HospitalInspections.org

Based on medical record (MR) review and document review, it was determined that 9 (patients N1, N14-N18, and N20-N22) of 22 MRs reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide an appropriate medical screening examination performed by a QMP (Qualified Medical Personnel) and the facility failed to complete the required documentation for an appropriate transfer for 1 (N21) of 22 MRs reviewed.

Findings include:

1. See findings cited at 489.24(l), A2406 and 489.24(e)(1) and (2), A2409.

Based on policy and procedure review, document review, and medical record review, the facility failed to provide an appropriate medical screening examination by a QMP (Qualified Medical Personnel) as determined qualified by hospital bylaws or rules and regulations and designated in a document approved by the governing body for 9 of 22 (N1, N14-N18, and N20-N22) individuals who presented to the ED.

Findings:

1. Policy No.: ER-A-009 titled, "Emergency Medical Treatment at [F1]", revised/reapproved on 11/2011, was reviewed on 1/9/14 at approximately 4:30 PM and indicated on pg.:
A. 2, under Definitions section, points 3.0 "Medical screening" means:, 3.2, and 3.2.1, ..."Screenings include vital signs; oral history; physical examination of affected or potentially affected systems; consideration of known chronic conditions; any testing needed to determine presence of an emergency medical condition including use of hospital personnel and on-call physicians;"
B. 3, under Definitions section, points 4.0 "Qualified medical person" means:, and 4.1, "An emergency physician, on-call physician, obstetrician, house physicians including residents with appropriate clinical privileges, as set forth in the Medical Staff Bylaws, Rules, and Regulations [or, Emergency Department Nurse acting in accordance with Emergency Department policies and procedures to identify an emergency medical condition] as set forth in the Medical Staff Bylaws."

2. Rules and Regulations of the Medical Staff were reviewed on 1/9/14 at approximately 4:50 PM and confirmed on pgs. 91 and 92, under Section II - Emergency Services, "Medical screening will be performed by a qualified medical person. A 'qualified medical person' is defined as an emergency physician, on-call physician, obstetrician, house physicians including residents with appropriate clinical privileges, (or, Emergency Department nurses acting in accordance with Emergency Department policies and procedures to identify an emergency medical condition)."

3. Policy No.: ER-A-004 titled, "Obstetrical Patients Presenting Through the Emergency Department", revised/reapproved 8/2013, was reviewed on 1/9/14 at approximately 4:50 PM and indicated on pg. 1, point 1.1, "Obstetrical patients presenting through the Emergency Department must have an initial medical screening conducted by the Emergency Department RN, utilizing the 'Initial Assessment of the Obstetrical Patient' form."

4. The initial assessment of the obstetrical patients form does not address or identify elements to be included in the medical screening exam as per emergency medical treatment policy ER-A-009 for patients N1, N14, N15, N16, N17, N18, N20, N21 and N22.

5. OB Registered Nurses are not documented as qualified medical persons in the Rules and Regulations of the Medical Staff.

6. Review of closed patient medical records on 1/9/14 at approximately 12:20 PM, indicated Patient:
A. N1 was a 34-year-old who presented to the ED on 12/22/13 at 1326 with an admission diagnosis of "pregnancy, abdominal pain". Documentation in the medical record included:
i. form titled "Initial Assessment of Obstetrical Patient":
ii. per ED Notes section of medical record, "Patient not seen in ED".
iii. per LDRP (Labor, Delivery, Recovery and Postpartum) Log, presented to the OB department on 12/22/13 at 1327 for an OB assessment by an OB Registered Nurse.
iv. physician evaluated patient/situation remotely via phone at 1411.
v. patient was discharged to go directly to facility #2.
vi. lacked a medical screening examination by a qualified medical person.

B. N14:
i. pregnant, presented to the ED 12/25/13 at 1304 with an admission diagnosis of "term pregnancy, leaking" and was assessed by an ED RN via the form titled "Initial Assessment of Obstetrical Patient".
ii. per ED Notes section of medical record, "Patient not seen in ED".
iii. was escorted to the OB Department where a medical screening exam was done at 1308 by an OB registered nurse.
iv. physician evaluated patient/situation remotely via phone at 1408.
v. discharged home at 1420 in stable condition on 12/25/13.
vi. lacked a medical screening exam by an approved QMP./

B. N15:
i. pregnant, presented to the ED 12/21/13 at 1953 with a chief complaint of "abdominal/back pain" and was assessed by an ED RN via the form titled "Initial Assessment of Obstetrical Patient".
ii. per ED Notes section of medical record, "Patient not seen in ED".
iii. was escorted to the OB Department where a medical screening exam was done at 1942 by an OB registered nurse.
iv. physician evaluated patient/situation remotely via phone at 2233.
v. discharged home at 2248 in stable condition on 12/21/13.
vi. lacked a medical screening exam by an approved QMP.

C. N16:
i. pregnant, presented to the ED 12/9/13 at 1214 with an admission diagnosis of "pregnancy" and was assessed by an ED RN via the form titled "Initial Assessment of Obstetrical Patient".
ii. per ED Notes section of medical record, "Patient not seen in ED".
iii. was escorted to the OB Department where a medical screening exam was done at 1222 by an OB registered nurse.
iv. physician evaluated patient/situation remotely via phone at 1249.
v. discharged home at 1310 in stable condition on 12/9/13.
vi. lacked a medical screening exam by an approved QMP.

