HospitalInspections.org

Based on review of facility documents, on-call schedules, and staff interviews (EMP), it was determined that the facility failed to have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control.

Findings include:

A review of the policy entitled "Scope of Emergency Services" dated September 2011, revealed, "... There is a rotating on-call schedule of staff physicians in the specialties available to the Emergency Physician for consultation or for unusual contingencies. ... Policies and Procedures: ... 4. A current roster of the entire medical staff, including all categories, and a current on-call schedule for Medicine, Surgery, Gynecology, and EENT shall be posted in the Emergency Department at all times. ... ."

1) A review of the on-call schedules provided by the facility were reviewed for the last six months. Call schedules provided by the facility included specialities such as Pediatrics, Radiology, Obstetrics, Gastroenterology, General Surgery, Ophthalmology, Urology, Hospitalist, Anesthesia, Pathology, Psychiatry, Family Practice, and Cardiology. It was noted that some specialties were limited to one or two physicians.

2) Surveyors requested a policy related to On Call and limited specialities. EMP1 and EMP2 confirmed on June 22, 2012, that there is no specific policy related to instances in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control.

Based on review of facility documents, and staff interviews (EMP), it was determined that the facility failed to maintain a central log on each individual who comes to the dedicated emergency department, as defined in 489.24 (b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

Findings include:

Review of the policy entitled "Scope of Emergency Services" dated September 2011, revealed, "... Control Record: The Emergency Department will keep a control log book containing the following information for each patient treated in the Emergency Department: 1. Date 2. Time 3. Patient's name and Medical Record # 4. Age 5. Sex 6. Nurse Triaging Patient 7. Admitting Physician 8. Diagnosis or complaint 9. Service of doctor 10. Disposition 11. Time of disposition."

1) Interview with EMP1, EMP2, and EMP3 on June 20, 2012, revealed that the facility's Obstetrics Department is considered a dedicated Emergency Department, and that unscheduled patients present there for care.

2) A review of the Obstetric (OB) Department patient log, dated December 1, 2011 to June 20, 2012 was completed. During review of the OB patient log, it was noted that the patients are not differentiated between scheduled and unscheduled.

3) Interview with EMP3, on June 20, 2012, revealed that patients presenting in the daylight are more likely to be scheduled. Stated that anything after 4:00 PM and until 7:00 AM, would be unscheduled. EMP3 also confirmed the findings that patients are not differentiated on the log.

Based on review of facility documents, closed medical records (MR), and staff interviews (EMP), it was determined that the facility failed to follow adopted policies, by failing to provide an appropriate medical screening examination for six of 15 Obstetrics (OB) medical records reviewed. (MR1, MR3, MR5, MR7, MR10, MR14)

Findings include:

Review of the facility's Medical Staff By-Laws/Rules and Regulations, revealed "... Medical Screening Examinations for obstetrical patients ... Patients 20 weeks gestation or greater, with obstetrical presentations may receive a medical screening examination to rule out labor. Exam will be conducted in thee Maternity Department. A qualified evaluator to perform a medical screening exam is: reve. 7/11; 10/11 1) A Registered Nurse who has completed the probationary period and initial competencies in the Maternity Dept.: or 2) A licensed or certified Nurse Midwife with midwifery privileges at this hospital or 3) A licensed Practitioner with medical staff privileges at this hospital that include obstetrical care or emergency medicine. Screening exam form will score criteria: prompt calling obstetrician, or if labor is ruled out, patient will be sent to the E.D. ... ."

