HospitalInspections.org

Based on a tour of the Emergency Department (ED) and staff interview, conducted on January 29, 2013 at approximately 2:00 PM, it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor or information indicating whether or not the hospital participates in the Medicaid program.

Findings include:

1. Observation of the main entrance to the ED revealed no signage posted.

2. Observation of the waiting areas revealed only one sign in the adult waiting area and one sign in the closed room (balloon room) in the pediatric waiting area. There were no signs in the pediatrics waiting area outside of the "balloon room".

3. Observation of the patient treatment bays in the ED revealed no signage posted.

4. Observation of the ambulance entrance revealed no signage posted.

5. All of the above findings were confirmed by Staff #2.

Based on review of the "OB Triage Log," staff interview, and medical record review, it was determined that the facility failed to ensure that an accurate OB Triage Log was maintained.

Findings include:

1. On 1/30/13 and 1/31/13, the OB Triage Log was reviewed and was noted to have gaps in entries for patient discharge times, discharge dispositions, and mode of arrival.

The following was observed:

a. Review of the OB Triage Log for 1/7/13 had one time entry of 1330 for Patient #26. The entry did not indicate if 1330 was the patient's time of arrival or time of discharge.

i. Upon interview on 1/30/13 at 10:30 AM, Staff #11 stated that there should be two time entries on the OB Triage Log next to the patient's name to indicate a time of arrival and a time of discharge.

ii. Review of Medical Record #26 indicated that the patient arrived to the OB triage area on 1/7/13, was triaged at 11:46, and then discharged at 1330. The time on the log was Patient #26's time of discharge.

b. Review of the OB Triage Log for 1/7/13 had one time entry of 1427 for Patient #27. The entry did not indicate if 1427 was the patient's time of arrival or time of discharge.

i. Review of Medical Record #27 indicated that the patient arrived to the OB triage area on 1/7/13, triaged at 1512, and later discharged at 2100. The time on the log was Patient #27's time of arrival.

c. Review of the OB Triage Log for 1/13/13 lacked evidence of Patient #28's discharge disposition.

d. Review of the OB Triage Log for 1/13/13 lacked evidence of Patient #29's time of discharge.

e. Review of the OB Triage Log for 1/2/13 lacked evidence of Patient #31's mode of transportation on arrival and discharge disposition.

2. Further review of the OB Triage Log indicated other gaps in the log entries for patient times of arrival, times of discharge and patient discharge dispositions.

A. Based on staff interview and medical record review, it was determined that in 3 of 6 medical records of patients leaving the ED without being seen, the facility failed to provide evidence of an appropriate medical screening exam.

Findings include:

1. Documentation in Medical Record #1 indicated that the patient presented to the ED on January 7, 2013 at 11:39 AM. The patient was triaged at 12:35 PM.

a. Documentation on the triage note states, "...Abdominal pain. ...Pain 8/10."

b. Documentation in the nursing notes at 10:23 PM states, "Patient called for the first time. No answer. Patient not found in the waiting area..."

c. Documentation in the nursing notes at 10:43 PM states, "Patient called for the second time. No answer. Patient not found in the waiting area..."

d. Documentation in the nursing notes at 11:05 PM states, "Patient called for the third time. No answer. Patient not found in the waiting area..."

e. The patient was in the ED for 10 hours, 8 minutes and there was no evidence that a medical screening exam was performed by qualified medical personnel.

f. The above was confirmed by Staff #2.

2. Documentation in Medical Record #2 indicated the patient presented to the ED on January 7, 2013 at 12:07 PM. The patient was triaged at 12:31 PM.

a. Documentation on the triage note states, "...Headache...Pain 10/10."

b. Documentation in the nursing notes at 10:27 PM states "Patient called for the first time. No answer. Patient not found in the waiting area..."

c. Documentation in the nursing notes at 10:43 PM states "Patient called for the second time. No answer. Patient not found in the waiting area..."

d. Documentation in the nursing notes at 11:05 PM states "Patient called for the third time. No answer. Patient not found in the waiting area..."

e. The patient was in the ED for 9 hours, 56 minutes and there was no evidence that a medical screening exam was performed by qualified medical personnel.

f. The above was confirmed by Staff #2.

3. Documentation in Medical Record #3 indicated the patient presented to the ED on January 7, 2013 at 12:31 AM. The patient was triaged at 2:02 PM.

a. Documentation on the triage note states, "...Vomiting...Pain 7/10."

b. Documentation in the nursing notes at 10:28PM states "Patient called for the first time. No answer. Patient not found in the waiting area..."

c. Documentation in the nursing notes at 10:44PM states "Patient called for the second time. No answer. Patient not found in the waiting area..."

d. Documentation in the nursing notes at 11:05PM states "Patient called for the third time. No answer. Patient not found in the waiting area..."

e. The patient was in the ED for 7 hours, 25 minutes and there was no evidence that a medical screening exam was performed by qualified medical personnel.

f. The above was confirmed by Staff #2.


21953

B. Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to provide a complete medical screening exam to all obstetric patients in 1 of 6 obstetric medical records reviewed.

