HospitalInspections.org

Based on the findings at A2406 and A2408, the facility failed to ensure compliance with CFR 489.24.

Based on interviews, record review, and document review, the facility failed to conduct an appropriate medical screening exam for 1 of 50 patients sampled (Patient #41).

Findings include:

Patient #41

Record Review

The facility's (UMC) log revealed Patient #41 presented on 7/20/11 at 7pm (or 6pm) and the next column indicated, "Pt to Valley (a nearby acute care facility)." The log had other columns which were not completed, including the chief complaint.

There were no clinical records for Patient #41 at UMC.

Patient #41's record at Valley dated 7/20/11 revealed the following:

- The patient arrived at 1927 (7:27 pm), by wheel chair and was triaged as urgent (must be seen in 20 minutes).
- Notes indicated, "Pt. (patient) was brought here via wheelchair fr. (from) UMC by admitting clerk fr. Labor and Delivery. Pt. apparently having lower abdominal pain. Pt. denies any vaginal bleeding. Pt. took the bus and came to UMC since it is the closest hosp. (hospital) fr. the bus stop....lower abdominal stabbing pain started at about 1800 (6pm)... previous C-section (Caesarean section) 9 mos (months) ago...pain scale 7 (out of 1-10)."
- The MD (medical doctor) Labor and Delivery Triage/Outpatient orders indicated the patient had false labor pains.
- The patient received an IV (intravenous) infusion of Isolyte which was started at 2117 (9:17pm). A urine toxicology screen was also done which resulted in "negative" results for: Phencyclidine, THC-Cannabinoids, Barbiturates, Methamphetamines, Methadone, Opiates, Cocaine, Benzodiazepines, and Amphetamines.
- MD noted "...no vaginal bleeding noted and no other c/o (complaints). Pt. first saw (name of routine MD) today in his office. EDC (estimated date of confinement) of 11/11/2011, 23.6 wks (weeks) IUP (intrauterine pregnancy)..."
- Antenatal Discharge Instructions dated 7/20/11, indicated the patient was discharged at 2330 (11:30pm) in stable condition, to home, and was ambulatory.

Interview (UMC)

On 9/6/11 in the afternoon, the Manager of L&D (Labor and Delivery) indicated at the front desk a clipboard was kept with stickers for sign in log comprising of: the patient's name, time in, chief complaint, the time seen, the bed, discharge time and disposition. If a patient presents to L&D with contractions, the charge nurse would do a mini triage and relay to the triage nurse and the sticker would be given to the triage nurse. The nurse would conduct a basic triage, monitoring strip, physical exam and may do cervical exam if near term, if not near term call the physician. Once the nurse calls the physician, they may order labs. Ultimately, the physician would be called for all patients presenting and informed of examination/lab results. Nurses were L&D qualified by perinatal education and certified by medical staff. The L&D nurses were qualified to perform the medical screening exam.

On 9/8/11 at approximately 3:30pm during a telephone interview, the Manager of L&D was interviewed about Patient #41's entry on the log dated 7/20/11 and the lack of information:
- "Pt. to Valley" was all that was written. The Manager of L&D responded that sometimes after signing in and before triage, the patient looks at the number of people in the waiting room and may decide to leave, but the reason for leaving should have been on the log. The Manager of L&D could not imagine why it would be blank under the columns and indicated usually leaving AMA (against medical advice) or another reason would be entered. After referring the Manager of L&D to the date on the log and asking to speak to the nurse listed at the top of the log, the Manager of L&D indicated she would look for whatever documentation she could find.

At approximately 4pm via telephone, the Manager of L&D indicated she recalled Patient 41's name because she had conducted an investigation regarding this patient. The Manager of L&D indicated the patient had gotten off of a bus at the bus stop which was located between the UMC and Valley. The patient had presented to UMC because UMC was the closest hospital from the bus stop. The Charge nurse had two deliveries when the patient presented. The patient presented with cramping and was registered at Valley. The patient's physician had no privileges at UMC. The patient presented with her sister and two children. Triage had the sticker. The sister was asking the patient questions about why they were not at Valley. The Admitting rep said, "Why don't we admit/register you." The Office rep said we may have to charge you if admitted here. The patient's sister started to argue. The Admission rep thought she would be nice and wheeled the patient to Valley. The Manager of L&D indicated the Unit secretary and Admission rep said the patient wanted to go to Valley. When the Triage nurse came out, the patient was no longer there. The Manager of L&D received a call from Valley regarding Patient #41's arrival from UMC and started her investigation.

