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Based on review of facility documents and staff interviews (EMP), it was determined the facility failed to adopt policies which may affect quality of care, by not ensuring that obstetrical patients receive additional medical screening examinations when presenting symptoms may not be labor related.

Findings:

Review of UPMC Bedford Memorial Bylaws, dated April 25, 2011, revealed "...XI ... Section 6 - Quality Patient Care Committee ... The purposes of the Committee are: ... (e) to review clinical and professional Staff policies ... XII. Medical Staff ... Each patient's general medical condition shall be the responsibility of a qualified physician appointee of the medical staff. The Medical Staff shall operate as an integral part of the hospital and, through it's department chiefs, officers, and committees, shall be responsible and accountable to the Board for the discharge of those duties and responsibilities delegated by the Board from time to time, and specifically for the following purpose: (a) To monitor the quality of medical care in Hospitals and to report and make recommendations thereon to the Board and Member so that all patients admitted to or treated at any of the facilities, departments, or services of the Hospitals shall receive quality care and that one level of care shall be provided throughout the Hospitals ... ."

Review of UPMC Bedford Memorial Medical Staff Bylaws and Rules and Regulations, dated December 16, 2010, revealed "... Article II ... The medical staff has responsibility for the quality of medical care delivered to patients ... ."

Review of UPMC Bedford Memorial policy entitled "Obstetrical Medical Screening", dated July 19, 2011, revealed "Purpose: To ensure that every patient that presents with a medical emergency receive a proper medical screening exam by a qualified provider/evaluator prior to leaving the hospital. Scope: Obstetric staff and Emergency Department staff. Policy: The pregnant patient will be screened to determine the appropriateness of services in either the Emergency Department or in Labor and Delivery. Definitions: A. Dedicated Emergency Department is any department or facility of the hospital, whether on or off campus that: (a) is licensed by the State as an emergency department; or (b) is held out to the public as a place that provides care for emergency medical conditions without an appointment; or (c) based on a representative sample of patient visits during the previous calendar year, provides at least one-third (1/3) of all its outpatient visits for the treatment of emergency medical conditions without an appointment. B. Emergency Medical Condition is "a medical condition manifesting itself by acute symptoms of sufficient severity ... such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; or with respect to a pregnant woman who is having contractions that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or the unborn child ". C. Medical Screening Exam (MSE) is an appropriate exam within the capability of the hospital to determine whether an emergency medical condition exists ... E. Qualified Medical Provider/Evaluator (QMP) is: 1. A licensed Obstetrician or Emergency Physician with staff privileges at this hospital. 2. A licensed or Certified Nurse Midwife with midwifery privileges at this hospital. 3. A registered nurse who has completed the probationary period and initial competencies in the Obstetrical Department. Procedure: Medical Screening of the OB Patient A. A pregnant patient 16 weeks or greater presenting with possible labor or having abdominal or vaginal symptoms will be escorted to the Obstetrical Department after the maternity nurses have been notified and will be given appropriate treatment: 1. Patients reporting to the OB Department may be evaluated by a qualified evaluator using the standard OB Evaluation form. 2. The patient will be scored as indicated on the OB Evaluation form and the score documented. Use the last value obtained for an item for the purpose of scoring. 3. If a patient is expected to deliver immediately, the OB Evaluation form need not be completed. 4. If the results of any scoring indicate that a physician exam is required, a MSE needs to be completed by the Obstetrician or Midwife. 5. Regardless of the score on any box, the Nurse Evaluator may request a physician exam for the purpose of patient safety. 6. Patients not requiring a physician exam may be discharged upon phone orders from the Obstetrician or Midwife. The patient should be given appropriate discharge instructions prior to leaving. The patient will be provided with a copy of the instructions and a singed and dated copy of the instructions will be placed in the medical record. 7. All phone contacts with the physician will be appropriately documented in the medical record. 8. Patients after exam by a physician or 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 b. Discharge poses no risks to the mother or fetus 9. The patient should be given appropriate discharge instructions prior to leaving. The patient will be provided with a copy of the instructions and a signed and dated copy of the instructions will be placed in the medical record. 10. Nursing observation and nursing care will be documented in the medical record. Physician orders and exams will be documented in the medical record. B. A pregnant patient less than 16 weeks with abdominal or vaginal symptoms will be evaluated in the Emergency Department: 1. Fetal heart tones will be assessed with a Doppler stethoscope. 2. The ED physician shall complete the MSE and notify the Obstetrician as appropriate. C. A pregnant patient 16 weeks or greater presenting to the ED with medical problems or traumatic injuries not related to the pregnancy will be evaluated by the Emergency physician and given appropriate treatment: 1. The ED physician shall complete the MSE and notify the obstetrician as appropriate. 2. ED physician will treat medical condition and/or traumatic injuries. 3. ED nurses, OB nurses, and/or physician will assess fetal heart tones with a Doppler, as needed. D. A pregnant patient 16 weeks or greater presenting unscheduled directly to the OB department will be given the appropriate treatment: 1. The Qualified Nurse Evaluator will perform an initial assessment on the patient. 2. If it is determined that the patient is not experiencing a pregnancy related problem the patient may be safely escorted to the Emergency Department to receive a MSE by the ED physician as appropriate ... Documentation ...B. All medical screening exams must be documented."
