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Based on record review and staff interview, the hospital failed to ensure that a patient that arrived to the facility's emergency department received a medical screening examination (MSE), by a qualified health professional for two (2) of 25 sampled patients (Patient 22 and 23).

This deficient practice had the potential for patients not receiving needed care.

Findings:

1. A review of Patient 22's electronic medical record was conducted with Director of Acute Care Service/ ED Services (DACEDS) on 11/06/19, at 10:38 a.m. The ED Timeline indicated Patient 22 arrived on 10/30/19, at 11:05 AM, with the complaint that Patient 22 had been involved in a motor vehicle accident (MVA) about two (2) hours ago and was 25 weeks pregnant. At 11:06 AM, Registered Nurse (RN) began the triage and at 11:08 AM, indicated Patient 22 was " .... here for fetal monitoring," and the OB Screening. The "full triage" was completed 11:10 AM and Patient 22 was "sent to Labor & Delivery (L&D) at 11:10 AM accompanied by a nurse."

On 11/6/19 at 11:10 AM, the surveyor asked if there was an "OB Screening," and what did the OB screening consisted of. The DACEDS stated, "The OB screening was basic information use by the triage nurse to ask patient's due date, where she is having contractures, do you have urge to push, did your water brake, is there fetal movement?" The DACEDS stated, "No, the MSE in the ED was done and Patient 22 was not seen by the provider."

2. Patient 23 arrived at the ED on 7/26/19 at 12:02 PM, with the complaint of "pain in back and stomach" due to an MVA and was 38 weeks pregnant. The Timeline indicated RN began the triage at 12:08 PM and at 12:16 PM, the OB screening was complete. At 12:17 PM, Patient 23 was sent to L&D.

During an interview on 11/05/19, at 10:40 AM, the Triage RN stated,"If a pregnant lady walks in and has medical problems, she would be cleared of any medical problems. The RN would communicate to the physician, he/she clears the patient, if stabilized, to go upstairs to L&D. The triage RN notifies the OB RN to come down to escort the patient to L&D. She further stated, "all patients 20 weeks or less go upstairs after being cleared but the facility's policy states 24 weeks.

The DACEDS reviewed the electronic medical record and stated, "There was no MSE conducted in the ED."

A review of a facility's policy titled, "Obstetrical Patients," effective date 11/2017, indicated, "If a patient presents to the ED requesting L&D, she will be escorted to L&D for a Medical Screening Exam (MSE). IF she presents to ED seeking emergency services, the MSE will be conducted in the ED.

Based on record review and staff interview, the hospital failed to ensure there was no delay providing an appropriate medical screening examination (MSE), for Patient 14 who arrived at ED seeking emergency medical care at 3:13 PM. Patient 14 did not have an MSE until 9:10 PM (6 hours later).

This deficient practice had the possibility of a patient not receiving appropriate treatment.

Findings:

Patient 14 arrived at the ED on 11/3/19 at 15:13, with a complaint of "abdominal pain and 25 weeks pregnant." At 3:13 PM, the triage began, at 3:14 PM, orders were placed by the nurse practioner (NP) for urinalysis with microscopic. An OB screening (are you having contractions, did your water break, and fetal movement) was done and at 3:21 PM and Patient 14 was sent to L&D. At 3:26 PM, a Bed Request for L&D (Labor and Delivery) - (Labor Delivery Room) LDR/LDR-01 and charting was completed.

A review of the Triage RN notes dated 11/3/19, at 4:33 PM, indicated the on call physician was notified of patient's complaint and history and orders were received.

A review of the physician's telephone orders dated 11/3/19, between 4:05 PM and 8:37 PM, included orders for imaging, laboratory work, drug screen, fetal nonstress test, to place Patient 14 in an out patient bed, and continuous electronic fetal monitoring.

The Fetal Assessment indicated a note (returned to bed and the on call physician notified at 8:10 PM, and on call physician on the way).

Reviews of the OB Admission History and Physical was dated 11/3/19, at 9:10 PM and the Obstetrical Vaginal Delivery Note was dated 11/3/19, at 9:15 PM by the on call physician.

The Timeline "Events" indicated Patient 14 was "a transfer in" on 11/3/19, at 9:26 PM.

A review of a facility's policy tilted, "Obstetrical Patients," dated 11/2017, indicated a patient that presents to the ED requesting L&D, will be escorted to L&D for a MSE. If the patient presents to the ED seeking emergency services, the MSE would be conducted in the ED.

The Standard is not met. Based on Interview and Record review the Hospital failed to assure:
Transfer Patient #1, who was 25 weeks pregnant and having contractions, after medical treatment to a higher level of care. (A2409) CFR489.24 (e)(1)(i) and CFR489.24 (e) (2)(i)

This deficient practice had the potential for a negative outcome of the pregnancy.

A review of Patient #1's medical records, documented Patient #1 presented to the Emergency Department (ED) on 7/28/19 at 2:03 AM, with a complaint of abdominal pain and was 25 weeks pregnant. At 2:05 AM, Patient 1 was sent to Labor and Delivery (L&D). The Medical Screening Examination (MSE) was completed by RN #1 at 2:40 AM, and included: Uterine activity exam using an external "toco" transducer (a monitoring tool that determines the length and frequency of uterine contractions during labor) at 2:30 AM, documented no uterine contractions. Patient #1's Membrane and Cervix exam indicated membranes were intact and Patient #1 had no bleeding at 2:30 AM. Patient #1's Pain assessment, on a Scale of 0 to 10 was six (6) and located in her abdomen and back.
A review of MD #1's telephone orders included administration of Lactated ringers, 500 ml Intravenous (IV) bolus given at 2:55 AM, Lactated ringers IV bolus 1000 ml at 3:07 AM, and Terbutaline injection 0.25 mg given subcutaneously at 3:10 AM. A review of Patient #1's record titled, 'Uterine Activity Assessment', at 3:00 AM, documented Patient #1 had three (3) to four (4) uterine contractions per minute. The uterine contractions duration was between 40 seconds to 70 seconds each. A review of Patient #1's 'Uterine Activity Assessment', documented at 4:15 AM, indicated Patient #1 had three (3) to five (5) uterine contractions per minute with a duration of 30 seconds to 70 seconds each.

