HospitalInspections.org

Based on medical staff rules and regulations, policy and procedure review, medical record review, and staff and physician interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

1. Based on policy and procedure review, Medical Staff Rules and Regulations, medical record reviews and staff interviews, the facility failed to ensure the on-call provider for labor and delivery meet the on-call responsibilities in order to provide evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition for 2 of 26 sampled medical records reviewed ( Patient #14, Patient #26)

~cross refer to - Tag A2404

2. Based on policy review, medical record review and interviews the hospital failed to ensure that an appropriate medical screening examination was provided for patients (Patient #3 and Patient #14) for two (2) of 26 patients who presented to the hospital's Dedicated Emergency Department (DED).


~cross refer to - Tag A2406

Based on policy and procedure review, Medical Staff Rules and Regulations, medical record reviews and staff interviews, the facility failed to ensure the on-call provider for labor and delivery meet the on-call responsibilities in order to provide evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition for 2 of 26 sampled medical records reviewed ( Patient #14, Patient #26)

The findings include:

Review of facility policy "EMTALA- Reporting an On-Call Physician's failure or Refusal to Respond" revised 08/2021 revealed "...PROCEDURE: I. If a physician who is on the Dedicated Emergency Department on-call schedule fails or refuses to respond to a request for examination or treatment services with in 45 minutes, the physician 's failure or refusal shall be documented in writing and reported to the administrator-on-call..."

Review of facility "Medical Staff Rules and Regulations" reviewed/ amended 10/2018 revealed "...4. RESPONSE TIMES: Response times for either telephonic or physical response are noted below:...Emergency Room- thirty (30) minute response time telephonically; forty-five (45) minutes to response time for physical response following the initial telephonic contact...Nurse inquiries- thirty (30) minutes to respond telephonically..."


1. Review of the closed Dedicated Emergency Department (DED) medical record on 02/03/2022 for Patient #26 revealed a 24-year-old female presented to DED on 01/01/2022 at 2222 for a complaint of shortness of breath. Review of the Emergency Department (ED) Timeline revealed at 2224 Patient #26 was assigned an acuity of 3 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Review of the Vital Signs at 2224 revealed "BP: 188/106; Temp: 36.6; Heart Rate: 70; Resp: 24; SpO2: 98% ..." Review of the Pain Assessment at 2225 revealed a pain score of 7 out 10 on a 0-10 pain scale (0 means no pain and 10 means severe pain). Review revealed there was no indication where Patient #26's pain was located. Review of the ED Notes at 2228 revealed "Spoke w/ (with) CN (charge nurse) in Womens (sic) Pav (pavilion) and informed that pt was flagging for pre-eclampsia". Review revealed the ED Disposition was set to "Send to L&D (labor and delivery) at 2229 and Patient #26 was "dismissed" from the DED at 2229.

Review revealed Patient #26 arrived in L&D on 01/01/2022 at 2232. Review of the Nurses note at 2240 revealed "Pt to Obs 1 via wheelchair w/SO (significant other) from ED. Pt to bathroom to change and obtain urine specimen. Pt reports constant epigastric pain that feels like tightness and pressure which makes her feel short of breath. States the pain started around 1800 and has gotten progressively worse and is now 8/10. Review of the Nurses note revealed at 2309 a call was made and a voice message left for Physician #1. Review revealed between 2309 and 2358 the nursing staff documented 4 telephone call attempts to contact Physician #1, 3 telephone calls to Facility A's operator to verify Physician #1 was on call and request additional telephone numbers, and 1 telephone call to Facility C.

Review of the Nurses note at 01/02/2022 at 0020 revealed "Message sent by charge nurse (Name of Nurse) to (Non-OB Physician Name) (on call physician for [Facility C] practice). Review revealed an attempt to reach Physician #1 was made at 0035 with no return call. Review revealed at 0039 the Non-Ob Physician on call for Facility C contacted the L&D department, notified them if unable to reach Physician #1, to try Physician #3, and if that was unsuccessful to treat Patient #26 as an unassigned patient. Review of the Nurses note at 0049 revealed "Called (Physician #3's Name) and updated on pt arrival and status including history, EFM tracing, vital signs, and deferment of SVE. Provider states she will manage patient and attempt to contact (Physician #1's Name).