Review of "Appendix 1 UPMC Bedford Memorial Instructions for Completing the Obstetric Medical screening Evaluation Form. 1. Fill out the form for unscheduled patients presenting to the floor. 2. Keep the form with the patient's chart. 3. Complete Box A. If scored 2 or more in Box A than an exam by a physician or midwife is required. 4. If patient is exhibiting signs of labor complete Box B. If score is 3 or greater in Box B than an exam by a physician or midwife is required. 5. Complete box C if patient has established an objective labor pattern. There is an area for up to 3 exams. Use the last exam total for the purpose of scoring. If the score for Box C is 7 or greater than a medical screening exam is required by a physician or CNM. 6. Use your nursing judgment/assessment if Box A, Box B, Box C, or all of the Boxes should be completed. 7. Do not total all the boxes together. The boxes are scored individually. 8. If at any time regardless of the score, the nurse may request an exam from a physician or CNM for the purpose of patient safety."
1) Review of MR1 and MR3 revealed both patients (PT1 and PT2) presented to the Obstetrics Department for a medical screening examination, to rule out labor. In addition, both patients also presented with other medical complaints. Once labor was ruled out, it was noted that neither patient received further medical examinations for the other medical complaints.
A review of the document entitled "Appendix F UPMC Bedford Obstetric /EMTALA Department Patient Log" was completed on August 9, 2011, The log revealed that PT1 presented to the Obstetrics Department on July 24, 2011 at 2010 via ambulance. The log indicated that PT1 was unscheduled, and had not been seen by a qualified medical personnel/evaluator. The log also indicated that PT1 was discharged to home.
A review of the patient's (PT1) "Obstetric Evaluation" contained within MR1 dated July 24, 2011, at 8:15 PM revealed, " ... OTH1, Patient: PT1, Regardless of score in any box, the nurse may request a physician exam for patient safety, Evaluator's Signature: [unmarked], Box A Checklist B/P 140/90 or > ... No, Headache ... No, Vomiting ... No, Visual Difficulties ... No, Epigastric Pain ... No, Total Box A ... 0. If patient has established objective labor pattern no contractions B/P stable low. ... Criteria Yes = 1. ... 2 or more = physician exam. ... Box B Checklist PARA ... 0, Duration LAST labor [unmarked], Prior C-Section ... No, Prenatal Care ... No, Prior Fetal Demise ... No, Multiple Gestation ... No, Cerclage or incompetent cervix ... No, Gestational Age 36 weeks, Total Box B, If patient has established objective labor pattern . ... Criteria ... 34-38 weeks = 2, Score 2 ... 3 or more = physician exam. ... Box C Checklist [unmarked]. ... "
Review of MR1 also revealed "LD-Flowsheet" nursing documentation dated July 24, 2011, at 8:11, which stated, "... Pt states (the patient's) had diarrhea x 2 days now. Last time today at 1700, denies eating spicy or greasy foods ... 20:38 Paged OTH1 who was on call and report given on findings with this pt. Orders received to do Q 15 min B/P/s x 2, if stable may go home and be seen by (the patient's) Dr. in Chambersburg this week. Orders for clean catch u/a to check for bacteria and ketones. Call back to OTH1 if u/a positive, otherwise if negative and b/p stable, pt. may go home. ... 7/24/11 Annotation Comment 21:53 report of u/a results called to OTH1, verbal orders to discharge pt to home...Told to go home, drink lots of fluids and follow up with (the patient's) Dr. in Chambersburg with next appointment on Aug 2, or before if necessary. ... ."
