HospitalInspections.org

A complaint survey was conducted at Charleston Area Medical Center on October 07, 2024 through October 08, 2024. It was determined the facility is not in compliance with the requirements of 42 CFR, Part 489 - The Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Based on document reviews, medical record review, and staff interviews, it was determined the facility failed to provide an appropriate Medical Screening Exam (MSE) to rule out an Emergency Medical Condition (EMC) in one (1) out of twenty (20) Patients, (Patient #1). This failure has the potential to negatively affect all patients receiving a medical screening from the facility.

Findings include:

A policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)" revised on 02/01/2023 was reviewed. This policy states in part, " ...Policy: ... will comply with the requirement of the Emergency Medical Treatment and Active Labor Act (EMTALA) by ensuring that when an individual come by him or herself or with another person to [Facility] or it premises and a request is made by the individual or on the individual's behalf for medical examination or treatment, [Facility] or a department thereof will provide for an appropriate Medical Screening Examination within the capability of the Emergency Department, including ancillary services routinely available to the Emergency Department, to determine whether or not an emergency medical condition exists or, with respect to a pregnant woman having contraction whether the woman is in labor. If it is determined that the individual has an emergency medical condition, stabilizing treatment will be provided and they will be either admitted, discharged, or transferred as appropriate ... 3. How to Provide the Medical Screening Examination [MSE] C. Individuals coming to the Emergency Department will be provided a MSE beyond initial triage. Triage is not equivalent to an MSE. Triage is to determine the sequence in which Patients will be seen, not the presence or absence of an emergency medical condition. G. Depending on the Patient's presenting symptoms, the MSE may range from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures. H. A MSE is not an isolated event. It is an ongoing process. The medical record must reflect continuous monitoring according to the Patient's needs and must continue until he/she is stabilized or appropriately transferred. There will be evidence of this evaluation documented in the medical record to discharge or transfer. Stabilization: Purpose: To ensure that all Patients determined to have an emergency medical condition shall be stabilized prior to being transferred or discharged as required under EMTALA. Procedure: 1. To stabilize or be stabilized means, with respect to an emergency medical condition, that the individual is provided such medical treatment as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition ... 2. A Patient will be deemed stabilized if the treating physician attending to the Patient in the [Facility] Emergency Department or other designated areas has determined within reasonable clinical confidence that the emergency medical condition has resolved ..."

A review was conducted of the "Medical Staff Bylaws, Policies and Rules and Regulations," adopted 11/28/17. Section "Rules and Regulations" states in part, "...Article X Emergency Services ...10.1 General: (a) Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care ...10.2. Medical Screening Examinations: (a) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening examinations within applicable Hospital policies and procedures are defined as: (1) Emergency Department physicians; (2) Emergency Department physician assistants; (3) Emergency Department nurse practitioners; and (4) Obstetrical Registered Nurses (only in the case of women in labor.) (b) The results of the medical screening examination must be dictated within 48 (forty-eight) hours of the condition of an Emergency Department visit."

A review was conducted of a document titled "Triage of the Antepartum/labor Patient in Special Delivery Unit Maternal Fetal Triage Index," no date listed. The Maternal Fetal Triage Index revealed in part, " ...Urgent /Priority 2 (Two): Does the woman or fetus have urgent/priority 2 (Two) vital signs? Or is the woman being in severe pain without complaint or contractions? Or is this a high-risk situation? Or will this woman and/or newborn require a higher level of care than institution provide ... Examples of High-Risk signs ... Difficulty breathing ..."

A medical record review was conducted for Patient #1. Patient #1 was presented to the hospital on 07/20/24, due to the chief complaint for tachycardia. The patient endorsed that [he/she] was experiencing tachycardia for a few days. The patient stated that they had been experiencing tachycardia [a fast heart rate] accompanied by palpitation, chest pain, shortness of breath (SOB) and dizziness. The patient confirmed issues with palpitation and syncope in the past and was seen by a cardiologist for it with no etiology identified. The patient is currently twenty-nine (29) weeks pregnant and is a status G5P2AB2 [G=Gravida the number of times the patient has been pregnant, P=Para the number of children the patient has given birth to, AB=abortion/miscarriage the number of abortions/miscarriages the patient has had] and denies any pregnancy complaints. There was no abdominal pain/trauma, vaginal bleeding or leakage or did the patient voice any other concerns or complaint at the time of the initial emergency department (ED) provider evaluation. This patient was triaged at the level three (3) acuity and was assigned to the regular emergency department.

A review of Emergency Department Triage Process Emergency Severity Index (ESI) Algorithm. The ESI revealed that Acuity #3 was a danger zone vital.

Staff # 6 ' s "Initial evaluation" of Patient #1 dated 7/20/24 at 7:12 p.m. describes [Patient #1] presented with irregular heartbeat. Staff #6 evaluation continues in part, " ...Medical Decision Making: The patient is a twenty-two [22] year [gender] who presents with tachycardia and fatigue in the context of a twenty-nine [29] week pregnancy. Patient is persistently tachycardic, sinus on the monitor/EKG, but maintaining her blood pressure. No pregnancy related complaints and normal fetal heart tones. Given the pronounced tachycardia without clear etiology, after a discussion of the risk/benefits of computed tomography angiography [CTA] to [his/her] /baby, the patient agrees to CTA. Negative for pulmonary embolism [PE] but does show very small pericardial effusion. Urinalysis [UA] shows small bacteriuria/pyuria, but also with significant qualms. No urinary symptoms ..."

May it be noted that the patient was twenty-nine (29) weeks pregnant and there was no evidence in the Patient ' s medical record of an OB/GYN consultation.

An interview was conducted on 08/20/24 at 3:03 p.m. with Staff # 3. Staff # 3 stated, "I did the triage for [Patient #1], the triage was done as a regular Patient. The ED providers are the ones who decided consultation with OB/GYN. There is a sheet in the ED department that is a guide for pregnant Patients up to twenty (20) weeks, this how we triage the Patient if there are any alerts indicating the Patient is sent upstairs to the OB/GYN emergency department. In this case the Patient did not meet the criteria to go upstairs."

A phone interview was conducted on 08/20/24 at 3:21 p.m. with Staff #6. Staff #6 stated: "I did not recall [Patient #1]. When asked if it would have been appropriate for Patient #1 to be seen at ER and not by an Obstetric when Patient #1 was twenty-nine (29) weeks pregnant. Staff #6 stated, "Over twenty (20) weeks of pregnancy, Patients would go to the OB (Obstetric) emergency department, but a pregnant woman without pregnancy issues would stay in the ED. If the Patient came to the regular ER, that means the OB is not even involved." Patient #1 was discharged with first (1st) degree heart blockage because it is not a serious risk."