HospitalInspections.org

Based on record review and interview, the facility failed to maintain an accurate Emergency Department Log which reflects all individuals who enters the Facility's Emergency Department requesting service.

Findings:

Interview with Admitting Clerk (I):
During an interview via the telephone on 06/13/2017 at 11:37 a.m. with Admitting Clerk (I), he stated "The Patient popped up at the window at the registration area and told me "my water broke". I could tell she was about 9 months pregnant and she looked like she was in pain. I immediately went to inform the ER nurses. There was an agency nurse there I do not know her name. I also told the other nurses in the emergency room. The doctor was not there. The Agency Nurse came out and told the Patient that we do not have L and D service. The Patient ended up calling the ambulance from her cell phone. The Patient said she was hot so I placed her in a chair and pushed her near the door. She asked me to fan her until the ambulance came. When the EMT personnel came, one of the EMT's asked the nurse why the Patient was not treated. I did not hear the rest of the conversation. I did not hear the Patient refuse treatment, I heard her asked to call an ambulance. The entire event lasted for approximately 10-15 minutes.
Generally we have a sign in sheet at the window of the admission area, but because the Patient was in an emergency state I immediately called the nurse. I did not get the Patient's name."


Interview with Emergency Department Physician (A):
During an interview on 06/13/17 at 10:00 a.m. with the Facility's Cardio Vascular Surgeon and Facility's Emergency Department Physician (A) revealed, he was working in the Emergency Department on the morning of May 31. He said he was in the Physician's sleep area when Registered Nurse (J) informed him that there was a pregnant lady who came to the registration desk. The Patient told the staff that her water broke. The staff informed the Patient that they did not have an OBGYN service but the doctor could see her. The Patient immediately used her cell phone to make a call and the ambulance came right away. He said he came out to speak to EMS but he saw the tail end of the ambulance driving away. He said he did not "eyeball the Patient". The Patient was not registered in his computer and that he did not know the Patient's name. Physician (A) said he did not conduct a Medical Screening Examination on the Patient because he did not see the Patient. He said he was only told about the presence of the Patient after the EMS ambulance Personnel came in and requested a bed.


Reviewed Hospital Central Log 5/01/2017 - 06/13/2017:
Review of the Facility's Central Log of Patients visiting the Hospital Emergency Department requesting service, dated 05/01/2017 to 06/13/2017, revealed no evidence of Patient #1 visiting the facility.

Based on record review and interview, the Facility's staff failed to ensure the facility operationalize its Policy and Procedure to ensure a pregnant woman (with an Emergency Medical Condition) who presented to the Facility's Emergency Department was provided with a Medical Screening Examination in 1 of 1 pregnant individual from 30 sampled patients (Patient #1).

Findings:

Review of Facility's Current Policy on (Transfer of Patient) EMTALA Policy; Policy #ADM.01.048.1. Reviewed by facility 11/14. directed staff as follows:
"it is the Policy of Hospital (A) (the Hospital) (1) to provide a medical screening examination by a qualified medical person to any individual who comes to the Emergency Department seeking an examination or medical treatment (whether or not eligible for insurance benefits and regardless of ability to pay) to determine if the individual has an emergency medical condition and, (2) if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the medical condition, within the capability of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below. The Hospital shall not delay the provision of a medical screening examination, further medical examination and treatment, or appropriate transfer in order to inquire about the individual's method of payment or insurance status.
The policy applies to all individuals presenting anywhere in the Hospital, even if they present at a location other than the emergency department."

Definition Emergency Medical Condition:
"A medical condition manifesting itself by acute symptom of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such as that the absence of immediate medical attention could reasonably be expected to result in either: placing the health of the individual (or respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of bodily organ or part; or With respect to a pregnant woman who is having contractions: that there is inadequate time to effect a safe transfer to another hospital before delivery; or that the transfer may pose a threat to the health or safety of the woman or her unborn child."
"Stabilized" or "to stabilize" means With respect to any emergency medical condition: that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of an individual from Hospital; or to provide such medical treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the Hospital; or
With respect to a pregnant woman who is having contractions and who cannot be safely transferred, that the woman has delivered the child and the placenta."

Interviews:
Interview on 06/13/2017 at 8:20 a.m during entrance to the facility with the Facility's Director of Nursing revealed, a Patient who was pregnant had come to the Facility's Emergency Department requesting service, but the nurses on duty told the Patient that the facility did not have obstetrical and gynecological service. The Patient called an ambulance and left the facility. She said the Facility did not have any record on the Patient or knows the Patient's name.

