HospitalInspections.org

Based on observation, interview, record review, and review of the facility's policies and procedures on Medical Screening Exam, Treatment and Transfer of Individuals in Need of Emergency Medical Services, and the Emergency Medical Services (EMS) trip report, it was determined the facility failed to ensure one (1) of twenty-one (21) patients (Patient #1) selected for review and who had presented to the facility's dedicated Emergency Department (ED) seeking medical care received a medical screening examination (MSE). Patient #1 presented to the ED, sign in and put labor as the chief complaint for the visit. However, there was no staff available to triage the patient. The patient's family member used the phone in the waiting room to inform the ED staff Patient #1's water had broken and they thought the patient was in labor. Registered Nurse (RN) #1 informed the family member the hospital did not have Obstetrics and the patient would have to call 911 or go to the nearest hospital who delivered babies. Patient #1 and the family member left, went to a gas station near by and called EMS. EMS transported the patient to a hospital twenty-four (24) miles away. The receiving hospital documentation revealed Patient #1 was in active labor upon arrival and delivered a viable baby via cesarean (C-section) later that evening.

Upon knowledge of the incident, the hospital initiated an investigation and re-educated two Registered Nurses (RN #1 and RN #2). However, the facility did not take further corrective actions to ensure all patients received a MSE and re-educate all staff who worked in the ED prior to the start of the survey on 09/02/14.

The findings include:

Review of the facility's EMTALA Medical Screening Exam policy, last revised March 2013, revealed when an individual comes to a dedicated ED and a request is made for an examination or treatment for a medical condition, a Medical Screening Exam (MSE) will be performed to determine whether an emergency medical condition (EMC) exists. In respect to a pregnant woman having contractions, it will be determined whether the woman is in labor and whether the treatment is explicitly for an EMC.

Review of facility policy titled EMTALA: Treatment and transfer of Individuals in need of emergency medical services, revised March 2013, revealed the ED would provide an appropriate MSE to any individual, including an infant, regardless of their ability to pay. If the hospital determines that an individual does have an EMC or is in labor, necessary stabilizing treatment would be provided or an appropriate transfer of the individual.

Review of the EMS transport record for 08/25/14, revealed EMS received a 911 call at 10:04 AM, and arrived on-scene at 10:08 AM at a local gas station. The report revealed Patient #1 was sitting in a private car upon their arrival. The patient told the EMS staff she/he had sought treatment at the local hospital for back pain early that morning. The patient was released and went home where the patient experienced a gush of fluid, described as "water breaking". The patient told the EMS staff there was a concern that she could be in labor and she didn't even know she was pregnant. The record revealed the patient told the EMS staff that she had returned to the local hospital's ED but was told to seek treatment somewhere else because the hospital did not handle childbirth and had no Obstetrics. The report detailed the assessments and vital signs taken by EMS and documented time of arrival at the receiving hospital (Hospital #2) at 10:52 AM.

Interview with the chief of the local EMS, on 09/03/14 at 4:46 PM, revealed he overheard the 911 call from the patient on 08/25/14. He stated the EMS ambulance was dispatched to a local gas station. The call reported a women's water had broken and they thought the person was in labor. The chief was told by the EMS staff the patient returned to the local hospital's ED after a visit to the ED earlier that morning for back pain and was told the hospital did not have OB and could not deliver babies. He stated he provided a courtesy call to the hospital to inform them of the incident and possibility of an EMTALA violation.

Review of Hospital #2's ED documentation revealed the ED physician conducted a MSE at 10:59 AM with findings of Patient #1 uterine fundus noted above the umbilicus. The chief complaint was labor with possible emergency delivery. The clinical impression was third trimester pregnancy with possible rupture of membranes. An Obstetric (OB) nurse was at bedside. She confirmed late pregnancy with amniotic fluid and positive fetal movement. The patient was immediately taken to the Labor and Delivery Unit. Review of the Labor and Delivery (LD) flowsheet revealed the OB Physician performed a vaginal exam, on 08/25/14 at 11:34 AM that revealed dilation at five (5) centimeter (cm) and 70% effacement. The record revealed the patient progress to 100% of effacement and dilation of eight (8) cm but failed to progress with dilation of ten (10). The OB Physician and Patient #1 decided a Cesarean (C-section) was necessary at 6:49 PM. A viable female was born at 7:45 PM with Apgar score of a nine (9) within five (5) minutes.

