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Based on review of medical records, ambulance trip reports, and Policy and procedures and interviews the facility failed to ensure that an individual who presented to the dedicated emergency department with presenting signs and symptoms of vaginal bleeding and abdominal pain was provided an appropriate medical screening examination that was within the capability and capacity of hospital to determine whether or not an emergency medical condition existed for 1 (#14) of 25 sampled patients. Refer to findings in Tag A-2406.

Based on review of medical records, ambulance trip reports, and Policy and procedures and interviews the facility failed to ensure that an individual who presented to the dedicated emergency department with presenting signs and symptoms of vaginal bleeding and abdominal pain was provided an appropriate medical screening examination that was within the capability and capacity of hospital to determine whether or not an emergency medical condition existed for 1 (#14) of 25 sampled patients.


Findings:


Closed clinical record review on 3/14/2017 for Patient revealed that Patient #14 presented by ambulance to Hospital A's DED on 02/17/2017 at 1323 (Visit #2). Review of the ambulance run report revealed Patient #14 complained of abdominal pain, vaginal bleeding, and nausea, with vital signs of BP 106/58; P 85; R 18; and SpO2 100. Patient #14 received a Saline Lock IV, and 4 mg (milligrams) Zofran IV, which helped relieved her nausea symptoms while enroute to Carolina East Medical Center (Hospital A). Patient #14's vital signs at 1325 were: BP 102/72; P 99; R 18; T 37.0 ° C; and SpO2 98 % RA. Review of a triage note, written by Registered Nurse (RN) #1 on 02/17/2017 at 1324, revealed, "Chief Complaint: 6 wks (weeks) preg (pregnant) vag (vaginal) bleeding abd (abdominal) pain. Seen here last night for same and had Vag US 'empty sac' and HCG had dropped. Told was poss (possibly) aborting. Told to come back for bleeding. Is having some cramping. Using 1 pad/hr (hour)..." Review of an ED Irregular Discharge note, written by RN #1 on 02/17/2017 at 2046 (6 hours and 23 minutes after presentation to the DED), revealed, "...Left Without Treatment... ED Irregular Discharge Comment: Called x (times) 2 no answer." There was no documentation in the medical record to indicate that patient #14 was re-evaluated by a qualified medical person for her presenting signs and symptoms complaint of abdominal pain and vaginal bleeding when she presented to the hospital for a second visit on 2/17/2017.

Telephone interview with MD #1 on 03/15/2017 at 1345, revealed, Patient #14's MSE was standard for her complaint, she was stable for discharge, and received appropriate discharge instructions.

Interview on 03/15/2017 at 1020 with RN #1 revealed he recalled Patient #14. Interview revealed her vital signs were stable to send her to triage. RN #1 recalled 02/17/2017 to be an extremely busy day for Hospital A's DED. Patient #14 reported her vaginal bleeding was saturating less than 1 sanitary pad per hour. RN #1 advised Patient #14 to inform him if her rate of vaginal bleeding increased to saturating 2 sanitary pads per hour, or if there were any other changes in her condition. Interview revealed Patient #14's mother verbalized concern with the wait time, and questioned why Patient #14 was not being assessed by a L&D physician, to which RN #1 informed her that patients with a gestational age less than 20 weeks were initially evaluated by ED physicians, who would consult an L&D physician if necessary; and that Patient #14 would be placed in a treatment room as soon as possible. RN #1 did not recall ever seeing an IV access in Patient #14. Interview revealed during Patient #14's wait, there was constantly new patients waiting for triage, but a visual assessment of patients waiting in the lobby was conducted between each new patient. RN #1 recalled seeing Patient #14 step outside once, after which she returned to the lobby to continue to wait. When a room became available and Patient #14 was called, there was no response and she was unable to be located in the lobby. Interview revealed RN #1 had conferred with the DED Charge Nurse, who was aware of the extended wait times for DED treatment rooms.

Policy and Procedure

The facilities Policy and Procedure titled "EMTALA Treatment of Patients with Emergency Medical Conditions: Policy number: 100.54; Effective Date: 11/19/14. The policy revealed in part, "POLICY: it is the policy of Carolina East Medical Center ("Carolina East") that all of the following individuals presenting to a dedicated emergency department including women in labor, be given an appropriate medical screening examination by a qualified medical person ("Provider") which includes all of the following: physician, advanced practice registered nurse, physician assistant or appropriately trained registered nurse, to determine whether or not an emergency medical condition exists: Individuals who request, ...examination or treatment for a medical condition ...if the Provider determines that an emergency medical condition exists, or that a woman is in labor and having contractions, the patient shall be treated ...DEFINITIONS: Capability means having qualified personnel and facilities available at the hospital to provide a medical screening exam and treatment as required to stabilize the individual's medical condition. Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment, and encompasses such things as numbers and availability of qualified staff, beds, and equipment as well as the hospital's past practices of accommodating additional patients in excess of its occupancy limits. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual ...in serious jeopardy; serious impairment to any bodily function."

Interviews
Interview on 03/15/2017 at 1000 with the DED Charge Nurse she did not specifically recall Patient #14. Interview revealed patients that present with unstable vital signs by ambulance do not go to triage. Interview revealed, "We try not to send patients that have an IV or have received medications from EMS (ambulance), but sometimes it is unavoidable." Interview revealed that 02/17/2017 was a "very busy" day for Hospital A's DED.

Hospital B, closed medical record review on 03/15/2017 revealed Patient #14 presented to Hospital B on 02/17/2017 at 2203, with vital signs as follows: BP 120/80; P 105; R 18; SpO2 100%; and T 97.6 ° F (Fahrenheit). Review of a provider note, written by MD #2 on 02/18/2017 at 0620, revealed, "...Chief Complaint: VAGINAL BLEEDING. Still present. The symptoms are described as mild. The patient has had intermittent, crampy pelvic pain. She has had abnormal bleeding described as spotting and passing slots and tissue. The bleeding has required use of about 2 pad per day. No abdominal pain, vaginal pain, low back pain, flank pain or vaginal discharge. No vaginal itching, pain with urination, urinary frequency, urgency of urination or hematuria. Currently pregnant. In 1st trimester. Recently diagnosed. Pregnancy confirmed with home test... Recent medical care: The patient was seen recently at another facility in the emergency department. (Several times. QN (HCG Total) was 250 2 days ago, and 160 or 170 yesterday.) ... Bedside Pelvic Sonogram: Endometrial wall thickening is present. No free fluid. No intrauterine pregnancy. No visible gestational sac or yolk sac. The exam was performed by me. Transvaginal views were obtained... HCG: Urine HCG positive Serum 71... Pt with likely incomplete AB with HCG level dropping daily. No abd or pelvic ttp (tenderness to palpation) and lower susp (suspicion) of ectopic although this was disc (discussed) extensively with pt as HCG level may be unreliable - disc return precautions and need for close f/u (follow up). Not a RhoGAM candidate. Disposition: Discharged. Condition: good and stable. CLINICAL IMPRESSION: Incomplete spontaneous abortion. No complications..." Review revealed other labs resulted at Hospital B to be unremarkable.

The facility failed to ensure that an appropriate medical screening examination was provided that was within the capability and capacity of the hospital to determine whether or not an emergency medical condition existed for Patient #14 on 2/17/2017.