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Based on review of hospital documents, review of clinical records and interviews with hospital staff, it was determined the hospital failed to follow it's policies and procedures to ensure compliance with the requirements of 42 CFR 489.24. The hospital failed to follow it's policies on medical screening examination and transfers.

Findings:

1. A hospital document, titled, Screening/Stabilizing/Transfer Policy, documented, "... Medical Screening Examination (MSE): An examination which is sufficiently detailed to determine within reasonable clinical confidence, whether the patient suffers from an emergency medical condition which includes a pregnant woman having contractions... The examination must include medically indicated screens, tests... and history and physical examination as indicated by the presenting signs and symptoms. Ancillary services available to other patients in the hospital must be utilized, as necessary..."

The emergency room record for patient #1 was reviewed for evidence of a medical screening exam. The history and physical examination completed by the physician documented, "... Chief Complaint: 'I think I'm having a miscarriage.'... Medical Decision-Making: The patient was evaluated in triage. A medical screening examination was performed. In light of no obstetric coverage, I will have the patient go to the [hospital name deleted] emergency department where they do have obstetric coverage... vital signs stable and she is to proceed there directly. She states understanding of this... Assessment:... Vaginal bleeding by history..."

The physical examination did not include documentation of a gynecological exam.

On 07/02/12 at 2:45 p.m., Staff F stated she assisted in the care of Patient #1 in the emergency department. She stated she did not see the physician perform a physical examination on the patient. She stated the patient did not receive a gynecological exam.

On 07/03/12 at 9:15 a.m., patient #1 was asked if she had received a physical examination by the physician. She stated the physician asked her questions about her symptoms and her medical history but did not perform an exam.

2. The Screening/Stabilizing/Transfer policy also documented, "... If, following the MSE, the patient is determined to have an EMC [emergency medical condition], the treating physician must determine if the patient is stable... A stable patient may be transferred, at the patient's request,... At a minimum, transfer of the stable patient must include the following elements:

1. Permission of the patient...
2. The receiving facility accepts the patient and has both the capability and the capacity to treat the condition; and
3. Adequate records reflecting the evaluation and treatment of the patient are sent to the receiving facility with the patient...

Hospital Personnel Duties:... 1. If a patient is transferring to another facility, the following forms will be completed as documentation of services rendered: Transfer Consent, Physician Certification and Transfer Information form... 2. Refusals for Examination/Treatment/Transfer: when a patient refuses examination, treatment, or transfer as suggested by the Physician, the staff will assist the patient and physician in the completion of either the Refusal of Transfer to Another Medical Facility form or AMA Against Medical Advice form. Staff will document in the electronic medical record all interventions and/or efforts to provide services to the patient..."

There was no documentation the patient refused examination and treatment at the Oklahoma Heart Hospital or that the patient left against medical advice.

There was no documentation of the patient's request and consent for a transfer to another hospital emergency room.

There was no documentation the emergency department personnel followed the hospital policies and procedures regarding transfers.

Based on clinical record review, policy and procedure review and staff/patient interviews, it was determined the hospital failed to provide an appropriate medical screening examination for one (#1) of twenty records reviewed for evidence of medical screening exams.

Findings:

1. A hospital document, titled, Screening/Stabilizing/Transfer Policy, documented, "... Medical Screening Examination (MSE): An examination which is sufficiently detailed to determine within reasonable clinical confidence, whether the patient suffers from an emergency medical condition which includes a pregnant woman having contractions... The examination must include medically indicated screens, tests... and history and physical examination as indicated by the presenting signs and symptoms. Ancillary services available to other patients in the hospital must be utilized, as necessary..."

2. The emergency room (ER) record for patient #1 was reviewed for evidence of a medical screening exam. The record documented the patient presented on 01/06/2012 at 1639 with complaints of vaginal bleeding. The nurse and physician documented the physician went to the triage area to see the patient. (This is not in the examination rooms portion of the ER.) The nurse recorded the patient's vital signs as: pulse - 88 beats per minute; blood pressure - 108/99; respirations - 14 per minute; and oxygen saturation as 99%. She also documented, "To triage for complaints of a possible miscarriage, reports she was 3-4 months since last menstrual cycle and was told by her physician she was pregnant...complains today at work she has been having abd (abdominal) cramping similar to menstrual cramping. Complains of heavy bleeding."

The history and physical examination completed by the physician documented, "... Chief Complaint: 'I think I'm having a miscarriage.'... Medical Decision-Making: The patient was evaluated in triage. A medical screening examination was performed. In light of no obstetric coverage, I will have the patient go to the [hospital name deleted] emergency department where they do have obstetric coverage... vital signs stable and she is to proceed there directly. She states understanding of this... Assessment:... Vaginal bleeding by history..."

The physical examination was not complete. It did not include documentation of a gynecological exam.

3. On 07/02/2012, the Staff G confirmed he did not perform a vaginal examination on the patient, but stated he did use a stethoscope to examine the patient (See Finding #5 for refute.)

4. On 07/02/12 at 2:45 p.m., Staff F stated she assisted in the care of Patient #1 in the emergency department. She stated the physician accompanied her to the triage room. When asked, she told the surveyors that this was not a usual practice. She stated she did not see the physician perform a physical examination on the patient. She stated the patient did not receive a gynecological exam.

5. On 07/03/12 at 9:15 a.m., patient #1 was asked if she had received a physical examination by the physician. She stated the physician asked her questions about her symptoms and her medical history but did not perform an exam. She stated he did not touch her - did not even use a stethoscope.

6. Information from the other hospital documented, the patient arrived at 1705 and was triaged at 1734 with complaining of abdominal pain and vaginal bleeding; being 12 to 18 weeks pregnant with a possible miscarriage. Laboratory documentation in the chart reflects lab was ordered and drawn per the emergency room physician protocol for vaginal bleeding. Documentation stipulates the patient was taken to a room and assessed by the emergency room nurse at 2000. Nursing documentation also stipulates the patient was seen by the emergency room provider at 2118.