HospitalInspections.org

An unannounced onsite complaint survey was conducted related to allegations regarding the Emergency Medical Treatment & Labor Act (EMTALA) contained within complaint number SC00055843 at Prisma Health Oconee Memorial Hospital from 10/16/2023 to 10/19/2023. The hospital was determined to be out of compliance with 42 CFR 489.20(l) and 489.24.

The findings include:

Based on record reviews, interviews and review of the hospital's policy and procedure, the hospital failed to ensure that one of 22 patients received an Emergency Medical Screening Examination (MSE) to determine if an emergency medical condition (EMC) existed. (Patient #1)

Cross refer to A2406.

Based on record reviews, interviews, video review and review of the hospital's policy and procedure, the hospital failed to ensure that one of 22 patients received an Emergency Medical Screening Examination (MSE) to determine if an emergency medical condition (EMC) existed. (Patient #1)

The findings include:

1. Record review on 10/16/23 at 4:30 PM for Patient #1 revealed the patient presented ambulatory to the Emergency Department (ED) on 10/02/23 at 11:45 PM for a chief complaint of "24 weeks pregnant fall on stomach". Review of the patient's chart revealed the patient had fallen on a gravel road and presented to the ED post a triage call with the patient's OB physician group triage. Patient #1's vital signs were obtained at 11:47 PM by emergency technician (EMT) #1, Temperature 98.4 degrees Fahrenheit (F), heart rate (HR) 70, respirations (RR) 15, blood pressure right arm 119/68, SpO2 100% (percent) room air; with a triage start at 11:48 PM by Registered Nurse (RN) #1, sent to the hospital's labor and delivery (L&D) unit status at 11:50 PM by RN #1 and transported to the OB Birthplace department at 11:54 PM by RN #2. RN #2 documented at 12:05 AM the OB triage acuity level of "3-urgent" which meant "a patient who requires two (2) or more resources for the physician to determine disposition. Vital signs are necessary to determine ESI (emergency severity index) III acuity and can be used to upgrade the patient to an ESI level II if appropriate". Further review revealed there was no documentation of an MSE on the patient's chart to determine an EMC by a Qualified Medical Personnel (QMP). Patient 1 was discharged from the OB Birthplace Department at 2:10 AM.

Record review on 10/16/23 at 5:00 PM for Patient #1's "Nurse Triage in Telephone Triage" with the OB on-call physician group at Blue Ridge at 11:18 PM revealed the chief complaint as pregnancy problem, onset date 10/02/23". Review of initial assessment questions revealed the patient stated she "tripped down a hill one hour ago, and hit her stomach, knee abrasion, no pain, baby moving well, and no vaginal bleeding". Patient #1 was dispositioned to the Emergency Department (ED) for "Pregnant 20 or more weeks and fall to ground or floor".

Review of the patient's "OB Triage Abdominal Trauma Standing Orders" on 10/17/23 at 10:35 AM revealed "Notify provider (specify) of assessment findings, utilize Maternal Fetal Triage index to assign a priority score, and notify provider of score, vital signs with BP (blood pressure) in sitting position on arrival the Blood pressure (BP), Heart Rate (HR) and Respiratory Rate (RR) every 1 hour, fetal monitoring external continuous. Obtain order to discontinue, Rainbow draw...".

Observations on 10/16/23 at 12:17 PM of the hospital video surveillance revealed Patient #1 entered the hospital at 11:42 PM, 11:44 PM: was standing at the main ED desk with EMT #1, 11:46 PM: Patient #1 followed EMT #1 into triage room #1, RN #1 walked up to the main ED desk. RN #1 walked over to triage room #1 at 11:48:05 PM outside of the door, 11:48:50 PM: RN #1 walked from the outside of the triage room to the main desk and picked up the telephone, at 11:49:14 PM: EMT #1 exited triage room #1, 11:49:26 PM: Patient #1 exited triage room #1 and sat down in a chair in front of the main ED desk, and from 11:52:35-11:52:48 PM: Patient #1 and (2) family members ambulated from the main ED desk to a set of chairs in the Alternative Care Side (ACS) of the ED department to wait. At 11:58:09 PM: someone from the OB department took Patient #1 from the ACS area via wheelchair to the OB unit. At 2:03:04 AM: Patient #1 was escorted via wheelchair back to the ACS area with (2) family members and allowed to ambulate at 2:03:12 AM through the ED area by the main ED desk and out of the ED doors at 2:03:47 AM.