Review of the OB policy entitled "Medical Screening Examinations", dated September 2011, revealed "It is the policy of J.C. Blair Memorial Hospital to provide a medical screening examination to all patients presenting for unscheduled obstetrical evaluation, testing or services within the capabilities of the Maternity Unit and the ancillary services routinely available to the Maternity Department, including the use of on-call physicians. Patients 20 weeks gestation or greater, with obstetrical presentations (other than for scheduled procedures) may receive a medical screening examination in the Maternity Department consistent with this policy. Patients fewer than 20 weeks gestation will be provided a medical screening examination in the Emergency Department. For emergency situations such as life-threatening trauma, imminent delivery or profuse hemorrhage, the patient will receive medical screening exam in the Emergency Department and the location of further assessment and treatment will be at the medical discretion of the Emergency Department physician ... Definitions: Emergency Medical Condition. 1. A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of prompt and appropriate medical attention could result in: a. Placing the health or safety of the patient or unborn child in serious jeopardy; b. Serious impairment to bodily functions; c. Serious dysfunction of any bodily organ or part; 2. The following conditions are declared to be emergency conditions by statute and regulations: a. Pregnancy with contractions present. b. Acute pain rising to the level of the general definition of emergency medical condition. c. Psychiatric disturbances. d. Symptoms of substance abuse (including alcohol). Stabilize. With respect to an emergency medical condition as defined above, to provide that treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration is likely to result from (or occur during) the transfer of the individual; and with respect to a pregnant female experiencing contractions that the baby and placenta have been delivered. Transfer. The movement of the patient, for any reason - including - discharge from the premises of the hospital, except as a result of departure against medical advice or as the result of death ... Qualified Evaluator. A qualified evaluator is: 1. A Registered Nurse who has completed the probationary period and initial competencies in the Maternity Department; or 2. A licensed or certified Nurse Midwife with midwifery privileges at this hospital; or 3. A licensed Physician with medical staff privileges at this hospital that include obstetrical care or emergency medicine. Procedure. 1. A patient who tells staff she is 20 weeks or greater pregnant and in possible labor or having abdominal or vaginal symptoms will be escorted to the Maternity Unit after the maternity nurses have been notified. 2. A patient who tells staff she is 20 weeks or greater pregnant and having symptoms other than abdominal or vaginal will be logged in by the Emergency Department, triaged and receive a medical screening examination, if they present there initially. 3. Patients with less than 20 weeks estimated gestation will be evaluated in the Emergency Department following the Emergency Department patient screening policy. 4. This policy shall also apply to those patients presenting for obstetrical and gynecological conditions for scheduled procedures, where hospital personnel observe abnormal conditions or the onset of labor. 5. If the OB practitioner has called the ED physician to inform that he/she is sending a patient into the E.D., the E.D. physician will inform the triage nurse of that discussion. Triage and medical screening examination still need to occur. 6. All patients reporting to the Maternity Unit for evaluation will receive at least the standard obstetrics evaluation by a qualified evaluator using the Obstetrics Evaluation Form. Patients requesting a "labor check" or asking to be evaluated for their ability to reach another facility must receive the standard evaluation,unless they refuse evaluation in writing on the refusal of services form. 7. The patient will be scored as indicated on the Obstetrics Evaluation form and the patient will be given a score at the conclusion of each exam and the score noted ... 9. When the results of any scoring indicates that a physician exam is indicated, or upon the request of a nurse evaluator, the patient's attending physician or nurse midwife, or the on-call obstetrician shall personally examine the patient for the purpose of completing the medical screening examination. 10. Patients with 6 or fewer points in Block C, with no physician exam required after evaluation by a Qualified Evaluator may be discharged upon telephone orders from the private attending physician or on-call physician or CNM ... 11. All phone contacts with the attending or on-call physician shall be noted and timed in the record. 12. Patients, after examination by a physician or nurse midwife as indicated by the scoring criteria, may be discharged upon the written order of a physician if: a. delivery is not expected in the next 6 hours; and b. discharge poses no likelihood of material deterioration in the condition of the mother or fetus; and c. discharge does not pose a threat to the health or safety of the mother or fetus ... 13. Pertinent nursing observations other than those provided in the Obstetrics Evaluation form and nursing care provided shall be documented on a standard patient record form. Physician orders shall be documented in the standard medical record."