A review of the document entitled "Appendix F UPMC Bedford Obstetric /EMTALA Department Patient Log" was completed. The log revealed that PT2 presented to the Obstetrics Department on August 6, 2011, at 2139. The log indicated that PT2 was unscheduled, and had not been seen by a qualified medical personnel/evaluator. The log also indicated that PT2 was discharged to home.
A review of MR3 for PT2, dated August 6-7, 2011, revealed nursing documentation which stated, "OB Triage ... 8/6/11 ... 21:48 ... Arrival Information ... Hx of UTI in June and Tx with antibiotic, follow up specimen was clear. ... Subj. Assess (All Pts) ... Nausea/Vomiting ... vomited this am Subj. Assess. (PTL) Urinary Urgency and Frequency ... went 3 x since 2100 ... Provider Notification ... 22:11 ... answered the phone and orders obtained for VE [vaginal exam] and clean catch U/A [urinalysis] ... 22:50 Provider Information ... reported UA results to OTH5 via telephone ... Orders received ... Macrobid 100mg PO now and prescription will be called to pharmacy of choice in AM discharge to home."
An interview was conducted with EMP7 on August 7, 2011, at 1:20 PM. EMP7 stated "... I talked to OTH1 [regarding PT1] ... I told [OTH1] what [the patient] score was [obstetrical evaluation] and [OTH1] ordered a urinalysis. [OTH1] said that [the patient] didn't need to be seen because [they were] not in labor. We've always felt that the doctors should come in to see the patients ... When patient presents to the OB unit we usually put a gown on them, get a clean catch urine, ask the doctor for the order, monitor vital signs, ask questions, do a head to toe assessment, triage, NST [non stress test], HFO [hold for observation]. The questions are usually relating to bleeding, when they had sex last, burning, medications, last time they took meds, problems with pregnancy, allergies, and height and weight. If the patient still has complaints, then you call the doctor. We cannot diagnose a medical diagnosis. We're just doing the assessment. Assessing for labor and getting a history. The doctor may come in to see the patient or go back down to the ED."
2) An interview was conducted with EMP8 on August 9, 2011, at 1:50 PM. EMP8 stated, "... I didn't know how much we are like an ED. We monitor heart tones, vital signs, urinary symptoms, do the assessment, bowel sounds and vaginal exams if appropriate and then call the doctor. My personal preference is that everyone sees the doctor. When we call them then they need to come."
3) An interview with EMP1, on August 9, 2011, at 4:45 PM, regarding the Obstetric Evaluation Form and policy, revealed "We're going to change our process. Everyone is going to be seen by a physician. Everyone coming unscheduled will be seen by a physician."

Based on review of facility documents, and closed medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow adopted policies related to the delineation of responsibilities for patient care, by ensuring that patients not experiencing a pregnancy related problem, received further medical examination within the capability of the hospital for two of two patients (MR1, MR3), and failed to ensure that all adopted policies, require obstetrical patients to receive additional medical screening examinations when presenting symptoms may not be labor related.

Findings:

Review of "UPMC Policy and Procedure Policy: HS-LE000: Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011 I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals. 3. Medical Screening Exam (MSE) is an appropriate exam within the capacity of the hospital to determine whether an emergency medical condition exists. ... 5. Qualified Medical Person ("QMP") is defined as a licensed physician or other appropriately qualified individual as determined by each hospital in their respective by-laws or rules and regulations. V. Procedure 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a shall offer a Medical Screening Exam to such person. ... 3. If necessary, following the Medical Screening Exam, Qualified Medical Personnel shall offer further medical examination and such treatment as may be required to stabilize the medical condition within the hospital's resources ... ."
