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Based on document review and staff interviews, the hospital's administrative staff failed to ensure the hospital's emergency department staff followed the hospital's policies and provided an adequate medical screening examination to 1 of 17 reviewed emergency department patients (Patient #1) and 1 of 3 reviewed obstetrical department patients (Patient #2). Failure follow the hospital's policies which required the ED staff to provide an adequate medical screening examination resulted in the hospital staff discharging Patient #1, who then required emergency medical care at a hospital approximately 25 miles away for treatment of a life-threatening infection. Failure follow the hospital's policies which required the ED staff to provide an adequate medical screening examination resulted in the hospital staff discharging Patient #2 without screening Patient #2 to determine if Patient #2 had a non-obstetrical emergency medical condition. The hospital's administrative staff identified an average of approximately 1,800 patients per month who presented to the emergency department and requested a medical screening examination.

Findings include:


1. Review of the policy "EMTALA: Transfer and Emergency Examination ED", effective 1/2022, revealed in part, "Each individual who seeks examination or treatment on Medical Center Premises shall be offered a medical screening examination to determine whether an emergency medical condition exsits ...". The policy defined an emergency medical condition as "A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical condition could reasonably be expected to result in: 1. Placing the health of the individual (or, with respect to a pregnant women, the health of the women or her unborn child) in serious jeopardy, 2. Serious impairment of bodily functions, or 3. Serious dysfunction of any bodily organ or part ..."

"A Medical Screening Exam (MSE) ... [is the] process required to reach, with reasonable clinical confidence ...whether the individual has an Emergency Medical Condition (EMC) or not ...a MSE appropriate to the individual's presenting signs and symptoms as well as the capability and capacity of the Medical Center ..."

" ...the medical screening examination will occur in the Emergency Department except: pregnant women reporting contractions or having complications with pregnancy may be directed to the Birth Center for examination as appropriate (unless another medical condition require they be examined in the Emergency Department.)".



2. Record review of Patient #1 revealed the following:

a. On 11/7/21 at approximately 12:56 AM, the Long-Term Care (LTC) staff at Patient #1's LTC facility summoned Emergency Medical Services (EMS) staff to transport Patient #1 to Trinity Regional Medical Center, due to Patient #1's complaints of pain. Shortly prior to the EMS staff arriving in Patient #1's room, the LTC staff administered 6 milligrams (mg) of Dilaudid (hydromorphone, a potent opiate pain medication used to treat severe pain).

b. Patient #1 presented to the ED at Trinity Regional Medical Center on 11/7/21 at approximately 1:20 AM. Registered Nurse (RN) H documented Patient #1's chief complaint was "... pain in whole body..."

c. At 1:45 AM, RN H documetented Patient #1 rated their pain at 10 out of 10 "Worst Possible Pain)."

d. At 1:52 AM, ED Physician I documented Patient #1's skin was "negative for color change and rash." ED Physician I's physical exam of Patient #1's skin revealed "General: Skin is warm and dry. Capillary Refill: Capillary refill takes less than 2 seconds." (Capillary refill provides an indication if a patient has adequate blood flow to a part of the body) ED Physician I then documented "Patient has chronic pain issues. [Patient #1] was sent here for [Patient #1's] pain. Prior to arrival [at the hospital, Patient #1] had gotten 6 mg of Dilaudid and a 0.5 mg Ativan (a medication to relieve anxiety). ... [Patient #1] continued to complain of pain.... Unfortunately with [Patient #1], I do not feel there is ever a way that [Patient #1] is going to be out of pain. I think [Patient #1's] expectations of pain control are way out of proportion."

e. At 06:36 AM, RN C documented they discharged Patient #1 back to Patient #1's LTC facility.