1) A review of MR1, revealed "Outpatient Record Maternity ... June 6, 2012, Arrived 0513 Discharged 0640...Orders/Time Outpt or Observation, Non-Stress Test, Clear Liquids, UA, Have patient go to Lewistown Hospital ... Final Diagnosis: IUP, 40 3/7 weeks gestation. Indication: fever x 5 days; spotting. ... ." Continued review of MR1 revealed " Obstetric Evaluation " dated June 5, 2012, revealed, "... Regardless of score on any box the Nurse Evaluator may require physician exam for Patient Safety ... Total Box A ... Findings 0 ... Criteria 2 or more = physician exam ... Score 0 ... If Patient has established objective labor pattern ... Total Box A [sic] ... Findings 0 ... Criteria 3 or more =physician exam ... Score 0 ... If patient has objective labor pattern Total Box C ... 1st Exam Score ... Total Box C 1 ... Criteria > 7=md/nmw Exam. Document was unsigned by the Nurse Evaluator. Continued review of MR1 revealed "NST Record" dated June 5, 2012, revealed, "...Temperature: 99.1 ... Reason for NST: fever; spotting ... ." Review of MR1 also revealed "LD-Flowsheet" dated June 6, 2012, which stated, "... Annotation Comments ... 05:15 urine sample obtained for UA patient states [patient] has had a fever since Friday, up to 102.6 ... Was seen at family doctor yesterday and had bloodwork drawn and is waiting for results. Denies nausea/vomiting, tolerating sips of clear liquids and toast. ... 06:20 [OTH1] called and informed about patient and baby's status. [OTH1] said to have patient go to Lewistown. ... 06:33 patient discharged with instructions to go to Lewistown. ... ."
A review of MR3, revealed "Outpatient Record Maternity ... January 31, 2012, Arrived 2230 Discharged 0010 ... Orders/Time Outpt [circled] or Observation, Non-Stress Test, Clear Liquids, UAM, Discharge ... Final Diagnosis: IUP, 36 1/7 weeks gestation. Indication: abd pain. ... ." Continued review of MR3 revealed "Obstetric Evaluation" undated, which stated "... Regardless of score on any box the Nurse Evaluator may require physician exam for Patient Safety ... Total Box A ... Findings [blank] ... Criteria 2 or more = physician exam ... Score 0 ... If Patient has established objective labor pattern ... Total Box A [sic] ... Findings [blank] ... Criteria 3 or more =physician exam ... Score 4 ... If patient has objective labor pattern Total Box C ... 1st Exam Score ... Total Box C 1 ... Criteria > 7=md/nmw Exam. Continued review of MR3 revealed, "NST Record" dated January 31, 2012, revealed, " ... Reason for NST: had constant pain in the left side of abdomen, has started to ease up since she's been here ... . " Review of MR3 also revealed "LD-Flowsheet" dated January 31, 2012, which stated, "... Annotation Comments ... 22:48 OTH1 called ... Keer [sic] for one hour and send home if not contracting . ... ."
