HospitalInspections.org

2406
Based on medical record review, review of facility Medical Screening Examination (MSE) policy and provider interviews the facility failed to ensure 1 of 20 sampled patients (Patient 7) received an adequate MSE to determine if the patient had an Emergency Medical Condition (EMC). This failure placed the patient at risk of harm. The patient was discharged with a potential EMC.

Findings are:

A. Review of a closed medical record showed Patient 7 presented to the ED on 2/10/17 at 3:25 a.m. complaining of spotting in the third trimester (31 weeks) of pregnancy along with burning when urinating and soreness in her lower back. At 3:25 a.m. ED staff documented Patient 7's blood pressure was elevated at 149/98 (normal blood pressure range is between 120 - 139 / between 80-89. At 3:40 a.m. ED staff checked the fetus' heart rate which was between 130 - 150 beats per minute (normal is 120 - 160 beats per minute). At time unknown, the advanced practice registered nurse (APRN) A examined Patient 7 and documented she had a history of pre-eclampsia (a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and/or kidneys) and was being treated with Procardia (medication for treatment of high blood pressure). Further documentation showed "It does appear that patient is having some contractions which also might be associated with her urinary symptoms." Blood and urine specimens were obtained for testing at 3:53 a.m. which showed the presence of a urinary tract infection. The mid-level practitioner's final assessment "Urinary tract infection, possible pre-term contractions, spotting at 31 weeks gestation." Further documentation showed contact with Patient 7's obstetrician along with a plan to "send patient by private vehicle to Hospital B (located 3 hours away)." "Patient will be discharged from our ED and is to go to Hospital B per private vehicle as soon as possible."

At 5:15 a.m. the ED discharged Patient 7 from the ED. The medical record did not contain evidence that the APRN A performed an examination sufficient to determine whether an emergency medical condition existed, did not certify in the medical record whether Patient 7 was in false labor, or whether there was adequate time for the patient to arrive at Hospital B safely prior to delivery.

Review of APRN A's privileging list dated 5/1/16 indicated she was qualified to perform pelvic exams women.

The following lab was ordered-urinalyis showed a urinary tract infection; complete metabolic profile showed slight abnormalities, no critical levels; complete blood count showed a slightly elevated white blood.

During an interview on 8/10/17 at 12:32 p.m., APRN A stated that she faxed copies of the fetal heart monitoring strips and copies of the patient's lab results to Dr. F who was located three hours away at Hospital B. APRN A confirmed that she did not perform a pelvic exam (to determine any cervical changes associated with pre-term labor, to find out how far the baby had moved down the birth canal, or to check for leakage of amniotic fluid or bleeding from the vagina). APRN A stated that it was safe for Patient 7 to travel three hours by private vehicle to Hospital B for a pelvic exam by Dr. F.

The APRN A stated that the patient was offered an ambulance and "adamantly refused", and that Dr F instructed the APRN A to not do a vaginal exam. Patient 7's medical record lacked documentation of being offered an ambulance and that the Obstetrician instructed the APRN A to not do a pelvic examination to determine if the patient was in labor.

B. Review of the undated facility policy titled "Transfers and Emergency Examination" identified that "Medical Screening Examination. For any individual who comes to the Emergency Department, and on whose behalf a request for examination or treatment for a medical condition is made, an appropriate medical screening examination shall be provided within the capabilities of the Emergency Department (and ancillary services routinely available to the Emergency Department) to determine whether or not an emergency medical condition exists." The policy identifies "A physician or a physician assistant or advanced registered nurse practitioner under the supervision of a physician shall be called to perform the medical screening examination in the event that any of the following systems or conditions is identified." The policy identified "Obstetrical Patients. A pregnant woman having contractions shall be provided a medical screening examination to determine whether she is in an emergency medical condition (inadequate time to effect a safe transfer prior to delivery or transfer may pose a threat to the health or safety to the woman or the unborn child). If after a reasonable time of observation (Which may be by Hospital nursing staff), it is determined that no emergency medical condition exists, the woman may be treated, transferred or discharged, as appropriate. The physician shall document in writing the findings and his certification that the woman in false labor if her signs and symptoms support that conclusion. If an emergency condition exists, it cannot be "stabilized" as defined by EMTALA. Accordingly, no transfer may be made of a pregnant woman in such an emergency medical condition, except by the request of the woman (or a person acting on her behalf) or pursuant to a physician's certification that the benefits of transfer outweigh the risks."

The policy and the hospital Medical Staff Rules and Regulations last approved 12/20/16 identify that "Emergency Room. All patients presenting to the Hospital requesting emergency care shall be treated in accordance with Hospital policies and procedures governing emergency medical screeening in compliance with the Emergency Medical Treatment and Active Labor Act ("EMTALA").