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Based on interview and record review, the facility failed to comply with CFR 489.24, by failing to ensure:

1. The medical screening exam (MSE) for Patient 15 was conducted by a Qualified Medical Professional according to the Governing Body's Rules and Regulations. (Refer to A2406).

2. a. Transfer documents were completed for Patients 9 and 11, to include the risks and benefits involved in a transfer, and;

b. The responsible party (s) for Patient 16 was informed of the decision to transfer the patient to another facility. (Refer to A2409).

Based on interview and record review, the facility failed to ensure the medical screening exam (MSE) for Patient 15 was conducted by a Qualified Medical Professional according to the Governing Body's Rules and Regulations. This failure may result in an inappropriate and/or inaccurate MSE and impact the ongoing provision of medical care.

Findings:

A review of Patient 15's record was conducted on October 15, 2015. Patient 15 presented to the facility's Emergency Department (ED) on September 25, 2015, at 10:11 p.m.. The patient's chief complaint was pregnancy with a spontaneous rupture of membranes (sac surrounding the fetus). A medical screening examination was not done at that time.

A non stress test (noninvasive test to determine fetal viability by recording the baby's heartbeat while the fetus is resting and moving) was conducted on September 25, 2015, at 10:23 p.m. The test result was documented as "nonreactive" (when the heart does not beat faster when the baby moves, or if the baby is quiet and not moving). The obstetric physician was notified of this potentially abnormal result at 11 p.m.

Further record review indicated Licensed Vocational Nurse (LVN) 1, conducted an assessment of Patient 15 on September 25, 2015, at 11:46 p.m. The assessment document did not reflect that the assessment was reviewed and co-signed by a Registered Nurse.

The record indicated on September 26, 2015, at 1:45 a.m., Patient 15 had a caesarian section (C-Section: fetus is surgically removed from the uterus).

A review of the facility policy, "Admission Assessment and Reassessment, Labor and Delivery(undated)," was conducted. The purpose indicated, "To assess the patient's condition in order to: provide a baseline for developing a plan of care and gather information to accurately report the patient's condition to the physician."

The policy indicated, "All patients admitted to the Labor and Delivery Department are initially assessed within five (5) minutes of arrival, by a licensed nurse experienced in the care of the laboring patient."

An interview was conducted with the Registered Nurse (RN) 1, on October 5, 2015, at 10:15 a.m. RN 1 stated, "Only a Registered Nurse can perform assessments on obstetric patients who come to our department from the ED."

A review of LVN 1's personnel file was conducted with the Director of Human Resources (HRD) on October 6, 2015, at 3 p.m. The HRD stated, "LVN 1's job description indicated she was hired as a medical/surgical nurse. There is no documentation in LVN 1's personnel file to indicate LVN 1 is qualified to work in obstetrics, or labor and delivery."

A medical screening examination was conducted by LVN 1, on September 26, 2015, at 2:27 a.m., 45 minutes after Patient 15 had a C-Section and four hours after Patient 15 initially presented to the ED.

A record review reflected an MSE was conducted by LVN 1, on September 26, 2015, at 2:27 a.m., 45 minutes after Patient 15 had a c section and four hours after Patient 15 presented to the ED.

An interview was conducted with RN 2 on October 6, 2015, at 2:30 p.m. RN 2 stated a medical screening exam was only to be performed by a qualified registered nurse. RN 2 further stated, "Conducting a medical screening examination includes a full assessment of the pregnant patient, to include a pregnancy history, surgical history and allergies. A fetal monitor would be placed upon the pregnant patient in order to evaluate the babies' status. A vaginal exam would be conducted as indicated and a call would be placed to the physician to give a complete update on the patient's status."

A review of the facility's policy, "Medical Screening Examination, Transfer and/or Referral to Outside Facility, (Effective Date 1/2000)," was conducted. The policy indicated, "Who May Perform the Examination: The medical screening examination will be performed by a Qualified Medical Person to determine, within reasonable medical probability, whether a person presenting to the Hospital seeking medical services is suffering from an emergency medical condition."

The policy further indicated, "Qualified Medical Person means the following: The following professionals have been identified by the Hospital's Governing Body as qualified to administer a medical screening examination: Physician: M.D., Physician: D.O., Physician's Assistant: PA. Under the direction of the supervising Emergency Department physician. Registered Nurse assigned to the labor and Delivery Department pursuant to Standard of Care: Assessment/Screening of the pregnant patient presenting to the Hospital with questionable labor status."