Review of UPMC Bedford Memorial policy entitled "Obstetrical Medical Screening", dated July 19, 2011, revealed "Purpose: To ensure that every patient that presents with a medical emergency receive a proper medical screening exam by a qualified provider/evaluator prior to leaving the hospital. Scope: Obstetric staff and Emergency Department staff. Policy: The pregnant patient will be screened to determine the appropriateness of services in either the Emergency Department or in Labor and Delivery. Definitions: A. Dedicated Emergency Department is any department or facility of the hospital, whether on or off campus that: (a) is licensed by the State as an emergency department; or (b) is held out to the public as a place that provides care for emergency medical conditions without an appointment; or (c) based on a representative sample of patient visits during the previous calendar year, provides at least one-third (1/3) of all its outpatient visits for the treatment of emergency medical conditions without an appointment. B. Emergency Medical Condition is "a medical condition manifesting itself by acute symptoms of sufficient severity ... such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; or with respect to a pregnant woman who is having contractions that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or the unborn child ". C. Medical Screening Exam (MSE) is an appropriate exam within the capability of the hospital to determine whether an emergency medical condition exists ... E. Qualified Medical Provider/Evaluator (QMP) is: 1. A licensed Obstetrician or Emergency Physician with staff privileges at this hospital. 2. A licensed or Certified Nurse Midwife with midwifery privileges at this hospital. 3. A registered nurse who has completed the probationary period and initial competencies in the Obstetrical Department. Procedure: Medical Screening of the OB Patient A. A pregnant patient 16 weeks or greater presenting with possible labor or having abdominal or vaginal symptoms will be escorted to the Obstetrical Department after the maternity nurses have been notified and will be given appropriate treatment: 1. Patients reporting to the OB Department may be evaluated by a qualified evaluator using the standard OB Evaluation form. 2. The patient will be scored as indicated on the OB Evaluation form and the score documented. Use the last value obtained for an item for the purpose of scoring. 3. If a patient is expected to deliver immediately, the OB Evaluation form need not be completed. 4. If the results of any scoring indicate that a physician exam is required, a MSE needs to be completed by the Obstetrician or Midwife. 5. Regardless of the score on any box, the Nurse Evaluator may request a physician exam for the purpose of patient safety. 6. Patients not requiring a physician exam may be discharged upon phone orders from the Obstetrician or Midwife. The patient should be given appropriate discharge instructions prior to leaving. The patient will be provided with a copy of the instructions and a singed and dated copy of the instructions will be placed in the medical record. 7. All phone contacts with the physician will be appropriately documented in the medical record. 8. Patients after exam by a physician or 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 b. Discharge poses no risks to the mother or fetus 9. The patient should be given appropriate discharge instructions prior to leaving. The patient will be provided with a copy of the instructions and a signed and dated copy of the instructions will be placed in the medical record. 10. Nursing observation and nursing care will be documented in the medical record. Physician orders and exams will be documented in the medical record. B. A pregnant patient less than 16 weeks with abdominal or vaginal symptoms will be evaluated in the Emergency Department: 1. Fetal heart tones will be assessed with a Doppler stethoscope. 2. The ED physician shall complete the MSE and notify the Obstetrician as appropriate. C. A pregnant patient 16 weeks or greater presenting to the ED with medical problems or traumatic injuries not related to the pregnancy will be evaluated by the Emergency physician and given appropriate treatment: 1. The ED physician shall complete the MSE and notify the obstetrician as appropriate. 2. ED physician will treat medical condition and/or traumatic injuries. 3. ED nurses, OB nurses, and/or physician will assess fetal heart tones with a Doppler, as needed. D. A pregnant patient 16 weeks or greater presenting unscheduled directly to the OB department will be given the appropriate treatment: 1. The Qualified Nurse Evaluator will perform an initial assessment on the patient. 2. If it is determined that the patient is not experiencing a pregnancy related problem the patient may be safely escorted to the Emergency Department to receive a MSE by the ED physician as appropriate ... Documentation ...B. All medical screening exams must be documented."
Review of "Appendix 1 UPMC Bedford Memorial Instructions for Completing the Obstetric Medical screening Evaluation Form. 1. Fill out the form for unscheduled patients presenting to the floor. 2. Keep the form with the patient's chart. 3. Complete Box A. If scored 2 or more in Box A than an exam by a physician or midwife is required. 4. If patient is exhibiting signs of labor complete Box B. If score is 3 or greater in Box B than an exam by a physician or midwife is required. 5. Complete box C if patient has established an objective labor pattern. There is an area for up to 3 exams. Use the last exam total for the purpose of scoring. If the score for Box C is 7 or greater than a medical screening exam is required by a physician or CNM. 6. Use your nursing judgment/assessment if Box A, Box B, Box C, or all of the Boxes should be completed. 7. Do not total all the boxes together. The boxes are scored individually. 8. If at any time regardless of the score, the nurse may request an exam from a physician or CNM for the purpose of patient safety."
Review of UPMC Bedford Memorial's policy entitled "OB Patients Presenting to the Emergency Department", dated July 2011, revealed "Procedure: 1. Any pregnant patient 16 weeks or greater presenting with possible labor or having abdominal or vaginal symptoms will be escorted to the Obstetrical Department after the maternity nurse have been notified by ED personnel ... 2. Any pregnant patient 16 weeks or greater presenting to the ED with medical problems or traumatic injuries not related to pregnancy will be evaluated by the Emergency physician and given appropriate treatment ... 3. Any pregnant patient 16 weeks or less presenting with abdominal or vaginal symptoms will be evaluated in the Emergency Department ... 4. All OB transfers will be documented in the Emergency Department Log if they are transferred to the OB department for further treatment."
