HospitalInspections.org

1. Based on medical record review, policy and procedure review, policy and procedures, Obstetrical(OB) on-call Physician schedules, facility OB Algorithm and facility staff interviews it was determined the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department,(ED) including ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition exists for 1 (Patient #1) of 22 sampled patients who arrived to the ED complaining of abdominal pain and 28 weeks pregnant.

Refer to findings in Tag A-2406.


.

Based on medical records review, policy and procedure review, . Obstetrical(OB) on-call Physician schedules, facility OB Algorithm and facility staff interviews it was determined the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department,(ED) including ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition exists for 1 (Patient #1) of 22 sampled patients who arrived to the ED complaining of abdominal pain and 28 weeks pregnant.

The findings included:

A review of the "Respecting EMTALA (COBRA) Compliance" policy, Policy # AD-03-039, effective date 12/90, last revised date 1/17 revealed in part, " Emergency Medical Conditions means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the patient or, with respect to a pregnant patient, the health of her unborn child in serious jeopardy, or serious impairment of bodily functions, or serious dysfunction of any bodily organ or part ... Floyd Medical Center will provide for an appropriate medical screening examination of the individual within its capability (including all ancillary services routinely available to Floyd Medical Center (FMC) to determine if an emergency medical condition exits."

A review of the "Triage for the Perinatal Patient" policy, Policy # WC-OB-CAR-019, effective date 1/22, last revised date 6/22 revealed 1. when a patient arrives to the ECC (Emergency Care Center), the emergency personnel will identify patients who are currently pregnant or have delivered in the previous 6 weeks. 2. if a patient is pregnant or within 6 weeks postpartum, the emergency personnel will obtain the patient's name, OB provider's name, chief complaint, and EGA (Estimated Gestational Age) (how many weeks pregnant). If the patient's chief complaint and/or EGA are appropriate for L&D (labor and delivery) Triage (See OB Triage Algorithm), the ECC nurse will notify the L&D unit of patient's information and an L&D staff member will come pick up the patient. If the patient's chief complaint and/or EGA are not appropriate for L&D Triage, the patient will be seen in the ECC and the L&D charge nurse will be notified if there is an order for evaluation by a Labor and Delivery Nurse.


A review of the "Standards of Care, ECC" policy, Policy # 02-018, effective date 11/12, last revised date 7/21 revealed 1. Assessment. B. Subjective/Objective Assessment. Obtains pertinent subjective and objective data while providing physical, emotional, and psychosocial support to the health care consumer, family and others as appropriate. 1. Primary: involves a brief, rapid assessment to identify actual or potential life-threatening illness or injury. 2. Secondary: complete vital signs are taken for all patients with the following additions: include fetal heart tones (FHTs- monitoring measures the heart rhythm of the fetus) for pregnant patients (greater than 12 weeks gestation). Past medical and surgical history, any significant medical or surgical history should be documented in the chart.

The facility's OB Triage Algorithm, Page WC-OB-CAR-019 was reviewed. The section titled "Pregnancy related Chief Complaint, revealed in part, "Vaginal bleeding >14 weeks gestational age -Leakage of fluid consistent with ruptured membranes, regardless of gestational -Abdominal or back pain > 16 weeks gestational age. Plan of Action: Plan: Patient goes directly to L&D (Labor and Delivery)-ECC (Emergency Care Center) staff will notify L&D of patient's arrival, OB physician, EGA (Estimated Gestational Age) and c/o (Complaint). - Patients with c/o vaginal bleeding or ruptured membranes will be transported to L&D by ECC staff. If delivery is in progress, notify L&D charge nurse for assistance-L&D will notify OB Physician on Call."

The facility's Obstetrical On-Call list for July 2022 was reviewed. The Obstetrical On-Call list validated that an Obstetrical Physician (Ancillary Service/Capability) was on call on July 25, 2022 when patient #1 presented to the hospital.

A review of the medical record revealed that Patient (P) #1 was a 22-year-old female who arrived at the facility's Emergency Department (ED) by private vehicle on 7/25/22 at 3:18 p.m. due to abdominal pain, diarrhea, and cough. P#1 is 28 weeks pregnant (having a child developing in the uterus). On 7/25/22 at 3:18 p.m. RN DD documented P#1's triage and assessment notes revealed her chief complaint was right lower abdominal pain and diarrhea. Patient is 28 weeks OB. Denies vaginal bleeding. Further review revealed Vital Signs Assessed: Yes; Pain Symptoms: Yes; ED Condensed Treatment & Assessment: Yes; Presents with Neurological Symptoms: No. Continued review of triage notes revealed Diagnoses: Abdominal Pain - Pregnancy; Rapid Pain Assessment. Primary Pain Location: Abdomen. Vitals: Temperature: 99 Degrees Fahrenheit; Blood Pressure: 125/85; Peripheral Pulse Rate: 98 bpm (beats per minute); SpO2 (oxygen): 95%; Respiratory Rate: 18br/min; O2 Therapy: room air. Tracking Acuity: ESI (Emergency severity Level-an ED tool that identifies patient should not wait to be seen, and sorting of patients in the ED according to urgency of their need for care) 3-Urgent. There was no documentation in the medical record to indicate that Fetal Heart Tones were initiated during triage.