The Manager of L&D indicated she told the Admissions Representative and Unit Secretary, "You can't say anything to the patients (re: insurance, pay, MD)." One of them asked, 'Why not?' The Manager of Labor and Delivery responded, "that interfered with the ability to provide care."

The Manager of L&D called back at approximately 4:30pm to follow-up that the Admissions Representative (Admit Rep), the Unit Secretary, and either the Triage nurse or the Charge nurse or both of them would be available for interview on 9/9/11 at 7am.

On 9/9/11 at approximately 7am, a telephone interview with the Triage nurse, the Charge nurse, the Unit Secretary, and the Director of Admitting was conducted with the Manager of L&D also in attendance, regarding Patient #41's presentation on 7/20/11:

Interview with the Triage nurse revealed:
- "I overheard there was a patient to be seen. I overheard conversation between the patient, Admit clerk and secretary. Patient of (name of MD). They were explaining had patients at Valley.
- When I got to that patient to triage her, the Admit clerk said she wanted to go to Valley Hospital.
- This was a time of day I am getting report of many patients - I don't recall that day how many, but I was evaluating what was going on with other patients.
- I received the sticker, placed it on the log and I would have recorded the chief complaint. That day I went into the room and other things were going on and when I was ready for her, she (the patient) was gone. When it was time to screen her, the Admit Rep came back and told me."

Interview with the Charge nurse revealed:
- "I wasn't aware of the situation. The Triage nurse assignment is totally separate. Patients are brought back by priority. I know that night was busy and I was doing a delivery. I try to help out what's going on out there.
- What I do is I ask what they're coming for and I write the MD's name down and I can take them (the patients) in myself. It depends on whatever is going on.
- I wasn't aware of the incident until I received a phone call. I received a phone call from the L&D nurse at Valley and she informed me that my Admit Rep brought her in the wheelchair because insurance would not be covered at UMC. I was told the patient was triaged and sent home. I, in turn hung up the phone and yelled at people and notified the manager. There was no nurse intervention - we were not allowed to do anything before the patient was taken to Valley."

Interview with the Unit Secretary of L&D revealed:
- "The patient's sister was trying to roll her (Patient #41) upstairs in the wheelchair and 2 children. I asked the patient her name, who was her MD, and to sign the sticker. I explained that her MD did not have privileges but she could still be seen. The sister did the speaking and would not let the patient speak. We couldn't see the patient's face. The patient had her head in her hand. The Admit Rep was asking the patient for ID (identification) and if the patient had an insurance card.
- The sister said they were supposed to go to Valley but they liked our hospital anyway. The sister was hostile to me and I'm not sure why.
- The Triage nurse was the one who wrote the patient's name on the log.
- I don't care if people pay us or not, even though she had records at Valley. (Name of Admission Rep) also explained that they would still see her. The sister said the patient was uncomfortable.
- We were 'busy as all get out' (very busy), nurses were in change of shift.
- (Name of Admission Rep) went out and calmed the patient's sister down. We have Plexiglas, so I couldn't see what was happening. (Name of Admission Rep) told me, 'I'm coming back. I'm going on a break.' The patient's sister was arguing and the patient was apparently uncomfortable.
- I also received a phone call from Valley's on-call administrator. I told the administrator what happened. I said we would have accepted Medicaid but it was the doctor who didn't have privileges here."

Interview with the Director of Admitting who was the supervisor of the Admission Rep revealed:
- "(Name of Admission Rep) was open and honest about it. She just wanted to help the patient."
Later that morning, the the Director of Admitting called back and stated the Admission Rep had gone to the ER (Emergency Room) for personal reasons and would not be able to interview.

