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Based on interview and review of medical records and hospital policies, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This resulted in the lack of a MSE, or the lack of an appropriate MSE, for 3 of 16 (#1, #27, and #28) pregnant patients whose records were reviewed. Findings include:

Refer to A2406 as it relates to the failure of the hospital to provide appropriate medical screening examinations to pregnant patients.

Based on a central log review and staff and patient interview, it was determined the hospital failed to retain the medical information for 1 of 1 patient (Patient # 28), who was turned away from the hospital without being examined. This resulted in the inability of the hospital to track all patients who came to the emergency department. Findings include:

Patient #28 was interviewed on 4/28/10 at 10:20 AM. She stated she went to the hospital's emergency department the evening of 4/09/10, and without being examined, told to go on to another hospital. On 4/22/10 at 1:17 PM, the hospital's registrar was interviewed. She stated Patient #28 was a 28-year-old female who was 30 weeks pregnant. She stated Patient #28 complained of labor pains. The registrar stated she entered Patient #28's information into the hospital's central log. She said Patient #28 was told by a nurse to go to another hospital. She stated she then deleted Patient #28's information from the hospital central log.

The hospital's central log for April 2010 was reviewed on the morning of 4/22/10. It did not include the Patient #28's information.

The Director of Quality and Risk Management was interviewed on 4/22/10 at 9:20 AM. She confirmed Patient #28's information had been deleted from the central log.

The hospital failed to retain information related to Patient #28 in the central log.

Based on staff and patient interview and review of medical records and hospital policies, it was determined the hospital failed to ensure appropriate medical screening examinations were provided to 3 of 16 (#1, #27, and #28) pregnant patients whose records were reviewed. This resulted in the inability of the hospital to ensure an emergency medical condition did not exist. Findings include:

1. Patient #28 was interviewed on 4/28/10 at 10:20 AM. She stated she went to the Emergency Department at West Valley Medical Center late on the evening of 4/09/10. She said she was 30 weeks pregnant at the time. She stated she told the Registrar she had been having contractions for 1.5 hours and needed to be monitored. She stated the Registrar called the L&D Unit. She stated a nurse from that unit talked with her on the telephone while she sat in the Emergency Department. She said the nurse told her the hospital did not accept patients who were less than 35 weeks pregnant. She said the nurse told her she would have to go to another hospital (which was approximately 29 miles away.) She stated she told the nurse her physician told her to go to West Valley Medical Center if she was having contractions. Patient #28 stated the nurse said she was sorry but Patient #28 still had to go to the other hospital. Patient #28 stated she then left and went to the other hospital where she was examined and treated.

Patient #28's medical record from the receiving hospital documented a 28 year old female who presented to that hospital at 12:02 AM on 4/10/10. The "OB Triage Flowsheet," dated 4/10/10 at 12:25 AM, stated Patient #28's contractions began at 9:00 PM on 4/9/10 and were 5-7 minutes apart. The record stated her membranes were intact. The record stated she was monitored and treated until 2:05 AM on 4/10/10, when she was discharged. The record stated her contractions had stopped by then.

Staff E was interviewed on 4/22/10 at 9:40 AM. She was an RN on the L&D Unit. She stated she got a call from the Registrar at about 11:30 PM on 4/09/10. Staff E stated the Registrar told her Patient #28 was having contractions and asked to place the patient in a room. Staff E stated she told the Registrar the patient was a high risk patient and should go to another hospital. Staff E stated she talked on the telephone with Patient #28 and recommended the patient go to the other hospital. Staff E said Patient #28 was "OK" with going to the other hospital. Staff E stated she called the other hospital approximately 10 minutes after Patient #28 had left and told them the patient was coming.

The Chief Nursing Officer was interviewed on 4/22/10 at 8:45 AM. She stated a medical record had not been generated for Patient #28.

The hospital failed to provide Patient #28 with a medical screening examination to determine if an emergency medical condition existed.

