HospitalInspections.org

Based on medical record (MR) review, document review, interview and in 1 (one) of 23 medical records reviewed, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA).

Findings:
The facility failed to provide an appropriate medical screening examination for Patient #1.

See Tag A2406

Based on document review, medical record review, and interview, in one (1) of 23 medical records reviewed, the facility failed to provide an appropriate medical screening examination.(Patient #1)

Findings include:

Review of the Medical Record for Patient #1 identified: a 36W0D (weeks/days) pregnant patient who presented to the Emergency Department (ED) on 9/11/2024 at 10:25 AM for vomiting. The patient was then escorted to the Obstetrics Department Triage Unit on 9/11/2024 at 10:27 AM. Patient reported 5 episodes of emesis (vomiting) since discharge yesterday and was observed for emesis in Triage. The Patient reported No vaginal bleeding. The patient reviewed their obstetrical history with a Nurse Midwife. Patient had a history of Pulmonary Tuberculosis, asthma, multiple pregnancies, and neonatal death with fetal malformation.
The patient's vital signs were Blood pressure 118/69 (normal range 90/60 - 120/80), Pulse 112 (normal range 60-100 beats per minute), Respirations 20 (normal range 12-18 breaths per minute), Temperature 97.9 degrees (normal range 97.8- 99.1 degrees Fahrenheit), and Sp02 (blood oxygen) 100% on room air (normal range: 95 - 100).

There was no documented evidence of a physical exam in the patient's medical record.

The patient remained in the ED and received assessment and treatment to include administration of intravenous fluids, pelvic exam, Fetal Heart Monitoring, and medication to stop the vomiting.

On 9/11/2024 at 3:53 PM, the patient was discharged home with a prescription for Reglan 10mg tablets, to be taken as needed for nausea and vomiting at home.

On 9/11/2024, at 3:52 PM nursing noted written by Staff A (Staff Nurse) "Patient seen by Certified Nurse Midwife (CNM) and being discharged in stable condition. Discharge instructions given and educated to return to triage if any pain, decreased fetal movement, vaginal bleeding, or loss of fluids. The Patient verbalized understanding."

On 9/11/2024, Discharge Summary, no time indicated on document, written by Staff B, Certified Nurse Midwife, (DNP), "Being observed for emesis. Patient reports feeling better and is ready to go home. Patient stated they were able to eat fruit and keep it down. Patient discharged on oral Reglan once daily as needed (PRN). Patient verbalizes understanding of how and when to take medication."

There was no documented evidence in the medical record that the patient received a medical screening exam on 9/11/2024.

Interview on 10/18/2024, at 12:21PM with Staff B, Certified Nurse Midwife, (DNP), stated "every patient receives a physical exam when they come to triage, I did the exam, but I forgot to document it."

The facility Operating Procedure titled, "Emergency Medical Treatment and Labor Act (EMTALA)," last reviewed 6/8/2018, stated "Every individual that comes to the Emergency Department of a System facility - whether it is in a (DED) Dedicated Emergency Department or on Hospital Property - must be provided a Medical Screening Examination within the capability of the facility's emergency department to determine whether an EMC or Emergency Medical Condition exists ..."

This finding was confirmed with Staff E, Chief of Emergency Services, on date 10/17/2024 at 4:02 PM.