Findings include:

Reference#1: Facility policy NO: CCP-PC-002 (CHMCH), titled 'Emergency Care' states, "... V. PROCEDURE ... D. Medical Screening Examination ... 3. Documentation ... f. False Labor (if applicable). A woman experiencing contractions is in true labor unless a physician, certified nurse midwife or other Qualified Medical Person acting within the scope of his/her practice and State law, certifies that, after a reasonable time of observation, the woman is in false labor."

Reference #2: Facility policy NO: MAT:O.1 (CHMCH), titled 'Obstetrics Triage Patient (Assessment of the)' states, "... IV. POLICY: ... C. Medical Screening Examination (MSE): 1. A MSE is an examination conducted by a Qualified Medical Person that is sufficient to determine, with reasonable clinical confidence, whether an Emergency Medical Condition exists. A MSE is a process, not an isolated event. a. Qualified Medical Persons are defined as: 1) Obstetricians 2) Certified Nurse Midwives (CNM) 3) Family Practice physicians appropriately privileged in Obstetrics b. A Qualified Medical Person performs the MSE. c. The OBT nurse assigns the Emergency Severity Index (ESI) Level. 2. The attending or designated --- Women's Group (--- WG) LIP evaluates the patient in person. ... F. Prior to discharge from OBT, the LIP certifies that the patient is not in active labor. Documentation of the certification is recorded on OBT Discharge Instructions."

1. On 1/31/13, review of Medical Record #25 indicated per the 'OB Triage Assessment' that the patient arrived to OB Triage on 1/7/13 at 1427 for Preterm Labor. The patient was 34/6 weeks Gestation age and her estimated date of delivery was 2/12/13. The nursing staff applied fetal monitors and monitored the patient. Further review of Medical Record #25 indicated the following:

a. A nursing note dated and timed 1/7/13 at 1900 stated, "Cervical dilation: 0" and "Membranes: Intact."

b. A physician progress note dated and timed 1/7/13 at 18:56 stated, "Triage Note: pt to [SIC] discharged at request of Dr. --- pt presents c/o irregular ctx denies vb/rom +FM 124/70 78 FHR category 1 irreg ctx VE per RN long thick closed 34 6/7 preterm ctx labor precautions reviewed discharge home."

2. Staff #8 was interviewed on 1/31/13 regarding the process for evaluation of a patient in pre-mature labor. Staff #8 stated that the patient is placed on a monitor and the LIP [Licensed Independent Practitioner] is notified that the patient is in OB Triage. A monitor is placed on the patient and a strip is reviewed to assess for contractions, a head to toe assessment is done, urine sample obtained, the patient's belly is felt for contractions, and if there is leaking fluid the physician is notified and a nitrizine strip is tested. Staff #8 stated the nursing staff can do sterile vaginal exams (SVE), but tend to have the physician do the SVE because they may do additional testing on vaginal fluid. Staff #8 stated that the physician will do a SVE or speculum exam to ascertain that the patient is not dilating and this is a standard of care. Staff #8 stated that if the patient is in active labor, then the nurse will do the vaginal exam, but if the patient is possibly going home then the physician will need to establish that the patient is not in labor.

3. On 1/31/13, Staff #6 and Staff #8 were interviewed, at which time a review of Medical Record #25 was conducted -- monitor readings indicated that the patient was having one contraction in 30 minutes. Staff #6 and Staff #8 stated that this is okay; the Category 1 fetal heart meant that the fetal heart rate was normal. The physician documentation at 1856 and the nursing note with vaginal exam, documented at 1900 (as above in #1), were reviewed by Staff #6 and Staff #8.

a. Staff #8 confirmed during interview, that the physician should have done a vaginal exam on Patient #25 to rule out labor prior to discharge, as per the policies in Reference #1 and Reference #2 above.

b. Staff #6 stated that this nurse can do the vaginal exam because this nurse is an experienced nurse.

4. Staff #7 stated during interview on 1/31/13 at 1:25 PM that he/she thinks it is not a problem that the nurse performed the vaginal exam on Patient #25 instead of the physician because this nurse is an OB/GYN nurse and is competent to do vaginal exams. Staff #7 also stated that their (facility) policy does not specify who has to perform the vaginal exam for the MSE [medical screening exam].

5. The policy in Reference #1 indicates that it is up to the LIP to determine if a woman is in false labor. The policy in Reference #2 does not define a nurse as a LIP.

Staff interviews were conflicting as to whether the physician should have performed the vaginal exam on Patient #25. Without the physician performing the vaginal exam on Patient #25 to rule out labor, it could not be determined if Patient #25 was provided a complete MSE.

Based on staff interview and medical record review, it was determined that in 2 of 6 medical records of patients that were transferred, the facility failed to provide evidence of a completed transfer form.

Findings include:

1. Documentation in Medical Record #13 indicated that the patient presented to the ED on September 15, 2012 at 5:13 PM with a complaint of 2nd and 3rd degree burns on approximately 30% of his/her body. This patient was in need of a higher level of care (Burn Unit).

a. Documentation on page 1 of 3 of the transfer form did not state the risks of the transfer.

2. Documentation in Medical Record #22 indicated that the patient presented to the ED on August 20, 2012 at 1:57 PM with a complaint of abdominal pain. Testing indicated a bowel obstruction. This patient was in need of a higher level of care (Pediatric Intensive Care Unit).

a. Page 2 of 3 of the transfer form; the consent to transfer signature page, was not in the medical record.

3. The above was confirmed by Staff #2.