HospitalInspections.org

Based on medical record (MR) review, facility policy, Medical Staff Rules and Regulations, Hospital B, (receiving hospital) MR, and interviews, it was determined Grove Hill Memorial Hospital failed to:

1. Complete an appropriate Medical Screening Examination.

2. Establish an effective policy for stabilizing patients prior to discharge or transfer.

3. Follow policy to ensure stabilizing treatment was provided for a patient who presented to the Emergency Department (ED) with psychiatric complaints.

4. Complete an appropriate transfer.

This deficient practice negatively affected one of four patients who presented to the ED with problems of pregnancy including, Patient Identifier (PI) # 8, and one of four patients who presented to the ED with altered mental status, including PI # 2, and had the potential to affect all patients treated at this facility.

Findings include:

Cross Refer to A 2406, A 2407, and A 2409 for findings.

Based on medical record (MR) review, facility policy, Hospital B, (receiving hospital) MR, and interviews, it was determined Grove Hill Memorial Hospital failed to complete an appropriate Medical Screening Exam (MSE) that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one of four patients who presented to the Emergency Department (ED) with presenting problems of pregnancy.

This deficient practice negatively affected Patient Identifier (PI) # 8 and had the potential to affect all patients treated at this facility.

Findings include:

Facility Policy: EMTALA (Emergency Medical Treatment and Labor Act) Guidelines for Emergency Department Services.

Policy Number: 2302

Revised: 08/2017

Policy:

... All patients shall receive a Medical Screening Examination that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis...MEDICAL SCREENING EXAMINATIONS: Medical Screening Exams should include at a minimum the following ...Physical exam of the affected systems and potential systems ...EMERGENCY MEDICAL CONDITIONS: An emergency medical condition is any condition that is a danger to the patient or unborn fetus ...


1. PI # 8 presented to the ED on 9/22/24 at 11:00 AM with complaints of 28 week gestation obstetrical (OB) with abdominal cramping that started at 9:00 AM.

Review of the ED Provider Note dated 9/22/24 at 11:23 AM revealed Employee Identifier (EI) # 8, ED Medical Director, documented PI # 8 was aware her OB physician had moved to another hospital and PI # 8 needed to be placed on a fetal monitor and evaluated for preterm labor.

Further review of the ED Provider Note dated 9/22/24 at 11:23 AM revealed EI # 8 documented the Final Diagnosis of Round Ligament Pain and cannot rule out preterm labor without fetal and uterine monitoring. EI # 8 documented he/she advised PI # 8 to drive immediately to the hospital where her OB physician was practicing, which was 84 miles away.

There was no documentation a pelvic exam to evaluate cervical dilation was performed.

Review of the Nursing Note dated 9/22/24 at 11:35 AM revealed a Fetal Heart Tone (FHT) assessment of 165.

Review of the ED Discharge Instructions dated 9/22/24 at 11:40 AM revealed PI # 8 was discharged and instructed to drive to another hospital for monitoring.

A telephone interview was conducted on 11/6/24 at 10:36 AM with PI # 8 who stated after the doctor had seen her the nurse told her she did not need to come there and needed to go somewhere else... "They discharged me and I went to (Hospital B, receiving hospital) and I lost my baby, I had a miscarriage."

An interview was conducted on 11/6/24 at 12:19 AM with EI # 2, Registered Nurse (RN), who stated when OB patients present to the ED, the patient is triaged, FHT are checked, and the ED physician may do a vaginal exam.

An interview was conducted on 11/6/24 at 1:00 PM with EI # 8 who stated PI # 8 had already contacted her OB doctor and was to follow up with him/her. EI # 8 stated PI # 8 was discharged and was planning to go somewhere the next morning.

An interview was conducted on 11/7/24 at 10:30 AM with EI # 1, Chief Nursing Officer, who confirmed there was no documentation a pelvic exam was performed as part of the MSE.

Review of the Discharge Summary from Hospital B revealed PI # 8 was admitted on 9/22/24 at 4:02 PM with decreased fetal movement and abdominal pain. PI # 8 experienced an Intrauterine Fetal Demise during evaluation and was admitted to Labor and Delivery for induction of labor and delivered a non-viable infant on 9/23/24.

