HospitalInspections.org

Based on document review, review of medical records, review of policies and procedures and interviews with key personnel on August 30, 2012, September 5-6, and September 20, 2012, it was determined that the hospital failed to provide an appropriate medical screening examination.

The evidence is as follows:

1. 42 CFR ?489.24(a)(1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department," as defined in paragraph (b) of this section, the hospital must-(i) Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations..."

2. A review of Medical Record A was conducted. The patient presented to the Emergency Department on March 10, 2012, with a chief complaint of vaginal bleeding. Nursing documentation stated: "Bleeding all day but large gush 1 hour PTA [prior to arrival], states no heartbeat heard in office today, 15 weeks pregnant. G4P2 [Gravida 4 Para 2]." The nurse documented at 1947: "...several large clots noted, saved for lab." The nurse documented the vital signs as: Pulse: 119, Resp [respirations]: 18, Blood Pressure 126/79, and Pain Level: 6.

3. The physician documented on the patient's physical exam section: "passed fetal products in the ED." The clinical impression was "abortion complete." The physician documented under "HPI" that the patient was experiencing "mild moderate vaginal bleeding ...pelvic cramping..." and under the heading of 'vaginal bleeding ' he documented: "abnormal bleeding." The "pelvic exam" section of the document was blank (contained no documentation that a pelvic exam was performed).

4. During an interview with Patient A on August 30, 2012, she confirmed that the physician did not conduct a pelvic examination during her emergency department visit on March 10, 2012.

5. Further review of the physician's documentation on the "Emergency Physician Record Female Urogenital Problems" form indicated that he failed to perform a pelvic examination, to order any laboratory tests or diagnostic tests, or to send the products of conception for pathology. The physician failed to order testing to determine hemodynamic stability.

6. An interview was conducted with the attending physician on September 6, 2012. When asked if a pelvic examination would be included as part of a routine examination in a case of spontaneous abortion, he stated: "I'm sure you also have a copy of this record."

7. 1,000 ML [milliliters] of normal saline was ordered and subsequently administered intravenously at 1943. The medical record failed to contain documentation of any reassessment following administration of the normal saline.

8. An interview was conducted with the attending physician on September 6, 2012. When asked if he felt that the care Patient A received was appropriate he stated: "Yes. I wish I had known the patient was upset. I don't recall the case, though."

9. During the interview with the Emergency Director on September 5, 2012, she was asked if a pelvic examination would have typically been performed for Patient A. She stated: "if the patient passed the complete sack, perhaps not. I would have preferred a pelvic exam and better documentation."

10. During the interview with the Emergency Director on September 5, 2012, she was also asked if any peer review had been conducted on Record A. She stated: "No, it doesn't meet the criteria for peer review."

11. During an interview with the Physician Vice President of Quality and Safety on September 5, 2012, he stated: "I don ' t feel he violated hospital policy. I don't believe he egregiously violated our by-laws ...I will counsel him on that ...this case will now be peer reviewed." The documentation provided to the survey team on September 20, 2012 failed to include any evidence that this case had been reviewed for performance improvement.