Review revealed at 0205 Physician #3 was at bedside updating Patient #26 on the POC. Review of the Provider note at 0217 revealed "seen OB triage for elevated blood pressure and epigastric pain ... Abdominal Pain: presented with 8/10 epigastric pain, now better (no intervention), obtain RUQ (right upper quadrant) ultrasound given pain and elevated LFTs (liver function test), IV (intravenous) morphine written, consider GI (gastrointestinal) cocktail for pain ... Elevated blood pressure: severe range BP on arrival in triage, now mild range in 140s/80s without intervention. PIH (pregnancy induced hypertension) labs obtained and notable for platelets of 146, normal creatine, elevated LFTS (799/626), elevated LDH 932, UPC elevated at 0.464; these are concerning for possible HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. - if RUQ ultrasound negative for stones, will need to start IV Magnesium and plan to transfer patient to tertiary care facility ..." Review of the History and Physical note dated 01/02/2022 at 0839 revealed " ... She (Patient #26) was diagnosed with preeclampsia with severe features. LFTs were significantly elevated, 714 and 613. Patient was placed on magnesium sulfate and induction of labor was started. Overnight her platelets have been decreasing from 147 to 118. Now the concern is evolving HELLP ... Plan: Transfer to tertiary care facility (Facility B Name) ... Will transfer due to possible need for blood products in the event of worsening thrombocytopenia and hemorrhage ..." Review revealed Patient #26 was transferred via ambulance to Facility B on 01/02/2022 at 1022.

Telephone interview on 02/03/2022 at 1459 with Physician #1 revealed he was the primary OB physician for Patient #26 prenatal care and was on call on 01/01/2022. Interview revealed Physician #1 was out of town for his granddaughter's birthday and fell asleep. Interview revealed Physician #1 seen the multiple messages upon awaking the next morning.

Telephone interview on 02/03/2022 at 1530 with Registered Nurse (RN) #2 revealed she was the primary nurse for Patient #26 when she arrived to Labor and Delivery. Interview revealed Patient #26 went to the main emergency department prior for epigastric pain and elevated blood pressure prior to arriving to labor and delivery. Interview revealed RN #2 could not get in touch with Physician #1. Interview revealed RN #2 called the facility operator to confirm Physician #1 was on call and to check for additional telephone numbers for Physician #1. Interview revealed the general provider that was on call said to call Physician #3. Interview revealed Physician #3 came in and did the medical screening exam on Patient #26. Interview revealed RN #2 could not recall how long between when Patient #26 presented to L&D and when Physician #3 was notified she had arrived and her condition.

Telephone interview on 02/03/2022 at 1558 with Physician #3 revealed she remembered Patient #26. Interview revealed Patient #26 was a patient of Physician #1 and Physician #1 was on call on 01/01/2022. Interview revealed Physician #1 was the primary and the back up on call. Interview revealed when a patient presents to L&D, the staff contact the patient's primary provider, in this case Physician #2. Interview revealed if there is problems contacting the primary provider the staff then contact the provider that is on call as the back up for the primary and again in this case was Physician #1. Interview revealed the L&D staff contacted Physician #3 saying they could not get up with Physician #1 and Patient #26 was there. Interview revealed Physician #3 took care of Patient #26 and started putting orders in until she could arrange child care for her to go into the hospital to see the patient. Interview revealed Physician #3 evaluated Patient #26, reviewed the labs, ultrasound and felt Patient #26 needed a higher level of care because of HELLP syndrome. Interview revealed Physician #3 transferred Patient #26's care to the unassigned provider services. Interview revealed the "biggest thing was the delay in getting (Patient #26) worked up and getting transferred."

Telephone interview on 02/02/2022 at 1314 with Physician #4 revealed she was transferred care for Patient #26 from Physician #3. Interview revealed Patient #26 had been diagnosed with Preeclampsia. Interview revealed Physician #3 had expressed concerns about Patient #26's labs may be concerning HELLP syndrome. Interview revealed Physician #4 felt the patient needed to be transferred to a facility that had a greater variety of blood products available to help treat HELLP. Interview revealed Patient #26 was stable when Physician #4 transferred her to Facility B.