2. Patient #1's medical record documented a 19 year old female who presented to the emergency department on 4/02/10 at 7:52 PM. The face sheet of her medical record indicated she was approximately 29 weeks pregnant and stated her reason for admission was "DISCHARGE." The first nursing note on the "LD-Flowsheet" was dated 4/02/10 at 8:00 PM. It stated Patient #1 complained of pelvic cramping. The flowsheet stated Patient #1 did not have signs or symptoms of a urinary tract infection but stated a urine specimen was obtained. An order for a urine test was not documented. The note did not state why the urine specimen was obtained and results of laboratory test were not included on the medical record. The nursing note on the flowsheet at 8:20 PM, stated "Dr. [name] in department. Report given on pt's c/o sharp pain to pelvic area, gestation, efm tracing. Orders received to discharge pt to home." The flowsheet stated Patient #1 was discharged at 8:40 PM. An assessment of Patient #1's pain, e.g. number on a pain scale or whether it was related to contractions, was not documented. The record did not document if the pain had resolved or decreased prior to discharge. Even though the flowsheet stated the physician had given an order to discharge Patient #1, the order was not documented.

Staff A, the RN who cared for Patient #1 on 4/02/10, was interviewed on 4/26/10 at 1:05 PM. She reviewed the medical record. She confirmed an order to discharge Patient #1 was not documented. She stated she did not describe Patient #1's pain and did not know if it was resolved prior to discharge.

Staff B, the physician noted in Patient #1's medical record, was interviewed on 4/23/10 at 10:15 AM. He stated he did not remember the patient. He stated he may have been on the floor at the time but did not see Patient #1 and said he did not know if he gave an order to discharge the patient.

In accordance with the statutorial mandated Quality Improvement Organization review, the physician reviewer on 06/08/2010, determined that the hospital did not provide an MSE that was appropriate to the individual's medical complaint(s) and symptoms. The hospital failed to provide Patient #1 with a medical screening examination to rule out the existence of an emergency medical condition.

3. Patient #27's medical record documented a 19 year old female who presented to the emergency department on 3/31/10 at 5:19 PM. The face sheet stated the reason for the visit was "34 WEEKS PREGNANT BACK PAIN." The nursing note on the "LD-Flowsheet," dated 3/31/10 at 5:25 PM, stated "pt presents with right sided back pain, pt reports that she has been cleaning all day and cleaning carpets. pt reports that she feels fetal movement, [negative] for bleeding." At 5:28 PM, the nurse documented "clean cath dipped, negative findings, dr. [name] notified, pt to dc to home." The final nursing note on the flowsheet was dated 3/31/10 at 6:05 PM. It stated Patient #27 was not having contractions. A discharge note was not documented. Patient #27's presenting complaint was back pain. The medical record did not include documentation of an assessment of her back pain. No medical history was documented. No documentation was present that Patient #27 stated she was having contractions or thought she was in labor. An order to discharge Patient #27 was not documented.

Staff D, the RN who treated Patient #27, was interviewed on 4/23/10 at 3:45 PM. She stated Patient #27 was brought to the L&D floor because she was pregnant. She stated she did not think Patient #27's back pain was related to her pregnancy. She stated she assessed Patient #27's pregnancy but did not assess her back pain. She confirmed an order to discharge Patient #27 was not documented.

In accordance with the statutorial mandated Quality Improvement Organization review, the physician reviewer on 06/08/2010, determined that the hospital did not provide an MSE that was appropriate to the individual's medical complaint(s) and symptoms. The hospital failed to provide Patient #27 with a medical screening examination for her presenting complaint of back pain.

4. The policy "MEDICAL SCREENING OF THE OBSTETRICAL PATIENT,"revised 7/04, stated the medical screening could be carried out by "Nurses with advance training following screening protocols that outline the examination and/or diagnostic work up required to determine if an emergency medical condition exists." The policy further stated "Physician's order required for patient to be discharged or observed for a longer period." As noted above, the medical records did not contain physician orders to discharge Patient #1 and Patient #27.

The hospital did not provide patients with medical screening examinations necessary to determine if an emergency medical condition existed, nor did it follow its policies related to such examinations.