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Based on medical record review, facility Medical Staff Bylaws, facility policies, and staff interviews, the facility failed to ensure that patients in the Labor and Delivery (L&D) Department received an appropriate medical screening examination (MSE) by ensuring that they had an effective policy in place that ensured an appropriate medical screening examination would be provided by qualified medical personnel. Review of three (3) L&D medical records revealed that a patient (#22) was not provided an appropriate medical screening examination by qualified medical personnel to determine whether or not an emergency medical condition (EMC) existed. Refer to findings in Tag 2406.

Based on medical record review, facility Medical Staff Bylaws, facility policies, and staff interviews, the facility failed to ensure that patients in the Labor and Delivery (L&D) Department received an appropriate medical screening examination (MSE) with an effective policy in place that ensured an appropriate medical screening examination would be provided by qualified medical personnel. Review of three (3) L&D medical records revealed that patient (#22) was not provided an appropriate medical screening examination by qualified medical personnel to determine whether or not an emergency medical condition (EMC) existed.

Findings include:

Review of the facility Clinical Policy, CPR-318, "Assessment of OB Patients Greater or Equal to 20 Weeks and Intrapartum Patient Care Guidelines," effective date 09/1982, last revised 03/2011, revealed that an Initial Assessment/OB Assessment was inclusive of an initial assessment, MSE, and would be performed for each patient that presented for care. Continued review revealed that the Registered Nurse (RN) in the L&D Assessment Area is responsible for performing the assessment and communicating the data to the attending physician or nurse mid-wife.


Review of the, "DeKalb Medical at North Decatur Medical Staff Bylaws, Policies, and Rules and Regulations, " effective date 09/01/2004, revealed that a MSE is required by federal law and regulation (42 USC 139dd, 42 CFR 489.24) to be provided to any person who comes to the Hospital ' s Emergency Department or Labor and Delivery Department and requests examination or treatment. Further review revealed an MSE may be provided in the Labor and Delivery Department for a pregnant woman who is having contractions by the following individuals: a. A Practitioner with appropriate clinical privileges; b. a certified nurse midwife employed by the Hospital or by a practitioner; or c. a labor and delivery nurse in consultation with a physician.

Review of the patient medical record (#22) revealed the patient presented to the L&D Department on 09/19/16 at 23:59 p.m. with a complaint of cramping with back pain. The OB (Obstetrical ) triage note dated 9/20/2016 at 2:15 AM was reviewed. The section of the noted titled, "Provider notification", revealed in part, "G1PO pt (patient) with iup (intra uterine pregnancy) 32.4 weeks presented c/o (complaint of) lower abd (abdominal ) and back pains, u/a (urinalysis) result wnl (within normal limits) pt having ctx (contractions) 2-3 min (minutes), c/o pain 10/10 (pain scale 0-10, 0-no pain and 10- excruciating pain) . Further review of the record revealed the physician telephone orders to the RN were to administer intravenously a bolus dose of Lactated Ringers solution, and terbutaline (medication used to stop contractions and delay the labor process), ft pt. still contracting after 3rd dose terb(terbutaline) admit and start magnesium, perform sve (sterile vaginal examination). The patient was discharged to home by the RN on 09/20/16 at 05:35 a.m. The record revealed the patient had an MSE performed by an RN and was treated per MD telephone instructions. The facility failed to ensure that on 9/19/2016 Patient #22 received an appropriate medical screening examination by a qualified medical personnel.

During an interview with the Director of Labor and Delivery (DLD) (#10) on 09/20/16 at 3:08 p.m. in the Conference Room, the DLD confirmed that the nursing staff is performing the MSEs on patients presenting to the L&D department for treatment. The DLD explained that the Hospital ' s plan is to have all patients presenting to the L&D Department to be seen by an MD by 10/2016.

During an interview with RN #9 on 09/21/16 at 9:30 a.m. in the Conference Room, the RN stated all patients are given an MSE by the triage RN in L&D. When asked if there was a list delineating which of the nurses could perform an MSE, RN#9 indicated that any of the nurses in L&D were permitted to examine patients. The RN stated that the staff would call the MD to notify him/her of a patient ' s arrival to the department. The RN further explained that the physician ' s orders are given over the phone to the RN. When asked if the nurses were given any kind of competencies or special training to perform an MSE examination, the RN stated they had not received any kind of special training or testing to measure competency.



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