During the interview with the above staff, the Manager of L&D was asked about their recent EMTALA training and the following was reported:

- Staff were supposed to have EMTALA training annually.
- The Triage nurse had EMTALA training last on 2/4/10.
- The Charge nurse had EMTALA training on 3/2/10.
- The Unit secretary had EMTALA training on 2/18/10.
- The Manager of L&D indicated she would see to it that certain measures would change regarding EMTALA training.

The Director of Admitting reported receiving EMTALA training in January 2011, but the Admission Rep did not have EMTALA training. The Director of Admitting said that she would change the policy.

Document Review

The following policies indicated:
- Screening Stabilization and Transfer Individuals with Emergency Medical Conditions approved 3/17/09, "... It is the policy of University Medical Center:
...To provide a Medical Screening Examination by a Qualified Medical Person to any individual who comes to the Hospital and seeks an examination or medical treatment to determine if the individual has an Emergency Medical Condition, whether or not eligible for insurance benefits and regardless of ability to pay...
It is further the Hospital's Policy that it shall not:
...Delay the provision of a Medical Screening Examination, stabilizing treatment, or appropriate transfer in order to inquire about the individual's method of payment or insurance status..."
- "...Medical Screening Examination" - means the screening process required to determine with reasonable clinical confidence whether an Emergency Medical Condition does or does not exist."
- "...Qualified Medical Person" - means an individual other than a licensed physician who is certified in one of the following professional categories and who has demonstrated current competence in the performance of a Medical Screening Examination: ... Labor & Delivery Nurses with neonatal Resuscitation Training.
The above- referenced categories of professionals have been approved by the Hospital's Governing Body as qualified to administer one or more types of Medical Screening Examinations and complete /sign a certification for transfer in consultation with a physician."

The facility failed to provide Patient #41 a Medical Screening Exam by Labor and Delivery Qualified Medical Providers.

Complaint #29006

Based on interview, record review, and document review, the facility failed to conduct an appropriate medical screening exam for 1 of 50 patients sampled (Patient #41) due to issues/concerns surrounding insurance, registration, and MD privileges.

Findings include:

Patient #41

Record Review

The facility's (UMC) log revealed Patient #41 presented on 7/20/11 at 7pm (or 6pm) and the next column indicated, "Pt to Valley (a nearby acute care facility)." The log had other columns which were not completed, including the chief complaint.

There were no clinical records for Patient #41 at UMC.

Patient #41's record at Valley dated 7/20/11 revealed the following:

- The patient arrived at 1927 (7:27 pm), by wheel chair and was triaged as urgent (must be seen in 20 minutes).
- Notes indicated, "Pt. (patient) was brought here via wheelchair fr. (from) UMC by admitting clerk fr. Labor and Delivery. Pt. apparently having lower abdominal pain. Pt. denies any vaginal bleeding. Pt. took the bus and came to UMC since it is the closest hosp. (hospital) fr. the bus stop....lower abdominal stabbing pain started at about 1800 (6pm)... previous C-section (Caesarean section) 9 mos (months) ago...pain scale 7 (out of 1-10)."
- The MD (medical doctor) Labor and Delivery Triage/Outpatient orders indicated the patient had false labor pains.
- The patient received an IV (intravenous) infusion of Isolyte which was started at 2117 (9:17pm). A urine toxicology screen was also done which resulted in "negative" results for: Phencyclidine, THC-Cannabinoids, Barbiturates, Methamphetamines, Methadone, Opiates, Cocaine, Benzodiazepines, and Amphetamines.
- MD noted "...no vaginal bleeding noted and no other c/o (complaints). Pt. first saw (name of routine MD) today in his office. EDC (estimated date of confinement) of 11/11/2011, 23.6 wks (weeks) IUP (intrauterine pregnancy)..."
- Antenatal Discharge Instructions dated 7/20/11, indicated the patient was discharged at 2330 (11:30pm) in stable condition, to home, and was ambulatory.