On 09/02/14 at 9:47 AM, an interview with the OB Nurse, who performed an assessment on Patient #1 at the receiving hospital (Hospital #2), revealed the patient was brought to the ED via EMS. The ED physician performed a MSE and called the OB unit requesting an assessment. She went to the ED to assess the patient and found the patient's fundus could be palpated. An ultrasound was performed that confirmed a live fetus with a heart rate. The patient was transferred to the Labor & Delivery Unit and a fetal monitor was placed around the patient's abdomen.

The OB Nurse at Hospital #2 stated Patient #1 told her of a recent visit at Hospital #1 earlier that day for back pain. The patient told the nurse she did not know she was pregnant. The patient was diagnosed with a muscle strain in the lower back and discharged home with some medications. The facility did not assess her pregnancy status. Additionally, the patient's abdomen was not assessed and no pregnancy test was performed.

At home, the patient said she went to the bathroom and some type of fluid was running down her legs. Patient #1 told the OB Nurse she returned to Hospital #1, but when she signed in at the ED waiting room, nobody was present. A family member who had accompanied the patient to the hospital picked up the phone in the ED waiting room and called the ED department. The patient told the OB nurse the family member informed the person who answered the phone they thought the patient was in labor and her water had broken. The person who answered the phone told the family member to go to another hospital because that hospital did not have Obstetrics. Additionally, the patient told the OB Nurse at Hospital #2 they left and went to a gas station across the street and called EMS.

The OB Nurse confirmed the patient was in active labor when she presented to the ED of Hospital #2. She stated she reported what Patient #1 had told her to the house supervisor because she realized this could be an EMTALA violation. She stated this could have been fatal for the baby if the patient had compressed the core because she didn't know she was pregnant.

Telephone interview with the OB Physician, on 09/02/04 at 10:01 AM, revealed Patient #1 was in active labor (confirmed by ultrasound) when the patient presented to the receiving hospital, Hospital #2. She stated if the labor had no monitoring there could have been a delivery of the baby without any trained help and the baby could have had problems. She said the patient told her Hospital #1 told her to go somewhere else because they did not do OB care. She stated this was an unusual case because the patient did not know she was pregnant.

Interview with Patient #1 and a family member, on 09/02/14 at 11:18 AM, revealed the patient had gone to the ED earlier that morning for back pain. The patient stated she was seen by a physician, was diagnosed with a muscle strain and was discharged with pain medication. Patient #1 went home and tried to sleep but couldn't. She stated when she went to the bathroom, a liquid like substance was running down her legs and this scared the patient. She yelled for the family member and when the family member saw the fluid, she asked the patient if she could be pregnant. The patient told the family member she didn't think so. Patient #1 stated the family member took the patient back to the same hospital the patient had visited earlier that morning. The family member said she dropped the patient off at the ED door and went and parked the car. When the family member entered the ED waiting room, she saw the patient sitting in a chair crying. The patient told the family member there was nobody at the window where you signed in for ED treatment. The family member stated she used the telephone in the ED waiting room to call the ED department and a female answered. (Later identified as RN #1). She told RN #1 she thought the patient was pregnant and her water had broken. She was told to contact the patient's OB doctor. When the family member told RN #1 the patient did not have one, she was told to go to another hospital because this hospital did not deliver babies. The family member said she attempted to tell RN #1 the patient needed to be checked to see if the patient was in labor. However, she would not let the patient back into the ED. The family member said she was told to call 911. I told them, "you have got to be kidding." The family member continued to say, they got back into the car and drove to a gas station where she called 911. The family member stated she called EMS because she was afraid and the patient was crying. The patient stated EMS arrived, determined the patient was in labor and transported the patient to Hospital #2. The patient stated she was very afraid because she didn't know what to expect and was worried something would go wrong with the baby.