Telephone interview on 02/03/2022 at 1149 with Registered Nurse (RN) #5 revealed she remembered Patient #26. Interview revealed the nursing staff could not get a hold of the provider that was on call and had to call another provider in the practice.

Interview on 02/03/2022 at 1618 with Physician #6 confirming Physician #1 was on call for Facility C on 01/01/2022. Interview revealed the unassigned OB provider should have been called with in 30 minutes of the staff being unable to contact the on call.

Review on 02/07/2022 of the closed medical record for Patient #26 from Facility B revealed Patient #26 arrived to Facility B's L&D unit on 01/02/2022 at 1138. Review of the History and Physical note dated 01/02/2022 at 1257 revealed Patient #26 was "admitted for preeclampsia with severe features by LFT's, BP's ... Presented with severe epigastric pain now improved ... Proceed with induction for pre-E w/ SF (preeclampsia with severe features)." Review of the medical record revealed Patient #26 was discharged from Facility B on 01/04/2022 at 1856.

2. Review of a closed Labor and Delivery medical record for Patient # 14 revealed a 33-year-old female that presented to the Labor and Delivery unit on 01/07/2022 at 1636 with a chief complaint of fall. Review of the Vital Signs at 1700 revealed "Heart Rate: 93; BP: 138/90." Review of the Vital Signs at 1703 revealed "Temp: 36.9; Resp: 16; ... Pain Management: ... 0-10 Pain Scale: 4; Pain Location: Back; Buttocks." Review of the Event Timeline at 1715 revealed a telephone message was left for Certified Nurse Midwife (CNM) #8 with no indication of a return call. Review of the Nurse note at 1716 revealed "Pt is 33w6d (33 weeks and 6 days) G4P1 (gravida -number of pregnancies; para-number of births after 24 weeks pregnancy) presented ... from work after a fall at 1415 today ... moved her rolling chair and ... jacket was on the floor and got caught up in the wheels and the chair tipped over ... fell on her back and butt ... complains of back pain and has a history of spinal fusion ... no contraction noted, denies any vaginal bleeding, leaking of fluid, or cramping ..." Review of the Event Timeline at 1828 revealed a telephone message was left for CNM #8 with no indication of a return call. Review of the Event Timeline revealed at 2047 contact was made CNM #8 to provide a "status update" and "request evaluate: remote" for Patient #14. Review revealed at 2049 (4 hours and 13 minutes since arrival) CNM #8 placed orders for blood work for Patient #14. Review of Nurses note at 2110 revealed "SBAR (situation, background, assessment, recommendation) provided of patient arrival, patient has been monitored for almost four (hours) since arrival. CNM requests RN to notify patient she will order some labs." Review of the Nurses note filed 01/08/2022 at 0058 revealed "01/08/2022 at 0040 CNM on unit and discharge orders entered." Review revealed Patient #14 was discharged and ambulated off the L&D unit on 01/08/2022 at 0108.

Telephone interview on 02/03/2022 at 1334 with Certified Nurse Midwife (CNM) #8 revealed Patient #14 came in due to a fall at work. Interview revealed CNM #8 was at Facility D for a delivery. Interview revealed CNM #8 could see tracings and had no concern as the baby looked fine on the monitor. Interview revealed there was a lot going on that night and CNM #8 had not felt Patient #14 was having an acute problem, she was not in labor, she was not having contractions, and the baby looked fine on the monitor. Interview revealed when CNM #8 finished the deliveries and got things settled down at Facility D, she went to see Patient #14.

Based on policy review, medical record review and interviews the hospital failed to ensure that an appropriate medical screening examination was provided for patients (Patient #3 and Patient #14) for two (2) of 26 patients who presented to the hospital's Dedicated Emergency Department (DED).

The findings include:

Review of facility policy "EMTALA- Medical Screening Examination/ Qualified Medical Personnel" revised 06/2021 revealed ".. PROCEDURE:.. I. Policy Statement: Any individual who presents to a dedicated emergency department requesting examination or treatment for a medical condition shall be provided an appropriate medical screening examination..."

