HospitalInspections.org

Based on interview, review of the Emergency Room (ER) log, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure one (1) of twenty (20) sampled patients (Patient #1) who presented to the ER seeking assistance as defined in §489.24(b), was included on the ER log.

The findings include:

Review of the facility's policy titled, "Obstetrical Patient in ED", dated 08/29/16, revealed patients presenting to the ER who are equal to or greater than twenty (20) weeks with an obstetrical complaint will be sent directly to Labor and Delivery. There was no mention of the patient being added to the ER log.

Review of ER specific policies revealed no policy which mentioned the ER log.

Interview with Registrar #1, on 10/14/16 at approximately 8:12 AM, and review of Registrar #1's Safe Care Report, dated 08/28/16, revealed Patient #1, who was thirty-eight (38) weeks pregnant, presented to the ER on 08/27/16 (Saturday) complaining of possible contractions. Registrar #1 reported she asked Registrar #2 to call up to Labor and Delivery for a bed while she tried to register Patient #1. She stated Patient #1 talked to a nurse on the phone and left the hospital without being added to the ER log.

Review of the ER log, dated 08/27/16, revealed Patient #1 was not included.

Interview with Registrar #2, on 10/14/16 at approximately 8:35 AM, revealed she contacted the Labor and Delivery department when Patient #1 arrived at the ER. She stated the nurse requested to speak to the patient on the phone and the patient left the facility without being added to the ER log. She stated she overheard Patient #1 state the nurse advised her to go to her regular physician because if they admitted her, the patient's regular physician did not have privileges at the hospital and would not be able to see her.

Interview with the Registrar Supervisor, on 10/14/16 at approximately 9:20 AM, revealed when pregnant women present to the ER with contractions, the registrar calls Labor and Delivery. She stated if the patient goes to Labor and Delivery, the patient is not added to the ER log. She revealed all types of patients enter through the ER entrance. She stated when any pregnant patient who is twenty (20) weeks or more pregnant enters the ER, regardless of complaint, the registrar tells the Charge Nurse and the Charge Nurse calls Labor and Delivery. She revealed the Charge Nurse and the Labor and Delivery Nurse determine if the patient is seen in the ER or taken to Labor and Delivery. If the patient is taken to Labor and Delivery, the patient is registered in the Labor and Delivery department and not on the ER log.

Interview with Registered Nurse (RN) #1, on 10/13/16 and 10/14/16 at 9:40 AM, revealed a patient presenting to the ER who is 20 weeks or greater pregnant will be sent to the Labor and Delivery department for a medical screening exam and will not be put on the ER log. She stated the facility's policy was revised because of the facility's investigation. She revealed the policy now calls for the registrar to contact an ER nurse to call Labor and Delivery for a patient presenting to the ER who is 20 weeks pregnant or greater and they will decide where the patient will be seen. The policy revision does not make provisions for a patient who is 20 weeks or greater into their pregnancy to be put on the ER log.
Review of the facility's communications, investigations, and action plans revealed the facility has placed interventions in place and the facility is currently in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

Based on interview, record review, review of the facility's policy, and review of the facility's Medical Staff Rules and Regulations, it was determined the facility failed to have an effective system in place to ensure one (1) of twenty (20) sampled patients (Patient #1) who presented to the Emergency Room (ER) received an appropriate Medical Screening Examination (MSE) to determine whether or not an emergency medical condition exists.

The findings include:

Review of the facility Emergency Services Medical Staff Rules and Regulations, last revised February 2012, revealed qualified medical personnel would perform a Medical Screening Examination (MSE) for all persons that present to/at the Emergency department. In the case of the pregnant patient who is having contractions or other acute symptoms of sufficient severity related to the pregnancy, the MSE will be completed by a Registered Nurse (RN) of the Maternal Child Department using protocols and procedures approved by the medical staff of the Maternal/Child Committee.

Review of the facility's policy titled, "Medical Screening Exam", with policy start date of 03/01/15, revealed, pregnancy with contractions, over twenty (20) week gestation are triaged to the Obstetrics (OB) Department for evaluation and screening by an experienced OB nurse.

Interview with Registrar #1, on 10/14/16 at approximately 8:12 AM, and review of Registrar #1's Safe Care Report, dated 08/28/16, revealed Patient #1, who was thirty-eight (38) weeks pregnant, presented to the ER on 08/27/16 (Saturday) complaining of possible contractions. Registrar #1 stated she asked Registrar #2 to call up to Labor and Delivery for a bed while she tried to register Patient #1. She stated Patient #1 talked to a nurse on the phone and left the hospital without receiving a MSE. She stated she did not believe this was right and filled out a Safe Care Report.

