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Based on a review of twenty-two emergency department records, patient #1's 9/29/12 inpatient obstetrical record, a review of the hospital's bylaws, and a review of the policies and procedures for patients who present to the emergency department, it was determined that in one (patient #1) of twenty-two patients who presented to the hospital requesting emergency services, the hospital failed to ensure compliance with 489.24. Patient #1 was thirteen weeks pregnant and presented to the hospital with abdominal pain and heavy vaginal bleeding on 9/28/12. There was not an exam room available, so she was told that she had to wait to be seen. Patient #1 did not receive any pain medication for one hour and forty minutes after her arrival at the ED, and a pelvic exam and subsequent treatment was not provided to patient #1 for two and one half hours after her arrival at the ED.

Based on documentation and interviews, the hospital failed to ensure that each patient who presented to the emergency department received an appropriate medical screening examination without delay, in one of twenty-two patients reviewed (patient #1). Patient #1's medical screening examination, which included a pelvic exam and corresponding treatment related to her pregnancy, was not provided to patient #1 for two and one half hours after her arrival at the ED. Findings include:

Patient #1's emergency department (ED) record was reviewed and revealed that patient #1, who was thirteen weeks pregnant with her first child, presented to the ED's triage area on 9/28/12 at 11:28 p.m. with complaints of bilateral, cramping, abdominal pain that radiated to her lower back. Patient #1 reported that she had been having ongoing vaginal spotting for the duration of the pregnancy and that the bleeding increased yesterday. The patient told triage nurse (E) that the vaginal bleeding was bright red today, and the amount of bleeding increased at 10:00 p.m. this evening while she was at home. The patient described her pain level at 5/10 with the pain increasing to 10 plus at intervals.

The ED record revealed that following her arrival at the ED, patient #1 was told to wait in the waiting room until further treatment could be provided. Patient #1 waited for forty minutes in the waiting room. Within the next one hour and thirty minutes, patient #1 was moved to two different exam rooms, and she continued to wait to be seen by the provider, nurse practitioner (G). Patient #1 did not receive any pain medication for one hour and forty minutes after her arrival at the ED. A pelvic exam and further treatment was not provided to patient #1 for two and one half hours after her arrival at the ED. Following the pelvic exam patient #1 was taken to the Operating Room at approximately 4:00 a.m. on 9/29/12, and physician (F) performed a D & C on patient #1.

Patient #1 was interviewed by phone on 10/25/12, and she stated she arrived at the ED at approximately 11:00 p.m. on 9/28/12. She was thirteen weeks pregnant with her first child and her water broke at 9:00 p.m. that evening. She was having severe abdominal pain (she stated the contractions were every ten minutes) and bleeding when she arrived at the ED. She stated she was crying when she was explaining her symptoms to triage nurse (E). Nurse (E) told patient #1 that he had checked with another staff person and was told that there was not an exam room available for patient #1. Nurse (E) told patient #1 to wait in the waiting room. Patient #1 stated it was extremely difficult to sit in the chair in the waiting room because she was having contractions and was shaking and felt like she was going to faint. She went to the bathroom a couple of times while she was in the waiting room and noted that the bleeding continued to be very heavy. She stated she waited for approximately one hour in the waiting room and was moved to a small exam room where she waited for another hour and then was moved to a large exam room. She stated she was screaming while she was in the large exam room. Nurse practitioner (G) entered the room following an additional fifteen minute wait, and patient #1 received two doses of pain medication via an IV. Patient #1 stated nurse practitioner (G) performed a pelvic exam on her about two and one half hours after patient #1 arrived at the ED, and nurse practitioner (G) removed blood clots and the fetus during the exam. Patient #1 stated there was a delay in providing treatment to her when she arrived at the ED. She stated having a miscarriage was a very traumatic experience, and the delay in treating her "made it even more awful." She stated she wondered why she even bothered to go to the ED.

Nurse (E) was interviewed by phone on 11/1/12, and he stated he was working as the triage nurse on the evening of 9/28/12. The ED was very busy that evening. Patient #1 was bleeding and in a lot of pain when she arrived at the ED that evening. Due to patient #1's symptoms, patient #1 should have been promptly seen following her arrival at the ED, but patient #1 had to wait because there was not an available exam room. Nurse (E) stated patients in the ED that evening probably could have been transferred to other areas/rooms in order to free up an exam room for patient #1 following her arrival at the ED.

Nurse (C) was interviewed in person on 10/30/12 and by phone on 11/1/12. He stated he reviewed the incident, and he determined that considering patient #1's condition on 9/28/12 and 9/29/12, her wait time in the ED was too long, and she should have received care more promptly. He stated he plans to provide education to staff related to the incident and the specific needs of the obstetrical patient in the ED.

Nurse Practitioner (G) was unavailable for an interview during the investigation.