HospitalInspections.org

Based on record review and policy review, the hospital failed to follow their policy and maintain an appropriate Emergency Department (ED) central log for one patient (#3) out of 20 ED records reviewed from 04/01/23 through 01/30/24.

Review of the hospital's document titled, "Rules and Regulations of the Medical Staff of Texas County Memorial Hospital (TCMH)," revised 2023, showed the hospital must maintain the following for a period of no less than five years: a central log on each individual who comes to the ED. The log shall record: (1) patient identification; (2) date of service; (3) medical complaint; (4) provider name; and (5) patient disposition, including whether the patient received treatment, refused treatment or whether the patient was transferred, admitted and treated, stabilized and transferred or discharged. Patient Registration: The process of obtaining registration information should not interfere with the timeliness of the medical screening exam (MSE); ... should not include statements to a patient that would explicitly or implicitly discourage the patient from obtaining an MSE.

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition [EMC]) Guidelines," dated 05/04/09, showed the following:
- All patients presenting to Texas County Memorial Hospital's ED, or Labor and Delivery (L&D) Department, must be accepted and evaluated regardless of the patient's ability to pay.
- All patients shall receive a MSE completed by a physician, that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis.
- A MSE should include at a minimum the following: ED Log entry including disposition of patient; patient's triage (process of determining the priority of a patient's treatment based on the severity of their condition) record; vital signs (VS, body temperature [degree of hotness or coldness of the body, normal is 98.6], blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80], heart rate [the number of times a heart beats within a certain time period, usually a minute, normal for an adult is 60 to 100 per minute] and breathing rate); history; physical exam of affected systems and potentially affected systems; exam of known chronic conditions; necessary testing to rule out an EMC; notification and usage of on-call physicians to diagnose and/or stabilize the patient as necessary; VS upon discharge or transfer; and complete documentation of the MSE.
- An EMC is any condition that is a danger to the patient or unborn fetus (unborn child) or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future.
- EMCs include pregnancy with contractions (the periodic tightening and relaxing of the uterine muscle) [defined as unstable].

Review of the hospital's Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) department policy titled, "Transfer of a Patient to Another Facility," dated 02/2016, showed all patients will receive a MSE by the OB Department qualified medical examiner (Registered Nurse (RN) or Physician) regardless of condition, race, religious preference, or ability to pay.

Review of Patient #3's medical record showed she was a 19-year-old, 38-week pregnant female who presented to the OB Department on 04/18/23 at 9:11 PM with a chief complaint of contractions and possible rupture of membranes (a fluid-filled bag [amniotic sac] that surrounds and protects a fetus). She was evaluated, found to not be in labor, and was discharged home on 04/19/23 at 1:23 AM.

Review of Patient #3's medical record from Hospital B showed she presented to Texas County Memorial Hospital on 04/20/23 and was told that they had no OB physicians available and that she would have to be transferred and advised to be seen elsewhere. Patient #3 then presented to Hospital B on 04/20/23 at 8:30 AM, where she was evaluated and admitted for labor induction due to elevated blood pressures.

Based on interview, record review and policy review, the hospital failed to maintain an accurate central log for patients who presented to the Emergency Department (ED) for care. The hospital failed to enter one patient (#3) on the log out of 20 ED records reviewed from 04/01/23 through 01/30/24.

Review of the hospital's document titled, "Rules and Regulations of the Medical Staff of Texas County Memorial Hospital (TCMH)," revised 2023, showed the hospital must maintain the following for a period of no less than five years: a central log on each individual who comes to the ED. The log shall record: (1) patient identification; (2) date of service; (3) medical complaint; (4) provider name; and (5) patient disposition, including whether the patient received treatment, refused treatment or whether the patient was transferred, admitted and treated, stabilized and transferred or discharged. Patient Registration: The process of obtaining registration information should not interfere with the timeliness of the medical screening exam (MSE); ... should not include statements to a patient that would explicitly or implicitly discourage the patient from obtaining an MSE.

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition [EMC]) Guidelines," dated 05/04/09, showed the following:
- All patients presenting to Texas County Memorial Hospital's ED, or Labor and Delivery (L&D) Department, must be accepted and evaluated regardless of the patient's ability to pay.
- All patients shall receive a MSE completed by a physician, that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis.
- A MSE should include at a minimum the following: ED Log entry including disposition of patient; patient's triage (process of determining the priority of a patient's treatment based on the severity of their condition) record; vital signs (VS, body temperature [degree of hotness or coldness of the body, normal is 98.6], blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80], heart rate [the number of times a heart beats within a certain time period, usually a minute, normal for an adult is 60 to 100 per minute] and breathing rate); history; physical exam of affected systems and potentially affected systems; exam of known chronic conditions; necessary testing to rule out an EMC; notification and usage of on-call physicians to diagnose and/or stabilize the patient as necessary; VS upon discharge or transfer; and complete documentation of the MSE.
- An EMC is any condition that is a danger to the patient or unborn fetus (unborn child) or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future.
- EMCs include pregnancy with contractions (the periodic tightening and relaxing of the uterine muscle) [defined as unstable].

Review of the hospital's Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) department policy titled, "Transfer of a Patient to Another Facility," dated 02/2016, showed all patients will receive a MSE by the OB Department qualified medical examiner (Registered Nurse (RN) or Physician) regardless of condition, race, religious preference, or ability to pay.