A review of MR5, revealed "Outpatient Record Maternity ... April 5, 2012, Arrived 1940 Discharged 2200 ... Orders/Time Outpt [circled] or Observation, Non-Stress Test [circled], Clear Liquids [circled], Stadol 2mg IM x1 then D/C to home ... Final Diagnosis: IUP, 37 3/7 weeks gestation. Indication: abd pain, pelvic pressure, HA. ... ." Continued review of MR5 revealed "Obstetric Evaluation" dated April 5, 2012, revealed, "... Regardless of score on any box the Nurse Evaluator may require physician exam for Patient Safety ...Total Box A ... Findings [blank] ... Criteria 2 or more = physician exam ... Score [blank] ... If Patient has established objective labor pattern ...Total Box A [sic] ... Findings [blank] ... Criteria 3 or more = physician exam ... Score [blank] ... If patient has objective labor pattern Total Box C ... 1st Exam Score ... Total Box C [blank] ... Criteria > 7=md/nmw Exam. Review of MR5 also revealed "NST Record" dated April 5, 2012, revealed, " ... Reason for NST: pelvic pressure, headache, abdominal pain ... ." Continued review of MR5 revealed "LD-Flowsheet " dated April 5, 2012, which stated "... Annotation Comments ... 9:50 basin and ginger ale provided to patient as [patient] is c/o nausea ... 29:29 MD phoned, T. O. for Stadol 2 mg IM x 1 then d/c to home ... 21:13 D/C'd to home; discharge instructions given and explained ... ."
A review of MR7 revealed, "Outpatient Record Maternity ... March 30, 2012, Arrived 1915 Discharged 2100 ... Orders/Time Outpt or Observation, Non-Stress Test [circled], Clear Liquids ... 2030 OTH2 made aware of pt status, Orders received from OTH2 to have pt be admitted or pt may leave after signing "AMA" paper to go to family OBGYN at Mt Nittany. 2100 Pt signed "AMA" paper after deciding to leave for Mt Nittany Medical Center ... Discharge Instructions: ... Go to Mount Nittany Hospital ... Final Diagnosis: IUP, 36 3/7 weeks gestation. Indication: Groin Pain ..." Continued review of MR7 revealed "Obstetric Evaluation" dated March 30, 2012, which stated, "... Regardless of score on any box the Nurse Evaluator may require physician exam for Patient Safety ... Total Box A ... Findings [blank] ... Criteria 2 or more = physician exam ... Score [blank] ... If Patient has established objective labor pattern ... Total Box A [sic] ... Findings [blank] ... Criteria 3 or more = physician exam ... Score 0 ... If patient has objective labor pattern Total Box C ... 1st Exam Score ... Total Box C [blank] ... Criteria > 7=md/nmw Exam. Notation added to document that stated: "Pt left "AMA" to Mt Nittany." Continued review of MR7 revealed "NST Record" dated March 30, 2012, which stated, " ... Reason for NST: Groin pain/discomfort starting in am ... ." MR7 also revealed "LD-Flowsheet" dated March 30, 2012, which stated, "... Annotation Comments ... 20:24 OTH2 made aware of pts status. Orders received to admit [sic] pt for labor or have pt sign "AMA" paper to leave to go to Mt Nittany for evaluation. Pt signed "AMA" leaving to go to Mt Nittany ... ."
A review of MR10 revealed "Outpatient Record Maternity ... June 2, 2012, Arrived 2150 Discharged 2325 ... Orders/Time Outpt [circled] or Observation, Non-Stress Test, Clear Liquids, UA, D/C to home. ... Discharge Instructions: Make an appt with OB doctor this week. Drink plenty of fluids. Final Diagnosis: IUP, 37 6/7 weeks gestation. Indication: Cramping, N/V ... ." Continued review of MR10 revealed "Obstetric Evaluation" dated June 2, 2012, which stated, "... Regardless of score on any box the Nurse Evaluator may require physician exam for Patient Safety ... Total Box A ... Findings 0 ... Criteria 2 or more = physician exam ... Score 0 ... If Patient has established objective labor pattern ... Total Box A [sic] ... Findings 0 ... Criteria 3 or more = physician exam ... Score 0 ... If patient has objective labor pattern Total Box C ... 