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Based on a review of medical records, policies and procedures, medical staff bylaws, and staff interviews, it was determined that the facility failed to provide an ongoing, appropriate medical screening examination (MSE) within its capacity and stabilizing treatment for one (P#1) of 21 sampled patients. P#1, who was 21 weeks pregnant, presented to the facility's (F#1) emergency department (ED) on 10/14/22 with complaints of abdominal pain for several days. P#1 reported that she had been seen in another facility's ED twice for the same complaints. On 10/15/22, P#1 presented to another facility's (F#2) ED with persistent pain. It was determined that P#1 required immediate surgical intervention, and she suffered a fetal demise prior to the start of the procedure.

Findings included:

Cross refer to A2406 as it relates to F#1's failure to ensure that an appropriate ongoing medical screening examination was conducted on P#1.

Based on review of medical records, policy and procedures, medical staff bylaws, and staff interviews it was determined that the facility (F#1) failed to provide an ongoing appropriate medical screening examination (MSE) within its capability for one patient (P) (P#1) of 21 sampled patients. Specifically: P#1 presented to the facility's emergency department on 10/14/22 at 11:43 a.m. with complaints of " Generalized weakness and Abdominal pain for three days" and was 21 weeks pregnant. Facility#1 failed to provide radiologic services and fetal monitoring to the patient and was treated with medications and discharged home. P #1 presented to F#2 on 10/15/22 with persistent abdominal pain. It was determined that P#1 required surgical intervention for ovarian torsion (twisted) and bilateral ovarian cysts. P #1 was admitted to F#2 and suffered a fetal demise prior to undergoing an exploratory laparotomy.

Findings included:

Review of the medical record revealed that Patient #1 (P #1) presented to the facility's (F#1) Emergency Department (ED) on 10/14/2022 at 11:43 a.m. for chief complaint of generalized weakness and abdominal pain. P #1 was 21 weeks pregnant. P#1 reported abdominal pain at 10 on a scale of 0 to 10 and described the pain as worse pain ever. P#1's vital signs at 11:46 a.m. included a heart rate of 116 beats per minute (normal was 60-100 beats per minute and respiratory rate (RR) of 19 breaths per minute (normal was 12-20 breaths per minute. Other vital signs were within normal limits.

P #1 was placed in a room at 11:48 a.m., triage started at 12:07 p.m. P #1 reported to triage nurse that she was 21 weeks pregnant and had had abdominal pain a few days prior to her coming to the ED. P #1 said she was seen at an affiliated hospital the day prior and was told that her abdominal pain was not related to her pregnancy. P #1 also reported that she had seen her Primary Care Doctor today and the doctor sent her to the ED to get lab work done. P #1 said she had her last bowel movement (BM) four days ago. P #1 had an acuity (emergency severity index ESI) 3 when triage was completed.

Continued review of the record revealed that orders were entered at 12:08 p.m. for blood work, urinalysis, and pregnancy test (HCG). Blood was collected for the lab tests at 12:16 p.m. Lab results at 12:26 p.m. included a White Blood Cell (WBC) (one indication of infection) count of 15.70 (Normal Range: 3.40 - 10.80).

A medical screening examination was started by Doctor DD at 2:03 p.m. and documented at 2:30 p.m. revealed that P #1 was a 25-year-old female who was currently 21 weeks pregnant; presented to the ED for evaluation of abdominal cramping with an onset of 3 days ago. P #1 stated she believed symptoms were related to food poisoning. Patient #1 reported the pain was associated with nausea and vomiting that has resolved within the last 24 hours. P #1 was currently able to tolerate oral intake. Patient also noted onset of constipation for the last 4 days. P #1 reported pain worsened with movement. She denied any other alleviating factors for her symptoms. Patient noted symptoms persisted this morning prompting ED visit. Patient denies history of appendectomy (removal of the appendix) or cholecystectomy (removal of the gallbladder). P #1 denied onset of fever, vaginal discharge, vaginal bleeding. MD notes stated Per Medical Record, P #1 was evaluated at a sister facility 3 days prior on 10/13/22 where she was told her symptoms were not pregnancy related. P #1 was sent here to get labs drawn and for treatment of persistent symptoms.

