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Based on hospital policy review, medical record review, physician and staff interviews the hospital failed to provide an appropriate medical screening examination within the capability of the hospital's dedicated emergency department, which included physician supervision, for one (1) of 9 patients that presented to Labor and Delivery for evaluation and treatment. Additionally, the hospital is not in compliance with 42 CFR §489.20 and §489.24.

Findings included:

The hospital's Dedicated Emergency Department (DED) / Labor and Delivery Department failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including appropriate physician supervision, for one (1) of 9 patient's who presented to Labor and Delivery for evaluation and treatment (Patient #1).

Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.

Based on policy and procedure review, medical record review, and staff and physician interviews, the hospital failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's Dedicated Emergency Department (DED) / Labor and Delivery Department, which included appropriate physician supervision, for one (1) of 9 patients that presented to Labor and Delivery (L&D) for evaluation and treatment (Patient #1).

The findings included:

Review of the Hospital's "EMTALA - Emergency Medical Treatment and Labor Act" policy, effective 04/2017, revealed "...When an individual comes to the dedicated emergency department of the hospital, and a request is made on the individual's behalf for a medical screening examination or treatment, the hospital shall provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists. For (Name of Hospital A Health System) facilities, dedicated emergency departments include emergency departments and labor and delivery departments....Individuals who may perform the medical screening examination....Physicians and the following categories of individuals are designated as qualified medical personnel authorized to perform a medical screening examination to determine the existence of an emergency medical condition, subject to appropriate physician supervision and established protocols....Labor and Delivery Department: labor and delivery nurses who have passed competencies and course requirements to work in labor and delivery... ."

Review of the Hospital's policy "Obstetrical Medical Screening Examination (MSE)", effective date 08/2017, revealed "...If the QMP (Qualified Medical Personnel) completing the initial assessment is a labor and delivery (L&D) Registered Nurse (RN), the provider will be notified of the patient's arrival and assessment findings as indicated in procedures. If the MSE is performed by a L&D RN, patient discharge will occur in collaboration with the provider. Documentation will include status of obstetrical compliant (sic) prior to discharge. ..."

Review of the L&D record, on 09/10-11/2019, revealed Patient #1 arrived to L&D Triage on 08/03/2019 at 1332 as an ambulatory/walk-in for a blood pressure check. Review of a "Problem List" revealed this was an In Vitro Fertilization (IVF) pregnancy. Review of flowsheets revealed vital signs (VS) at 1344 were Blood Pressure (BP) 135/79 and Pulse (P) 79. At 1346, the Patient's temperature was noted as 98.1 and respirations 18. L&D flowsheet review revealed an electronic fetal monitor (EFM) was applied at 1347 which noted a baseline fetal heart rate of 145 and noted an external TOCO (to measure uterine activity). Membrane status was stated to be intact. Review of a Nursing Obstetrical (OB) Physical Assessment, at 1347, revealed "Pregnancy Associated Assessments" that stated Patient #1 denied headache, denied visual disturbance, and denied epigastric pain. It also noted "....Reflexes Normal .... LLE (left lower extremity) Clonus Absent .... RLE (right lower extremity) Clonus Absent. ...." Review of the OB Physical Assessment also revealed Neurological, Musculoskeletal, Respiratory, Cardiac, Gastrointestinal, and Genitourinary assessments were within defined limits (WDL). The Peripheral Vascular assessment was stated as WDL except 2+ RLE edema and 2+ LLE edema. Further record review revealed Patient #1 denied contractions, vaginal bleeding, leaking of fluid, or pain (with a pain score of 0 on a scale from 0-10) at 1346. At 1400, vital sign review revealed BP was documented as 126/78 and P 80. BP was noted as 128/84 with P 78 at 1415, and at 1430, BP was 124/82 and P 81. At 1439, mild occasional contractions were noted, the fetal heart baseline was stated as 130, with moderate variability, and accelerations present without decelerations. A note stated "Patient Reports Positive Fetal Movement". Patient #1's BP and P were evaluated again at 1445 and BP was 126/87 and P 75. Flowsheet review revealed at 1500 a BP was documented as 151/85, with a "comment" that the BP cuff was on the patient's wrist. Another BP and P were taken at 1508 and were noted to be 134/85 and 75 respectively. SpO2 during the time period ranged from 97 -100% on room air. A complete blood count and comprehensive metabolic panel were verbally ordered and obtained as was a point of care urinalysis. Review of the urinalysis, resulted at 1350, revealed a "Trace" urine protein. At 1508 the EFM noted a fetal heart baseline of 135, with moderate variability, accelerations present, and no decelerations noted. A note indicated fetal movement was "...Observed; Palpated; Patient Reports Positive Fetal Movement. ..." Review of Uterine Activity revealed no contractions noted. Record review revealed a Discharge Order was verbally received at 1511 and electronically signed by the MD at 1526. L&D record review did not reveal any medications ordered or given to Patient #1 during the visit. Record review revealed Patient #1 was discharged at 1515 on 08/03/2019. Review of the L&D document did not reveal a physician saw Patient #1 during the L&D visit. Review revealed a Registered Nurse conducted the entire medical screening examination. Record review did not reveal specific notation of calls to a MD, but did reveal verbally ordered labs and discharge. Further review did not reveal a physician reviewed Patient #1's L&D medical record. Record review did not show evidence of supervision of care and stabilization by a physician.