1) Review of MR1 and MR3 revealed both patients (PT1 and PT2) presented to the Obstetrics Department for a medical screening examination, to rule out labor. In addition, both patients also presented with other medical complaints. Once labor was ruled out, it was noted that neither patient received further medical examinations for the other medical complaints.
A review of the document entitled "Appendix F UPMC Bedford Obstetric /EMTALA Department Patient Log" was completed on August 9, 2011, The log revealed that PT1 presented to the Obstetrics Department on July 24, 2011 at 2010 via ambulance. The log indicated that PT1 was unscheduled, and had not been seen by a qualified medical personnel/evaluator. The log also indicated that PT1 was discharged to home.
A review of the patient's (PT1) "Obstetric Evaluation" contained within MR1 dated July 24, 2011, at 8:15 PM revealed, " ... OTH1, Patient: PT1, Regardless of score in any box, the nurse may request a physician exam for patient safety, Evaluator's Signature: [unmarked], Box A Checklist B/P 140/90 or > ... No, Headache ... No, Vomiting ... No, Visual Difficulties ... No, Epigastric Pain ... No, Total Box A ... 0. If patient has established objective labor pattern no contractions B/P stable low. ... Criteria Yes = 1. ... 2 or more = physician exam. ... Box B Checklist PARA ... 0, Duration LAST labor [unmarked], Prior C-Section ... No, Prenatal Care ... No, Prior Fetal Demise ... No, Multiple Gestation ... No, Cerclage or incompetent cervix ... No, Gestational Age 36 weeks, Total Box B, If patient has established objective labor pattern . ... Criteria ... 34-38 weeks = 2, Score 2 ... 3 or more = physician exam. ... Box C Checklist [unmarked]. ... "
Review of MR1 also revealed "LD-Flowsheet" nursing documentation dated July 24, 2011, at 8:11, which stated, "... Pt states (the patient's) had diarrhea x 2 days now. Last time today at 1700, denies eating spicy or greasy foods ... 20:38 Paged OTH1 who was on call and report given on findings with this pt. Orders received to do Q 15 min B/P/s x 2, if stable may go home and be seen by (the patient's) Dr. in Chambersburg this week. Orders for clean catch u/a to check for bacteria and ketones. Call back to OTH1 if u/a positive, otherwise if negative and b/p stable, pt. may go home. ... 7/24/11 Annotation Comment 21:53 report of u/a results called to OTH1, verbal orders to discharge pt to home...Told to go home, drink lots of fluids and follow up with (the patient's) Dr. in Chambersburg with next appointment on Aug 2, or before if necessary. ... ."
A review of the document entitled "Appendix F UPMC Bedford Obstetric /EMTALA Department Patient Log" was completed. The log revealed that PT2 presented to the Obstetrics Department on August 6, 2011, at 2139. The log indicated that PT2 was unscheduled, and had not been seen by a qualified medical personnel/evaluator. The log also indicated that PT2 was discharged to home.
A review of MR3 for PT2, dated August 6-7, 2011, revealed nursing documentation which stated, "OB Triage ... 8/6/11 ... 21:48 ... Arrival Information ... Hx of UTI in June and Tx with antibiotic, follow up specimen was clear. ... Subj. Assess (All Pts) ... Nausea/Vomiting ... vomited this am Subj. Assess. (PTL) Urinary Urgency and Frequency ... went 3 x since 2100 ... Provider Notification ... 22:11 ... answered the phone and orders obtained for VE [vaginal exam] and clean catch U/A [urinalysis] ... 22:50 Provider Information ... reported UA results to OTH5 via telephone ... Orders received ... Macrobid 100mg PO now and prescription will be called to pharmacy of choice in AM discharge to home."
