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Tag No.: A2400
44100
Based on policy review, medical record review, and staff interview, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This resulted in the failure to provide appropriate MSE for a patient who presented to the ED seeking services. Findings include:
Refer to A2406 as it relates to the failure of the hospital to ensure all patients presenting to the hospital for emergency sercices were provided a complete MSE.
Tag No.: A2406
44100
Based on policy review, medical record review, and staff interview, it was determined the hospital failed to provide an appropriate MSE to 1 of 5 patients (Patient #8) who presented to the ED and were pregnant. Failure to provide a complete MSE including fetal heart tones to a woman greater than 20 weeks pregnant who presents to the ED, regardless of chief complaint, puts patient and fetus at risk of a serious negative outcome. Findings include:
A hospital policy titled, "Obstetrical Triage in the Emergency Department," approved 9/20/23 was reviewed. The Procedure was presented in a flow chart which stated, "Is Patient >= 20 weeks gestation?". If yes, then "ER Nurse will triage and do an assessment. Is complaint labor related " If no, then "Patient stays in ER with LDR RN responding for fetal monitoring." This process was not followed. An example includes:
Patient #8 was a 22-year-old female who presented to the ED on 1/18/24 at 10:47 AM. Chief complaint was documented by DO who saw Patient #8 as, "cough, congestion, and wheezing at night. She is 26 weeks pregnant." There was no documentation to indicate any fetal monitoring was conducted as per hospital policy.
The Resident DO was interviewed on 1/24/24, starting at 5:06 PM. He stated that he had worked several shifts in the ED at the time of the incident in question. He stated he recalled Patient #8. When asked if he was aware Patient #8 was 26 weeks pregnant, he confirmed that he did know she was pregnant. He stated, "I asked her if everything was ok with the baby and she said yes, she saw her OB a few days ago. I didn't do a dopler, I was not aware that it's a requirement." The Resident confirmed he did not document his inquiry regarding Patient #8's pregnancy.
The Resident was shown the hospital policy titled "Obstetrical Triage in the Emergency Department" with the flow chart and asked if he had seen this before. He stated he had not.
The RN assigned to Patient #8 was interviewed on 1/24/24, starting at 5:50 PM. The RN stated she was still on orientation and today was her fifth day on shift in the ED. When asked if she recalled Patient #8, she stated she did recall the patient. Her triage note was reviewed and stated, "Patient here with complaints of cough, SOB, ear pressure, congestion, and runny nose that started last week Saturday. Denies fever, chills or body aches. 26 wks pregnant." When asked if she inquired about pregnancy concerns with Patient #8, the RN stated she did, and stated, "I asked her if she had any concerns about pregnancy and she did not , she said the baby was moving." The RN confirmed she did not document her inquiry regarding Patient #8's pregnancy.
The RN was shown the hospital policy titled "Obstetrical Triage in the Emergency Department" containing the flow chart and asked if she had seen this before. She stated, "no, I have not."
The hospital failed to ensure a MSE was completed for Patient #8.