Closed medical record review of Patient #3 revealed a 3-year-old male who presented to Facility A's DED on 12/30/2021 at 1406 for an arrival complaint of "fell, has bruise to the side." Review revealed triage began at 1442. Review of ED triage note at 1443 revealed "Pt. (patient) ambulatory to triage with his mom. Pts mom states that he fell 2 days ago and hit his right hip/abd (abdomen). Now has blood in his urine with voiding." Vital signs at 1443 Temp 98.1 F (oral); Heart Rate 121 and SpO2(Oxygen level) 99% on room air. Review revealed Patient #3 was moved to treatment area at 1652 and MSE began at 1653. Laboratory order for Urinalysis with Culture reflex placed and collected at 1655. Review revealed at 1713 chest x-ray orders placed and at 1749 renal ultrasound orders placed. Review revealed at 1900 Patient #3 disposition set to "Transfer to Another Facility." ED Notes at 1946 revealed " DSS (department of social services) worker (named), called this RN. CPS (child protective services) report filed with DSS by this RN." Review of ED Provider Notes on 12/30/2021 at 2025 revealed "ED Clinical Impression: Final Diagnoses: Nonaccidental injury to child and Acute cystitis with hematuria ... ED Assessment/Plan: History: Chief Complaint: Patient presents with Fall ... This patient is a 3-year-old male presenting for evaluation hematuria. Mother states the patient is a hyperactive child. He routinely is jumping on things and falls. He has numerous bruises. They are located on his torso and arms. Patient denies pain complaints. He is playful and cooperative. He is cooperative and appropriate with parents. ED Course: Seen in the emergency department for hematuria. I do have concerns for nonaccidental trauma in this individual. Myself nor nursing address this with the patient and the patient's mother repeatedly stated to me after I discussed transfer with her for hematuria and UTI (urinary tract infection) that you think I am abusing my child. She is amenable to transport via ambulance at this time. Provided oral cephalosporin (antibiotic) for UTI. Diagnosis Concern for nonaccidental trauma, UTI, hematuria ..." Review revealed at 2120 a 22-gauge peripheral IV (intravenous) catheter was placed to Patient #3 right forearm. Review revealed at 0019 on 12/31/2021 "Named Mobile Transport here at this time for transport to Facility E Pediatrics ..." Patient #3 is transferred from the Facility A at 0102 on 12/31/2021.

Closed medical record for Patient #3 at Facility E revealed Patient #3 was admitted on 12/31/2021 and transferred to Facility F at 0557 on 12/31/2021. Review of the Discharge Summary on 12/31/2021 revealed "Hospital Course: On arrival he was noted to have significant splenomegaly (enlarged spleen), bruising, and petechiae. Initial CBC (complete blood count) was collected and demonstrated a white blood cell count of 590.8, with 64 blasts, 195 absolute lymphocytes, and 389.9 absolute neutrophils. Consulted (named Facility F) heme onc [sic] who recommended hyperhydration and allopurinol (medication to decrease uric acid levels). Transfer was initiated to Facility F PICU (pediatric intensive care unit) for further care ..."


Closed medical record for Patient #3 at Facility F revealed Patient #3 was admitted on 12/31/2021 at 0935 and discharged from the facility on 01/21/2022 at 0914. Review of the discharge summary on 01/21/2022 revealed "Admission Diagnosis: Leukemia ... Brief Hospital Course: "named patient" is a previously healthy 3 y.o. boy who was admitted to the facility F PICU as transfer from Facility E for suspicion of acute leukemia with profound leukocytosis and hyperuricemia. At Facility E initial labs revealed WBC 591 (64%blasts), Hb (hemoglobin) 6.4, plt (platelets) 53, INR (international normalized ratio) 1.4. He was transferred to Facility F for definitive care ..."

Interview on 02/01/2022 at 1430 MD (medical doctor) #10 revealed he was the attending physician who performed MSE on Patient #3. Interview revealed he was concerned for non-accidental trauma due to the mom saying "You think I am abusing my child." Interview revealed he deferred further work up to Facility E. Interview revealed the decision was made not to further work up since Facility A does not admit children. Interview revealed he believes Patient #3 had an appropriate MSE.