Vital signs taken at 2:20 p.m. included a heart rate of 118. Doctor DD placed an order for Tylenol #3 (Tylenol with codeine) that was administered at 2:54 p.m. Morphine (medication for severe pain) 4mg administered at 2:54 p.m. Zofran (anti vomiting medication) 4 mg administered at 2:55 p.m. and intravenous fluids (IVF) started at 2:54 p.m.

At 2:54 p.m. P#1 reported a pain score of 10.

At 5:20 p.m. a re-evaluation was completed by Doctor DD and lab results were reviewed. P #1 was advised to follow up with OBGYN (doctor who was taking care of her and her baby during pregnancy) after discharge. The clinical impression was generalized abdominal pain.

A review of the Discharge Summary dated 10/28/22 at 9:28 p.m. from Facility (F)#2 revealed that P#1 arrived on 10/25/22 at 10:57 a.m. with complaints of nausea, vomiting and abdominal pain. She reported severe pain. P#1 reported that that she had been seen in F#1's ED as well as two prior ED visits to another facility. P#1 had been informed that the pain was due to pregnancy. At F#2, results of an ultrasound and CT revealed that P#1 had bilateral ovarian structures with concern for ovarian torsion.

Review of Policy Stat ID 11101630, last revised on 1/27/22, titled "Transfer Activities in Accordance with EMTALA Requirements Policy" revealed that the purpose of the policy was to establish guidance for providing appropriate medical screening examinations (MSE), stabilizing treatment and appropriate transfer of patients in accordance with the Emergency Medical Treatment and Labor Act (EMTALA), and all regulations promulgated thereunder.

Definitions included:

Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to, severe pain, psychic disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in
either:
a. Placing the health of the individual or, with respect to a pregnant woman, the health of the women or her unborn child in serious jeopardy or;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part; or
d. With respect to a pregnant woman who is having contractions:
o That there is inadequate time to effect a safe transfer to another hospital before delivery; or
o That the transfer may pose a threat to the health or safety of the woman or her unborn child

Qualified Medical Person - The qualified medical person (QMP) who performs the medical screening (as outlined in the Medical Rules and Regulations): In the Emergency Room: A physician, Certified Nurse Practitioner or Physician's Assistant (in conjunction with a physician).

Stabilized or to Stabilize -
A. With respect to an emergency medical condition:
That no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of an individual from the hospital; or to provide such medical treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the Hospital

Within the capability - of the emergency department or of the Hospital means those capabilities which the hospital is required to have as a condition of its Emergency Department license, including on-call physicians and specialists and ancillary services routinely available to the Emergency Department.

The document stated that it is the policy of [Facility]shall abide by the requirements set forth in EMTALA regulations for patients presenting to the hospital seeking emergency treatment by:
Providing an appropriate medical screening examination (MSE)
Providing necessary stabilizing treatment for emergency medical conditions and labor.

Review of Policy Stat ID 12824579, last revised 12/29/2022, titled "Obstetrical Patients in the Emergency Department Policy" revealed that the purpose of this policy was to define the guidelines for all obstetrical (OB) patients presenting to the Emergency Departments across [the hospital system]
It is the policy of [the facility] that all obstetrical patients presenting to the Emergency Department will be managed appropriate to their specific needs as determined by the presentation and gestation. The policy revealed that obstetrical patients who present to the Emergency Department with: Gestation equal to or greater than 20 weeks with complaints of labor and/or exhibiting signs and symptoms of labor the following will happen:
-A registered nurse will evaluate the patient prior to being transported to Labor and Delivery to verify that delivery is not imminent. - An evaluation and medical screening exam will be performed by a qualified medical provider in Labor and Delivery.
o-In the event the patient does not have an obstetrician on staff at the hospital, the obstetrician on-call for the Emergency Department will be contacted to care for the patient.
- If after the medical screening and examination performed in Labor and Delivery, it is determined that the patient is not in active labor, the patient will be discharged home from Labor and Delivery with follow-up care instructions or discharged from Labor and Delivery to the Emergency Department for further evaluation and/or treatment.