1st Exam Score ... Total Box C 0 ... Criteria > 7= md/nmw Exam. Notation added to document that stated: " Pt left "AMA" to Mt Nittany." Review of MR10 also revealed "NST Record" dated June 2, 2012, which stated, " ... Reason for NST: pt c/o cramping with nausea and vomiting all day long. She stated she was outside all day and has visible sunburn on bilateral face and arms. ... . " Continued review of MR10 revealed "LD-Flowsheet " dated June 2, 2012, which stated, "... Annotation Comments ... 21:54 Pt stated she was discharged from [OTH1] practice on may [sic] 19 due to insurance. [Patient] has not been to an OB provided [sic] since then. [Patient] stated that [patient] has [patient] address change and insurance things straighten [sic] out and will call [OTH1] office this week. ... 23:15 [OTH1] called and made aware of pt, c/o cramping and n/v all day, sunburn, u/a results, FHR and mild occasional mild contractions and that pt is tolerating clear liquids without difficulty. Ok to discharge to home and instruct to call Monday to make an appt with an OB doctor. ... . "
A review of MR14 revealed "Outpatient Record Maternity ... December 18, 2011, Arrived 1955 Discharged 2100 ... Pressure & cramping started [approximately] at 1300. + FM. [No] bleeding. Celestone 10/26/2011. PTL in October stopped with MgSO4. ... Orders/Time Outpt [circled] or Observation, Non-Stress Test , Clear Liquids, D/C home to follow-up with regular provide in am. ... Final Diagnosis: IUP, 34 weeks gestation. Indication: cramping ... ." Continued review of MR14 revealed "Obstetric Evaluation" dated December 18, 2011, which stated, "... Regardless of score on any box the Nurse Evaluator may require physician exam for Patient Safety ... Total Box A ... Findings [blank] ... Criteria 2 or more = physician exam ... Score 0 ... If Patient has established objective labor pattern ... Total Box A [sic] ... Findings [blank] ... Criteria 3 or more = physician exam ... Score [blank] ... If patient has objective labor pattern Total Box C ... 1st Exam Score ... Total Box C [blank] ... Criteria > 7=md/nmw Exam. Continued review of MR14 revealed "LD-Flowsheet" dated December 18, 2011, revealed, "... Annotation Comments ... 20:04 pt c/o cramping and pressure that started approx 1300 today. hx PTL in October w/ tx of MgSO4 IV ands celestone. ... 20:57 pt given discharge instructions and discharged to home." Review of MR14 revealed "Discharge Summary" nursing documentation dated December 18, 2011, revealed, "... Teaching/Instructions/Referrals ... Comments Follow up with regular provider in Lewistown tomorrow. ... ."
2) The review of the medical records with EMP3 on June 21, 2012, revealed that MR1, MR3, MR5, MR7, MR10, and MR14 failed to contain documentation that an OB patient received a medical screening examination either on the obstetrical unit or in the emergency department that addressed their presenting complaints. It was also noted that all medical records contained the OB triage form, which EMP3 stated indicated that the patient was unscheduled. EMP3 confirmed the findings.