An interview was conducted with EMP7 on August 7, 2011, at 1:20 PM. EMP7 stated "... I talked to OTH1 [regarding PT1] ... I told [OTH1] what [the patient] score was [obstetrical evaluation] and [OTH1] ordered a urinalysis. [OTH1] said that [the patient] didn't need to be seen because [they were] not in labor. We've always felt that the doctors should come in to see the patients ... When patient presents to the OB unit we usually put a gown on them, get a clean catch urine, ask the doctor for the order, monitor vital signs, ask questions, do a head to toe assessment, triage, NST [non stress test], HFO [hold for observation]. The questions are usually relating to bleeding, when they had sex last, burning, medications, last time they took meds, problems with pregnancy, allergies, and height and weight. If the patient still has complaints, then you call the doctor. We cannot diagnose a medical diagnosis. We're just doing the assessment. Assessing for labor and getting a history. The doctor may come in to see the patient or go back down to the ED."
3) An interview was conducted with EMP8 on August 9, 2011, at 1:50 PM. EMP8 stated, "... I didn't know how much we are like an ED. We monitor heart tones, vital signs, urinary symptoms, do the assessment, bowel sounds and vaginal exams if appropriate and then call the doctor. My personal preference is that everyone sees the doctor. When we call them then they need to come."
4) An interview with EMP1, on August 9, 2011, at 4:45 PM, regarding the Obstetric Evaluation Form and policy, revealed "We're going to change our process. Everyone is going to be seen by a physician. Everyone coming unscheduled will be seen by a physician."

Based on review of facility documents, closed medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide an appropriate medical screening examination for two of ten OB medical records reviewed. (MR1, MR3)

Findings include:

Review of "UPMC Policy and Procedure Policy: HS-LE000: Legal Subject: Emergency Medical Treatment And Active Labor Act (EMTALA) Date: March 31, 2011 I. Policy: It is the policy of UPMC to comply will all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 USC1395dd. II. Purpose: The purpose of this policy is to set forth hospitals' requirements under EMTALA. III. Scope: This policy applies to all domestic UPMC hospitals. 3. Medical Screening Exam (MSE) is an appropriate exam within the capacity of the hospital to determine whether an emergency medical condition exists. ... 5. Qualified Medical Person ("QMP") is defined as a licensed physician or other appropriately qualified individual as determined by each hospital in their respective by-laws or rules and regulations. V. Procedure 1. If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a Medical Screening Exam to such person. ... 3. If necessary, following the Medical Screening Exam, Qualified Medical Personnel shall offer further medical examination and such treatment as may be required to stabilize the medical condition within the hospital's resources ... ."
Review of UPMC Bedford Memorial's policy entitled "Vaginal Exams", dated June 2011, revealed "Policy: Vaginal examinations to assess the progress of labor by determining dilatation, station, and effacement are performed by Registered Nurses who have been trained by experienced Obstetrical nurses during orientation with physicians' assistance ... ."
Review of UPMC Bedford Memorial's "Department of Obstetrics/Gynecology Rules and Regulations," dated January 2008, revealed, "... I. Type of Patient ...C. Obstetrical Hold for Observation Patients. 1. Patients that present with obstetrical problems are evaluated by the obstetrical nurse. These patients do not have to be evaluated by the attending physician/midwife. This applies to patients presenting with problems that the OB RN is competent to evaluate. The Obstetrician must be notified of all patients presenting for obstetrical care and disposition determinations are made by the physician. The Physician may make the care determination based on the information given by the Obstetrical Nurse ... ."
Review of UPMC Bedford Memorial policy entitled "Obstetrical Medical Screening," dated July 19, 2011, revealed, "Purpose: To ensure that every patient that presents with a medical emergency receive a proper medical screening exam by a qualified provider/evaluator prior to leaving the hospital. Scope: Obstetric staff and Emergency Department staff. Policy: The pregnant patient will be screened to determine the appropriateness of services in either the Emergency Department or in Labor and Delivery. Definitions: A. Dedicated Emergency Department is any department or facility of the hospital, whether on or off campus that: (a) is licensed by the State as an emergency department; or (b) is held out to the public as a place that provides care for emergency medical conditions without an appointment; or (c) based on a representative sample of patient visits during the previous calendar year, provides at least one-third (1/3) of all its outpatient visits for the treatment of emergency medical conditions without an appointment. B. Emergency Medical Condition is "a medical condition manifesting itself by acute symptoms of sufficient severity ... such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; or with respect to a pregnant woman who is having contractions that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or the unborn child ". C. Medical Screening Exam (MSE) is an appropriate exam within the capability of the hospital to determine whether an emergency medical condition exists ... E. Qualified Medical Provider/Evaluator (QMP) is: 1. A licensed Obstetrician or Emergency Physician with staff privileges at this hospital. 