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

The findings included:

Based on policy review, medical record reviews and physician and staff interviews the hospital failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) for one of four obstetrical patients reviewed (Patient #19) by failing to show evidence of discussing risks of refusing a medical screening to an obstetrical patient who was moved/transferred from the OB ED to the Main ED and then left without being seen.

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.

Based on policy review, medical record reviews and physician and staff interviews the hospital failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) for one of four obstetrical patients (Patient #19) by failing to show evidence of discussing risks of refusing a medical screening to an obstetrical patient who was moved from the Obstetrics ED (Emergency Department) to the Main ED and then left without being seen.

The findings included:

Review of the hospital policy titled "Refusal of Care (North Carolina)" last revised 07/15/2021 revealed " ...VI. DOCUMENTATION. A. The patient's....refusal of recommended care must be documented in the patient's medical record....1. Document the discussion with the patient...about the benefits of receiving care, the risks of refusing the care, and any appropriate alternatives. 2. Complete and have the patient...sign, date and time the appropriate refusal of care form...3. If a patient...refuses to sign the appropriate form, a team member should document the refusal to sign on the appropriate form. The team member should sign, date and time the form on the witness signature line. B. If a patient is unable to be located in the ED, document in the medical record the number of times the patient was called to come back to a room and each time this occurred."

OB (Obstetrics) ED record review on 10/12/2022 revealed Patient #19 was an 18-year-old female who arrived at the OB ED on 04/11/2022 at 2206 with a complaint of abdominal pain and vomiting blood. Review of the (Hospital) Obstetrics Emergency Department Provider Note, dated 04/11/2022 at 1034 by MD #1 revealed "... (Patient #19) is an 18 y/o (year-old) G (gravida) 1 P (Para) 0 with estimated delivery: 08/13/2022 who presents for abdominal pain and nausea/vomiting. Pt. (patient) notes that she has been having vomiting on and off since February. She notes that today she saw blood in her vomit. This is the first time that has happened ...Clinical Impression: Abdominal pain during pregnancy in second trimester, 22 weeks gestation of pregnancy, Vomiting affecting pregnancy, Hematemesis (bloody vomit) with nausea. ED Disposition: Transfer to another facility, Condition: Stable, Comment: (Patient #19) should be transferred to (Hospital Name-same hospital as OB ED) hospital ED ..." Medical record review revealed Patient #19 was monitored, had a physical exam, and Non-Stress Test (prenatal test used to check on the baby's health) in the OB ED and was cleared to be transferred internally to the hospital's general emergency department for evaluation of hematemesis. Review of the ED Care Timeline dated 04/12/2022 at 0206 revealed OB MD #1 placed orders " ...Transfer Patient.... ED. ..." Medical record review on 04/12/2022 at 0206 revealed Patient #19 was moved/ transferred from the OB ED, via wheelchair to the main hospital DED (Dedicated Emergency Department) to be evaluated for hematemesis. Review of the ED Notes dated 04/12/2022 at 0211 (6 minutes after leaving the OB ED) by ED technician #2 revealed "...patient was sitting on the left side of the lobby, waiting for her ride while she still has an IV (intravenous) in her hand....She stated she was waiting for her ride to come....This CNA (certified nursing assistant) asked the patient on 2 separate occasions to confirm if she was being seen in the ED to follow up on her complaint of vomiting blood. Pt. states both times that she would like to leave and that she is okay with being taken out of the system. This CNA let the triage RN know about the patient and that she was leaving. This CNA removed the 20 G (gauge) IV in the patient's left hand prior to patient departure. ..." Review of the ED Care Timeline dated 04/12/2022 at 0247 by Triage RN #3 revealed "... Disposition: ....Left without being seen. ..." Record review did not reveal a discussion with Patient #19 of the risks of refusing medical screening in the main ED prior to her leaving without being seen.

Request on 10/13/2022 to interview ED Technician #2, DED Triage RN #3, and DED Nurse Manager #5 revealed none of them were available for interview.

Telephone interview on 10/13/2022 at 1655 with OB ED Labor and Delivery RN #4 revealed " ..once the patient is cleared in OB, we explain to the patient they need to be checked in the ED, we gather the chart, and OB staff escort the patient to the main ED for further evaluation. The provider calls the ED Charge Nurse to let them know the patient has been cleared from OB but is being transferred and gives report. No AVS (after visit summary) is generated until the patient is discharged from the Main ED. ..." Interview revealed patient report was called to the Main ED Charge Nurse and OB staff escorted patients when transferred to the Main ED. Interview revealed Patient #19 did not receive discharge instructions or risks of leaving without being seen prior to leaving the OB ED for the Main ED for further evaluation.

Telephone interview on 10/13/2022 at 1715 with OB MD #1 revealed "...Before we send anyone to the Main ED, I clear them from an OB standpoint. I educate the patient, and the patient agrees to the transfer. I call report to the ED, and someone physically escorts the patient down. ..." Interview revealed Patient #19 did not receive discharge instructions or risks of leaving without being seen prior to leaving the OB ED before she was moved/ transferred to the Main ED for further evaluation.