Further review of Emergency Documentation revealed on 7/25/22 at 8:45 p.m. Medical Doctor (MD) II documented P#1's history of present illness, 22-year-old female G (Gravida-number to indicate the number of pregnancies a woman has had) 1, P (Para -number of completed pregnancies beyond 20 weeks) 0 at estimated 28 weeks presents with lower abdominal pain for couple days. Is a sore crampy pain without any vaginal bleeding? She has decreased oral intake and some mild diarrhea. Urinary urgency infection 0 and frequency. She feels dehydrated. No other associated symptoms. No history of similar in the past .MD II documented the patient's Active Problem was: Pregnancy. She follows with (name if clinic) women's clinic. Continued review revealed MD II reviewed P#1's symptoms that included abdominal pain, nausea, vomiting, diarrhea. MD II documented medical decision-making rationale revealed this patient presents with lower abdominal pain of unclear etiology (cause or origin of disease). On exam, patient with tenderness in suprapubic (occurring above the pubis) abdomen (the belly). No peritoneal (relating to or enclosed by the peritoneum, the membrane lining the abdominal cavity) signs including rebound or involuntary guarding. No evidence of acute abdomen at this time. The laboratory test ordered for the patient was a CBC (Complete blood Count a test that measures many features of your blood to include infection) 15.8 (hospital's normal reference range was 5.1-10.0) was abnormal. The Urinalysis lab test ordered on 7/25/2002 revealed UA (urinalysis- White blood Count was greater than 50, Red Blood Cells-3.5 and Bacteria-3+). Continued review MD II documented plan revealed blood and urine ordered at triage. Results indicate urinary tract (kidneys, ureters, bladder, and urethra) infection (bacteria grow in the urinary tract). There is no vaginal bleeding necessitating pelvic ultrasound (an imaging exam that creates pictures of your pelvic organs) at this time. No tenderness in the right lower quadrant (right side below your belly button) concerning for appendicitis. Patient is able to tolerate p.o. (medication by mouth) but has had some nausea. She is comfortable with the plan of oral antibiotics (drug used to treat infections caused by bacteria) and antiemetics (a drug that prevents or reduces nausea and vomiting) and discharged home to follow up with her OB/GYN (Obstetrician/Gynecologist) in the outpatient setting. On 7/25/22 at 11:02 p.m. P#1's Discharge Vital Signs and Pain Report revealed that Pain present at discharge: No; High Peripheral Pulse Rate of 110 reported to MD II wanting to proceed with discharge. The facility failed to ensure that an appropriate medical screening examination was performed within the capability of the hospital's emergency department for Patient #1 who was 28 weeks pregnant with a pregnancy complaint of abdominal pain. The patient was not assesses by a Qualified Medical Personnel for 5 hours and 29 minutes after arrival no fetal heart tones were performed. The facility failed to ensure that fetal heart tones (FHT) were performed as stated in the facility's policy and procedure. The facility also failed to utilize the OB physician on-call on 7/25/2022 to provide further evaluation and treatment to determine whether or not an emergency medical condition existed. Additionally, the facility failed to follow their OB algorithm, as Patient#1's pregnancy related complaint was "abdominal pain", as there was no documentation in the medical record that the Emergency Care Center staff had notified L&D of the patient's arrival, OB Physician and Estimated Gestational Age. As these multiple failures placed the Pregnant patient (Patient #1) health and the health of her unborn child in serious jeopardy.

An interview was conducted with Emergency Department (ED) Clinical Director (CD) AA and ED Clinical Manager (CM) BB on 8/16/22 at 5:00 p.m. in the Administration conference room. CD AA stated if a patient who is pregnant (having a child developing in the uterus) arrives to the ED with symptoms not related to their pregnancy, the Triage Nurse will document the symptoms (a physical or mental feature which is regarded as indicating a condition of disease) as the "chief complaint" (symptoms that cause a patient to seek medical care) and then document the pregnancy and the Estimated Gestational (describes how far along the pregnancy is) Age (EGA) of the unborn baby. CD AA continue to say that it is the protocol of the ED is for the ED Registered Nurses (RNs) to check the fetal heart tones (the number of heart beats per minute) of the unborn baby of greater than or equal to 15 weeks gestational age with a doppler ultrasound (sounds having an ultrasonic frequency) no matter the reason for the visit. CM BB explained that for patients with greater than 12 weeks gestation the physician will complete a quick exam to include an ultrasound, to see if the baby is moving and to hear the heartbeat. Fetal heart tones are documented in the medical record. If the heart tones are abnormal (undesirable) then the patient will move up in acuity and be considered an urgent patient needing to be seen. CD continued to say that he conducts monthly ED staff meetings and during these meetings EMTALA (anyone coming to an emergency department must be stabilized and treated, regardless of their ability to pay) policies and protocols are discussed. He continued to explain that EMTALA is a part of the staff's annual competencies as well.