Review of the hospital's document titled, "Call Schedule, 4/1 to 4/30, 2023," revised 04/26/23, showed there was an OB physician on call on 04/18/23 and 04/20/23. On 04/19/23, there was no OB physician listed on call and it listed OB as being on diversion.

According to the EMResource website page for the State of Missouri, Texas County Hospital had been accepting Emergency Care OB since 03/09/23. There were no other updates listed.

Review of Patient #3's medical record showed she was a 19-year-old, 38-week pregnant female who presented to the OB Department on 04/18/23 at 9:11 PM with a chief complaint of contractions and possible rupture of membranes (a fluid-filled bag [amniotic sac] that surrounds and protects a fetus). She was evaluated with a normal urinalysis (a laboratory examination of a person's urine), tocodynamometry (TOCO, device that measures the intensity, frequency, and duration of contractions), sterile vaginal exams (SVE, exam to determine progress and status of labor), negative ROM plus test (rapid test for the detection of amniotic fluid in vaginal secretions of pregnant women with signs and symptoms of rupture of membranes), and fetal non-stress tests (NST, a screening test used in pregnancy to assess fetal status by means of the fetal heart rate and its responsiveness). It was the determination of the on-call OB physician that she was not in labor. Her BPs were evaluated regularly and on 04/19/23 at 12:30 AM BP was 140/97; a manual recheck showed a BP of 112/82. Upon discharge her BP was recorded at 134/81. Nursing reviewed discharge instructions and Patient #3 denied any questions or concerns at that time. Patient #3 walked off the OB Department in stable condition on 04/19/23 at 1:23 AM.

There was no record of Patient #3 being seen at Texas County Memorial Hospital after 04/18/23.

Although requested, the hospital was unable to provide video footage of the ED entrance and reception desk for 04/20/23.

Review of Patient #3's medical record from Hospital B showed the following:
- On 04/20/23 at 9:01 AM, a nursing admission assessment showed Patient #3 presented to the unit at 8:30 AM with a chief complaint of vaginal bleeding and high blood pressure. Her symptoms reportedly started at 4:00 AM that morning.
- Physician documentation showed that Patient #3 was 39-weeks pregnant. Patient #3 reported that she presented to Texas County Memorial Hospital L&D due to concerns for bleeding. She was told they did not have any delivering doctors on call, so she was advised to be seen elsewhere. She presented to Hospital B for further evaluation. In Hospital B's L&D Triage, she was found to have high blood pressure, headache and seeing flashes of light that made her dizzy. She had no history of elevated blood pressure previously during the pregnancy. She was admitted for induction of labor due to concerns for gestational hypertension (a form of high blood pressure in pregnancy).
- Patient #3 was discharged on 04/23/23 after spontaneous vaginal birth on 04/21/23.

During a telephone interview on 02/14/24 at 4:51 PM, Patient #3 stated that she presented to Texas County Memorial Hospital on 04/18/23 because she thought she was in labor. She was told that she was not in labor and was discharged home. On 04/20/23, she woke up in the morning with vaginal bleeding and went back to Texas County Memorial Hospital at around 5:00 AM. She presented to the ED reception desk and the receptionist called OB. The receptionist gave Patient #3 the phone, and the OB staff told her that there was no OB physician available, but the OB staff "could look at her; but if anything was seriously wrong, they would have to transfer her to another hospital. If she thought anything was seriously wrong, she could go to another hospital." Patient #3 then left the hospital and presented to Hospital B, where she was admitted for high blood pressure. Patient #3 verified that she never went to the OB department at Texas County Memorial Hospital and never received an evaluation on 04/20/23.

During an interview on 01/30/24 at 11:45 AM, Staff D, Registration Clerk, stated that she greeted patients, registered them (name, date of birth, and chief complaint), then sent them back to triage. With OB patients, she registered the patient, called the OB department for direction on where to send the patient (depending on how far along in their pregnancy they were), and then walked the patient down to OB. Patients were never turned away.

During an interview on 01/31/24 at 9:05 AM, Staff H, OB RN, stated that on 04/18/23, Patient #3 presented with leaking for about two days. She was evaluated and was not in labor. She did not remember if any OB patients came in on 04/19/23 or 04/20/23. They did go on OB diversion a couple of times last year. There was always an OB nurse in the hospital available to assess OB patients. When they were on OB diversion and a pregnant woman came in with an OB complaint, they were triaged and seen by the OB nurses. The ED physician would oversee their care, and patients would have been treated and could have delivered at the hospital while on OB diversion. If needed, they could also transfer a stable OB patient.

During an interview on 01/30/24 at 12:10 PM, Staff G, ED RN, stated that they never turned patients away. OB patients greater than 20 weeks pregnant were sent to the OB department. If OB was on diversion, they would have called the OB Department, and the ED physician would care for the patient.

During an interview on 01/30/24 at 11:55 PM, Staff F, ED Medical Director, stated that if a pregnant woman presented with an OB complaint; if they were over 20 weeks pregnant, they were sent to the OB department for the MSE. If OB was on diversion, registration would not turn the patient away. They would have been seen and treated in the ED.