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Based on medical record review and review of the facility's "Medical Staff Bylaws and Rules and Regulations," the facility failed to provide an appropriate medical screening exam (MSE) to evaluate a pregnant patient (25 weeks gestation) for other possible emergency medical conditions related to pain and possible gallstones after triage in the Labor and Delivery Department ruled out fetal distress or complications for one (1) of 20 medical records reviewed; Patient #1.

Findings Include:

Review of Patient #1's medical record for 09/01/2024 reveals Patient presented to the Emergency Department (ED) at 2:28 p.m. with a complaint of abdominal pain, 25 weeks pregnant, and possible gallstones. Triaged by Registered Nurse (RN) #1 at 2:46 p.m. and report called to RN # 2 in Labor and Delivery department because patient is over 20 weeks gestation in pregnancy and patient transported to the Labor and Delivery Department.

Review of Patient #1's medical record "OB-Progress Notes" for 09/01/2024 at 2:55 p.m. revealed the Patient was triaged by Obstetric Registered Nurse (OBRN) #2. Patient #1 complaint of abdominal pain that worsens at times with worse pain this morning, denies contractions, vaginal bleeding or fluid leaking. Patient #1 states, " ...Primary Care Physician (PCP) reported seeing gallstones on a recent scan ..." no follow-up care has been scheduled. Fetal monitors placed; urinalysis obtained, no evidence of contractions, fetal distress or demise, urinalysis results protein-positive (+) one (1), blood-large, ketones -moderate, urobilinogen-one (1), bilirubin-negative, glucose-negative, nitrates-negative. The RN called the Obstetric Physician on-call, Physician #1, with results from Labor and Delivery Department triage assessment and received orders for Patient #1's discharge and to follow-up with clinic or Primary Care Provider (PCP). Progress note reveals Patient #1 was discharged at 3:54 p.m.

There was no documented evidence of a history and physical exam to determine the etiology of present complaint of abdominal pain, details of pain, or presence of other symptoms which may suggest and emergent medical condition by a qualified medical practitioner.

Cross refer to A-2406/489.24(a) for further information documenting the facility's failure to complete a medical screening examination by a qualified medical practitioner (QMP) to determine if an emergency medical condition (EMC) exists.

During the Exit conference with the Director of Quality Services, Director of Compliance, Executive Director of Clinical Services, Chief Nursing Officer and the Chief Executive Officer on 10/17/2024 at 1:00 p.m. survey findings were discussed, and no further information was presented for review.

Based on staff interview, medical record review, and policy and procedure review, the facility failed to provide an appropriate medical screening exam (MSE) to evaluate a pregnant patient (25 weeks gestation) for other possible emergency medical conditions related to pain and possible gallstones within the capability of the facility's emergency department by a qualified medical practitioner to determine if an emergency medical condition (EMC) exist after triage in the Labor and Delivery Department ruled out fetal complications for one (1) of 20 medical records reviewed; Patient #1

Findings Include:

Review of Patient #1's medical record revealed the patient presented to the Emergency Department (ED) 25 weeks pregnant with a complaint of abdominal pain on 09/01/2024 and was triaged and sent to the Labor and Delivery Department for evaluation. Patient #1 was triage by a Registered Nurse (RN). Patient reported Primary Care Physician (PCP) saw gallstones on a recent scan, but no follow-up care has been scheduled. No reported vaginal bleeding, no fluid leakage, fetal monitoring shows no contractions, urinalysis results protein-positive (+) one (1), blood-large, ketones -moderate, urobilinogen-one (1), bilirubin-negative, glucose-negative, nitrates-negative. The RN called Physician with results from Labor and Delivery Department triage and received orders for discharge and to follow-up with clinic or PCP.

There was no documented evidence a medical screening exam (MSE) with a history and physical exam was performed by a qualified medical practitioner or documentation Patient #1 was sent back to the main Emergency Department (ED) for a MSE to determine the etiology of the patient's presenting complaint and if an emergent medical condition (EMC) existed that was not related to pregnancy.

Interview on 10/16/2024 at 2:00 p.m. with Physician #1, (Obstetrician-Gynecologist (OBGYN) on-call on 09/01/2024) revealed based on report received Patient #1 was not in distress, pregnancy was not in danger. Physician stated he did not send the patient back to the ED.

Interview with ED Triage nurse #1 on 10/15/2024 at 3:05 p.m. confirmed he triaged Patient #1, notified the Labor and Delivery Department and transported Patient #1 via wheelchair to Labor and Delivery. ED triage nurse confirmed this was policy and procedure for obstetrical patients over 20 weeks of gestation.

Review of the facility's policy and procedure, "Obstetric (OB) Patients Presenting to Emergency Department," #ED 554, revised date 06/01/2023, revealed " ...4. Abdominal Pain ... 1. Ambulatory patients 20 weeks or greater gestation: a. All ambulatory OB patients presenting to the Emergency Department shall register per ED procedures as outpatients b. All ambulatory OB patients will be given a triage assessment in the Emergency Department by the triage nurse. i. If the patient has an OB related problem, and is determined to have no respiratory or circulatory instability, she is to be taken to the Obstetrical Department ... c. The Obstetrical Department will be notified of the patient in the Emergency Department and patient will be transported to the Obstetrical Department by ED staff. d. The patient will be assessed by an OB nurse and the patients on-staff physician, or the on-call Obstetrician will be notified for exam. i. The obstetrician must assess the patient within a reasonable amount of time. ii. This evaluation constituted the medical screening exam as is required of all patients presenting to the Emergency Department ...".

Review of the facility's policy, "Triage/Medical Screening Exam," policy #ED 578, revised date 06/01/2023 reveals " ...An appropriate medical screening exam will be provided within the capability of the ED, including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists. ED's obligations to perform a medical screening examination shall be triggered when: (i) an individual presents to the emergency department and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition; ...Only qualified medical personnel may provide medical screening examinations ...".

During the Exit conference with the Director of Quality Services, Director of Compliance, Executive Director of Clinical Services, Chief Nursing Officer and the Chief Executive Officer on 10/17/2024 at 1:00 p.m. survey findings were discussed, and no further information was presented for review.