Interview with Admitting Clerk (I):
During an interview via the telephone on 06/13/2017 at 11:37 a.m. with Admitting Clerk (I) revealed he stated "The Patient popped up at the window at the registration area and told me "My water broke." I could tell she was about 9 months pregnant and she looked like she was in pain. I immediately went to inform the ER nurses. There was an agency nurse there I do not know her name. I also told the other nurses in the emergency room. The doctor was not there. The Agency Nurse came out and told the Patient that we do not have L and D service. The Patient ended up calling the ambulance from her cell phone. The Patient said she was hot, so I placed her in a chair and pushed her near the door. She asked me to fan her until the ambulance came. When the EMT personnel came, one of the EMT's asked the nurse why the Patient was not treated. I did not hear the rest of the conversation. I did not hear the Patient refuse treatment, I heard her asked to call an ambulance. The entire event lasted for approximately 10-15 minutes.
Generally we have a sign in sheet at the window of the admission area, but because the Patient was in an emergency state I immediately called the nurse. I did not get the Patient's name."

Interview with Emergency Department Physician (A):
During an interview on 06/13/17 at 10:00 a.m. with the Facility's Cardio Vascular Surgeon/Facility's Emergency Department Physician (A) revealed, he was working in the Emergency Department on the morning of May 31. He said he was in the Physician's sleep area when Registered Nurse (J) informed him that there was a pregnant lady who came to the registration desk. The Patient told the staff that her water broke. The staff informed the Patient that they did not have an OBGYN service but the doctor could see her. The Patient immediately used her cell phone to make a call and the ambulance came right away. He said he came out to speak to EMS but he saw the tail end of the ambulance driving away. He said he did not "eyeball the Patient". The Patient was not registered in his computer and that he did not know the Patient's name. Physician (A) said he did not conduct a Medical Screening Examination on the Patient because he did not see the Patient. He said he was only told about the presence of the Patient after the EMS ambulance Personnel came in and requested a bed.

Interview with Licensed Vocational Nurse (B):
During an interview on 06/13/2017 at 11:20 a.m. via the telephone with Licensed Vocational Nurse (B), she stated "I never knew the Patient's name I never saw the Patient, I heard someone say a pregnant lady had showed up in the emergency room and the other Agency Nurse (J) had told the Patient that that we did not have women's service. Later someone from EMT came into the ER and shouted "We need a bed". My response was "We do not have a bed." When asked why did she responded to the EMT's request for a bed in the negative. She stated "The Patient was already told we do not have women services." She said after EMT's request for a bed they left immediately.

LVN (B) was asked when the last time she was trained/in-serviced on EMTALA requirements. She stated "I may have had training on EMTALA when I was in Labor and Delivery but that was a long time ago."

Interview with Registered Nurse (K):
During an interview via the telephone on 06/13/2017 at 4:30 p.m. with Registered Nurse (K) revealed the following: RN (K) said, on 05/31/2017 at approximately 5:15 a.m. she returned from her break when Admission Clerk (I) approached her and informed her that a Patient's water broke and the Patient had left with EMS. She said she notified the Physician on duty about the Patient but the ambulance transporting the Patient left before the Patient was seen by the Physician.
Registered Nurse (K) said she has being working at the facility for approximately two years. She said she was not provided training or in-service on the EMTALA requirement but knew "We are expected to take care of patients." She said she received this information from another facility she had worked.

Interview with Agency Registered Nurse (J):
During an interview on 06/14/2017 at 7:40 a.m. with Agency Registered Nurse (J) revealed she works through a staffing company. She said she had previously worked at the facility in 2007, took a sabbatical of two years and returned to work at the facility since August 2016.
Agency Registered Nurse (J) said she did not know the Patient's name who had come to the Emergency Department on May 31, 2017 in a pregnant state. The Patient did not provide information but she could tell the Patient was familiar with the facility based on her conversation.
Agency Registered Nurse (J) said she was sitting at the desk in the area where the ambulance brings patients into the Emergency Department. "The guy from admitting came over and stated "A lady is in the waiting area is pregnant, I know we don't have OB, you want to come and take a look at her."
Agency Registered Nurse (J) said "I went out there to look at her, she looked huge. I thought she had been here before. I told her we did not have a pediatrician but that doesn't mean we cannot see you. I think she asked if there was any other facility in the area. She got on her cell phone. I don't know who she was talking to. She made the decision to leave. I did not offer to assess her.
A minute after EMS drove up and came in. EMS said "I need a bed." Nurse (B), the other Nurse present, said "We don't have a bed, we don't have those services."
I called Dr (A) and told him that there was a pregnant lady here, I want you to come out. The Dr came out and the ambulance was pulling out."

