HospitalInspections.org

Based on review of the hospital EMTALA (Emergency Medical Treatment and Labor Act) policies, staff/physician and record reviews, the facility failed to ensure staff followed their policies and did not provide 1 out of 20 patient records sampled from July 2020 - January 2021 (Patient 2) with a medical screening examination sufficient to determine whether or not an emergency medical condition existed.

Findings are:

A. Review of facility policy titled "MEDICAL SCREENING & TRANSFER" dated 9/2020 defines an Emergency Medical Condition (EMC) as:
1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in a. "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; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part; or
2. Pregnant Women with Contractions. With respect to a pregnant woman who are having contractions, a medical condition for which: a. There is inadequate time to effect a safe transfer of the woman to another hospital before delivery; or b. Transfer may pose a threat to the health or safety of the woman or the unborn child.

A Medical Screening Examination (MSE) is defined as: An examination within the capability of Hospital's Dedicated Emergency Department (DED)--including ancillary services routinely available to the dedicated emergency department-- to determine with reasonable clinical confidence whether an EMC exists. The MSE must be provided by "qualified medical personal".

Upon presentation on Hospital Property, an individual who is not otherwise a Hospital patient shall be provided an appropriate MSE within the capabilities of the DED.

It is the policy of (this hospital) to provide a MSE to all individuals presenting for emergency medical treatment within (this hospital) capabilities and without regard to the particular medical or specialty services sought. (This hospital) will not deny evaluation, treatment, or stabilization to any individual on the basis of his or her perceived or actual: ability to pay; insurance coverage; race; national origin; sex; age or disability. (This hospital) will not deny evaluation, treatment or stabilization to any individual on the basis of his or her presenting complaint, condition, or because his or her personal physician is not a member of the Hospital Medical Staff.

MSE to Confirm Labor: All individuals requesting examination for confirmation of the onset of labor --ie., pregnant women experiencing contractions--will be provided a MSE, despite the fact that (this hospital) does not operate or maintain obstetrical services.

B. Review of the facility Emergency Room Central Log revealed on 1/9/2021 at 20:45 (8:45 PM) a 26 year old female, name "unknown" presented to the emergency department. In the column labeled "Minutes Spent w/Patient" staff entered "0", in the column labeled "Minutes between Provider Notification and arrival" staff entered "0", in the column labeled "Nature of Injury/Illness" staff entered "30 wks pregnant, contractions, discharge", in the column labeled "Refused Treatment" staff entered "X". Staff did not enter any information (left blank) in the columns labeled "Provider Arrival Time", "Emergency", "Non-Emergency", "Trauma", "Did Provider Evaluate", "Treatment/Stabilization", "Admitted", "Transferred", "Receiving Facility", "Treated and Discharged." Staff entered "20:48: (8:48 PM) in the column labeled "Time" and did not enter any information (left blank) the column labeled "Instruction Provided."

C. In an interview on 1/13/21 at 5:40 PM, ED nurse Registered Nurse (RN A) stated that patient (Patient) 2 came to the ED entrance on 1/9/2021. RN A opened the door and the patient asked "am I in the right place?" RN A stated that Patient 2 said she was "26 years old, 30 weeks pregnant having contractions and vaginal discharge." RN A stated, "she asked if we provided OB (obstetrical) care." RN A stated she told Patient 2 that they are a small hospital and OB care is limited, that they have a doppler (machine to hear heart beat) and an emergency delivery kit, and told the patient we could examine her but would probably have to transfer her to (Hospital B). RN A stated she told the patient she could call the provider on call and escorted Patient 2 to the nursing station. The on call provider (Nurse Practitioner- NP) B was called and informed that the patient was asking about OB care. The NP B said we don't have a TOCO (a machine to monitor uterine contractions), Fetal Monitor or infant warmer. RN A said the patient said "OK, I am going to (Hospital B) then left." RN A said "I didn't get the patient's name."

D. In a phone interview on 1/13/21 at 2:00 PM, NP B confirmed she was the practitioner on-call on 1/9/21. When asked what NP B knew about (Patient 2) on 1/9/21 she stated, "I got a call Saturday evening after 8:00 PM, the nurse said there was a 30 week pregnant lady asking if she should be (at this hospital) and wanted to know if we had OB capabilities." "RN A said the patient was not asking to be seen, she just wanted to know if she was in the right place." "I told the RN we could evaluate & treat the patient and if she had an OB problem, we would send the patient to (Hospital B), but then the RN said the patient left."

Based on medical record review, nursing interviews, provider interviews, patient interview and review policies and procedures related to EMTALA the facility failed to provide 1 out of 20 patient records sampled from July 2020 - January 2021 (Patient 2) with a medical screening examination (MSE) sufficient to determine whether or not an emergency medical condition (EMC) existed. This failure has the potential to place all ED patients presenting to the Emergency Department (ED) at risk of serious harm or death from an untreated EMC.

