HospitalInspections.org

Based on the hospital's Emergency Medical Treatment and Labor Act (EMTALA) policy, medical record review, emergency medical services (EMS) audio recording review, the hospital's Dedicated Emergency Department (DED) video recording and interview, the hospital failed to ensure all patients presenting to the hospital's DED received an appropriate medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 20 (Patient #1) patients presenting to the hospital's DED seeking medical attention.

Refer to the findings in deficiencies A 2406.

Based on hospital policy, document review, the emergency medical services (EMS) audio recording review, the hospital's Dedicated Emergency Department (DED) video recording review and interview, the hospital failed to maintain a central log that included each individual who presented to the DED seeking assistance for a medical condition for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's "Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services-EMTALA [emergency medical treatment and labor act]" policy revealed, ..."It is the policy of [name of the hospital] to comply with EMTALA...requirements for Emergency Services...The Hospital should maintain a Central Log on each individual who 'comes to the emergency department,'...seeking assistance...The purpose of the Central Log is to track the care provided to each individual who comes to the hospital seeking care for an EMC..."

2. Review of the EMS audio recording dated 11/9/17 revealed the following:
EMS to Hospital #1 - " [Name of Hospital #1]...enroute with 20 year old, 36 weeks, complains of contractions, water not broken, IV [intravenous} access has been established, anything further".
Hospital #1 to EMS - "I need full report upon arrival, [Name of Hospital #1] clear".

3. Review of the EMS "Prehospital Care Report" dated 11/9/17 revealed EMS received a call at 2:08 PM to assist Patient #1. EMS documented, "...Arrived on scene to find a 20 [year old female]...sitting in a wheelchair...Pt [patient] stated she was 36 weeks pregnant and having contractions...Pt was assisted onto stretcher...Transport initiated to [name of Hospital #1]...radio report called...".

4. On 12/4/17 at 1:25 PM, the Director of Regulatory for Hospital #1 gave this surveyor a video recording of the hospital's DED. The Director of Regulatory verified the patient in the video was Patient #1.
Observations of the hospital's DED video recording revealed Patient #1 was transported by EMS stretcher into the hospital's DED on 11/9/17 at 2:53 PM.
At 3:06 PM, Patient #1 is seen being escorted out of the hospital's DED by wheelchair.
At 3:07 PM, the EMS staff are seen taking the patient by wheelchair to a car in the hospital's parking lot, and assisted the patient into the car.
At 3:11 PM, the car is seen leaving the hospital's parking lot with Patient #1.

4. Review of the hospital's central DED log for 11/9/17 revealed Patient #1's name was not listed on the DED log.

5. In an interview on 12/4/17 at 1:00 PM in the conference room, the Chief Nursing Officer (CNO) stated the patient was brought to the DED on 11/9/17 via EMS ambulance. The CNO confirmed the patient's name and information was not entered on the hospital's DED Central Log.

Based on policy review, medical record review, emergency medical services (EMS) audio recording review, review of the hospital's Dedicated Emergency Department (DED) video recording, and interview, the hospital failed to ensure all patients presenting to the DED seeking medical attention received an appropriate Medical Screening Examination (MSE) to determine if an emergency medical condition existed for 1 of 20 (Patient #1) sampled DED patients.

The findings included:

1. Review of the hospital's "Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services-EMTALA [emergency medical treatment and labor act]" policy revealed, "...It is the policy of [Name of Hospital] to comply with EMTALA...requirements for Emergency Services...'Labor' means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician or other Qualified Medical Personnel (QMP)...certifies...that the woman is in false labor. A woman who is not in true active labor may still have an EMC if the individual has a medical condition such that the absence of immediate medical attention will place her or her fetus in serious jeopardy...'Medical screening examination' or 'MSE' means the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC [emergency medical condition] or not. A MSE is not an isolated event. It is an ongoing process that begins but does not end with triage...Procedures for Individuals Directly Presenting Directly to the Hospital Emergency Department: The Hospital's Qualified Medical Person should provide a medical screening examination to the individual's presenting symptoms..."

2. Review of the EMS #1 audio recording dated 11/9/17 revealed the following:
EMS to Hospital #1 - " [Name of Hospital #1]...enroute with 20 year old, 36 weeks, complains of contractions, water not broken, IV [intravenous] access has been established, anything further".
Hospital #1 to EMS - "I need full report upon arrival, [Name of Hospital #1] clear".

3. Review of the EMS #1 "Prehospital Care Report" dated 11/9/17 revealed EMS received a call at 2:08 PM to assist Patient #1. EMS documented, "...Arrived on scene to find a 20 [year old female]...sitting in a wheelchair...Pt [patient] stated she was 36 weeks pregnant and having contractions...Pt was assisted onto stretcher...Transport initiated to [name of Hospital #1]...radio report called...".