3) An interview was conducted with OTH1 on June 22, 2012, at 11:00 AM regarding the patient related to MR1. OTH1 stated, " ... We put [patient] on the monitor, [patient] was not in labor. ... We probably should have sent [patient] to the ED to be evaluated."

Based on review of facility documents and closed obstetrical medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to execute an appropriate transfer for two of 15 patients who had presented to the Obstetrics (OB) Department for treatment (MR1 and MR7).

Findings Include:

Review of the policy entitled "Transfers," dated July 2011, revealed, "... I. Scope: Applies to all patients ... Attending physician responsible for: 1. Contacts a Physician at the receiving institution for acceptance of the patient for admissions. 2. Notifies nursing supervisor and/or nursing staff of patient transfer and by what means patient is to be transferred. 3. Writes the transfer order on the patient chart with the name of the receiving facility and/or physician and date and time of transfer ... ."

Review of the policy entitled "Transfers from the Emergency Department (Auto, ambulance, or helicopter), dated September 2011 revealed, "Purpose: To evaluate and stabilize the patient for transfer. Policy: The decision to transfer a patient from the J.C. Blair Emergency Department to a specialist or specialty service of another medical institution shall be based primarily on the Emergency Physician's judgement that the patient's condition requires care of a nature which cannot be provided at J.C. Blair. However, we recognize other considerations exist regarding transfers, i.e.,, patient/family request (for any reason). The decision to transfer in these instances will be based upon the patient's condition, not financial concerns. The patient or legal guardian will be asked to initial and sign the Transfer Authorization Form, indicating their request for a transfer, refusal of a transfer, or consent to a recommended transfer. All transfers will be proceeded by direct person-to-person telephone contact between the J.C. Blair Emergency Physician and the receiving specialist or representative of the specialty service ... Once the decision to transfer has been made: A. Physician Responsibility. 1. Stabilize patient. No patient will be transferred to another facility until all efforts to stabilize the patient's condition have been made to the satisfaction of the receiving facility. 2. Decide to whom the patient should be transferred. 3. Confer with the receiving specialist or representative of receiving speciality service. 4. Institute any reasonable therapeutic suggestions that the specialist might recommend prior to transfer. 5. Determine appropriate means of transportation (ie. family transport, ambulance etc). If an RN is required for transport, he/she will be provided with written orders. 6. Fills in and signs the Transfer authorization form, indicating the name of the receiving facility and/or physician, date and time that consent is signed and that the risks and benefits were explained to the patient ... 7. Writes transfer note (E.D. chart) to include "reason for transfer" .. 11. Before the ambulance or helicopter departs the J.C.B. Emergency Department, notify the emergency department of the receiving institution of the transfer and of the previously made arrangements with the receiving specialist. Give the estimated time of arrival, patient's diagnosis and condition, so that the emergency department will not be caught unaware if the patient's condition should deteriorate during transport and require stopping there prior to direct admission. B. Emergency Department RN or Nursing Supervisor: 1. Contact nursing supervisor to assist with transfer as needed and provide the following information: ... 2. Copy patient chart to include: E.R. chart, nursing assessment form, x-rays, lab reports, EKG's, EEG's and CT scans. 3. Call report to receiving nursing unit. Note: If the patient is being admitted to a bed other than the ER, the Nursing Supervisor will confirm bed availability ... 5. Arrange for ambulance when indicated or helicopter at physician's request. 6. Arrange for necessary personnel to accompany patient when ambulance is indicated ... ."