Review of Medical Staff Bylaws, Article 11, under Emergency Services revealed Emergency Services and care will be provided to any person who comes to the emergency department as that term is defined in the EMTALA regulations, whenever there are appropriate facilities and qualified personnel available to provide such services or care. Medical screening examinations, within the capability, of the hospital will be performed on all individuals who come to the hospital requesting examination or treatment to determine the presence of an emergency medical condition.

During an interview with ED Doctor (Doctor) CC on 10/21/24 at 1:30 p.m. in the ED. Doctor CC explained that ED staff print out the specialty on call schedule daily and posted in the nurse's station. Doctor CC said the on-call was also available online. Doctor CC explained that for pregnant patients, they had OB Doctors on call that he could call directly or send a secure message. Doctor CC said these doctors were in-house Physicians and responded within 30 minutes if they toned to come see a pregnant patient. The on-call OB Doctor would respond to the ED more promptly if necessary. Doctor CC explained that if a pregnant patient was greater than 20 weeks gestation and presented with complaints related to her pregnancy, or any pregnancy concerns, they would call OB as soon as possible. Doctor CC explained that pregnant patients with obstetric complaints underwent fetal heart monitoring. Staff from the OB department would perform a fetal ultrasound in the ED when requested.

An interview with Doctor DD took place on 10/23/24 at 9:15 a.m. in the conference room. Doctor DD stated that she did not remember P #1 since the case was over two years ago. Doctor DD however explained that she reviewed the patient's visit and said P #1's chief complaint was not related to her pregnancy. Doctor DD said P #1 did not present with vaginal bleeding, did not have any contractions and that was the basis for her decision to treat P #1 with IV fluids and pain medications. Doctor DD said it was standard practice/protocol to do fetal heart tones on patients greater than 20 weeks gestation. Doctor DD explained that it was her usual practice to obtain fetal heart tones. Doctor DD explained that P #1 saw her OB doctor 12 hours prior to coming to the ED. Doctor DD said P #1's complaint was not related to her pregnancy, but her primary care OB sent her to the ED to have blood work done. Doctor DD reiterated that P #1 went to another ED twice before presenting to F#1 and it was determined that her abdominal pain was not OB related. After review of P#1's medical record, Doctor DD confirmed that fetal heart tone monitoring was not documented for P#1's visit on 10/14/22.

An interview with the ED Medical Director (Doctor) EE took place on 10/23/24 at 9:40 a.m. in the conference room. Doctor EE explained that when a pregnant patient presented in the ED, it was protocol to first determine if the patient was in labor, the patient's gestation, and determine if the patient showed signs of preterm labor. Doctor EE said the patient would still be treated and stabilized in the ED regardless of presented signs. Doctor EE explained that the ED provider would send the patient to Labor and Delivery only if the patient showed signs of preterm labor and pregnancy complications such as vaginal bleeding, tearing, fluid leakage. Doctor EE explained that fetal heart tones were performed on patients greater than 20 weeks gestation. He stated that this was the standard even if the patient did not show signs of pregnancy complications. Doctor EE said it did not matter if a patient saw her doctor before coming to the ED, it was still standard to assess the pregnancy.

A phone interview with RN GG took place on 10/23/24 at 10:10 a.m. RN GG was one of the nurses who cared for P #1 on 10/14/22 when she presented in the ED. RN GG did not remember P #1. RN GG explained that labor and delivery staff were usually notified of pregnant patient in the ED. RN GG said if the patient was more than twenty weeks pregnant, she would be transferred to labor and delivery. RN GG stated that even if the patient's chief complaint was not pregnancy related, they still called OB to report that they had a pregnant patient in the ED.