D. N17:
i. pregnant, presented to the ED 12/3/13 at 1701 with an admission diagnosis of "pregnancy, abdominal pain" and was assessed by an ED RN via the form titled "Initial Assessment of Obstetrical Patient".
ii. per ED Notes section of medical record, "Patient not seen in ED".
iii. was escorted to the OB Department where a medical screening exam was done at 1708 by an OB registered nurse.
iv. physician evaluated patient/situation remotely via phone at 1718.
v. discharged home at 2008 in stable condition on 12/3/13.
vi. lacked a medical screening exam by an approved QMP.

E. N18:
i. pregnant, presented to the ED 11/25/13 at 2238 with a chief complaint of "abdominal pain" and was assessed by an ED RN via the form titled "Initial Assessment of Obstetrical Patient".
ii. per ED Notes section of medical record, "Patient not seen in ED".
iii. was escorted to the OB Department where a medical screening exam was done at 2303 by an OB registered nurse.
iv. physician evaluated patient/situation remotely via phone at 2339.
v. discharged home at 2359 in stable condition on 11/25/13.
vi. lacked a medical screening exam by an approved QMP.

F. N20:
i. pregnant, presented to the ED 11/12/13 at 1009 with a chief complaint of "abdominal pain" and was assessed by an ED RN via the form titled "Initial Assessment of Obstetrical Patient".
ii. per ED Notes section of medical record, "Patient not seen in ED".
iii. was escorted to the OB Department where a medical screening exam was done at 1022 by an OB registered nurse.
iv. physician evaluated patient/situation remotely via phone at 1223.
v. discharged home at 1231 in stable condition on 11/12/13.
vi. lacked a medical screening exam by an approved QMP.

G. N21:
i. pregnant, presented to the ED at 2151 on 11/9/13 with an admission diagnosis of "labor" and was assessed by an ED RN via the form titled "Initial Assessment of Obstetrical Patient".
ii. per ED Notes section of medical record, "Patient not seen in ED".
iii. was escorted to the OB Department where a medical screening exam was done at 2151 by an OB registered nurse.
iv. was transferred to another acute care facility at 2252 with a NICU (Neonatal Intensive Care Unit) due to high risk pregnancy in fair condition on 11/9/13.
vii. lacked a medical screening exam by an approved QMP.

H. N22:
i. pregnant, presented to the ED at 2020 on 11/5/13 with an admission diagnosis of "preterm pregnancy" and was assessed by an ED RN via the form titled "Initial Assessment of Obstetrical Patient".
ii. per ED Notes section of medical record, "Patient not seen in ED".
iii. was escorted to the OB Department where a medical screening exam was done at 2039 by an OB registered nurse.
iv. physician evaluated patient/situation remotely via phone at 2059, 2158, and 2320.
v. discharged home at 0009 in stable condition on 11/6/13.
vi. lacked a medical screening exam by an approved QMP.

Based on medical record review, policy review and staff interview, the facility failed to provide an appropriate transfer for 1 (N21) of 14 Emergency Department (ED) patients transferred from F1 to another acute care facility in that the facility lacked documentation of a signed physician certification which included a summary of risks and benefits and lacked documentation of contact with the receiving facility.

Findings include:

1. Medical record at F1 indicated N21, pregnant, EDC 12/02/14, presented to the ED at 2151 on 11/9/13 with an admission diagnosis of "labor" and was assessed by an ED RN using the form Initial Assessment of Obstetrical Patient. N21 was escorted to the OB Department where a medical screening exam was done at 2151 by an OB registered nurse. Per flowsheet, dilation 1, effacement 80%, station -2, presentation vertex, intact membranes, contractions every 3 minutes for the last hour and a half. No bleeding or leaking of fluid. Prenatal care at outside network system. Per Orders, via telephone by physician, "terbutaline (BRETHINE) injection 0.25 mg, once" given at 2227. Per Orders, via telephone by physician "transfer patient." Authorization for Transport & Treatment with explanation of risks for transport was signed by patient and a witness. Patient Out of House Transfer Information form was initiated. Both forms lacked a summary of risks and benefits of transfer. The record lacked a signed physician certification which included a summary of risks and benefits and failed to evidence that the receiving facility was contacted regarding transfer of N21.

2. Review of policy titled Emergency Medical Treatment, #ER-A-009, last revised 11/11, page 3 of 7, 4.0 "Qualified medical Person" means:, 4.2, Only a physician member of the medical staff after the medical staff member has consulted with an individual permitted to provide the medical screening (if other than the physician) may sign the certification indicating that a determination has been made based upon the information available at the time of the transfer, the medial benefits reasonably expected from the provision of the appropriate medical care in another medical facility outweigh the increased risks of the individual, or when in the case of a woman in labor, an unborn child from being transferred.

3. Review of policies titled Emergency Medical Treatment, #ER-A-009, last revised 11/11 and Obstetrical Patients Presenting Through The Emergency Department, #ER-A-004, last revised 8/13 failed to evidence procedure for the transfer of an obstetrical patient to another acute care facility.

4. Personnel P6 was interviewed on 1/9/14 at approximately 12:37 PM, and indicated in regard to N21, nursing staff on the OB unit talked with D4 via phone, as D4 was at F3 and he/she wanted the patient transferred there because that campus had a NICU (neonatal intensive care unit) and he/she felt this patient might need that level of service for patient safety. There is no documentation of this conversation in N21's medical record.