Findings are:

A. In a telephone interview on 1/19/21 at 10:15 AM, Patient 2 stated "That Saturday (1/9/21) I went to the Osmond Hospital because I was having real bad low back pain, it felt like back labor, I also had some discharge and felt terrible." "We just moved here and live 10 minutes from the hospital, so I went there." "I pressed the ED button, I waited about 5 minutes before anyone showed up." "They said they can't help pregnant women, they don't have a monitor and don't do deliveries." "They took me to the nurses desk." "The RN (Registered Nurse) called the on call doctor and she told them about me." "The RN said I needed to drive over to (Hospital B) (35 miles away) for OB care." When asked if she was offered to be placed in a room and be examined, Patient 2 stated "No". "I was really frustrated, I tried calling the hospital while I was driving the 10 miles in but there was no answer." "I was having a lot of pain and felt terrible." "I drove myself to the hospital because of COVID and my significant other was home with the kids." "I thought about pulling over and calling 911 so that the ambulance would drive me there, but I made it." "Once I got to (Hospital B) they took me to the labor & delivery floor and the doctor saw me."

B. In an interview on 1/13/21 at 5:40 PM, ED nurse Registered Nurse (RN A) stated that patient (Patient) 2 came to the ED entrance on 1/9/2021. RN A stated she opened the door and the patient asked "am I in the right place?" RN A stated that Patient 2 said she was "26 years old, 30 weeks pregnant having contractions and vaginal discharge." RN A stated, "she asked if we provided OB (obstetrical) care." RN A stated she told Patient 2 that they are a small hospital and OB care is limited, that they have a doppler (machine to hear heart beat) and an emergency delivery kit, and told the patient we could examine her but would probably have to transfer her to (Hospital B). RN A stated she told the patient she could call the provider on call and escorted Patient 2 to the nursing station. The on call provider (Nurse Practitioner- NP) B was called and informed that the patient was asking about OB care. The NP B said we don't have a TOCO (a machine to monitor uterine contractions), Fetal Monitor or infant warmer. RN A said the patient said "OK, I am going to (Hospital B) then left." RN A said "I didn't get the patient's name. I called the DON (director of nurses) right after this happened and told her what happened. I didn't get a name, she told me to call (Hospital B) and I called and told the OB Supervisor, that a patient came in asking about OB care and told options were limited and she said she was going to your hospital"

C. In a phone interview on 1/13/21 at 2:00 PM, NP B confirmed she was on call on 1/9/21. When asked what NP B knew about (Patient 2) on 1/9/21 she said, "I got a call Saturday evening after 8:00 PM, the nurse said that there was a 30 week pregnant lady there asking if she should be (at this hospital) and wanted to know if we had OB capabilities." "The RN A said the patient was not asking to be seen, she just wanted to know if she was in the right place." "I told the RN we could evaluate and treat the patient and if she had an OB problem we would send her to (Hospital B), but then the RN said she (the patient) left."

D. Review of Patient 2's 1/9/2021 medical record from Hospital B revealed that Patient 2 arrived at 2135 (9:35 PM) complaining of feeling terrible and having severe back pain. Documentation showed that Patient 2 began having right sided back pain rated 8 out of 10 (10 being the most severe pain), and nausea/vomiting beginning at 7:00 PM (on 1/9/21). OB Physician A examined the patient and ordered imaging studies including a CT scan (special type of x-ray) of the abdomen and pelvis, and a renal ultrasound (pictures of the kidney's using high frequency sound waves) which showed right sided hydroureteronephrosis (swelling of the kidney and ureter [tube draining kidney]). Additionally, various blood tests were obtained including a Complete Blood Count (CBC) which showed that Patient 2 had an elevated white blood cell count (WBC) at 19.7 [normal range is 4-10, an elevated WBC indicates a possible infection]. A lab test of Patient 2's urine showed a high level of red blood cells 60-80 (normal red blood cell count in the urine is 0-5); 10-20 white blood cells (normal count in the urine is 0-5); 1 + bacteria (should be 0); and the pH (acid/base level) was alkaline at 8.5 (normal pH range is 4.5-8.0, when the urine is more alkaline, there is a greater likelihood of bacteria growing at a rapid rate and as a result a bladder infection can occur more easily). Further documentation showed that Patient 2 was admitted as an inpatient for ongoing examination and treatment including intravenous (IV) fluids for hydration, IV pain medications for severe pain, and IV antibiotics to treat a kidney infection.

E. In a telephone interview on 1/19/21 at 2:35 PM, Hospital B's OB physician A stated that at the time of admission on 1/9/21, Patient 2 had an emergency medical condition. When I saw her she had pyelonephrosis (disease of the kidney) and pyelonephritis (kidney infection). She was 29-30 weeks pregnant. She had a lot of pain. If she would not have passed the kidney stone and/or if the urologist wouldn't have been there in the morning, I would have transferred the patient to an Omaha hospital. She mentioned that she was at an outside hospital. If she had been seen at the other hospital they could have transferred her. I wouldn't have put her in a car to drive here (35 miles). She could have passed out from the pain, or gotten septic.