HospitalInspections.org

Based on document review and staff interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination. (A-2406)

An immediate jeopardy (IJ) investigation was conducted on 8/31/2022 through 9/2/2022 for complaint #IL00150713/2211085. The immediate jeopardy began on 8/31/2022, due to Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination (MSE).

2. The Hospital failed to provide an appropriate transfer to another Hospital. (A-2409)

Based on document review and staff interview, it was determined that in 1 of 20 (Pt #1) Emergency Department (ED) records reviewed, the Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination (MSE). This has the potential to affect all patients receiving care in an ED that treats approximately 34 patients a day.

Findings include:

1. On 08/31/2022 at approximately 10:00 AM the policy, "Triage: COBRA Compliance (revised 2007)" was reviewed. The policy stated "Procedure.... 2.... d. Any individual regardless of the reason for their visit, including pregnant women in labor, who, in the opinion of the triage personal, their own opinion and/or that of the people accompanying them, exhibit a sudden change in a chronic condition or present with the acute onset of symptoms which could constitute an emergency or urgent condition, will be directed by triage personnel directly and immediately to the care of a department nurse who will begin the evaluation and/or treatment without delay, notifying the appropriate physician as soon as it is practical."

2. On 08/31/2022 at approximately 11:30 AM, the ED patient log was reviewed. Pt #1 was on the ED log indicating Pt #1 presented to the ED on 08/09/2022 at 11:02 PM with a chief complaint of "eval." The log stated "Acuity Level: N/A, Providers: N/A, Diagnosis: N/A, Discharge Disposition: Duplicate/Invalid, Discharge Date/Time: 08/09/2022 11:05 PM."

3. On 08/31/2022 at approximately 11:45 AM, an interview was conducted with the Director of Quality and Safety (E #1) and the Chief Nursing Officer (E #3). E #1 stated "We had received a phone call from the Perinatal Center with concerns related to a pt who presented to (Receiving Facility) stating that (Pt #1) had presented to (Transferring Hospital) with concerns that (Pt #1's) water had broke. We started an investigation. Initially, there was no patient record (not on the log). Based on information provided by the Perinatal Center and a review of our cameras in the ED, we determined when the patient presented and when the patient left. We logged a Sensor (Patient Safety) event and spoke with the nurse."

4. On 09/01/2022 at approximately 9:00 AM, the video footages of the ED lobby and the ED hallway (outside of the triage room by the ED entrance/exit doors) were reviewed. The video footage from the ED lobby showed a Pt #1 presented to the registration desk at 11:02 PM. E #4 is noted taking Pt #1 and significant other through the ED door at 11:02 PM. Video footage from the ED hallway shows E #4 walking to lobby and bringing Pt #1 and significant other back into the triage room at 11:02 PM. Two and a half minutes later, significant other walks out the ED exit doors. At 11:05 PM E #4 escorts Pt #1 out the ED exit door to the lobby. Pt #1 continues and exits the hospital.

5. On 09/01/2022 at approximately 2:30 PM, an interview was conducted with ED Nurse (E #4). E #4 stated "Pt came in with significant other stating thought water had broke and was 25 weeks and 6 days pregnant. I told the patient the services we could offer and told the pt the hospital would be glad to see (Pt #1). The patient sent the significant other out to get the car. The patient asked me if (Pt #1) should go on or stay. I explained to (Pt #1) that (Pt #1) was considered high risk at 25 weeks and (receiving facility) was the best hospital for high risk pregnancy. I asked if (Pt #1) was having any pain and (Pt #1) said no. I did not get a name, birthday or any other information." E #4 confirmed Pt #1 did not receive a MSE.

A. Based on document review and staff interview, it was determined for 1 of 4 (Pt #1) obstetrical patients who presented to the Emergency Department (ED), the hospital failed to provide an appropriate transfer. This has the potential to affect all obstetrical patients receiving care in an ED that treats approximately 34 patients a day.

Finding include:

1. On 08/31/2022 at approximately 9:30 AM the policy, "OB: Maternal Transfer (revised October 2009)" was reviewed. The policy stated "Policy: Maternal patients >20 weeks will be transferred to the appropriate level of care... B. Maternal-Fetal Transport Data: All patients who are potentials for transfer to another facility should have the following available: Current vital signs, Fetal Heart Tones, Medical Screening, Presence of vaginal discharge (ie bleeding, amniotic fluid), IV fluids, previous and current medical records if available. Procedure: A. Assess the patient prior to transfer. "

2. On 08/31/2022 at approximately 11:45 AM, an interview was conducted with the Director of Quality and Safety (E #1) and the Chief Nursing Officer (E #3). E #1 stated "We had received a phone call from the Perinatal Center with concerns related to a pt who presented to (Receiving Facility) stating that (Pt #1) had presented to our facility with concerns that (Pt #1's) water had broke. We started an investigation. Initially, there was no patient record (not on the log). Based on information provided by the Perinatal Center and a review of our cameras in the ED, we determined when the patient presented and when the patient left. We created a Sensor (Patient Safety) event and spoke with the nurse."