Patient #1's medical record lacked evidence the hospital ED staff reassessed Patient #1's pain following the administration of the Skelaxin (a potent muscle relaxing medication) or at any point prior to Patient #1's discharge from the ED, despite Patient #1 initially rating their pain at 10 out of 10 (the worst possible pain). Additionally, Patient #1's medical record lacked evidence that the ED staff examined Patient #1 sufficiently to identify the presence of the pressure wound located on Patient #1's mid-back, despite Patient #1's ED medical record containing "Surgical wound, non healing" as a medical problem for Patient #1 and "Wound Dressing (Foam Dressing Bordered) PADS, Apply 1 application topically every thrid day as needed" listed in Patient #1's home medication list.



f. Patient #1 presented again to the ED at Trinity Regional Medical Center (TRMC) on 11/11/21 at 9:54 PM by ambulance with chief complaint of weakness and recent change of condition noted at by family when at the long-term care facility. Patient #1 tested positive for COVID-19 prior to ED visit on 11/11/21.

g. At 9:56 PM, RN C checked Patient #1's vitals, which showed Patient #1's blood pressure was 90/60 mmHg (millimeters of mercury, normal range 120/80 mmHg) and Patient #1's temperature was low at 96.8 degrees Fahrenheit (normal is 98.6 degrees). Patient #1 rated their pain at 10 out of 10 on a 1-10 pain scale (where 1 is almost no pain and 10 is the worst pain ever). RN C documented Patient #1 was alert and oriented to person, place, and events.

h. At 10:19 PM, Physician E documented Patient #1 was "Not in acute distress, normal appearance, she is not toxic-appearing" (not ill appearing) ... "alert and orientated to person, place, and time" ... "Behavior normal". Physician E ordered the hospital staff perform a chest x-ray on Patient #1 and perform basic laboratory blood tests to check if Patient #1 had an infection and Patient #1's overall health. The nursing staff administered intravenous (IV) fluids due to Patient #1's dehydration.

i. At 10:37 PM, RN C documented Patient #1 had a "marked difference in speech when patient's daughter arrived" to ED. ED Physician E ordered the nursing staff to administer Narcan (a medication to reverse the sedation effects from pain medications), in case Patient #1's changed speech pattern was due to Patient #1 receiving pain medication. (Patient #1 did not receive pain medication in the hospital's emergency department)

j. At 10:19 PM, ED Physician E ordered the nursing staff to administer Narcan to Patient #1, as Patient #1 continued to exhibit a changed speech pattern, and the prior administration of Narcan had not resolved Patient #1's changed speech pattern.

k. At 10:46 PM, RN C documented Patient #1 continued to experience low blood pressure with RN C documenting Patient #1's blood pressure as 87/58 mmHg (low blood pressure can indicate the patient has a life threatening systemic infection called sepsis).

l. At 11:01 PM, RN C documented Patient #1 continued to experience low blood pressure with RN C documenting Patient #1's blood pressure as 81/58 mmHg.

m. At 11:16 PM, laboratory test results indicated Patient #1 had an elevated White Blood Cell count of 14.66 (indicating Patient #1 had a possible infection) and Patient #1 had a low potassium level of 2.8 mEq/mL (low potassium can potentially cause a life-threatening condition where the heart doesn't beat correctly). Additional laboratory test results indicated Patient #1 was malnourished (which increased Patient #1's risk of developing pressure wounds).

n. At 11:23 PM, RN C documented Patient #1 continued to experience low blood pressure with RN C documenting Patient #1's blood pressure as 95/69 mmHg. Patient #1's blood pressure increased in response to the IV fluids and Narcan administration.

o. At 11:23 PM, ED Physician E ordered the nursing staff to administer Narcan to Patient #1, as Patient #1 continued to exhibit a changed speech pattern, and the prior administrations of Narcan had not resolved Patient #1's changed speech pattern.

p. At 11:30 PM, RN C verbally notified ED Physician E that Patient #1 had a critically low potassium level.

q. At 11:44 PM, ED Physician E instructed RN C to give Patient #1 oral potassium to increase Patient #1's potassium level.

r. At 12:26 AM, ED Physician E documented "Patient stable in ER. Patient without respiratory distress. Patient is released to home. Patient given potassium ... supplementation. Patient to cut back on Dilaudid." "Please stop Dilaudid, God bless you."

s. At 1:23 AM, the hospital staff discharged Patient #1 using a wheelchair. The hospital staff assisted Patient #1 into Patient #1's daughter's car.




3. During an interview on 3/2/22 at 9:00 AM, RN C revealed that when Patient #1 presented to the hospital's ED on 11/7/22, RN C felt like Patient #1 was acting as if the ED staff did not want to treat Patient #1 and then Patient #1 acted as if nothing was wrong with Patient #1.

