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Based on medical record review, staff interview, and review of facility policy and procedures it was determined the facility was not in compliance with 42 CFR 489.24. The facility failed to provide a complete medical screening exam for one patient (#5) of twenty patients sampled (see A2406).

Based on medical record review, staff interview, and review of policy and procedure it was determined the facility failed to ensure an appropriate medical screening examination was provided to determine whether or not an emergency medical condition existed for one (#5) of twenty patients sampled.

Findings include:

Review of the medical record for patient #5 revealed the patient arrived at the facility's ED (Emergency Department) on 6/25/2014 at 2:43 pm. The patient's complaint was abdominal pain that started approximately 2 hours prior to arrival. Nursing triage documentation revealed the patient was 32 weeks gestation and was seen by her Obstetrician in the morning with no problems noted. The patient was noted to be a unaccompanied walk in.

At 4:58 pm the ED physician performed a medical screening exam. Physician documentation revealed the patient was 32 weeks gestation presenting with 2 hours of constant mild abdominal "pressure". The patient denied flank pain, vomiting, diarrhea, dysuria, vaginal bleeding, discharge, odor, or rash. The symptoms were noted to be very mild and the patient had not had any prenatal complications. Physician physical exam revealed the abdomen was soft, non-tender, no guarding, no rebound, and the gravid uterus was non-tender.

Review of the ED course revealed physician documentation stated the patient looked well and had no pain on exam. Documentation revealed the patient had concern that she may be having contractions. Physician documentation stated he did not suspect the patient was having contractions and was safe to drive to labor and delivery at a nearby facility to be evaluated on a tocometer (an instrument for measuring and recording uterine contractions). Nursing documentation revealed FHT (Fetal Heart Tones) at 5:11 pm were 130's, strong and regular. Review of the physician documentation revealed no evidence the patient's obstetrician was notified and no other testing was performed. The physician's primary impression was third trimester abdominal pain and the patient was discharged at 5:13 pm.

Review of the discharge instructions stated the patient was to drive directly to labor and delivery at another local acute care hospital to be evaluated for pre-term uterine contractions. Nursing documentation revealed at 5:13 pm the patient was discharged from the ED. Review of the physician documentation revealed no evidence the physician notified the other local acute care hospital of the patient's instructions to go to labor and delivery for evaluation of uterine contractions.

Review of the facility policy #302-RI-124, " EMTALA - Florida Medical Screening Examination and Stabilization ", effective 2/23/2012, states 4(e)(ii) Pregnant Women: the medical records should show evidence that the screening examination includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membranes (i.e., ruptured, leaking and intact), to document whether or not the woman is in labor. A woman experiencing contractions is in true labor unless a physician, certified nurse-midwife or other QMP (Qualified Medical Personnel) acting within his or her scope of practice as defined by the hospital's medical staff bylaws and State practice acts, certifies that after a reasonable time of observation, the woman is in false labor.

Review of the medical record for patient #5 revealed the patient was triaged at 4:23 pm, a medical screening exam performed at 4:58 pm, and the patient was discharged at 5:13 pm. The fetal heart tones were noted at 5:11 pm to be 130's, strong, and regular. There was no evidence the medical screening exam included the minimum examination of a pregnant woman to include on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, or status of membranes.

Interview with the VP of Quality and Risk, the ED Director, and the CMO on 7/01/2014 at 12:00 pm confirmed the above information.