Medical record review revealed Patient #1 returned to Hospital A's OB triage unit on 08/14/2019 at 0607 (11 days later) with contractions and leaking of greenish fluid and was diagnosed with fetal demise. Review revealed Patient #1 vaginally delivered a non-viable infant on 08/14/2019 at 2056. Review of the discharge summary dated 08/15/2019 at 1039 revealed "...Plan: ....Stable for discharge home. 2. F/u in 1 week for BP check. Normal to mild BP since delivery. No sx of preeclampsia....Pt doing ok and desires discharge home. Normal lochia. Denies HA (headache), visual changes or RUQ (right upper quadrant) Pain. + voiding. Coping well with good family support ...Musculoskeletal: Right lower leg: Edema (1+ edema) present. Left lower leg: Edema (1+ edema) present ..." Review revealed Patient #1's last BP at 0824 on 08/15/2019 was 135/79. Review revealed Patient #1 was discharged home 08/15/2019.

Interview on 09/10/2019 at 1625 with RN #1, who cared for Patient #1 on 08/03/2019, revealed the RN did not recall the patient. Interview revealed when patients came in for blood pressure checks, the RN placed them on a Fetal Monitor, did serial blood pressure checks and notified the provider. Interview revealed RN #1 always notified the provider and there should be documentation to show the notification. Interview revealed RN #1 did not recall this situation and was not sure why she had no documentation of the physician notification. RN #1 stated the provider had to be called to get a discharge order and stated the "After Visit Summary" (discharge instructions) would not have printed without an order.

Telephone interview with Medical Doctor (MD) #2, on 09/11/2019 at 1545, revealed MD #2 did not recall the patient's visit on 08/03/2019 and did not recall any phone calls about the patient or requests for an ultrasound on Patient #1's 08/03/2019 visit. Interview revealed MD #2 did not realize all that had happened with Patient #1 until her post-partum visit. Interview revealed, after MD #2 reviewed the Medical Record, the BPs noted during the 08/03/2019 visit did not raise concerns nor did the lab results raise concerns. Interview revealed the CMP (Comprehensive Metabolic Panel) was "fine", the CBC (Complete Blood Count) showed a "little anemia", and the urinalysis showed 1+ protein, which MD #2 stated would only be significant if it was associated with increased BP. In reviewing and hearing about the record, MD #2 stated there was nothing he heard that was irregular or made him think he needed to deliver the patient sooner. Interview revealed he did not recall if he saw Patient #1 on that visit, but stated if he did not note anything in the record, he probably did not see the patient.

In summary, Patient #1 arrived to Labor and Delivery seeking a blood pressure check for possible pregnancy related hypertension. The record revealed the Registered Nurse conducted the medical screening examination and failed to reveal specific documentation to demonstrate review of the record and supervision of the care by the physician.