RN C then indicated that when Patient #1 arrived to the hospital's Emergency Department on 11/11/21, Patient #1 was alert and oriented. Prior to Patient #1's arrival at the Emergency Department, a nurse from Patient #1's long-term care facility called RN C and informed RN C that Patient #1 had experienced a change in Patient #1's condition that day. However, the long-term care nurse indicated they believed that the change in Patient #1's condition was not due to a medical condition, but was instead due to Patient #1's own behavior.

RN C had previously taken care of Patient #1 in the emergency department 4 days prior (the 11/7/21 ED visit). RN C remembered that Patient #1 previously could stand and pivot to transfer into a bed or chair, but during the ED visit on 11/11/22, Patient #1 could no longer stand and pivot to transfer themself. When Patient #1's daughter arrived in the ED, Patient #1 became sleepier and stopped talking to the ED staff. ED Physician E thought Patient #1 had received too much pain medication, so ED Physician E ordered RN C to administer Narcan twice to Patient #1. RN C felt that Patient #1's increased sleepiness and not talking was due to a behavioral issue with Patient #1, and not an underlying medical problem.


4. During an interview on 3/2/22 at 12:20 PM, ED Physician E revealed they did not recall providing care to Patient #1. However, ED Physician E indicated that when they evaluated a patient to determine if the patient had sepsis (a life-threatening systemic infection), ED Physician E would perform laboratory testing, obtain blood cultures (to check the patient's blood for an infection), obtain urine cultures (to check the patient's urine for an infection), examine the patient, and determine if Patient #1 had exposure to potential infections.

5. Review of Patient #1's medical record from Hospital #2 (located approximately 25 miles away) revealed that Patient #1 presented to the ED on 1/12/22 after the ED staff discharged Patient #1 from TRMC's emergency department. Upon arrival at Hospital #2's Emergency Department, the ED staff noted Patient #1 was lethargic, confused, and had an infected Stage IV pressure wound (a wound where the patient had lost all of the muscle and tissue in an area, resulting in exposure of the patient's bone).


6. Review of medical records revealed Patient #2, who was 29 weeks pregnant and had a history of anemia and asthma, arrived at the Trinity Regional Medical Center (TRMC) on 1/6/2022 at 7:10 PM. Registered Nurse (RN) B documented Patient #2 presented for complaints of cough, fever, leg cramps with high heart rate. RN B noted Patent #2 had a temperature of 101.3 degrees Fahrenheit, with heart rate of 120 beats per minute, and rated their pain at 4 (Moderate) on a scale of 1-10 (1 being almost no pain and 10 being the worst pain possible).

At 7:52 PM (42 minutes after Patient #2 arrived in the OB Department), RN B received orders from Obstetrician G over the phone to perform fetal heart tone monitoring (where the nursing staff monitored Patent #2's baby's heart rate and sounds), administer Tylenol to Patient #2, and screen Patient #2 for COVID-19. Patient #2's medical record lacked evidence of any further laboratory testing ordered by Obstetrician G, such as testing to determine the cause of Patient #2's fever.

At 8:29PM, RN B updated Obstetrician G about Patient #2's condition and RN B received orders to discharge Patient #2 from the hospital.

Patient #2's medical record lacked evidence that Patient #2 received a medical screening examination to determine the cause of Patient #2's fever, besides the testing for COVID-19. The medical record only contained evidence of the obstetrical medical screening examination.


7. During an interview on 3/1/22 at 3:33 PM, RN A recalled RN A took Patient #2 back to an obstetrical exam room in the obstetrical department, as Patient #2 arrived right at the time the nursing staff changed their shift. RN A did not provide any further care for Patient #2.

Normally, when a patient who is more than 20 weeks pregnant presents to the hospital's ED, the ED staff call the obstetrical unit to request the obstetrical nursing staff assess the patient. The obstetrical staff would request the ED staff to perform a medical screening examination to determine if the patient had an non-obstetrical emergency medical condition prior to sending the patient to the obstetrical unit. However, the obstetrical staff did not check to verify the emergency department staff had performed a medical screening examination on the patient prior to transferring the patient to the obstetrical unit. When a pregnant patient arrived on the obstetrical unit, regardless of their chief complaint, the obstetrical nursing staff evaluated the patient and performed an obstetrical medical screening examination. The obstetrical nursing staff would contact the on-call obstetrician and inform the obstetrician of their obstetrical exam findings. The obstetrician would provide verbal orders to the obstetrical nurse for any further testing on the patient, but would not normally come to the hospital to assess the patient, unless the patient was actively in labor.