3. On 08/31/2022 at approximately 2:00 PM, Pt #1's record from the Receiving Facility was reviewed. Pt #1 presented to the ED on 08/09/2022 at 11:45 PM and was taken to Obstetrical Triage Room #1. Pt #1's "OB History and Physical" stated, "(Pt #1) ... is being admitted for emergent cesarean section cesarean section due to PPROM (preterm premature rupture of membranes) with prolapse of fetal part and fetal bradycardia (low heart rate).... Per patient report, (Pt #1) has spontaneous rupture of membranes at 10:00 PM. (Pt #1) called the (primary OB's office) Telenurse and was advised to seek evaluation for rupture of membranes at (Transferring Hospital). Patient and partner reported that (Pt #1) was triaged and advised to come directly to (Receiving Hospital) as (Transferring Hospital) would not be able to intervene. It does not appear that the patient was evaluated by a physician or that fetal heart tones were obtained prior to leaving outside facility. (Pt #1) presented to triage, and on exam by (Maternal Fetal Medicine physician), (Pt #1) was noted to have a fetal arm prolapsing into the vagina. A Code Mom was initiated and the patient was transferred to the OR emergently. In the OR, BSUS (bedside ultrasound) demonstrated transverse (cross-lying) fetus. Fetal heart tones were not able to be obtained with external cardiotocography (continuous recording of the fetal heart rate obtained by an ultrasound transducer placed on the mother's abdomen) and fetal heart tones were unable to be visualized on BSUS (bedside ultrasound) with Doppler; however, possible fetal bradycardia was noted. FSE (fetal scalp electrode)was placed and FHT (Fetal Heart Tones) were indeterminate. She underwent an emergent classical cesarean section... delivered infant who was 930 grams (2 pounds 0.8 ounces) and had APGARs (describes the condition of the newborn at 1 minute, 5 minutes and 10 minutes of life. It is scored based on muscle tone, pulse, reflex irritability, skin color, and respiration) of 0, 0, 0 at 1, 5, and 10 minutes (indicating demise) respectively." The "OB Cesarean Delivery Operative Note" stated, "(Pt #1) reports that (Pt #1) had been experiencing cramping since 8/6/2022. On 8/9/2022, (Pt #1) felt worsening cramping and the sensation to have a bowel movement. While attempting to have bowel movement, (Pt #1) noted a large gush of clear fluid at 22:00. (Pt #1) subsequently presented to (receiving facility) for evaluation.... decision was made to proceed with an emergent cesarean section."

4. On 09/01/2022 at approximately 2:00 PM an interview was conducted with ED RN (E #4). E #4 stated "OB patients get triaged, assessed (including vitals and fetal heart tones), and then we notify the ED physician. After the medical screening exam (MSE), the physician will make a determination on the need for transfer and determine the means of transport (whether Advanced Life Support ambulance, transfer team from the receiving facility, or if capable of taking a private car). Pt #1 did not receive a medical screening exam so there was no determination made of the need for transfer or appropriate way to transfer"



B. Based on document review and interview, it was determined that for 3 of 10 (Pt #8, Pt #12 and Pt #14), clinical records reviewed for transfer, the Hospital failed to complete the transfer forms. This has the potential to affect all patients receiving care in an ED that treats approximately 34 patients a day.

Findings include:

1. On 09/01/2022 at approximately 11:00 AM, Pt #8's record was reviewed. Pt #8 presented to the Emergency Department (ED) on 7/27/2022 at 8:08 PM, with a chief complaint of overdose. Pt #8's medical screening examination was done at 8:08 PM. Pt. #8 was transferred to a Behavioral Health In-patient facility. Pt. #8's "Physician Certificate of Transfer" form was incomplete. The form lacked documentation of the relationship to the patient for consent to transfer. The form lacked documentation that medical records were sent to the receiving facility.

2. On 09/01/2022 at approximately 1:00 PM, Pt #12's record was reviewed. Pt #12 presented to the ED on 7/11/2022 at 1:42 AM, with a chief complaint of foot pain. Pt #12's medical screening examination was done at 1:50 AM. Pt. #12 was transferred to another facility with a diagnosis of foot abscess. Pt. #12's "Physician Certificate of Transfer" form was incomplete. The form lacked documentation that medical records were sent to the receiving facility.

3. On 09/01/2022 at approximately 3:15 PM, Pt #14's record was reviewed. Pt #14 presented to the ED on 8/8/2022 at 1:52 PM, with a chief complaint of Closed head injury. Pt #14's medical screening examination was done at 2:25 PM. Pt. #14 was transferred to another facility with a diagnosis of Traumatic Brain Injury. Pt. #14's "Physician Certificate of Transfer" form was incomplete. The form lacked documentation that medical records were sent to the receiving facility.

4. An interview with the Manager of Patient Safety (E #2) was conducted during the record reviews. E #2 verbally agreed the records do not indicate that the medical record was sent to the receiving facility and agreed the signature for Pt #8 did not indicate the relationship to the patient. E #2 stated, "The signature does not match any names listed on the patient's chart. I am unsure who signed the consent form."