During an interview on 10/17/23 at 7:53 AM to 8:35 AM, Registered Nurse (RN) #2 stated, "I was the charge nurse for the unit that night, and I take assignments. I had one (mom/baby) couplet that night. The ER staff will call to let us know that there is a patient that qualifies to come up to the floor. I don't remember receiving the call for us. Once she gets to the floor, the nurse does a triage assessment navigator and places the patient on the fetal monitor. This patient didn't have any complaints with me, no skin was broken, abdomen soft and non tender. She had no contractions that I recall and her baby was moving good. The fetal heart monitor is done in OBIX. The system communicates when the patient is on the monitor. It (OBIX) is just for monitoring heart rate, vital signs, and uterus activity in real time. Any results is saved in EPIX. I input my interpretation of what I see on the OBIX system into EPIX. Once I do an assessment (a triage assessment), I will contact the doctor for any additional orders. This lady had no issues and our physician likes a four hour window from the time of incident until they reach a four hour mark. Once I called the physician to tell him what I had done and the situation, he/she was good with her leaving at that point. The on-call physician for her physician group was who I contacted, MD #1. I was under the impression she had a MSE in the ER. Usually it's completed there and then they make a phone call to let me know the information. I called downstairs because I noticed there wasn't one, and I asked them to make sure they got it charted. It never dawned in my mind that one (MSE) wasn't done. I told them I needed it because I was about to discharge her home. Before I was to leave, I checked again and there was no MSE. I gave a report to my day shift charge nurse.
The laboring nurse can do an MSE with someone over 35 weeks and having contractions and nothing involving a fall. It's my experience the normal workflow is that the ED physician will do a MSE. If she had any negative consequences, then he/she (the on-call physician) would have come in. If there was any issues, we teach them (the staff) to ask the physician to come in. I took her back downstairs after the assessment".

During an interview on 10/17/23 at 8:40 AM to 8:55 AM, RN #1 stated, "I was taking a patient back and had a lot of patients to get them transitioned to the back (emergency room). I checked the computer board and saw it was a pregnant issue and asked her why she was here. Said she tripped and fell, and she was twenty-four weeks, I believe, and she said her OB doctor sent her over. She stated no complaints and just wanted to check on baby and make sure the baby was okay. I am to call for a MSE, and as you know, I didn't call for one, and I did call the floor and gave them a report and stated they would be down to get her. Normally it's a physician to physician communication if the patient states they are there for on-call physician. I was made aware of it (the issue) when the ED manager contacted me and asked me to call him/her. He/she asked about the situations and I admitted what I had done".

During an interview on 10/19/23 at 12:01 PM to 12:12 PM, Medical Doctor (MD) #1 stated, "I received a phone call after I was asleep and said patient had fallen and didn't immediately come in and came in later. Patient was on monitor over an hour before call and we sent the patient home. I didn't come in because the patient and baby were fine because patient was not symptomatic and baby was fine based on information from the nurse. The nurse gave me no notification that I didn't need to come in. I did not provide the patient with any discharge instructions. The purpose of the addendum note was because someone contacted me and said the patient didn't get an MSE. On every patient I'm expecting notification prior to discharge and I've received that as far as I know".

During an interview on 10/19/23 at 9:50 AM, Nurse Manager #1 stated, "The ED physician is to complete an MSE on the patients before they come to the unit (OB department), but that was not done".

Hospital policy, entitled, "Medical Screening Exams by Nurses in Obstetrics", revealed,
"Procedural Steps:
1. Patients who present to Obstetrics (OB) with only a complaint of possible labor or labor symptoms and who are 35 0/7 weeks estimated gestational age or beyond will have a medical screening exam (MSE), as required by EMTALA, by Qualified Medical Personnel (QMP) Obstetrics nurse or other QMP for the purpose of determining if active labor exists.
2. ... The OB QMP RN may not perform a MSE on patients:
2.1 Presenting at gestational ages less than 35 0/7 weeks with any complaint
4. The MSE for possible labor should typically include:
4.1. Obtaining a patient history and an examination sufficient to determine if a complaint other than labor may be present.
4.2. Completion of a digital cervical exam as indicated to determine cervical dilation, effacement, and station.
4.3. Evaluation of external fetal heart rate monitoring and uterine activity monitoring
4.4. The registered nurse, who has been validated as competent to perform the MSE, will consult with a Health medical staff member with obstetrical privileges prior to a final determination being made about an emergency medical condition".

Hospital policy, entitled, "Emergency Medical Treatment and Labor Act (EMTALA)" revealed "6. OB Screening: A part of the OB department in the hospital with Qualified Medical Personnel to perform the MSE will be a determination of whether the patient is in labor. The OB department, where screening is performed, is considered an extension of the facility emergency department or located within a facility that provides OB care for the purpose of performing a medical screening exam...".