HospitalInspections.org

Based on a review of documentation and interview, the facility failed to provide 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 or not an emergency medical condition exists.

Findings included:

Facility based guideline entitled, "Guidelines for the Care of the OBED (obstetric emergency department) Patient" stated in part,
"IV. Policy:

All patients presenting to Labor and Delivery (L&D) will receive the Medical Screening Exam (MSE) by a qualified L&D RN. L&D RN 's are competent to perform the MSE on the obstetrical patient when the L&D nurse has satisfactorily completed the clinical competency requirements as approved by the Medical Staff ...

Guidelines:

All unscheduled obstetric patients presenting to the hospital who are directed to Labor and Delivery will receive a Medical Screening Exam (MSE) by a competent RN...

Following the examination and assessment of the patient, the RN will complete the Obstetrical Medical Screening Assessment (OMSA); communicate the findings with the appropriate physician and document findings in the electronic health record. Based on the patient's status and Screening Score, the physician will determine the final disposition of the patient and give any final patient orders. A discharge order cannot be taken over the phone if the screening score does not fall within the appropriate guidelines.
The physician will be notified of any patient condition that warrants immediate action, regardless of the patient's Screening Score or lack of conditions listed in Part A of the OMSA.

The MSE report is a permanent part of the chart and documentation will include a note stating that admission report has been given to the physician per the MSE. This report uses documentation by exception ..."

Facility Policy entitled, "LDRP 1 Assessment and Medical Screening of the Pregnant Patient" stated in part,
"II. Purpose:

To serve as a guideline to the assessment, evaluation and disposition of the obstetrical patient presenting in labor or pregnancy associated concerns.

III. Policy:

A qualified registered nurse competent in obstetrical evaluation will assess, perform a medical screening, provide nursing care, and collaborate with the physician ...

General Information/Instructions: All Patients presenting to the labor area complaining of possible labor will be assessed and monitored and will be assumed in labor until proven otherwise. (EMTALA)"

Review of medical records for patients presenting with Obstetric complaints at the facility in January 2022 revealed the following:
* Patient #1's Obstetrical Medical Screening Tool form only had part of the Initial Assessment Score completed (EGA, Dilation, Effacement with ctx, Station with ctx, and Presentation with ctx) the remainder of the initial assessment and score where blank. The Discharge Assessment Score was blank and not filled in by nursing staff. Patient disposition was also not indicated on this form.

Review of 9 other obstetric patients presenting with similar obstetric symptoms (vaginal leaking) in January 2022 revealed the following:
* Patient #5's Obstetrical Medical Screening Tool form was incomplete. The Discharge Assessment Score was blank and not filled in by nursing staff.
* Patient #9's Obstetrical Medical Screening Tool form was incomplete. The Discharge Assessment Score was blank and not filled in by nursing staff.

2 of 10 obstetrical patient medical records reviewed did not have a Obstetrical Medical Screening Tool as required:
* Patients #2 and 6 had no Obstetrical Medical Screening Tool present in their records.
* The lack of an appropriate medical screening for these 2 patients was verified on 05/10/22 in interview with staff member #1.

In interview on 05/10/22, staff member #1 verified that the above obstetric patients did not receive appropriate medical screenings per the facility policy.