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Based on hospital policy review, medical record review, physicians and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings include:

The hospital's Dedicated Emergency Department (DED) qualified medical professional failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 10 sampled DED patients (#12) who presented to the hospital's labor and delivery department for evaluation and treatment.

~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A2406.

Based on policy and procedure review, closed medical record review, and physician and staff interviews, the hospital's Dedicated Emergency Department (DED) failed to provide a complete Medical Screening Examination (MSE) within the capability of the hospital's DED, including interpretation of ancillary testing, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 10 sampled DED obstetrical patients (Pt # 12) who presented to the hospital for evaluation and treatment.
The findings include:
Review of facility "EMTALA" policy, number NH-PC-CC-1132, effective July 2013, revealed "...It is....policy to provide care to individuals who come to the dedicated emergency department or present elsewhere with an emergency medical condition in a manner that best meets the needs of those individuals and that complies with applicable state and federal laws....A. Medical screening examinations 1. Individuals (including minors) entitled to a medical screening examination. a) Individuals in the dedicated emergency department (ED) seeking medical care - When an individual comes to the dedicated emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment, the hospital shall provide for an appropriate medical screening examination within the capability of the hospitals' emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists....2. Scope of the medical screening examination a) A medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. The hospital shall apply in a non-discriminatory manner....a screening process that is reasonably calculated to determine whether any emergency medical condition exists. The medical screening examination shall include both a generalized assessment and a focused assessment based on the individual's chief complaint, with the intent to determine the presence or absence of an emergency medical condition. Depending on the individuals' presenting symptoms, the medical screening examination may range from a simple process involving only a brief questioning and examination for individuals who come to the facility for non-emergency services to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures....3. Individuals who may perform the medical screening examination a) Medical screening examinations must be performed by individuals who are: i) Determined qualified by the hospital's Medical Staff Bylaws, or Rules and Regulations, which are approved by the hospital's governing body and ii) Functioning within the scope of their license and in compliance with state law and applicable Nurse and Medical Practice Acts....c) Physicians and the following categories of individuals are designated as qualified medical personnel authorized to perform a medical screening examination to determine the existence of an emergency medical condition, subject to appropriate physician supervision and established protocols"....iii) Labor and Delivery Department: labor and delivery nurses who have passed competencies and course requirements to work in labor and delivery and nurse midwives....C. Stabilization of individuals in the dedicated emergency department who have an emergency medical condition ....4. Stable for discharge - An individual is considered stable for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, reasonably could be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions....VII. DEFINITIONS Dedicated emergency department ....For....facilities, dedicated emergency department include emergency departments and labor and delivery departments. Emergency medical condition - a medical condition manifesting itself by acute symptoms of sufficient severity....such that the absence of immediate medical attention reasonably could be expected to result in: 1. 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. ..."
Closed DED Labor and Delivery medical record review of patient (Pt) # 12 revealed a 39 year old pregnant female that presented to the DED Labor and Delivery Department on 01/17/2016 at 2336 at 39 weeks gestation with her first pregnancy. Record review revealed Pt # 12 had a positive GBS [Group B Streptococcus - a type of bacteria found in a pregnant woman's vagina or rectum] test on 12/27/2015. Further review revealed "...No sensitivities sent w/ [with] PCN [Penicillin] allergy. For vancomycin [antibiotic]. ..." Review of nursing flowsheets revealed an electronic fetal monitor (EFM, a device to record fetal heart rate and uterine activity) was applied at 2349 and vital signs taken at 2350 which were temperature 97.9 F, heart rate 86, respirations 20, and blood pressure 99/65. Review of nursing flowsheets at 2353 revealed Pt # 12 reported contractions began on 01/17/2016 at 2130, denied vaginal bleeding, was "unsure" if she was leaking fluid, and reported a "mucous" vaginal discharge. On 01/18/2016 at 0008, review revealed, a cervical exam was completed by RN # 3 with "...Dilation 1.5 [centimeters], Effacement (%) 50, Station -3". Review of physician's orders at 0022, revealed a verbal/telephone order for "Microbiology-Other Orders Rupture of (Fetal) Membranes [ROM]" [amnisure test - a laboratory test to be done to check for ROM]. At 0045 review of Nursing Flowsheets revealed "...Uterine Activity....Contraction Frequency (min) [minutes] 2-6....Contraction Duration (sec) [seconds] 50-90....Contraction Quality Mild.... Resting Tone Relaxed. ..." Further review revealed "...Fetal Heart Rate....Baseline Rate 135 bpm [beats per minute]....Baseline Classification No Baseline Change....Variability Moderate 6-25bpm....Accelerations Present....Decelerations None. ..." Review revealed a physician's order, entered by RN #3 as a verbal order with readback, on 01/18/2016 at 0051, to "Discharge patient". Record review did not reveal documentation of the phone call or report given by the RN to the physician. At 0055, review of a nursing note revealed "Discharge instructions given and explained. Pt verbalizes understanding. Questions and concerns addressed. Pt discharged to home accompanied by family in NAD [no apparent distress]. Pt remains undelivered." Review of results of the amnisure test for ROM revealed it was resulted on 01/18/2016 at 0057 (six minutes after the verbal order was obtained to discharge the patient home) with a "Positive" result. Review did not reveal any notation related to the positive result. Further review revealed Pt # 12 departed the facility on 01/18/2016 at 0100.