Interview (UMC)

On 9/6/11 in the afternoon, the Manager of L&D (Labor and Delivery) indicated at the front desk a clipboard was kept with stickers for sign in log comprising of: the patient's name, time in, chief complaint, the time seen, the bed, discharge time and disposition. If a patient presents to L&D with contractions, the charge nurse would do a mini triage and relay to the triage nurse and the sticker would be given to the triage nurse. The nurse would conduct a basic triage, monitoring strip, physical exam and may do cervical exam if near term, if not near term call the physician. Once the nurse calls the physician, they may order labs. Ultimately, the physician would be called for all patients presenting and informed of examination/lab results. Nurses were L&D qualified by perinatal education and certified by medical staff. The L&D nurses were qualified to perform the medical screening exam.

On 9/8/11 at approximately 3:30pm during a telephone interview, the Manager of L&D was interviewed about Patient #41's entry on the log dated 7/20/11 and the lack of information:
- "Pt. to Valley" was all that was written. The Manager of L&D responded that sometimes after signing in and before triage, the patient looks at the number of people in the waiting room and may decide to leave, but the reason for leaving should have been on the log. The Manager of L&D could not imagine why it would be blank under the columns and indicated usually leaving AMA (against medical advice) or another reason would be entered. After referring the Manager of L&D to the date on the log and asking to speak to the nurse listed at the top of the log, the Manager of L&D indicated she would look for whatever documentation she could find.

At approximately 4pm via telephone, the Manager of L&D indicated she recalled Patient 41's name because she had conducted an investigation regarding this patient. The Manager of L&D indicated the patient had gotten off of a bus at the bus stop which was located between the UMC and Valley. The patient had presented to UMC because UMC was the closest hospital from the bus stop. The Charge nurse had two deliveries when the patient presented. The patient presented with cramping and was registered at Valley. The patient's physician had no privileges at UMC. The patient presented with her sister and two children. Triage had the sticker. The sister was asking the patient questions about why they were not at Valley. The Admitting rep said, "Why don't we admit/register you." The Office rep said we may have to charge you if admitted here. The patient's sister started to argue. The Admission rep thought she would be nice and wheeled the patient to Valley. The Manager of L&D indicated the Unit secretary and Admission rep said the patient wanted to go to Valley. When the Triage nurse came out, the patient was no longer there. The Manager of L&D received a call from Valley regarding Patient #41's arrival from UMC and started her investigation.

The Manager of L&D indicated she told the Admissions Representative and Unit Secretary, "You can't say anything to the patients (re: insurance, pay, MD)." One of them asked, 'Why not?' The Manager of Labor and Delivery responded, "that interfered with the ability to provide care."

The Manager of L&D called back at approximately 4:30pm to follow-up that the Admissions Representative (Admit Rep), the Unit Secretary, and either the Triage nurse or the Charge nurse or both of them would be available for interview on 9/9/11 at 7am.

On 9/9/11 at approximately 7am, a telephone interview with the Triage nurse, the Charge nurse, the Unit Secretary, and the Director of Admitting was conducted with the Manager of L&D also in attendance, regarding Patient #41's presentation on 7/20/11:

Interview with the Triage nurse revealed:
- "I overheard there was a patient to be seen. I overheard conversation between the patient, Admit clerk and secretary. Patient of (name of MD). They were explaining had patients at Valley.
- When I got to that patient to triage her, the Admit clerk said she wanted to go to Valley Hospital.
- This was a time of day I am getting report of many patients - I don't recall that day how many, but I was evaluating what was going on with other patients.
- I received the sticker, placed it on the log and I would have recorded the chief complaint. That day I went into the room and other things were going on and when I was ready for her, she (the patient) was gone. When it was time to screen her, the Admit Rep came back and told me."