Interview with Registrar #2, on 10/14/16 at approximately 8:35 AM, revealed when Patient #1 arrived at the ER, she contacted the Labor and Delivery department. She stated the nurse requested to speak to the patient on the phone and the patient left the facility without receiving a MSE. She revealed she overheard Patient #1 state the nurse advised her to go to her regular physician because it they admitted her, the patient's regular physician did not have privileges at the hospital and would not be able to see her. She also reported she completed a Safe Care Report.

Review of RN #7's Safe Care Report, dated 08/27/16, revealed she received a call from the ER registration stating there was a thirty-eight (38) week pregnant patient in the ER who wanted to be checked to see if she was in labor. RN #7 reported she asked to speak to the patient and the patient stated she was having contractions every ten (10) minutes and felt heavy in the pelvis area. RN #7 revealed the patient stated her OB physician was in Murray so she told the patient if she was in active labor, she would be admitted and they would have to obtain her records from Murray. RN #7 reported she told the patient if she needed to be checked out here, the hospital would evaluate her, but it would be at the risk of having to keep her, and a physician who was not familiar with her history would assume her care. RN #7 reported the patient stated she would go to Murray (45 minutes away) where her physician was.

Interview with the Registrar Supervisor, on 10/14/16 at approximately 9:20 AM, revealed when pregnant women present to the ER with contractions, the registrar calls Labor and Delivery. She stated all types of patients enter through the ER entrance. She revealed when any patient who is twenty (20) weeks or more pregnant enters the ER, regardless of complaint, the registrar tells the Charge Nurse and the Charge Nurse calls Labor and Delivery. The Charge Nurse and the Labor and Delivery Nurse determine if the patient is seen in the ER or taken to Labor and Delivery without a MSE in the ER.

Interview with RN #1, on 10/13/16 and 10/14/16 at 9:40 AM, revealed a patient presenting to the ER who is twenty (20) weeks or greater pregnant will be sent to the Labor and Delivery department for a MSE. She stated the policy was revised because of the facility's investigation and now calls for the registrar to contact an ER nurse, who then calls Labor and Delivery, and they will decide where the patient will be seen without conducting a MSE in the ER. She further stated Patient #1 left the ER, and did not receive a MSE.

Interview with the Clinical Manager of Maternal Child Services, on 10/13/16 at 2:55 PM, revealed she had informed RN #7 when someone presented to the ER that he/she has to be seen, and Patient #1 met the criteria to be seen in the ER department. She stated that RN #7 did not think this was an EMTALA violation; however, she stated "I explained it was".

Interview with the Administrator on call for 08/27/16, on 10/14/16 at 1:11 PM, revealed he was informed of the situation regarding RN #7.

The facility discovered the deficiency and put an effective Plan of Correction (POC) into effect prior to the survey.

The facility implemented the following actions to correct the deficient practice:

1. The RN (#7) in the Obstetrics (OB) Department was terminated on 09/07/16.

2. The ER policy regarding pregnant patients presenting to the ER was revised on 09/16/16.

3. The ER staff were re-educated on EMTALA and the revised policy.

The State Survey Agency validated the facility's plan of action was carried out as follows:

1. Interview with the Chief Nursing Officer (CNO), on 10/13/16 at approximately 9:40 AM, revealed the RN in the Obstetrics Department (OB) was terminated based on the facility's investigation.

Interview with the Director of Human Resources, on 10/13/16 at approximately 11:45 AM, revealed the RN in the OB was terminated on 09/07/16.

2. Review of the facility's policy, Obstetrical Patient in the ED, dated 09/16/16, stated, "Obstetrical (OB) patients presenting to the Emergency Department (ED) will be provided care based on current medical condition and in consideration of her gestational age. Patients presenting with pregnancy equal to or greater than twenty (20) weeks and an obstetrical complaint will be sent to Labor and Delivery to undergo a Medical Screening Exam (MSE). Patients with non-obstetrical complaints will undergo a Medical Screening Examination (MSE) in the Emergency Department".

3. Interviews with Registrar #1, Registrar #2, RN #5, RN #6, the Patient Access Director, and the CNO, confirmed they had been re-educated on EMTALA and the revised policy regarding pregnant patients presenting to the ER.