A review of the policy entitled "Scope of Emergency Services" dated September 2011, revealed, "Policy: To describe the scope of Emergency Services insuring proper patient care. Procedure: J. C. Blair Memorial Hospital's Emergency Department is a Level II department. The Emergency Department meets the emergent medical needs of the community by providing adequate assessment and initial treatment to any ill or injured person presenting to the ED. All patients have the right to medical and nursing services without discrimination based upon race, color, religion, sex, sexual preference, national origin, or source of payment. The Emergency Physician will evaluate, treat, refer, transfer, or release the patient as he deems medically advisable. The Emergency Physician may elect to contact either a surgeon, an internist, a psychiatrist, or a gynecologist who is on call to participate in the evaluation and treatment of a patient. Transfer arrangements are made by the Attending Physician. However, all emergency and life-saving measures are carried out first. A transferred patient may be attended by a private duty nurse or paramedic, procured with the cooperation of the Nursing office and in accordance with EMTALA regulations. ... ."
1) A review of the patient's medical records from J.C. Blair (MR1) and Lewistown Hospital (MR31) was completed.
A review of MR1, revealed "Outpatient Record Maternity ... June 6, 2012, Arrived 0513 Discharged 0640...Orders/Time Outpt or Observation, Non-Stress Test, Clear Liquids, UA, Have patient go to Lewistown Hospital ... Final Diagnosis: IUP, 40 3/7 weeks gestation. Indication: fever x 5 days; spotting. ... ." Continued review of MR1 revealed " Obstetric Evaluation " dated June 5, 2012, revealed, "... Regardless of score on any box the Nurse Evaluator may require physician exam for Patient Safety ... Total Box A ... Findings 0 ... Criteria 2 or more = physician exam ... Score 0 ... If Patient has established objective labor pattern ... Total Box A [sic] ... Findings 0 ... Criteria 3 or more =physician exam ... Score 0 ... If patient has objective labor pattern Total Box C ... 1st Exam Score ... Total Box C 1 ... Criteria > 7=md/nmw Exam. Document was unsigned by the Nurse Evaluator. Continued review of MR1 revealed "NST Record" dated June 5, 2012, revealed, "...Temperature: 99.1 ... Reason for NST: fever; spotting ... ." Review of MR1 also revealed "LD-Flowsheet" dated June 6, 2012, which stated, "... Annotation Comments ... 05:15 urine sample obtained for UA patient states she has had a fever since Friday, up to 102.6 ... Was seen at family doctor yesterday and had bloodwork drawn and is waiting for results. Denies nausea/vomiting, tolerating sips of clear liquids and toast. ... 06:20 OTH1 called and informed about patient and baby's status. OTH1 said to have patient go to Lewistown. ... 06:33 patient discharged with instructions to go to Lewistown. ... ."
There was no documented evidence in the medical record that the patient received a medical screening examination form physician. EMP3 confirmed the above finding.
A review of MR31 dated June 5, 2012, revealed, "... pt to L & D room 4 via wc ... Pt states she presented to ER at JC Blair Hospital, was told [patient] was not pt of [OTH1] ... at JC Blair. pt [sic] was evaluated by 2 nurses but nurses were told by [OTH1] that pt should go to Lewistown Hospital for evaluation ... Pt states [patient] has been seeing [patient] PCP for c/o febrile illness for several days and has had several rounds of bloodwork done. Pt states [patient] has been taking tylenol [sic] with little relief, fever 102.2 this AM. ... Pt states [patient] has been having fever and chills since Friday [sic] afternoon 6/1/12. ... ."
An interview was conducted with OTH1 on June 22, 2012, at 11:00 AM related to the patient associated to MR1. OTH1 stated, " ... I think I told [patient] to go to the ED at Lewistown to be evaluated. ... ."
2) A review of MR7 revealed "Outpatient Record Maternity ... March 30, 2012, Arrived 1915 Discharged 2100 ... Orders/Time Outpt or Observation, Non-Stress Test [circled], Clear Liquids ... 2030 OTH2 made aware of pt status, Orders received from OTH2 to have pt be admitted or pt may leave after signing "AMA" paper to go to family OBGYN at Mt Nittany. 2100 Pt signed "AMA" paper after deciding to leave for Mt Nittany Medical Center ... Discharge Instructions: ... Go to Mount Nittany Hospital ... Final Diagnosis: IUP, 36 3/7 weeks gestation. Indication: Groin Pain ..." Continued review of MR7 revealed "Obstetric Evaluation" dated March 30, 2012, which stated, "... Regardless of score on any box the Nurse Evaluator may require physician exam for Patient Safety ... Total Box A ... Findings [blank] ... Criteria 2 or more = physician exam ... Score [blank] ... If Patient has established objective labor pattern ... Total Box A [sic] ... Findings [blank] ... Criteria 3 or more = physician exam ... Score 0 ... If patient has objective labor pattern Total Box C ... 1st Exam Score ... Total Box C [blank] ... Criteria > 7=md/nmw Exam. Notation added to document that stated: "Pt left "AMA" to Mt Nittany." Continued review of MR7 revealed "NST Record" dated March 30, 2012, which stated, " ... Reason for NST: Groin pain/discomfort starting in am ... ." MR7 also revealed "LD-Flowsheet" dated March 30, 2012, which stated, "... Annotation Comments ... 20:24 OTH2 made aware of pts status. Orders received to admit [sic] pt for labor or have pt sign "AMA" paper to leave to go to Mt Nittany for evaluation. Pt signed "AMA" leaving to go to Mt Nittany ... ."
There was no documented evidence in the medical record that the patient received a medical screening examination from physician. EMP3 confirmed the above finding.