Interview with the Charge nurse revealed:
- "I wasn't aware of the situation. The Triage nurse assignment is totally separate. Patients are brought back by priority. I know that night was busy and I was doing a delivery. I try to help out what's going on out there.
- What I do is I ask what they're coming for and I write the MD's name down and I can take them (the patients) in myself. It depends on whatever is going on.
- I wasn't aware of the incident until I received a phone call. I received a phone call from the L&D nurse at Valley and she informed me that my Admit Rep brought her in the wheelchair because insurance would not be covered at UMC. I was told the patient was triaged and sent home. I, in turn hung up the phone and yelled at people and notified the manager. There was no nurse intervention - we were not allowed to do anything before the patient was taken to Valley."

Interview with the Unit Secretary of L&D revealed:
- "The patient's sister was trying to roll her (Patient #41) upstairs in the wheelchair and 2 children. I asked the patient her name, who was her MD, and to sign the sticker. I explained that her MD did not have privileges but she could still be seen. The sister did the speaking and would not let the patient speak. We couldn't see the patient's face. The patient had her head in her hand. The Admit Rep was asking the patient for ID (identification) and if the patient had an insurance card.
- The sister said they were supposed to go to Valley but they liked our hospital anyway. The sister was hostile to me and I'm not sure why.
- The Triage nurse was the one who wrote the patient's name on the log.
- I don't care if people pay us or not, even though she had records at Valley. (Name of Admission Rep) also explained that they would still see her. The sister said the patient was uncomfortable.
- We were 'busy as all get out' (very busy), nurses were in change of shift.
- (Name of Admission Rep) went out and calmed the patient's sister down. We have Plexiglas, so I couldn't see what was happening. (Name of Admission Rep) told me, 'I'm coming back. I'm going on a break.' The patient's sister was arguing and the patient was apparently uncomfortable.
- I also received a phone call from Valley's on-call administrator. I told the administrator what happened. I said we would have accepted Medicaid but it was the doctor who didn't have privileges here."

Interview with the Director of Admitting who was the supervisor of the Admission Rep revealed:
- "(Name of Admission Rep) was open and honest about it. She just wanted to help the patient."
Later that morning, the the Director of Admitting called back and stated the Admission Rep had gone to the ER (Emergency Room) for personal reasons and would not be able to interview.

During the interview with the above staff, the Manager of L&D was asked about their recent EMTALA training and the following was reported:

- Staff were supposed to have EMTALA training annually.
- The Triage nurse had EMTALA training last on 2/4/10.
- The Charge nurse had EMTALA training on 3/2/10.
- The Unit secretary had EMTALA training on 2/18/10.
- The Manager of L&D indicated she would see to it that certain measures would change regarding EMTALA training.

The Director of Admitting reported receiving EMTALA training in January 2011, but the Admission Rep did not have EMTALA training. The Director of Admitting said that she would change the policy.

Document Review

The following policies indicated:
- Screening Stabilization and Transfer Individuals with Emergency Medical Conditions approved 3/17/09, "... It is the policy of University Medical Center:
...To provide a Medical Screening Examination by a Qualified Medical Person to any individual who comes to the Hospital and seeks an examination or medical treatment to determine if the individual has an Emergency Medical Condition, whether or not eligible for insurance benefits and regardless of ability to pay...
It is further the Hospital's Policy that it shall not:
...Delay the provision of a Medical Screening Examination, stabilizing treatment, or appropriate transfer in order to inquire about the individual's method of payment or insurance status..."
- "...Medical Screening Examination" - means the screening process required to determine with reasonable clinical confidence whether an Emergency Medical Condition does or does not exist."
- "...Qualified Medical Person" - means an individual other than a licensed physician who is certified in one of the following professional categories and who has demonstrated current competence in the performance of a Medical Screening Examination: ... Labor & Delivery Nurses with neonatal Resuscitation Training.
The above- referenced categories of professionals have been approved by the Hospital's Governing Body as qualified to administer one or more types of Medical Screening Examinations and complete /sign a certification for transfer in consultation with a physician."

The facility failed to provide Patient #41 a Medical Screening Exam by Labor and Delivery Qualified Medical Providers to assess the patient's status and communicate those findings to the physician to determine the patient's disposition, prior to any discussion of insurance/registration/privileges.

Complaint #29006