A review of the 'OB Triage Care Record', dated Sunday July 28, 2019, documented at 4:15 AM, RN#1 notified MD #1, by Phone that Patient #1 had continued uterine contractions. In the response section from MD #1 at 4:15 AM, it is documented "see orders discharge to higher acuity hospital with NICU". At 4:26 AM, a telephone with read back order from MD #1 documented, "Discharge Patient, MD instructs patient to immediately go to higher acuity hospital with NICU for r/o preterm labor". A review of Patient #1 discharge instructions dated 7/28/19 at 4:29 AM, in the after visit summary documented for Patient #1, to go to Torrance Memorial Hospital today to rule out preterm labor. There was no documentation of MD #1 examining or transferring Patient#1 by ambulance to a receiving hospital. Patient 1 was discharged while having uterine contractions to drive to another hospital to seek medical care for her ongoing uterine contractions.

During an interview with RN #1 on 11/14/19 at 7 PM, RN #1 stated that Patient #1 had continued to have contractions after receiving the terbutaline, at which time she called and notified MD # 1 that Patient #1 had continued to have contractions and asked if should she repeat the terbutaline. RN #1 stated she was instructed by MD #1 to proceed with discharging Patient #1 to higher level of care. RN#1 stated she asked MD #1 to come in to transfer the patient. MD #1 did not come in and instructed RN #1 to discharge the patient. During the interview, RN #1 was asked if the hospital had a system in place to address concerns about discharging a Patient that is 25 weeks pregnant and having ongoing preterm contractions. RN#1 stated that the House Supervisor could intervene and contact MD #1 or an alternate MD to assure the Patient was transferred by ambulance.

During an interview with MD #1 on 11/12/19 at 9:00 AM, MD #1 stated that most 'OB Call' was telephone calls. During OB Call MD #1 stated that he relies on the information provided by the RN. MD#1 stated that he would go to the hospital if the L&D RN indicated he needed to come in to see a patient, or transfer a patient. MD #1 indicated there was no in-house OB service. When asked about care for Patient#1 that was in preterm labor and discharged, MD #1 stated that if she was in preterm labor, she should not be discharged, she should be transferred to a higher level of care. When asked if he would send a patient out to Rule Out preterm labor to a higher level of care MD #1 stated he would not, he would come in and transfer the patient.

During an interview with the Assistant Director of ED, on 11/05/19 at 10:05 AM, the Assistant Director of ED stated that OB patients that present to the ED, after being cleared for non OB medical presentations, are sent to L&D. During an interview with the Medical Director of ED on 11/06/19 at 10:20 am, the Medical Director of ED stated that all OB patients under 20 weeks remain in ED. All OB Patients greater than 20 weeks are cleared for any medical conditions unrelated to OB, then sent to L&D for OB evaluation and treatment. The Medical Director of ED stated that he has not had any incidents where on an call OB did not come in when asked to. During an interview with the Chairman of the OB Department, on 11/06/19 at 1:40 PM, the Chairman of the OB Department stated there was 24/7, telephone on call OB coverage and no in-house L&D coverage/24 hour OB coverage. The Chairman of the OB Department stated that if a Patient had an EMC, including needing transfer to higher level of Care, the On Call OB physician would come in and transfer the patient to higher level of care. The Director of OB did not have any cases that were brought for his review involving patients with ongoing contractions that were discharged from the Hospital in the last 6 months. The Director of OB indicated that patients with preterm contractions should be stabilized and transferred by ambulance.

During an interview with the Quality Assurance Performance Improvement Director (QAPI Director) on 11/06/19 at 2:40 PM, the QAPI Director stated there were no EMTALA studies done. During an interview with the Director of Risk Management on 11/06/19 at 1:20 PM, the Director of Risk Management stated there was no root cause analysis or evaluation of the discharge of Patient #1 completed by the hospital.

During an interview with the OB/GYN director on 11/06/19 at 2:15 PM, the OB/GYN Director stated all RNs that complete an MSE in L&D complete training every year and are approved annually by the Governing body.

A review of a Facility Policy and procedure tilted "Standardized Procedure: Medical Screening Examination by L&D Registered Nurse", dated 4/2019, documented that Direct Physician supervision was not required during MSE of the OB patient ... Conditions requiring direct (in-person) evaluation of the patient by the physician included patients requiring transfer to a higher level of care for Maternal and/or fetal indications" and patients with "Preterm contractions or other signs/symptoms consistent with preterm labor not resolving as anticipated".

A review of a facility policy and procedure tilted "Transfer and/or transport Maternal or Neonate", dated 12/2017, indicated, "With respect to a pregnant woman who is having contractions: the hospital is required to stabilize the medical condition and arrange for the appropriate transfer of the individual to another facility".
A review of a facility policy and procedure tilted, "EMTALA Transfer Requirements," indicated, "Once emergency services and care are provided, the patient without an emergency medical condition or having contractions may be transferred once she is stabilized"

The Hospital failed to assure Patient #1 was transferred to a higher level of care after receiving medical treatment. Patient #1 was discharged while having preterm uterine contractions to drive to another hospital to seek medical care for her ongoing uterine contractions. The hospital failed to provide an appropriate transfer for Patient #1 that was 25 weeks pregnant and having uterine contractions.