient #1's medical record from the receiving hospital revealed: "...admit date: 9/24/2018; arrival time 2344 hours; on 9/24/2018 at 2345: labs obtained; discharged 9/27/2018...."

OB intrapartum H&P (history and physical) revealed: " ...Reason for admission: Labor, No fetal complication, No maternal complication...chief complaint from nursing intake: 9/24/2018 at 2319: contractions...History of Present Illness: the patient presents with contractions and that started earlier...No VB/LOF (vaginal bleed/loss of fluid)...Good FM (fetal movement)...No complications this preg. PNC (prenatal care) with (name of OB/Gyn MD #3). GBS negative...."

Obstetrical Exam revealed:
9/25/2018 at 0404: Cervix Dilation 10
9/25/2018 at 0312: Cervix Effacement (%) 100
9/25/2018 at 0404: Fetal Station +1

Delivery Information:
9/25/18 at 0419: Delivery of the Head
9/25/18 at 0419: Date/Time of Birth

Hospital policy titled "Care of the Obstetrical Patient", Policy # PCS/L&D 99, Approval Date: 11/2017, revealed: "...Policy: E. The Labor and Delivery/OBED Unit maintains a log of all patient seen in Labor and Delivery/OBED in compliance with federal and state requirements...D. The OB RN will perform an assessment on all presenting patients...."

Hospital policy titled "AMA (Against Medical Advise) Refusal of Treatment", Policy # PCS 3.9 Approval Date: Not documented revealed: "...Patients at Abrazo Arrowhead Campus will have the right to accept medical care or refuse medical treatment to the extent permitted by law and to be informed of the material medical risks of such refusal. Competent patients have a right to refuse medical Intervention...Documentation must use the e-Demand form #EDEMF2008- Leaving or Refusing Of Treatment Against Medical Advise...."

Hospital Policy titled "EMTALA" Policy # Admin/L E2 Approval Date: 11/2016 revealed: "...C. Central Log 1. The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE...the central log may include, directly or by reference, patient logs from other areas of the hospital where a patient might present for emergency services or receive a medical screening examination instead of in the traditional emergency department. These additional logs must be available in a timely manner for surveyor review. The hospital may also keep its log in an electronic format...F. Refusal of Treatment...the Hospital must take all reasonable steps to have the individual or the person acting on the individual's behalf acknowledge their refusal of further examination and treatment in writing. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual; the risks/benefits of the examination and /or treatment, the reasons for refusal; and if the individual refused to acknowledge their refusal in writing, the steps taken to secure a written informed refusal...."

Hospital internal document, with Reference Date 10/4/2018, revealed: "...11/5/2018...Patient arrived to OB triage between hours of 8-10 pm and OB triage was full, no beds. Asked how long it would be and she stated she was told 30-40 min. She did not register and claims she was given (name of the receiving hospital) information at nurses station and headed over there. Stated she was not looked at when at arrowhead (sic). (Receiving hospital's-name of the Risk Management) stated patient due date was 10/4/2018 and she delivered at (name of the receiving hospital). Drove herself there from Arrowhead...."

During the Labor and Delivery (L & D) Unit-tour on 11/27/2018 and 11/28/2018, the surveyors observed the L & D Intake Department. All the patients presenting at the Intake Department were required to complete a hospital form titled 'OB Triage/Medical Screening' Form.

OB Triage /Medical Screening Form requires the pt. to complete the following:
"...Date; Time; Legal Name; Date of Birth (DOB); Social Security #; Home Phone #; Current Address; Have you been to an Abrazo Hospital before? OB Doctor; Due Date; Date of last period; Reason for visit today...."

The form also includes: "...FOR YOUR SAFETY AND TO VERIFY PATIENT IDENTIFY: (sic) PLEASE PROVIDE PHOTO IDENTIFICATION AND INSURANCE CARDS WITH THIS FORM...If you have a Medical Emergency or are in Labor, you have the right to receive a Medical Screening Examination and necessary Stabilizing treatment/transfer, even if you cannot pay or do not have medical insurance...."

Employee #7 confirmed during an interview on 11/27/2018, that s/he remembered this case. S/he reported that every pt. is required to fill out the OB Triage /Medical Screening Form with name, DOB and reason for visit. Employee #7 stated, if the pt. cannot fill the form out, s/he would help them fill out.
S/he identified that at that point in time, the unit was very busy; Triage was full; there were 3 patients who presented at once with same symptoms. S/he identified the 4th pt. came in and thought she was "leaking fluid and complaining of pain." The pt. saw the person before her go to the waiting room as OB triage was full. The pt. did not want to wait and asked how long the wait would be. She was told unsure, trying to move as fast as we can, maybe thirty minutes or less. Employee #7 identified that s/he asked pt. #1 to sign in; however, the pt. refused treatment and asked for a closer hospital. She asked for the (name of the receiving hospital) phone number. Pt. #1 called the receiving facility on her cell phone and spoke to the OB department. Employee #7 said that s/he tried to get the pt. to register to be seen; pt. declined and left.

Employee #4 confirmed during an interview on 11/28 and 11/29 that she was not present when the event occurred; however, when she interviewed Employee #7 it was reported that the pt. presented to the unit and waited to register. When it was her turn to register, the pt. asked "how long is it going to be? (Probably, because she saw the pt. in front of her be escorted to the waiting room)."
The patient was told, "We are moving quickly but it could be 30 minutes." The pt. asked, "where the next nearest hospital was?" and she was told "you can go to any hospital." She was asked to register to be seen and the pt. refused to be registered and left the unit.

