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Based on staff interview and review of medical records, hospital policies, and staff credentials, 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 an appropriate MSE, for 1 of 3 pregnant patients (#7) who had other medical conditions in addition to the pregnancy and whose records were reviewed. Findings include:

Refer to A2406 as it relates to the failure of the hospital to provide an appropriate medical screening examination.

Based on staff interview and review of medical records, hospital policies, and credentials forms, it was determined the hospital failed to ensure an appropriate MSE was provided to 1 of 3 pregnant patients (#7) who had other medical conditions in addition to the pregnancy and whose records were reviewed. This resulted in the inability of the hospital to ensure an emergency medical condition did not exist. Findings include:

Patient #7's medical record documented a 17 year old female who presented to the hospital on 7/25/10 at 1:31 AM. The face sheet stated her reason for admission was "22 WEEKS PREG[NANT] HIT IN STOMACH." She was taken to the obstetrical unit for medical screening. Her "LD-Admission Assessment," written by Staff A, an RN, and dated 7/25/10 at 1:58 AM, stated "HOLDING ABD ON RIGHT SIDE OF ABD JUST BELOW UMBILICUS, STATES THAT WAS WHERE SHE WAS HIT." The assessment stated Patient #7's pain was 7 of 10 in intensity, constant, and sharp. The circumstances surrounding the assault were not documented.

Staff A documented on the "LD- Flowsheet," dated 7/25/10 at 1:51 AM, "HERE WITH COMPLAINT OF ABD PAIN RIGHT MED QUADRANT. STATES SHE WAS HIT HARD IN ABD BY FRIEND. HOLDING ABD WITH HAND OVER AREA WHERE SHE WAS HIT. NO REDNESS OR EDEMA NOTED. At 1:53 AM on 7/25/10, Staff A documented "HAND HELD US FOR FETAL TONES. UNABLE TO KEEP US WORKING AS BABY IS VERY ACTIVE AT THIS TIME." At 2:54 AM on 7/25/10, Staff A documented the fetus' heart rate had moderate variability. At 3:26 AM on 7/25/10, Staff A wrote "States pain almost gone. NO redness or abrasion noted on abd." Lastly, at 3:39 AM on 7/25/10, Staff A wrote "discharged amb to home." A nursing note at 2:18 AM stated the police had been notified of the assault. No other nursing notes were present in the medical record. A conversation with the physician was not documented. A telephone order from a physician was documented on 7/25/10 at 3:35 AM. The order stated to discharge Patient #7 to home and have her follow up with an obstetrician within 1 week.

No assessment of Patient #7's abdomen was documented except that it was not red or edematous. A set of vital signs for Patient #7 was not documented except for temperature and respirations at 1:58 AM on 7/25/10.

Staff A was interviewed on 8/04/10 at 7:05 PM. She stated Patient #7 was hit in the stomach. She stated Patient #7 did not complain of contractions or state fears that her unborn baby might have been harmed. She said Patient #7 complained of trauma to her abdomen. She stated Patient #7 was not having contractions. She stated after 1.5 hours, Patient #7's pain was gone. She stated she checked Patient #7's fetal heart tones and called Staff B, the physician on call. She stated Staff B was a resident. She said she told the physician Patient # 7 had been hit in the abdomen but her pain was resolving. She said she later called the physician back and received an order to discharge Patient #7. She stated, since Patient #7's pain had been relieved, she discharged the patient. She stated if Patient #7's pain had not been relieved, she would have sent the patient to the emergency room for further assessment. She stated she did not assess Patient #7's abdomen.

Staff B was interviewed on 8/04/10 at 1:05 PM. He stated he was a third year Family Practice resident. He stated he was on call for obstetrics at the hospital on 7/25/10. He stated he did not remember Patient #7 well. He said he had not seen her. He reviewed the medical record. He stated Patient #7 was not having contractions. He stated he would look for vaginal bleeding but said nothing was documented regarding bleeding. He stated Patient #7's abdominal injury was not evaluated. He stated he did not remember what verbal report he got from Staff A when he spoke to her. He stated it seemed like something more should have been done for the patient.

A form titled "MEDICAL SCREENING EXAMS IN LABOR & DELIVERY," dated 4/09/10, outlined Staff A's privileges in relation to MSEs. All of the privileges for the RN related to the assessment of labor and the health of the fetus. No privileges had been granted allowing Staff A to evaluate other medical conditions as part of an MSE. This was confirmed by interview with the Director of the Women's Unit on 8/04/10 at 7:25 PM.

The policy "Triage of Obstetrical Patient," dated 4/10, stated "If patient has been ruled out for labor but has other issues then the patient must be seen by either the OB physician or resident for these issues. If unseen by the OB physician then the patient should be transferred to the ED, after notifying the Nursing Supervisor. If patient does not wish to be seen by the ED then they must sign a waiver form and the nurse must document offer and refusal."

The Director of Quality and Risk Management was interviewed on 8/06/10 at 8:20 AM. She confirmed the policy "Triage of Obstetrical Patient" required further evaluation of patients who have other medical issues. She stated the policy was not followed in the case of Patient #7.

Hospital staff failed to provide a complete MSE to Patient #7.