Interview with Hospital #1's Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) on 09/02/14 at 1:50 PM, revealed the hospital was informed of the incident when the local EMS called and reported Patient #1 was in labor and this hospital had told the patient they did not deliver babies. The EMS chief had reported the patient told the EMS staff that Hospital #1 told the patient they could not treat her because the hospital did not have OB services and the patient would have to call 911 or go to a hospital that delivered babies. He stated Hospital #2 called and reported the incident too. The CEO stated the hospital was in the process of doing an internal investigation. He stated he had already identified the hospital's process of signing-in patients to be seen through the ED needed to be revamped. The hospital found the problem occurred when the patient came in through the walk-in area of the ED waiting room (around 9:56 AM). The patient signed in but the triage nurse was not available to retrieve the sign in slip that showed the chief complaint was labor. The triage nurse had left the office (located behind the glass where the sign in slips are deposited) to assess a patient in an ED exam room. He revealed the ED was very busy at that time.

He continued to say, when the triage nurse came back and saw the slip, she looked for the patient but the patient had already left. The investigation found the patient's family member had used the telephone in the ED waiting room to call the nurses' desk in the ED. However, the nurse who answered the phone thought the patient was calling from outside the hospital and that is why she told the patient to call 911 or go to a hospital that delivered babies. He said the investigation found a problem with the phone system due to the inability to ID calls from the ED waiting room. There were monitors in the ED waiting room and you could see the phone on the wall, however; the nurse had not looked at the monitors. The CEO stated the hospital had begun re-education with the two nurses and would include all nurses and physicians that work in the ED.

Tour of Hospital #1's ED, on 09/02/14 at 2:15 PM, revealed two entrances, a walk-in and an EMS entrance. Observation of the walk-in side revealed a small waiting room with two frosted windows noted, one for registration and one for the triage room. In front of the triage room, a pad of sign-in sheets were available for patients to put their name and chief complaint for the visit. After completion of the sign-in sheet, the patient would slide the slip under the frosted window of the triage room. A telephone was observed on the wall beside the door leading to the ED area. There were eleven (11) people sitting in the ED waiting room. EMTALA signage was observed on the wall in English and Spanish. Continued tour of the ED revealed a monitor mounted on the wall beside the nurses' station that monitored the waiting room. The telephone in the ED waiting room could be seen on the monitor.

Interview with the triage nurse, on 09/02/14 at 2:19 PM, revealed once a patient signs in and places the sign in sheet under the triage glass window; the triage nurse would review and prioritize by chief complaints. She revealed she would at times have to leave the triage room to assess patients in the ED exam rooms and that left the triage room unattended.

Telephone interview with RN #1, on 09/03/14 at 10:23 AM, validated she was the nurse who took the call from the ED waiting room on the morning of 08/25/14. She stated the ED was very busy that day, the phone rang and she automatically answered. She stated a woman, who sounded in distress, told her Patient #1 had been at the ED earlier that morning with back pain and now her water had broken and they thought she might be in labor. She asked her if the patient was pregnant and the caller told her they didn't know. RN #1 stated she put the woman on hold and went to speak with the Team leader (RN #2). She informed RN#2 what the caller said and RN#2 told this nurse to tell the caller to call 911 or come to the ED. She did recall saying to the woman, " we don't deliver babies here." She stated she told the caller to call EMS right away or go to the nearest hospital that delivered babies. The nurse said she was going to tell the caller they could come to the hospital but the caller became upset and said, " you have got to be kidding", " you will be hearing from my attorney," and hung up. RN #1 revealed she began her shift on 08/25/14 at 6:45 AM and must have been in the ED when Patient #1 came in for back pain, but she did not provide care for her, and did not recall seeing her. She stated she thought it was an outside call and didn't know the caller was in the ED waiting room. However, she had not asked the caller her name or her location. She indicated the telephone in the ED waiting room is mostly utilized by families wanting to see a family member who is in an ED exam room. The staff use the telephone to call family members back to the ED exam rooms. She revealed she had not looked at the monitor to see if the caller or patient was in the ED waiting room. She only informed the team lead what the caller said. She stated she had EMTALA training when first hired about a year ago. She spoke with the ED nurse manager and completed a refresher course online for EMTALA. Review of RN #1's education records revealed the online refresher course for EMTALA was completed on 08/29/14.