2. A licensed or Certified Nurse Midwife with midwifery privileges at this hospital. 3. A registered nurse who has completed the probationary period and initial competencies in the Obstetrical Department. Procedure: Medical Screening of the OB Patient A. A pregnant patient 16 weeks or greater presenting with possible labor or having abdominal or vaginal symptoms will be escorted to the Obstetrical Department after the maternity nurses have been notified and will be given appropriate treatment: 1. Patients reporting to the OB Department may be evaluated by a qualified evaluator using the standard OB Evaluation form. 2. The patient will be scored as indicated on the OB Evaluation form and the score documented. Use the last value obtained for an item for the purpose of scoring. 3. If a patient is expected to deliver immediately, the OB Evaluation form need not be completed. 4. If the results of any scoring indicate that a physician exam is required , a MSE needs to be completed by the Obstetrician or Midwife. 5. Regardless of the score on any box, the Nurse Evaluator may request a physician exam for the purpose of patient safety. 6. Patients not requiring a physician exam may be discharged upon phone orders from the Obstetrician or Midwife. The patient should be given appropriate discharge instructions prior to leaving. The patient will be provided with a copy of the instructions and a singed and dated copy of the instructions will be placed in the medical record. 7. All phone contacts with the physician will be appropriately documented in the medical record. 8. Patients after exam by a physician or 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 b. Discharge poses no risks to the mother or fetus 9. The patient should be given appropriate discharge instructions prior to leaving. The patient will be provided with a copy of the instructions and a signed and dated copy of the instructions will be placed in the medical record. 10. Nursing observation and nursing care will be documented in the medical record. Physician orders and exams will be documented in the medical record. B. A pregnant patient less than 16 weeks with abdominal or vaginal symptoms will be evaluated in the Emergency Department: 1. Fetal heart tones will be assessed with a Doppler stethoscope. 2. The ED physician shall complete the MSE and notify the Obstetrician as appropriate. C. A pregnant patient 16 weeks or greater presenting to the ED with medical problems or traumatic injuries not related to the pregnancy will be evaluated by the Emergency physician and given appropriate treatment: 1. The ED physician shall complete the MSE and notify the obstetrician as appropriate. 2. ED physician will treat medical condition and/or traumatic injuries. 3. ED nurses, OB nurses, and/or physician will assess fetal heart tones with a Doppler, as needed. D. A pregnant patient 16 weeks or greater presenting unscheduled directly to the OB department will be given the appropriate treatment: 1. The Qualified Nurse Evaluator will perform an initial assessment on the patient. 2. If it is determined that the patient is not experiencing a pregnancy related problem the patient may be safely escorted to the Emergency Department to receive a MSE by the ED physician as appropriate ... Documentation ...B. All medical screening exams must be documented."
Review of UPMC Bedford Memorial's policy entitled, "OB Patients Presenting to the Emergency Department," dated July 2011, revealed "Procedure: 1. Any pregnant patient 16 weeks or greater presenting with possible labor or having abdominal or vaginal symptoms will be escorted to the Obstetrical Department after the maternity nurse have been notified by ED personnel ... 2. Any pregnant patient 16 weeks or greater presenting to the ED with medical problems or traumatic injuries not related to pregnancy will be evaluated by the Emergency physician and given appropriate treatment ... 3. Any pregnant patient 16 weeks or less presenting with abdominal or vaginal symptoms will be evaluated in the Emergency Department ... 4. All OB transfers will be documented in the Emergency Department Log if they are transferred to the OB department for further treatment."
1) A review of the document entitled "Appendix F UPMC Bedford Obstetric /EMTALA Department Patient Log" was completed on August 9, 2011, The log revealed that PT1 presented to the Obstetrics Department on July 24, 2011 at 2010 via ambulance. The log indicated that PT1 was unscheduled, and had not been seen by a qualified medical personnel/evaluator. The log also indicated that PT1 was discharged to home.