4. On 12/4/17 at 1:25 PM, the Director of Regulatory for Hospital #1 gave this surveyor a video recording of the hospital's DED. The Director of Regulatory verified the patient in the video was Patient #1.
Observations of the hospital's DED video recording revealed Patient #1 was transported by EMS #1 per stretcher into the hospital's DED on 11/9/17 at 2:53 PM.
At 3:06 PM, Patient #1 is seen being escorted out of the hospital's DED per wheelchair.
At 3:07 PM, the EMS #1 staff are seen taking the patient by wheelchair to a car in the hospital's parking lot, and assisted the patient into the car.
At 3:11 PM, the car is seen leaving the hospital's parking lot with Patient #1.

5. Review of the EMS #2 "Prehospital Care Report" dated 11/9/17 revealed they received a call at 3:25 PM. The report narrative documented, "...Dispatched to street corner for party [Patient #1] with pregnancy problems...Pt [Patient #1]stated that she was transported to [name of Hospital #1] in a Fire Department Ambulance for vaginal pain. When she got there [Hospital #1], the hospital stated they had no beds, so they left to go to [name of Hospital #2] in a personal car. En route the car broke down...36 weeks, due December 9th and having vaginal pains for 3 hours. Pt stated some mucous has come out...Pt still had IV [intravenous]in her left AC [antecubital arm area] from the ambulance [EMS #1] that took her to [name of Hospital #1]...Pt monitored en route...At destination pt report given...care transferred [to Hospital #2]..."

6. Review of Hospital #2's OB [Obstetric] Triage Assess/Interventions DED nurses note dated 11/9/17 at 3:50 PM revealed, "patient [Patient #1] arrived with 18G INT [intravenous needle size] in LFA [left forearm] from ambulance [EMS #1] that transported her to [name of Hospital #1]. Patient states that after arriving at [name of Hospital #1] that they were told that they could not be seen because they were full and on diversion. Patient was not triaged by nurse or MD. Patient was told to leave and still had INT [intravenous needle] in arm. Patient left in personnel vehicle of support person which later broke down on the way to our facility [Hospital #2]. Another ambulance [EMS #2] was called which transported patient to put facility...".

Review of the DED physician notes at Hospital #2 revealed Patient #1 received a MSE at Hospital #2 on 11/9/17 at saw 4:06 PM.

Review of Hospital #2's Intrapartum Progress Notes Review DED physician's MSE note dated 11/9/17 at 6:14 PM revealed the physician documented the patient's cervical effacement was unchanged and the patient reported improvement in discomfort". The physician documented, "...Stable for discharge, strict labor precautions..."

Review of Hospital #2's "Discharge Summary" revealed the patient was ambulatory, discharged home in stable condition on 11/9/17 at scheduled for a follow up appointment on 11/17/17. The summary revealed a discharge diagnosis of Maternal Discomfort, Not in Labor.

7. In a telephone interview on 12/5/17 at 10:31 AM, Hospital #1's DED Nurse #1 stated she was the DED Nurse on duty when Patient #1 came to the Hospital #1's DED on 11/9/17. The DED Nurse stated she had called the Labor and Delivery (L&D) department and gave them a report and told them that Patient #1 needed to come to L&D for a MSE. The DED nurse stated the L&D nurse told her they were on diversion. The DED nurse stated she was placed on hold and then the L&D nurse told her they would see the patient. The DED nurse stated she told EMS that the L&D department was on diversion but would see the patient anyway. The DED nurse stated she then walked away. The DED nurse stated she assumed EMS took the patient to the L&D department. The DED Nurse verified the report information that she had given to the L&D nurse was information obtained from the EMS report and not from the physicians in the hospital's DED.

8. In a telephone interview on 12/5/17 at 11:00 AM, Hospital #1's L&D Nurse #1 stated she was working on 11/9/17 and took report from DED Nurse #1. The L&D Nurse stated she told the DED Nurse to send Patient #1 up to the L&D Department for a MSE and that she advised the DED Nurse that the L&D Department was on Critical Advisory. The L&D Nurse stated she was not sure in what order the information was given to the DED Nurse.

9. In a telephone interview on 12/7/17 at 10:25 AM Patient #1 was asked about her DED visit to Hospital #1 on 11/9/17. Patient #1 stated EMS staff "took me back in the Emergency Room [DED] where everyone was sitting around." Patient #1 was asked if she was saying the DED staff were sitting around and Patient #1 stated, "Yes."
The patient was asked what she told by the DED and Patient #1 stated, "No one from the hospital ever talked to me. The only ones that talked to me was the ambulance people and my mother." Patient #1 was asked if anyone at the hospital examined her or told her she could stay at the hospital and get examined and Patient #1 stated, "No."
Patient #1 was asked why she left Hospital #1 and went to Hospital #2 and Patient #1 stated, "My mother got to the Emergency Room before I did. She went up to Labor and Delivery and they told her they were on diversion because they didn't have any beds...The ambulance man...helped me from stretcher in wheelchair and took me to the parking lot...".
Patient #1 stated she delivered her baby early on 11/12/17, 3 days after the DED visit to Hospital #1..

The facility failed to ensure that their own policy and procedure related to
providing an appropriate MSE for a women who presented to the hospital in labor; as evidenced by failing to provide and appropriate MSE that was within the capability of the hospital's emergency department to determine whether or not an EMC existed for Patient #1 on 11/9/2017 who presented to the hospital's ED complaining of contractions.