Interview with RN #2, on 09/03/14 at 11:37 AM, revealed she was the triage nurse and team lead on 08/25/14. She clocked in for work around 6:45 AM and she was the nurse who cared for Patient #1 earlier that morning when the patient presented to the ED with back pain. She stated the patient's pain was a 7/10 upon arrival and discharge. She indicated general questions were asked during the assessment regarding menstruate periods. The patient stated her last period was sometime in October 2013 and the patient told the nurse she had irregular periods. When asked if any chance of pregnancy the patient answered, "No." Later that morning, she was in Exam Room #6 when RN #1 came and informed her a woman was on the phone stating her daughter's water had broken and she thought she may be in labor. She stated she instructed RN #1 to tell the caller to call 911 or take the patient to the nearest hospital that delivered babies. RN #2 stated she thought the call came from outside the hospital. When she went back to the triage room, RN #2 saw a sign-in slip from Patient #1 that had labor listed as the chief complaint. She said she called that person's name but there was no response. She then went to the ED waiting room and that person was not there. She said she looked in the ED bay and the hallway outside the ED walk-in entrance but did not see anyone. She stated the ED waiting room was full that morning and she didn't see anybody on the telephone when she searched the waiting room. RN #2 stated when she could not find the patient, she went to find RN #1 to ask her about the call. RN #1 told this nurse she thought the call had come from outside the hospital and the caller had told her the patient's water had broken.

Review of the facility's sign in form, utilized by the ED waiting area, revealed on 08/25/14 at 9:56 AM, Patient #1 signed in the ED waiting area and listed "labor" as the chief complaint/symptom. The triage nurse (RN #2) documented on the form she had called Patient #1 back for exam at 10:09 AM, however; the patient was not in the ED waiting room.

Continued interview with RN #2 revealed she had left the triage room to assess a patient who had come to the ED through the EMS entrance and was gone about fifteen (15) minutes. She indicated she was not in the triage room when Patient #1 signed in to the ED. She stated she had left the triage room unattended for over 30 minutes in the past and indicated the triage nurse was frequently away from the room. She stated if a patient came in the ED via EMS ambulance, the triage nurse was responsible for going to the exam room and conducting the assessment.

Interview with the ED nurse manager, on 09/03/14 at 4:30 PM, validated the triage nurse has to leave the triage room at times to conduct assessment on patients, especially those that come in via ambulance. She revealed nobody covers the triage room while the nurse is gone. She stated it is not the best set up and would like for the triage nurse to be in the room at all times. She stated the two nurses involved in the incident completed a refresher course on EMTALA. She indicated she was developing a read and sign education for all ED staff but that had not been developed to date.

Observation of the telephone system at the ED nurses' station, on 09/03/14 at 11:06 AM, revealed a double ring when a call was received outside the hospital. Demonstration of a call from the telephone in the ED waiting room revealed only one ring and it had a different sound. The ED telephone display caller ID, internal calls are ID by extension (four digits) and outside calls have the full number.

Observation of the monitor of the ED waiting room revealed the telephone on the wall was within view of the monitor. The monitor was located on the wall beside the ED nurse's station. However, if you were at the end of the desk, a wall protruded out, blocking view of the monitor if you were standing outside of the station. RN #1 stated she did not look at the monitor.

Another interview with Hospital #1's CEO, on 09/03/14 at 5:00 PM, revealed the hospital's action plan had just begun with training of RN #1 and RN #2. He further stated the rest of the ED staff will be re-educated by 9/30/14. He revealed the window for registration was un-frosted today (09/03) and they planned to implement a new registration process. He stated he had requested the telephone company to rewire the telephones in the ED to have a dedicated line from the ED waiting room.

Review of the current ED nurse roster revealed there were sixteen (16) full time nurses and seven (7) as needed (PRN). On 08/25/14, there were three (3) RN's working.

Review of the facility's ED central log for the last six (6) months revealed no patients had presented to the ED in labor.