A review of the patient's (PT1) "Obstetric Evaluation" contained within MR1 dated July 24, 2011, at 8:15 PM revealed, " ... OTH1, Patient: PT1, Regardless of score in any box, the nurse may request a physician exam for patient safety, Evaluator's Signature: [unmarked], Box A Checklist B/P 140/90 or > ... No, Headache ... No, Vomiting ... No, Visual Difficulties ... No, Epigastric Pain ... No, Total Box A ... 0. If patient has established objective labor pattern no contractions B/P stable low. ... Criteria Yes = 1. ... 2 or more = physician exam. ... Box B Checklist PARA ... 0, Duration LAST labor [unmarked], Prior C-Section ... No, Prenatal Care ... No, Prior Fetal Demise ... No, Multiple Gestation ... No, Cerclage or incompetent cervix ... No, Gestational Age 36 weeks, Total Box B, If patient has established objective labor pattern . ... Criteria ... 34-38 weeks = 2, Score 2 ... 3 or more = physician exam. ... Box C Checklist [unmarked]. ... "
Continued review of MR1 revealed EMS documentation dated July 24, 2011, which revealed, " ... Raystown Ambulance ... Dispatch: 19:33 ... Scene Information: Description: Pt sitting on bridge on side of road, holding abdomen. Husband with. ... Chief Complaint ... pt in labor. Duration: 2 hours ALS Assessment: Completed for Suspected Illness, History of Present Illness Dispatched by 911 for immediate response for 33 y/o female pt with chief complaint of being in labor. Pt is 35 weeks pregnant. Has been punched in the abdomen about 3-4 weeks ago with some bleeding. Non stress test done. Pt went home. Started with labor pains several hours ago. No discharge, water has not broken. Pt to cot, secured. To ambulance. VS taken. HPI and pMHX obtained. IV started kvo and pt placed on 3 l/m n/c. Contractions in ambulance were 2 in number, and lasted about 1-1 ? minutes. Medical command notified of patient condition with ETA of 5 minutes. Pt to go directly to OB floor. VS rechecked. No more contractions. Pt transported to UPMC Bedford without incident. To OB and report to staff RN. ... ."
Review of MR1 also revealed "LD-Flowsheet" nursing documentation dated July 24, 2011, at 8:11, which stated, "Stage of Pregnancy OB Triage ... Uterine Activity Monitor Mode-UA External, Contraction Frequency (min) none seen, Fetal Assessment Monitor Mode-Fetus A, FHR Baseline Rate 140, FHR Baseline Changes No Baseline Change, Variability Moderate 6-25bpm, Accelerations 15 x 15, Decelerations None. ... . 7/24/11 Annotation Comment ... 2027 Pt states (the patient's) had diarrhea x 2 days now. Last time today at 1700, denies eating spicy or greasy foods ... 20:38 Paged OTH1 who was on call and report given on findings with this pt. Orders received to do Q 15 min B/P/s x 2, if stable may go home and be seen by (the patient's) Dr. in Chambersburg this week. Orders for clean catch u/a to check for bacteria and ketones. Call back to OTH1 if u/a positive, otherwise if negative and b/p stable, pt. may go home. ... 7/24/11 Annotation Comment 21:53 report of u/a results called to OTH1, verbal orders to discharge pt to home. FOB (father of baby) wanted to talk to the Dr. insisting they want the baby taken tonight. Explained (the patient) is not in labor and we don't take or induce 36 week preg. unless medically indicated. Told to go home, drink lots of fluids and follow up with (the patient's) Dr. in Chambersburg with next appointment on Aug 2, or before if necessary. ... ."
2) A review of the document entitled "Appendix F UPMC Bedford Obstetric /EMTALA Department Patient Log" was completed. The log revealed that PT2 presented to the Obstetrics Department on August 6, 2011, at 2139. The log indicated that PT2 was unscheduled, and had not been seen by a qualified medical personnel/evaluator. The log also indicated that PT2 was discharged to home.
A review of MR3 for PT2, dated August 6-7, 2011, revealed nursing documentation which stated, "OB Triage ... 8/6/11 ... 21:48 ... Arrival Information ... [PT2] escorted to the floor by the ER staff Complaint started having some back pain since 0600, light then nothing, started getting bad around 2030 to night [sic]. Hx of UTI in June and Tx with antibiotic, follow up specimen was clear. ... Subj. Assess (All Pts) ... Time contractions began off and on all day, worse this evening since 2030 ... Subj. Assess. (R/O Preclampsia [sic]) ... Nausea/Vomiting ... vomited this am Subj. Assess. (PTL) Urinary Urgency and Frequency ... went 3 x since 2100 ... Provider Notification ... 22:11 ... answered the phone and orders obtained for VE [vaginal exam] and clean catch U/A [urinalysis] ... 22:50 Provider Information ... reported UA results to OTH5 via telephone ... Orders received ... Macrobid 100mg PO now and prescription will be called to pharmacy of choice in AM discharge to home."
3) During review of MR1 and MR3 with EMP2 on August 9, 2011, EMP2 confirmed that MR1 and MR3 failed to reveal a documented medical screening examination.