8. During an interview on 3/1/22 at 4:15 PM, RN B acknowledged they were Patient #2's primary nurse when Patient #2 presented to the hospital's obstetrical department. However, RN B could not remember any of the care RN B provided to Patient #2. However, RN B indicated that when a patient who is more than 20 weeks pregnant presented to the hospital, the Emergency Department staff sent the patient to the obstetrical unit, regardless of the patient's chief complaint. When the patient arrived on the obstetrical unit, the obstetrical nurses would assess and triage the patient. The obstetrical nurses provided an obstetrical medical screening examination, contacted the on-call obstetrician, and then received any necessary orders from the on-call obstetrician. The obstetrician would not normally come into the hospital to assess the patient, unless the patient was in labor. After the nursing staff contacted the on-call obstetrician, the nursing staff would complete the paperwork for the patient, and the on-call obstetrician would sign the paperwork the following day, including the documentation of the obstetrical medical screening examination.



9. During an interview on 3/1/22 at 4:30 PM, Obstetrician G revealed that the Emergency Department staff sent all patients who are more than 20 weeks pregnant to the Obstetrical department, regardless if the patient's chief complaint involved an obstetrical problem. The obstetrical nursing staff would perform an obstetrical exam on the patients and then call Obstetrician G. Obstetrician G would talk with the obstetrical nurse and Obstetrician G would provide orders to the nurse for the patient. Obstetrician G indicated that the ED staff expected the obstetrical staff to perform both the medical screening examination for both the obstetrical concerns and the patient's other emergency medical concerns. Obstetrician G did not feel qualified to address a patient's non-obstetrical emergency medical conditions, but the ED staff did not want the obstetrical staff to transfer a pregnant patient back to the ED for management of the patient's non-obstetrical emergency medical conditions, especially if the ED was busy at the time. Thus, even though Obstetrician G indicated they lacked knowledge to treat non-obstetrical emergency medical conditions, Obstetrician G had to treat the patient's non-obstetrical emergency medical conditions.


Please refer to A-2406 for additional information.

Based on document review and staff interviews, the hospital's administrative staff failed to ensure the hospital's emergency department staff provided an adequate medical screening examination to 1 of 17 reviewed emergency department patients (Patient #1) and 1 of 3 reviewed obstetrical department patients (Patient #2). Failure to provide an adequate medical screening examination resulted in the hospital staff discharging Patient #1, who then required emergency medical care at a hospital approximately 25 miles away for treatment of a life-threatening infection. Failure to provide an adequate medical screening examination resulted in the hospital staff discharging Patient #2 without screening Patient #2 to determine if Patient #2 had a non-obstetrical emergency medical condition. The hospital's administrative staff identified an average of approximately 1,800 patients per month who presented to the emergency department and requested a medical screening examination.

Findings include:

1. Record review of Patient #1 revealed the following:

a. On 11/7/21 at approximately 12:56 AM, the Long-Term Care (LTC) staff at Patient #1's LTC facility summoned Emergency Medical Services (EMS) staff to transport Patient #1 to Trinity Regional Medical Center, due to Patient #1's complaints of pain. Shortly prior to the EMS staff arriving in Patient #1's room, the LTC staff administered 6 milligrams (mg) of Dilaudid (hydromorphone, a potent opiate pain medication used to treat severe pain).

b. Patient #1 presented to the ED at Trinity Regional Medical Center on 11/7/21 at approximately 1:20 AM. Registered Nurse (RN) H documented Patient #1's chief complaint was "... pain in whole body..."

c. At 1:45 AM, RN H documetented Patient #1 rated their pain at 10 out of 10 "Worst Possible Pain)."

d. At 1:52 AM, ED Physician I documented Patient #1's skin was "negative for color change and rash." ED Physician I's physical exam of Patient #1's skin revealed "General: Skin is warm and dry. Capillary Refill: Capillary refill takes less than 2 seconds." (Capillary refill provides an indication if a patient has adequate blood flow to a part of the body) ED Physician I then documented "Patient has chronic pain issues. [Patient #1] was sent here for [Patient #1's] pain. Prior to arrival [at the hospital, Patient #1] had gotten 6 mg of Dilaudid and a 0.5 mg Ativan (a medication to relieve anxiety). ... [Patient #1] continued to complain of pain.... Unfortunately with [Patient #1], I do not feel there is ever a way that [Patient #1] is going to be out of pain. I think [Patient #1's] expectations of pain control are way out of proportion."

e. At 06:36 AM, RN C documented they discharged Patient #1 back to Patient #1's LTC facility.