Employee #2 confirmed that the OB Triage/Medical Screening Form is a standard requirement for all patients who present to the L & D Department to fill out.

Both, Employee #5 & Employee #7 confirmed during private interviews that every pt. that presents to the L& D unit will fill out the OB Triage/Medical Screening Form, and that they never had a patient who didn't fill out the form. Both reported, the only time when the form is not filled out by the patient is when they are in active labor, and in that case the unit secretary would fill out the information on patient's behalf. The information from the OB Triage/Medical Screening Form is entered in the system, patient is registered and a label is generated with the patient's name, age, DOB, admin date. This label is included in the L & D log, for each pt.

However, there was no documentation that patient #1 was entered in the log, in accordance with the hospital's policy titled 'Care of the Obstetrical Patient', and Section 489.20(r)(3).

There was no documentation that the hospital staff followed the facility EMTALA policy related to required documentation in the Central log, or following the AMA policy related to refusal of treatment and leaving AMA (Against Medical Advice).

Based on review of hospital policies/procedures, document review, and interviews, it was determined the hospital failed to perform a medical screening exam (MSE) on Patient #1 to determine whether or not, an emergency medical condition existed. Failure to conduct a MSE poses the high potential risk that a patient presenting with an emergency medical condition will not be identified and/or treated promptly and the needs of the patient addressed urgently to protect their health and safety.

Findings include:

Hospital's policy titled 'Care of the Obstetrical Patient', Policy # PCS/L&D 99, Approval Date: 11/2017, revealed: " ...Policy: A. The Hospital provides a medical screening examination to all patients presenting for obstetrical evaluation, testing or services within the capabilities of the obstetrical unit and the ancillary services routinely available to the Obstetrical Department consistent with this policy...D. The OB RN will perform an assessment on all presenting patients, including the AWHONN Laboring coping algorithm if appropriate, and assign a priority rating using the AWHONN Maternal Fetal Triage Index (MFTI)...E. the priority rating will be documented in the medical record...F. The OB RN will communicate to the Delivering Clinician regarding patient receiving an MFTI priority rating of 1 (Stat), who must be evaluated by the Delivering Clinician within a reasonable time according to Hospital bylaws...G. The OB RN will communicate to the Delivering Clinician regarding patient receiving an MFTI priority of 2 (Urgent), who must be evaluated by the Delivering Clinician within a reasonable time according to Hospital bylaws...H. The OB RN will communicate to the Delivering Clinician regarding the patients receiving an MFTI priority rating of 3 (prompt), who will determine the plan of care for the patient including the determination if the patient has an Emergency Medical Condition...I. The OB RN will communicate to the Delivering Clinician regarding the patients receiving an MFTI priority rating of 4 (Non-Urgent), who will determine the plan of care for the patient including the determination if the patient has an Emergency Medical Condition and assign a final disposition...."

Hospital's policy titled 'EMTALA', Policy # Admin/L E2, Approval Date: 12/2016, revealed: " ....G. Medical Screening Examination or MSE means the screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist...IV. Policy: ...A. The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists...H. Medical Person...means any individual or individuals determined qualified by Hospital bylaws or rules and regulations (and consistent with state licensure) to perform a Medical Screening Examination...in the hospital...limited to physicians, physician assistants, nurse practitioners and registered nurses who have been deemed qualified to certify false labor in conjunction with physician certification...V. Procedure: A. Triage and Registration 1. Triage a. As soon as practical after arrival, individuals who come to the Emergency Department should be triaged in order to determine the order in which they will receive a medical screening examination (MSE)

The hospital's policy 'EMTALA', with Policy #Admin/L E2, also requires: " ...F. Refusal of Treatment ...The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual; the risks/benefits of the examination and/or treatment; the reason for refusal; and if the individual refused to acknowledge their refusal in writing, the steps takes to secure the written informed refusal. Hospital personnel involved with the individual's care or witnessing the individual refusing consent must document the patient's refusal in the medical record...."

Employee #9 (L & D RN) stated that she remembered the case, occurred between 8-10 P.M. and that the patient's husband said that the pt. was in a lot of pain, asked how long was the wait and asked if there was a way they could go to a different hospital. Husband was told that (name of the receiving hospital) was the closest hospital to Abrazo, meanwhile Employee #7 gave them the receiving hospital phone number; and the husband called the hospital on his phone.
Employee #9 stated that she was charting at the time of the event; however, she didn't have any other contact with the patient; triage the patient or conduct a MSE.

Employee #7 stated during her/his interview on 11/27/2018, that Employee #9 (L&D RN) gave the hospital phone number to the patient.

Employee#10 (Charge RN) confirmed during an interview on 11/28/2018, that it was reported to her that the pt. presented to the unit, waited to register. When it was her turn to register, the pt. asked: "how long is it going to be?"...when she saw the patient in front of her be escorted to the waiting groom. The patient asked "where the next nearest hospital was?" and she was told "you can go to any hospital."
S/he confirmed that s/he didn't see or talk to the patient, as she was taking care of another labor patient.

Employee #4 reported that the pt. had refused treatment and left; and that was within her patient right.

However, there is no documentation to support that patient # 1 was offered a medical screening exam (MSE), and that the patient had refused the medical screening exam; as she was never put in the OB ED log.

There is no documentation that target pt.#1 was ever seen and evaluated before heading to the receiving hospital, which is located approximately 4.7 miles (typically 12-15 min traffic time).

Delivering Clinician (Laborist #2) who was working on 9/24/2018, (nights) identified during an interview on 11/28/2018 that s/he was not made aware of this case or this patient.