Agency Registered Nurse (J) said the way the Patient was sitting in the chair she knew the Patient was experiencing some discomfort but she cannot recall been told the Patient's water had broken. She said after speaking to the Patient she went and spoke with the other Nurse (B) and, so that was the reason why Licensed Vocational Nurse (B) told the EMS the facility did not have a bed. She said there was no Nursing Supervisor present in the facility during the occurrence but the staff present discussed it among themselves. Registered Nurse (J) said she did not notify the Physician present in the Emergency Department immediately. She said the Physician who was in the sleep area, which is located in the Emergency Department was notified after EMS came and requested for a bed.
RN (J) said "In hindsight I should have assessed the Patient."

Interview with the Facility's CEO:
Interview with hospital Administrator on 6/13/2017 at 2.51p.m revealed that all staff watch a video that addresses EMTALA, but it is not documented.

Interview with Human Services Director:
During an interview with Human Resource Director (F) on 6/13/2017 at 12:45 p.m., she acknowledged that the competencies in the Agency nurses files came from the agency and that there are no skills checklist on file, but should be.

Interview with Agency Registered Nurse (J):
Interview with Agency Registered Nurse (J) on 6/14/2017 at 7:40 a.m. revealed that she just recently started working at the facility again. She had orientation to the facility in the past when she worked there before in 2007. She was an Intensive Care Unit (ICU) nurse that was also working in the emergency room. She was given orientation to the Emergency Department by the way of someone showing her around, explaining the patients that are seen, core measures. She did not shadow or follow another nurse, nor was she given a skills checklist to complete. She did not receive EMTALA training at this facility.

Review of Written Statement from Admission Clerk (I):
Review of a Written Statement which was not dated, but signed by Admission Clerk (I) who was assigned to the Admission/Emergency Department on 05/31/2017, when Patient #1 requested service, revealed the following documentation: "The Patient walked in the lobby and stated that her water broke and she was pregnant. I told her to have a seat and immediately got a nurse from the ER. The nurse informed the lady that we did not have OB services at this facility and that she would be better served going to Hospital (G). I helped the Patient into the wheelchair and wheeled her to the front lobby. I fanned the patient with a clipboard until HFD arrived."

Review of Written Statement from Agency Registered Nurse (J):
Review of a Written Statement dated 5/31/2017, signed by Agency Registered Nurse (J) who was assigned to the Emergency Department on 05/31/2017 when Patient #1 requested service, revealed the following documentation:
"(I) presented to the front desk. He stated that a pregnant woman arrived at the admission desk and she stated that she thought her water had broken. Assessed to patient in the waiting room. She stated her friend dropped her off and she thought her water had broken. I informed her that we no longer had pediatric services. She stated she wanted to go somewhere else. She got on her cell phone and made a call. (I) placed her in a wheelchair and took her outside. The Patient was picked up by EMS. One of the drivers came into the Emergency Room and asked for the doctor. Dr (A) was informed, he came out to see the EMS but they had departed."

Reviewed Hospital Central Log 5/01/2017 - 06/13/2017:
Review of the Facility's Central Log of Patients visiting the Hospital Emergency Department requesting service, dated 05/01/2017 to 06/13/2017, revealed no evidence of Patient #1 visiting the facility requesting service.

Reviewed footage from Hospital Camera located at the entrance of the hospital:
Review of footage from hospital camera located at the entrance of the hospital, revealed the following timeline of Patient #1's arrival and departure outside the hospital entrance:
Footage from Camera #8
04:44:48: Taxi cab arrived with Patient #1 to the entrance of the Facility's lobby.
Approximately 04:46: Patient #1 disembarked from Taxi cab and entered Facility's lobby
Approximately 04:47: Taxi cab left the facility
Approximately 04:54: Patient #1 pushed in wheelchair by unknown person
Approximately 04:55: Unknown individual retraced step into hospital lobby and returned approximately 04:56.
Approximately 04:58:04: Ambulance and EMS personnel arrived at facility.
Approximately 05:01: Patient #1 placed in ambulance by EMT staff
Approximately 05:01:34: EMS staff entered Emergency Department entrance.
Ambulance left with Patient #1 from Hospital entrance at 05:03.

Listened to 911 tape from Patient #1:
Review of a 911 EMS recording dated 05/31/2017 revealed a conversation between two individuals, the dispatcher and an individual who identified herself as Patient #1. Patient #1 informed the 911 dispatcher that she was inside the front door entrance of the hospital, that she was nine months pregnant, her water broke, she was in pain and the baby was not born and the facility did not have OB (obstetrical) services. The dispatcher informed her that an ambulance was dispatched to her location and advised her not to go to the bathroom.