Patient #1's medical record lacked evidence the hospital ED staff reassessed Patient #1's pain following the administration of the Skelaxin (a potent muscle relaxing medication) or at any point prior to Patient #1's discharge from the ED, despite Patient #1 initially rating their pain at 10 out of 10 (the worst possible pain). Additionally, Patient #1's medical record lacked evidence that the ED staff examined Patient #1 sufficiently to identify the presence of the pressure wound located on Patient #1's mid-back, despite Patient #1's ED medical record containing "Surgical wound, non healing" as a medical problem for Patient #1 and "Wound Dressing (Foam Dressing Bordered) PADS, Apply 1 application topically every thrid day as needed" listed in Patient #1's home medication list.



f. Patient #1 presented again to the ED at Trinity Regional Medical Center (TRMC) on 11/11/21 at 9:54 PM by ambulance with chief complaint of weakness and recent change of condition noted at by family when at the long-term care facility. Patient #1 tested positive for COVID-19 prior to ED visit on 11/11/21.

g. At 9:56 PM, RN C checked Patient #1's vitals, which showed Patient #1's blood pressure was 90/60 mmHg (millimeters of mercury, normal range 120/80 mmHg) and Patient #1's temperature was low at 96.8 degrees Fahrenheit (normal is 98.6 degrees). Patient #1 rated their pain at 10 out of 10 on a 1-10 pain scale (where 1 is almost no pain and 10 is the worst pain ever). RN C documented Patient #1 was alert and oriented to person, place, and events.

h. At 10:19 PM, Physician E documented Patient #1 was "Not in acute distress, normal appearance, she is not toxic-appearing" (not ill appearing) ... "alert and orientated to person, place, and time" ... "Behavior normal". Physician E ordered the hospital staff perform a chest x-ray on Patient #1 and perform basic laboratory blood tests to check if Patient #1 had an infection and Patient #1's overall health. The nursing staff administered intravenous (IV) fluids due to Patient #1's dehydration.

i. At 10:37 PM, RN C documented Patient #1 had a "marked difference in speech when patient's daughter arrived" to ED. ED Physician E ordered the nursing staff to administer Narcan (a medication to reverse the sedation effects from pain medications), in case Patient #1's changed speech pattern was due to Patient #1 receiving pain medication. (Patient #1 did not receive pain medication in the hospital's emergency department)

j. At 10:19 PM, ED Physician E ordered the nursing staff to administer Narcan to Patient #1, as Patient #1 continued to exhibit a changed speech pattern, and the prior administration of Narcan had not resolved Patient #1's changed speech pattern.

k. At 10:46 PM, RN C documented Patient #1 continued to experience low blood pressure with RN C documenting Patient #1's blood pressure as 87/58 mmHg (low blood pressure can indicate the patient has a life threatening systemic infection called sepsis).

l. At 11:01 PM, RN C documented Patient #1 continued to experience low blood pressure with RN C documenting Patient #1's blood pressure as 81/58 mmHg.

m. At 11:16 PM, laboratory test results indicated Patient #1 had an elevated White Blood Cell count of 14.66 (indicating Patient #1 had a possible infection) and Patient #1 had a low potassium level of 2.8 mEq/mL (low potassium can potentially cause a life-threatening condition where the heart doesn't beat correctly). Additional laboratory test results indicated Patient #1 was malnourished (which increased Patient #1's risk of developing pressure wounds).

n. At 11:23 PM, RN C documented Patient #1 continued to experience low blood pressure with RN C documenting Patient #1's blood pressure as 95/69 mmHg. Patient #1's blood pressure increased in response to the IV fluids and Narcan administration.

o. At 11:23 PM, ED Physician E ordered the nursing staff to administer Narcan to Patient #1, as Patient #1 continued to exhibit a changed speech pattern, and the prior administrations of Narcan had not resolved Patient #1's changed speech pattern.