Record review of results of a previous amnisure test on Pt # 12 to assess for ROM revealed a "Negative" result on 01/14/2016 at 0930.
Record review revealed Pt # 12 returned to the DED L&D on 01/18/2016 at 0948 (8 hours and 48 minutes after departure). Review of History and Physical, date of service 01/18/2016 at 1153, revealed "...[Pt # 12] is a 39 y.o. female G1P0 [gravida 1, para 0] at 39w5d [39 weeks, 5 days]....The patient was seen here last night and an amnisure [to test for ROM] done at 0000 was positive. The patient was discharged to home and then presented to the office today for evaluation. AFI [amniotic fluid index - estimate of the amount of amniotic fluid] normal in the office, no evidence of ROM on SSE [sterile speculum exam]. Pt sent over to the hospital due to the above findings. ..." Further review revealed a cervical exam at 1113 with dilation 4 cm, effacement 90%, and station -1. Medication Administration Record review revealed Pt # 12 received doses of intravenous Vancomycin 1 gram in 250 ml (milliliters) NaCL 0.9% (Normal Saline) on 01/18/2016 at 1146 and 2350. Review of Obstetrics Discharge Note, dated 01/22/2016 at 0828, revealed Pt # 12 delivered by Cesarean Section on 01/19/2016 at 0132 with infant apgar scores of 8 at one minute and 9 at five minutes. Further review revealed Pt # 12 was discharged home on 01/22/2016.
Staff interview on 06/01/2016 at 1215 with the Chief Nursing Officer [CNO], Nurse Manager [NM] #1, and Patient Representative [Pt Rep] #2 revealed the hospital first became aware of a grievance when Pt #12 sent an email to hospital administration and DHSR [Division of Health Service Regulation]. Interview revealed the grievance process was followed and an immediate investigation was begun. Interview revealed they learned RN #3 was on duty and the nurse who sent the amnisure test. Interview revealed RN #3 looked in the computer, saw amnisure results and thought they were the results of the test being performed that night. Interview revealed those results were negative and RN #3 called and notified MD # 4 of a negative amnisure result after which MD # 4 placed a discharge order. Interview revealed RN #3 was reviewing a test result from 01/14/2016 and at the time of the RN's review the result of the current test had not been released. The actual result of the amnisure test done the night of 01/17/2016 was positive. The next morning (01/18/2016) Pt # 12 followed up at her OB (Obstetrician) office and a physician saw the positive result from the night before. Interview revealed this MD did other checks including getting an AFI, performing both a Fern test and a nitrazine test [both test for leakage of amniotic fluid]. The AFI was normal, and both the Fern and Nitrazine tests were negative for ROM. Pt # 12 was having contractions , interview revealed, and based on this and the positive result from the night before, the MD sent the patient back to the hospital where she was subsequently admitted. If MD # 4 had known of the positive results, interview revealed, Pt #12 would not have been discharged. Further interview revealed Pt # 12 delivered on 01/19/2016 after receiving more than one dose of antibiotics. Interview revealed RN #3 was educated to watch the dates and times of test results and it was discussed with other staff in shift change huddles.
Staff interview on 06/02/2016 at 0855 with RN #3, the RN who completed the MSE on Pt #12, revealed Pt # 12 came to the hospital with contractions and unsure if her water had broken. Interview revealed RN #3 did vital signs, attached an external fetal monitor, did a physical assessment and a cervical exam. Interview revealed Pt # 12 did not have obvious ROM on exam. RN #3 then called MD # 4, reported findings, and asked for an order to send an amnisure test to the Lab. The order was received, interview revealed, and the amnisure swab sent to the Lab. Pt # 12, RN # 3 stated, was kept on the monitor, but "she was not contracting a lot....so I went to see if the results of the test were back....I saw a negative result....I called the Doctor and told her there was a negative result." RN # 3 stated "...I also told her baby looked good....[Pt # 12] wasn't contracting a lot, wasn't in a lot of pain and the patient had a follow-up appointment in the morning. The doctor gave a discharge order. ..." Interview revealed RN #3 never realized that night that the amnisure result reported was not correct. Interview revealed RN # 3 learned of the positive result when she returned to work a few days later; that when the patient went to the office, they saw the positive test result. RN # 3 stated "...the patient had not said she had been there before, when I saw the negative result, I assumed it was from that night. ..." Further interview revealed that to prevent this in the future, RN # 3 "...will look at the dates, I will do that every time. ..."
Physician interview with MD # 4 revealed she was the MD on call the night of 01/17-18/2016. Interview revealed MD # 4 did not see Pt # 12 that night. Interview revealed MD # 4 received a call from the nurse, who reported assessment information on the patient, including her chief complaint, and MD # 4 then gave the order for an amnisure test to be done. Interview revealed they keep patients in the hospital until getting amnisure results. Interview revealed that patients with a positive result are then kept for admission. Further interview revealed the patient would not have been sent home had the MD known of the positive result.
NC00116889