Reviewed Emergency Medical Services Medical Record for Patient #1; Houston EMT:
Review of Houston Emergency Medical Services Medical Record for Patient #1, dated 05/31/2017 revealed the following entries:
Dispatch 05/31/2017 at 05:18:24
Unit notified: 05/31/2017 at 05:19:25
En route 05/31/2017 at 5:20:51
On scene 05/31/2017 05:25:06
Left scene 05/31/2017 05:30:17
Arrived at Hospital 05/31/2017 at 05:38:06
Narrative: "A031 AOSTF 27 y/o black female sitting in wheelchair outside of Hospital (A) doors with a Gentleman that she did not know attending the wheelchair. PT stated her water had broke 30 minutes ago and the hospital would not admit her. FF (O) and FF (PP) loaded Pt onto the stretcher securing both buckles and handrails raised with no problems, while FF (Q) ran inside and try to get a bed so we could at least deliver the baby in a hospital room. Hospital staff told him they didn't have an OB doctor and will not give us a room.
A031 Transported PT to Hospital (G) which was fairly close. While in route OB kit was prepared and 3 minutes out the baby started to crown so baby delivery was proceeded. Baby came out head first, suction was administered and umbilical cord was clamped and cut. Baby was wrapped to keep warm and was placed on mother's chest. During the process mother was placed on Oxygen 15LPM via non rebreather mask. By the time ambulance had reached destination and ER staff took PT from ambulance crew, ambulance crew did not have time to do Apgar scale on baby or even call telemetry while in route."

Hospital (G) Record For Patient #1:
Reviewed Demographic Data of Patient #1 completed at Hospital (G)
Review of the record revealed the following documentation:
Name: Patient #1
Date of Admission: 5/31/2017 at 5.57 a.m.
Date of Discharge: 6/2/2017.
Chief Complaint: Labor precipitous. Delivered Retained.

Review of Patient's History and Physical completed at Hospital (G) revealed the following entry: "Chief complaint Patient called EMS from Hospital (A) because staff told patient that they did not have OB services. EMS requested there to deliver baby and hospital refused. Transported to Hospital (G). Baby delivered our ambulance bay G5P4. Delivered 0536.
The patient presented with labor. The onset was just before arrival. Pregnancy status gravida 5 para 4. Pt states 9 months. Has had pre-natal care. Was in another ED and told to go outside and call 911 for active labor symptoms. Contractions: states she woke up from sleep with contractions. Pt delivered in ambulance in route to Hospital (G) from another area hospital. Fetal movement baby boy with cry initially per mother. General: arrives with baby on chest. RRWNL. Pink covered in vernix caseosa. Warm to touch clamped."



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Review of four Licensed nurses (who were assigned to the Emergency Department on 05/31/2017) human resources and training files, revealed no documentation of training or in-service for EMTALA requirements.

Record review of Contract Registered Nurse (J's) personnel and training record revealed no skills competency checklist, no documented hospital orientation, no documented departmental orientation and no Emergency Medical Treatment and Labor Act (EMTALA) training.

Record review of Staff Registered Nurse (K's) Personnel and training record revealed no documented EMTALA training.

Record review of Staff Licensed Vocational Nurse (B's) Personnel and Training record revealed no documented EMTALA training.

Record review of Contract Registered Nurse (L's) personnel and training record revealed no skills competency checklist, no documented hospital orientation, no documented departmental orientation, and no documented EMTALA training.


Record review of Facility Policy titled Competency Assurance dated 6/14/2016 revealed the following information:
This policy applies to all individuals providing care and services at Hospital (A).
Policy:
"It is the policy of the hospital to maintain a comprehensive program for ensuring that employees possess the skills and competencies required to safely and effectively provide patient care and services. Included in these programs are mechanisms for a assisting employees with developmental needs while ensuring the patient receives the appropriate care. Detailed descriptions of these policies and corresponding procedures are included in the following hospital policies:
c.) Orientation
d.) Skills/Competency Checklist
Record review of facility policy titled Agency Nurse Utilization: Orientation dated 3/2016 revealed the following information:
I. Outcome standards
A. The department clinical manager/director maintains the ultimate responsibility for the patient on the unit when such patients are assigned to an agency nurse.
B. The department clinical nurse manager/charge nurse is responsible for maintaining the quality of care through his/her assignment process. Assignments should be made on the competency level of the staff members on the unit and the patient acuity.
II. Process Standards
C. The agency nurse is to be given the following information:
1. Orientation Packet
2. Evaluation Form: He/She will be instructed to review the material and sign her acknowledgement of the information and return it to the nursing supervisor by the end of her first shift on duty."