Based on interview and record review, the facility failed;

1. To ensure transfer documents were completed for Patients 9 and 11, to include the risks and benefits involved in a transfer, and;
2. To ensure the responsible party(s) for Patient 16 were informed of the decision to transfer the patient to another facility.

These facility failures increased the potential to for the inability of the patient and/or the patient's/responsible party to make an informed decision regarding the risks and benefits of a transfer to another facility.

Findings:

1 a. The record for Patient 9 was reviewed on October 5, 2015. Patient 9 presented to the Emergency Department (ED), on October 3, 2015, at 1:28 p.m., with a chief complaint of abdominal pain.

Nursing Flowsheet documentation for October 3, 2015, at 7 p.m., indicated "Healthcare provider called and wanted to transfer pt. (patient) to...(name of facility)..."

Nursing Flowsheet documentation for October 3, 2015, at 9:33 p.m., indicated Patient 9 was transferred to another facility by ambulance.

The document titled "Emergency Department Request For Transfer/Consent To Transfer Certification For Transfer" was reviewed. The sections on the form to indicate the risks and benefits of transfer were blank.

b. The record for Patient 11 was reviewed on October 5, 2015. Patient 11 presented to the ED on September 23, 2015, at 10:12 a.m., with a chief complaint of left underarm swelling.

The document titled "Emergency Provider Record" dated September 23, 2015, at 10:15 a.m., indicated "Per insurance Transfer...(facility and physician's name)..."

The document titled "Emergency Department Request For Transfer/Consent To Transfer Certification For Transfer" was reviewed. The section on the form to indicate the risks of being transferred was blank.

During an interview with the Director of Quality (DQ), on October 5, 2015, at 10:30 a.m., the DQ reviewed the records for Patients 9 and 11, and was unable to find documentation which indicated the risks and/or risks and benefits of the impending transfers were explained to Patients 9 and 11.

The DQ stated all areas of the transfer form were required to be filled out prior to the patient's transfer. The DQ stated explaining the risks and benefits of being transferred to another facility for continued care, was an important part of the transfer process.

2. The record for Patient 16 was reviewed on October 5, 2015. Patient 16 presented to the Emergency Department (ED) on September 18, 2015, at 4:45 p.m., with a chief complaint of generalized weakness, multiple falls and failure to thrive. In addition, Patient 16 had two documented seizures prior to her arrival. Documentation reflected Patient 16 was oriented to her name and location. The full status of Patient 16's level of orientation was not reflected on the record.

The patient information sheet or (Face Sheet) for Patient 16 was reviewed. The document indicated Patient 16's sister was her first emergency contact. An additional individual was listed as the patient's secondary emergency contact. The phone numbers for both of these individuals were listed on the Face Sheet.

The document titled "Emergency Department Request For Transfer/Consent To Transfer Certification For Transfer," dated September 19, 2015, was reviewed. The section which indicated, "Patient Request for Transfer/Consent to Transfer" was signed by both a registered nurse and a licensed vocational nurse, as witnesses. The section where the patients or the patient's surrogate signed was blank.

Further record review failed to indicate attempts were made to notify Patient 16's emergency contacts of the ED physician's decision to transfer the patient to another facility for additional care and treatment.

An interview was conducted with the ED Registered Nurse (RN) 3, on October 6, 2015, at 10:45 a.m. RN 3 stated if a patient is unable to understand in order to complete an informed consent regarding being transferred, the ED staff had to attempt to notify the patient's emergency contact individual(s) or their responsible party to review the physician's recommendations with them. After reviewing Patient 16's record RN 3 stated she was unable to find documentation indicating that the patient's emergency contacts were notified.

The facility policy and procedure titled, "Medical Screening Examination, Transfer and/or Referral to outside Facility" effective date, January 2000, indicated, "Transfer For Care Outside the Hospital...Informed request: The individual or legal responsible party acting on the individuals behalf is first fully informed of the risks of the transfer and the benefits...acknowledges the request and his/hers awareness of the risks and benefits of the transfer in writing on the "Transfer Summary Form."