p. At 11:30 PM, RN C verbally notified ED Physician E that Patient #1 had a critically low potassium level.

q. At 11:44 PM, ED Physician E instructed RN C to give Patient #1 oral potassium to increase Patient #1's potassium level.

r. At 12:26 AM, ED Physician E documented "Patient stable in ER. Patient without respiratory distress. Patient is released to home. Patient given potassium ... supplementation. Patient to cut back on Dilaudid." "Please stop Dilaudid, God bless you."

s. At 1:23 AM, the hospital staff discharged Patient #1 using a wheelchair. The hospital staff assisted Patient #1 into Patient #1's daughter's car.




2. During an interview on 3/2/22 at 9:00 AM, RN C revealed that when Patient #1 presented to the hospital's ED on 11/7/22, RN C felt like Patient #1 was acting as if the ED staff did not want to treat Patient #1 and then Patient #1 acted as if nothing was wrong with Patient #1.

RN C then indicated that when Patient #1 arrived to the hospital's Emergency Department on 11/11/21, Patient #1 was alert and oriented. Prior to Patient #1's arrival at the Emergency Department, a nurse from Patient #1's long-term care facility called RN C and informed RN C that Patient #1 had experienced a change in Patient #1's condition that day. However, the long-term care nurse indicated they believed that the change in Patient #1's condition was not due to a medical condition, but was instead due to Patient #1's own behavior.

RN C had previously taken care of Patient #1 in the emergency department 4 days prior (the 11/7/21 ED visit). RN C remembered that Patient #1 previously could stand and pivot to transfer into a bed or chair, but during the ED visit on 11/11/22, Patient #1 could no longer stand and pivot to transfer themself. When Patient #1's daughter arrived in the ED, Patient #1 became sleepier and stopped talking to the ED staff. ED Physician E thought Patient #1 had received too much pain medication, so ED Physician E ordered RN C to administer Narcan twice to Patient #1. RN C felt that Patient #1's increased sleepiness and not talking was due to a behavioral issue with Patient #1, and not an underlying medical problem.


3. During an interview on 3/2/22 at 12:20 PM, ED Physician E revealed they did not recall providing care to Patient #1. However, ED Physician E indicated that when they evaluated a patient to determine if the patient had sepsis (a life-threatening systemic infection), ED Physician E would perform laboratory testing, obtain blood cultures (to check the patient's blood for an infection), obtain urine cultures (to check the patient's urine for an infection), examine the patient, and determine if Patient #1 had exposure to potential infections.

If a patient resided in a long-term care facility, ED Physician E indicated they were more likely to discharge a patient instead of admitting the patient to the hospital, as the patient had access to nursing care at their long-term care facility.


4. Review of Patient #1's medical record from Hospital #2 (located approximately 25 miles away) revealed that Patient #1 presented to the ED on 1/12/22 after the ED staff discharged Patient #1 from TRMC's emergency department. Upon arrival at Hospital #2's Emergency Department, the ED staff noted Patient #1 was lethargic, confused, and had an infected Stage IV pressure wound (a wound where the patient had lost all of the muscle and tissue in an area, resulting in exposure of the patient's bone).




5. Review of medical records revealed Patient #2, who was 29 weeks pregnant and had a history of anemia and asthma, arrived at the Trinity Regional Medical Center (TRMC) on 1/6/2022 at 7:10 PM. Registered Nurse (RN) B documented Patient #2 presented for complaints of cough, fever, leg cramps with high heart rate. RN B noted Patent #2 had a temperature of 101.3 degrees Fahrenheit, with heart rate of 120 beats per minute, and rated their pain at 4 (Moderate) on a scale of 1-10 (1 being almost no pain and 10 being the worst pain possible).

At 7:52 PM (42 minutes after Patient #2 arrived in the OB Department), RN B received orders from Obstetrician G over the phone to perform fetal heart tone monitoring (where the nursing staff monitored Patent #2's baby's heart rate and sounds), administer Tylenol to Patient #2, and screen Patient #2 for COVID-19. Patient #2's medical record lacked evidence of any further laboratory testing ordered by Obstetrician G, such as testing to determine the cause of Patient #2's fever.

At 8:29 PM, RN B charted "... Provided an emergency medical screening examination ...".

