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2500 HOSPITAL DRIVE

MARTINSBURG, WV 25401

COMPLIANCE WITH 489.24

Tag No.: A2400

Based on review of medical records (MR) and facility documentation, it was determined the facility failed to comply with §489.24 by failing to provide an appropriate medical screening examination (MSE) to rule out an emergency medical condition (EMC) (Refer to A2406).
Cross Reference:
489.24(a) & 489.24(c) Medical Screening Exam

MEDICAL SCREENING EXAM

Tag No.: A2406

Based on review of medical records (MR) and facility documentation, it was determined that the facility failed to provide an appropriate MSE to rule out an EMC in two out of 20 medical records reviewed (MR1 and MR11).

Findings include:

Review of facility policy "Emergency Medical Treatment and Labor Act (EMTALA) Policy," revised February 19, 2020, revealed " ...Purpose: To ensure that (1) all patients who present to Berkeley Medical Center (BMC) or [hospital name] or its premises requesting emergency services receive an appropriate Medical Screening Examination ...D. How to Provide the Medical Screening Examination (MSE) ...6. The MSE is the process required to reach, within reasonable clinical confidence, the point at which can be determined whether an emergency medical condition does or does not exist ...."

A review of the facility website, https://wvumedicine.org/berkeley/services/#All, revealed that the facility provided the following medical services, not limited to but including: laboratory, obstetrics and gynecology, and radiology-ultrasound.

Review of MR1 ``Emergency Department Visit Note," dated July 14, 2022, indicated the patient presented to the emergency department (ED) with complaints of vaginal bleeding and abdominal pain/cramping radiating to their back for two days. The patient reported they had an intra-uterine device (IUD- A long-acting contraception device that is inserted into the uterus). The physician documented the patient had bleeding from the cervix (the narrow passage forming the lower end of the uterus) with abdominal tenderness and differential diagnoses of "1. Dysfunctional uterine bleeding, 2. Side effect of [IUD], 3. Bacterial vaginosis, 4. Early pregnancy." Laboratory tests revealed a human chorionic gonadotropin quantitative test (hCG-a test that evaluates for the presence of a hormone produced when pregnant) of 307 mIU/ml (a level above 25 mIU/ml is considered positive for pregnancy). The physician further documented "labs reviewed and interpreted by me." The patient was discharged with a diagnosis of dysfunctional uterine bleeding.

Review of the American College of Obstetricians and Gynecologists (ACOG) website "Long-Acting Reversible Contraception (LARC): Intrauterine Device (IUD) and Implant Frequently Asked Questions," revealed " ...In the rare case that a pregnancy happens with the IUD in place, there is a higher chance that it will be an ectopic pregnancy [A pregnancy in a place other than the uterus, usually in one of the fallopian tubes]. This is a serious condition that needs medical attention right away ...." (retrieved from https://web.archive.org/web/20220707134059/https://www.acog.org/womens-health/faqs/long-acting-reversible-contraception-iud-and-implant).

There was no documented evidence that the hospital identified the cause of the bleeding or completed an appropriate MSE to identify the location of pregnancy in a patient who presented to the ED with an IUD and was found to have a positive pregnancy test.

Review of MR11"Emergency Department Visit Note," dated March 20, 2023, indicated the patient presented to the ED with a complaint that they had experienced two episodes of vaginal bleeding with difficult and painful urination. The physician documented that the patient was six weeks pregnant, as determined during a previous ED visit on March 6, 2023. The physician documented differential diagnoses of "1. UTI [urinary tract infection], 2. Threatened miscarriage [potential early pregnancy loss], 3. Ectopic pregnancy 4. Subchorionic bleed [bleeding beneath the membranes that enclose the embryo]." Lab tests revealed an hCG test result of 17,974 mIU/ml. The physician further documented the patient was discharged with the primary clinical impression of "Less than 8 weeks gestation of pregnancy" as well as "UTI."

There was no documented evidence that the hospital completed an appropriate MSE to rule out an EMC, including additional testing to rule out an ectopic pregnancy or identify the source of the patient ' s continued bleeding.