Interview on 02/02/2022 at 0950 with RN (registered nurse) #11 revealed she recalled Patient #3 stating he was very active running around triage. Interview revealed he had appropriate interactions with mom. Interview revealed she did not remove clothing nor notice and bruising on the patient.

Interview on 02/01/2022 at 1350 with RN # 9 revealed she recalled Patient #3. Interview revealed CPS (child protective services) needed to be involved due to extensive injury. Interview revealed Patient #3 mother stated, "I didn't hurt my child." Interview revealed she made the call to CPS at 1928. Interview revealed "they" (Facility A) don't deal with Peds that much, none of us do."

Interview on 02/01/2022 at 1625 with RN #12 revealed she assumed care on the night shift of Patient #3. Interview revealed she asked the MD if he wanted lab work to be drawn while starting the IV for transfer. Interview revealed the MD did not want any lab work to be drawn. Interview revealed Patient #3 was "fine and watching TV" up until transfer.

The medical screening exam for Patient #3 was incomplete and delayed as further work-up was not done prior to transfer.

2. Review of a closed Labor and Delivery medical record for Patient # 14 revealed a 33-year-old female that presented to the Labor and Delivery unit on 01/07/2022 at 1636 with a chief complaint of fall. Review of the Vital Signs at 1700 revealed "Heart Rate: 93; BP: 138/90." Review of the Vital Signs at 1703 revealed "Temp: 36.9; Resp: 16; ... Pain Management: ... 0-10 Pain Scale: 4; Pain Location: Back; Buttocks." Review of the Event Timeline at 1715 revealed a telephone message was left for Certified Nurse Midwife (CNM) #8 with no indication of a return call. Review of the Nurse note at 1716 revealed "Pt is 33w6d (33 weeks and 6 days) G4P1 (gravida -number of pregnancies; para-number of births after 24 weeks pregnancy) presented ... from work after a fall at 1415 today ... moved her rolling chair and ... jacket was on the floor and got caught up in the wheels and the chair tipped over ... fell on her back and butt ... complains of back pain and has a history of spinal fusion ... no contraction noted, denies any vaginal bleeding, leaking of fluid, or cramping ..." Review of the Nurses note filed at 2309 revealed " ... Notified CNM of Unable to trace FHR continuously due to patient being uncomfortable on the stretcher due to spinal fusion years ago. Order received to discontinue EFM (external fetal monitoring) until CNM can come and evaluate patient." Review of the History and Physical note dated 01/08/2022 at 0040 (8 hours and 4 minutes since arrival) revealed there was no documentation of a physical exam of Patient #14's back or buttocks area (area Patient #14 complained of pain upon arrival to L&D). Review of the Nurses note filed 01/08/2022 at 0058 revealed "01/08/2022 at 0040 CNM on unit and discharge orders entered." Review revealed Patient #14 was discharged and ambulated off the L&D unit on 01/08/2022 at 0108.

Telephone interview on 02/03/2022 at 1334 with Certified Nurse Midwife (CNM) #8 revealed Patient #14 came in due to a fall at work. Interview revealed CNM #8 was at Facility D for a delivery. Interview revealed CNM #8 could see tracings and had no concern as the baby looked fine on the monitor. Interview revealed there was a lot going on that night and CNM #8 had not felt Patient #14 was having an acute problem, she was not in labor, she was not having contractions, and the baby looked fine on the monitor. Interview revealed when CNM #8 finished the deliveries and got things settled down at Facility D, she went to see Patient #14.

Interview on 02/03/2022 at 1618 with Physician #6 revealed Patient #14 presented with a complaint of a fall. Interview revealed recommendations are to observe the patient for 4-6 hours on the monitor to make sure nothing is going on. Interview revealed with a fall, you are concerned with abruption, observe for contractions and bleeding. Interview revealed Physician #6 stated if the patient is complaining about pain in a location, would examine that area for sore spot and/or injury.

There was no documented medical screening exam for Patient #14's complaint of her fall.