The hospital failed to ensure that an appropriate MSE was provided for patient PI # 8 on 9/22/2024 as evidenced by failing to provide PI # 8 a pelvic examination which placed the health of safety of the patient and her unborn child at risk.

Based on Grove Hill Memorial Hospital medical record (MR) review, Hospital B, receiving hospital, MR review, Medical Staff Rules and Regulations, hospital policy, and interviews with staff, it was determined the hospital failed to:

1. To establish an effective EMTALA policy to ensure that stabilizing care was provided as required for patients prior to discharge or transfer.

2. To follow policy to ensure stabilizing treatment as required was provided for a patient who presented to the Emergency Department (ED) with psychiatric complaints.

This deficient practice affected one of four patients reviewed who presented to the ED with altered mental status including Patient Identifier (PI) # 2 and had the potential to affect all patients who present to this hospital with psychiatric complaints.

Findings include:

Grove Hill Hospital

Article XVI

Rules and Regulations

... 16.4 Emergency Services

... 16.4-2 ... All patients will be cared for under the rules of EMTALA (Emergency Medical Treatment and Labor Act)...

Hospital Policy: Psychiatric Evaluation

Policy Number: 1015

Revised: 09/2023

... Any patient accessing care at this facility who requires psychiatric treatment shall be managed through referral and transfer to a behavioral health facility and/or management through consultive psychiatric services on a temporary basis, until the patient's clinical condition has stabilized to allow for psychiatric facility transfer.

When the attending physician deems it necessary for the patient to have a psychiatric screen/evaluation, one of the following will be contacted ...

AltaPoint Telehealth

Southwest Alabama Mental Health ...

Primary Mental Health Nurse Practitioner ...

1. PI # 2 presented to Grove Hill Memorial Hospital ED on 9/5/24 at 8:05 AM via EMS with complaints of wandering in the woods because "he thinks terrorist are trying to get him."

Review of the ED Provider Note dated 9/5/24 at 8:49 PM revealed the ED physician documented "... presents with a (complaint of) walking through the woods and behaving in a strange manner ... Patient denies symptoms otherwise but admits to history of ADHD (Attention Deficit/Hyperactivity Disorder) and multiple personality disorder...Does not indicate a desire to harm self or others."

Review of the ED Provider Note, Risk Assessment, dated 9/5/24 at 8:49 PM revealed the ED physician documented "In review of patient's acute illness as a potentially lethal threat, necessity for admission considered for this patient. In my clinical judgement, this visit was emergent..."

Review of the Urine Drug Screen collected on 9/5/24 at 8:32 PM revealed the test was positive for the presence of Tetrahydrocannabinol (THC- marijuana) and negative for the presence of six other tested substances.

There was no documentation stabilizing treatment for the psychiatric emergency medical condition was provided, to include a psychiatric evaluation.

Further review of the ED Provider Note date 9/5/24 at 8:49 PM revealed a discharge diagnosis of Substance Abuse with plans to discharge home and follow up with his/her primary care provider.

Review of the ED Summary, Patient Education Documents dated 9/5/24 at 3:05 PM revealed the nurse documented PI # 2 requested to be admitted to the hospital for two days. The nurse documented the ED physician was notified of the patient's request and the ED physician stated he/she "had no reason to admit patient".

An interview was conducted on 11/6/24 at 2:50 PM with Employee Identifier (EI) # 9, ED Physician, who stated he/she remembered PI # 2 had taken something with THC that did not show up on the drug screen. EI # 9 further stated he/she was asked about admitting PI # 2 to the hospital but that his condition with the drugs was self-limiting.

An interview was conducted on 11/6/24 at 8:53 AM with EI # 1, Chief Nursing Officer, who confirmed there was no documentation a psychiatric evaluation was performed and PI # 2 was discharged to home after his/her request for admission to the hospital.

Review of the Hospital B ED Provider documentation dated 9/12/24 at 11:46 AM revealed PI # 2 presented to the ED on 9/12/24 at 11:15 AM with law enforcement for psychiatric admission medical clearance due to paranoid delusions, homicidal ideation, and multiple psychosis. PI # 2 was admitted to Hospital B's psychiatric unit with diagnoses including Bipolar Disorder Manifest as Mania with Psychotic Features, Positive Urine Drug Screen, and Homicidal Ideations.