At 8:29PM, RN B updated Obstetrician G about Patient #2's condition and RN B received orders to discharge Patient #2 from the hospital.

At 11:07 PM (almost 3.5 hours after Obstetrician G discharged Patient #2 from the hospital), the hospital laboratory staff completed the laboratory testing on Patient #2, which indicated Patient #2 had COVID-19.

Patient #2's medical record lacked evidence that Patient #2 received a medical screening examination to determine the cause of Patient #2's fever, besides the testing for COVID-19. The medical record only contained evidence of the obstetrical medical screening examination.

6. During an interview on 3/1/22 at 3:33 PM, RN A recalled RN A too Patient #2 back to an obstetrical exam room in the obstetrical department, as Patient #2 arrived right at the time the nursing staff changed their shift. RN A did not provide any further care for Patient #2.

Normally, when a patient who is more than 20 weeks pregnant presents to the hospital's ED, the ED staff call the obstetrical unit to request the obstetrical nursing staff assess the patient. The obstetrical staff would request the ED staff to perform a medical screening examination to determine if the patient had an non-obstetrical emergency medical condition prior to sending the patient to the obstetrical unit. However, the obstetrical staff did not check to verify the emergency department staff had performed a medical screening examination on the patient prior to transferring the patient to the obstetrical unit.

When a pregnant patient arrived on the obstetrical unit, regardless of their chief complaint, the obstetrical nursing staff evaluated the patient and performed an obstetrical medical screening examination. The obstetrical nursing staff would contact the on-call obstetrician and inform the obstetrician of their obstetrical exam findings. The obstetrician would provide verbal orders to the obstetrical nurse for any further testing on the patient, but would not normally come to the hospital to assess the patient, unless the patient was actively in labor.


7. During an interview on 3/1/22 at 4:15 PM, RN B acknowledged they were Patient #2's primary nurse when Patient #2 presented to the hospital's obstetrical department. However, RN B could not remember any of the care RN B provided to Patient #2. However, RN B indicated that when a patient who is more than 20 weeks pregnant presented to the hospital, the Emergency Department staff sent the patient to the obstetrical unit, regardless of the patient's chief complaint. When the patient arrived on the obstetrical unit, the obstetrical nurses would assess and triage the patient. The obstetrical nurses provided an obstetrical medical screening examination, contacted the on-call obstetrician, and then received any necessary orders from the on-call obstetrician. The obstetrician would not normally come into the hospital to assess the patient, unless the patient was in labor. After the nursing staff contacted the on-call obstetrician, the nursing staff would complete the paperwork for the patient, and the on-call obstetrician would sign the paperwork the following day, including the documentation of the obstetrical medical screening examination.



8. During an interview on 3/1/22 at 4:30 PM, Obstetrician G revealed that the Emergency Department staff sent all patients who are more than 20 weeks pregnant to the Obstetrical department, regardless if the patient's chief complaint involved an obstetrical problem. The obstetrical nursing staff would perform an obstetrical exam on the patients and then call Obstetrician G. Obstetrician G would talk with the obstetrical nurse and Obstetrician G would provide orders to the nurse for the patient. Obstetrician G indicated that the ED staff expected the obstetrical staff to perform both the medical screening examination for both the obstetrical concerns and the patient's other emergency medical concerns. Obstetrician G did not feel qualified to address a patient's non-obstetrical emergency medical conditions, but the ED staff did not want the obstetrical staff to transfer a pregnant patient back to the ED for management of the patient's non-obstetrical emergency medical conditions, especially if the ED was busy at the time. Thus, even though Obstetrician G indicated they lacked knowledge to treat non-obstetrical emergency medical conditions, Obstetrician G had to treat the patient's non-obstetrical emergency medical conditions.

Obstetrician G indicated that if a pregnant patient presented with a fever to the obstetrical department, such as Patient #2, Obstetrician G would order the nursing staff to perform an obstetrical screening examination, laboratory testing such as checking the patient's blood or urine for signs of infection, and all patients received routine screening for COVID-19 infection. Depending on the patient's symptoms and lab test results, Obstetrician G would order the nursing staff to either admit the patient overnight to the hospital for further monitoring or discharge the patient home. Obstetrician G normally relied on the obstetrical nursing staff to perform the obstetrical medical screening examination and would only go into the hospital to examine the patient if the patient was in active labor.