The facility failed to ensure that stabilizing care was provided as required for Patient #2 on 9/5/2024, for his identified emergency psychiatric condition.

Based on medical record (MR) review, facility policy, Medical Staff Rules and Regulations, Hospital B, (receiving hospital) MR, and interviews, it was determined Grove Hill Memorial Hospital failed to complete an appropriate transfer for one of four patients who presented to the Emergency Department (ED) with problems of pregnancy.

This deficient practice negatively affected Patient Identifier (PI) # 8 and had the potential to affect all patients treated at this facility.

Findings include:

Facility Policy: EMTALA (Emergency Medical Treatment and Labor Act) Guidelines for Emergency Department Services.

Policy Number: 2302

Revised: 08/2017

...Grove Hill Memorial Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of their medical condition, they are legally unstable as per EMTALA...

If a patient is to be transferred for medical necessity the following guidelines must be followed:

1. A physician certification that the risks of transferring the patient are outweighed by the potential benefits...

a. The receiving hospital must give acceptance in advance...

b. Patient gives written consent for transfer.

c. The patient must be transferred by an appropriate medical transfer vehicle. The patient may not be transferred in a private passenger vehicle unless the patient refuses to be transported by ambulance...

Copies of the medical record...will accompany the patient when transferred...

Grove Hill Memorial Hospital

Article XVI: Rules and Regulations

...16.4 Emergency Services

...17.2-12 The following elements are required for each transfer:

a. appropriate transfer forms

b. MD (Doctor of Medicine) orders include written transfer order, appropriate mode of transportation, personnel to accompany patient...

c. MD documented specific Risks/Benefits discussed.

d. Physician to physician acceptance with documented names and times.

e. MD certification that the benefits outweigh the risks...

1. PI # 8 presented to the ED on 9/22/24 at 11:00 AM with complaints of 28 week gestation obstetrical (OB) with abdominal cramping that started a 9:00 AM.

Review of the ED Provider Note dated 9/22/24 at 11:23 AM revealed EI # 8 documented the Final Diagnosis of Round Ligament Pain and cannot rule out preterm labor without fetal and uterine monitoring. EI # 8 documented he/she advised PI # 8 that he/she needed to drive immediately to the hospital where her OB physician was practicing, which was 84 miles away.

Review of the ED Discharge Instructions dated 9/22/4 at 11:40 AM revealed PI # 8 was discharged and instructed to drive to another hospital for monitoring.

There was no documentation an accepting physician was contacted and accepted the patient, no documentation another hospital was contacted for acceptance, and no documentation a transfer was arranged by qualified personnel.

A telephone interview was conducted on 11/6/24 at 10:36 AM, PI # 8 was asked if a transfer was arranged, PI # 8 responded, "no, they just told me I did not need to be there. They discharged me and I went to (Hospital B, receiving hospital) and I lost my baby, I had a miscarriage."

An interview was conducted on 11/6/24 at 12:19 AM with EI # 2, Registered Nurse (RN), who was asked about the process for when OB patients arrived in the ED. EI # 2 responded "we don't check them. We triage them like we do other patients, we check FHT and the doctor may do a vaginal exam. We either send them home or transfer them. If we can get an ambulance, we will send them by ambulance.

EI # 2 was then asked if he/she remembered when PI # 8 was in the ED. EI # 2 stated PI # 8 was supposed to go see his/her OB doctor but wanted to see another OB doctor. EI # 2 stated he/she faxed everything to the hospital and EI # 2 called a nurse to let them know that PI # 8 may be coming.

An interview was conducted on 11/6/24 at 1:00 PM with EI # 8 who was asked if he/she remembered when PI # 8 was in the ED. EI # 8 stated PI # 8 had already made contact with her OB doctor before he/she came to the ED and was to follow up with him/her. EI # 8 stated PI # 8 was discharged and was planning to go somewhere the next morning.

An interview was conducted on 11/7/24 at 10:30 AM with EI # 1, Chief Nursing Officer, who stated Grove Hill Memorial Hospital had closed the OB Department on 8/17/24 and any OB patient who required further OB services was to be transferred to another facility. EI # 1 stated PI # 8 was not transferred and confirmed there was no documentation of an accepting physician and no documentation transportation by qualified personnel was offered or arranged.