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Based on interview, medical record review, document review, and review of hospital policies and procedures, Critical Access Hospital L (Hospital L) failed to provide a Medical Screening Exam (MSE - assessment to determine the existence of a medical emergency) prior to discharge for 1 of 30 Sampled Patients (Patient 1). Patient 1 was 35 weeks pregnant when she arrived at Hospital L's Emergency Department (ED), after she had experienced Premature Rupture of Membranes (PROM- rupture of the fetal membranes prior to the onset of labor).
Patient 1 was sent to the OB unit (obstetric/labor and delivery) and later discharged from Hospital L with instructions to immediately drive to Hospital M (which was 30 minutes away by car).

According to the National Institute of Health, Preterm PROM is a major cause of perinatal (time-period immediately before and after birth) morbidity and mortality (illness and death) and is associated with 18% to 20% of perinatal deaths in the United States. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588/)

This failure placed Patient 1 (and her unborn baby) at risk for infection, increase incidence of cesarean (surgical) delivery, respiratory distress syndrome (responsible for 40%-70% of neonatal [newborn infant] deaths) and cord prolapse (the umbilical cord comes out of the uterus with or before the presenting part of the fetus (baby), which could cause compromised blood flow to the fetus).

Findings:

Review of a complaint, dated 4/6/18, submitted to the California Department of Public Health by Hospital M indicated Patient 1 presented to Hospital L's ED on 4/2/18, and was sent to the OB unit at 1:58 a.m. The complaint indicated Patient 1 was at 33 weeks gestation (pregnant), complained of ruptured membranes (her "water broke") and had a positive AmniSure test result (test to confirm rupture of membranes). The complaint indicated Patient 1 reported she smoked meth (Methamphetamine-a potent central nervous system stimulant, mainly used as a recreational drug) fifteen minutes before her membranes ruptured. The complaint indicated Registered Nurse J (RN J) notified Physician F, via telephone (about Patient 1's arrival), and he advised Patient 1 to stay overnight and wait for an 8 a.m. ultrasound (test to assess preterm labor) or drive herself to Hospital M. The complaint indicated a Medical Screening Exam (MSE) was not performed in the ED or OB, prior to Patient 1's discharge. The complaint indicated Patient 1 was, "discharged home" at 2:50 a.m., arrived at Hospital M at 3:51 a.m., and delivered her baby at 5:45 p.m. The baby was placed in the NICU (Neonatal Intensive Care Unit) after delivery.

Hospital L's ED Non-Treatment Encounter Log, dated 4/2/2018, revealed Patient 1 had entered the ED at 1:40 a.m., was 35 weeks pregnant, and was transferred, "down to OB."

During an interview on 4/16/18 at 2 p.m., Manager H stated Patient 1 came Hospital L with possible premature rupture of membranes. Manager H stated Patient 1 was considered pre-term (early labor), and Hospital M had a Level 2 NICU (Neonatal Intensive Care Unit). Manager H stated staff checked Patient 1's vital signs, which were normal, and verified her membranes were indeed ruptured (using AmniSure test). Manager H stated Patient 1 was a former meth addict, had smoked meth about fifteen minutes prior to her membranes rupturing, and was antsy to get out of there (Hospital L).

During an interview on 4/17/18 at 8:15 a.m., Manager I stated Patient 1 came to Hospital L's ED at approximately 2 a.m. and was taken to New Beginnings (the obstetric/labor and delivery unit), since her pregnancy was over twenty weeks. Manager I stated Patient 1 had reported her water had broken fifteen minutes after she took meth, and she did not know if she could make it to Hospital M, where her doctor worked. Manager I stated Patient 1 was placed on a monitor (fetal monitor to assess the health of the baby), and her nurse (RN J) telephoned the on-call physician (Physician F), who advised Patient 1 to stay overnight. Manager I stated Patient 1 did not want to stay overnight. After approximately one hour on the fetal monitor, RN J telephoned Physician F a second time, and informed him Patient 1 wanted to leave Hospital L. Manager I stated Physician F told RN J that Patient 1 could go if she wanted to, but she needed to go directly to Hospital M. Manager I stated no MSE was done (prior to discharge from Hospital L). Manager I stated Patient 1 arrived at Hospital M approximately one hour later and delivered her baby later that day at 5:30 p.m.

During an interview on 4/17/18 at 10:09 a.m., Manager H was asked about Hospital L's MSE process. Manager H stated an MSE consisted of vital signs (assessing blood pressure, heart rate, breathing, pain), history (obtaining patient's health history), head-to-toe physical assessment and a focused exam based on complaint (contractions, fetal monitor, sterile vaginal exam). Manager H stated Patient 1 had been monitored before discharge (had no contractions), and her AmniSure test was positive for ruptured membranes. Manager H stated Patient 1 reported being only thirty-three weeks pregnant (but she was actually thirty-five weeks pregnant) and had spotty (inconsistent) prenatal care; she stated these two facts would require a physician, not a nurse, to perform the MSE.

During a tour of Hospital L's Emergency Department (ED) on 4/17/18 at 10:45 a.m., RN K stated when a pregnant patient came to the ED, and was over twenty weeks gestation, ED staff would notify (via telephone) the OB unit, place the patient in a wheelchair, and transport her to the OB unit (where the MSE would occur).

During an interview on 4/17/18 at 11:15 a.m., RN J stated she was Patient 1's nurse the night she came to Hospital L. RN J stated Patient 1 walked in with a friend at approximately 1:30 a.m. and reported she was, "leaking" (from the PROM) and was thirty-five weeks pregnant. RN J stated she placed Patient 1 on a fetal monitor (to assess the baby's well-being) and tested the leaking fluid (to determine if it was amniotic fluid, which indicated PROM). RN J stated Physician F was on-call that night, and she telephoned him on two occasions. She stated during the second telephone conversation, Physician F stated Patient 1 could be discharged to Hospital M. RN J stated she telephoned Hospital M and gave them a brief history of Patient 1. When asked about her concept of an MSE, RN J stated a physician or qualified MSE provider should conduct the MSE. RN J stated she was not qualified to perform an MSE, and a physician should have seen Patient 1 prior to her discharge.

During an interview on 4/17/18 at 2:40 p.m., Manager H stated two nurses were working on the OB unit the night Patient 1 arrived, and neither nurse was qualified to perform MSE's. Manager H stated Patient 1 required a physician to conduct the MSE (not an RN) because Patient 1 had, "excluding factors" which prevented an RN MSE. She stated the excluding factors included the fact that Patient 1 was preterm (early labor) and she was a, "new patient" to Physician F (he nor his medical group had previously seen her).

During an interview on 4/18/18 at 9:05 a.m., Physician F was asked about the night Patient 1 came to Hospital L. Physician F stated Patient 1 was thirty-five weeks pregnant, was a meth user, and was possibly leaking fluid (ruptured membranes). Physician F stated he lived near-by but did not come to see Patient 1 that night; he stated his plan was to get an ultrasound in the morning and evaluate her then. When asked if he was aware both RN's who were on duty that night were not qualified to perform an MSE, he stated he was not aware. When asked if he was aware Patient 1 had not received an MSE (prior to discharge), he stated, "no," he had not asked the nurse. Physician F also stated he was wrong not to ask if Patient 1 had a ride to Hospital M.

Review of Patient 1's medical record (from Hospital L) indicated she had, "Premature rupture of Membranes," had used meth fifteen minutes before her membranes ruptured, complained of fluid leaking, and was a patient of Physician G (from Hospital M). Her medical record indicated she had been on the fetal monitor for approximately one hour. A report was given to Physician F regarding Patient 1's arrival to the facility, pregnancy history, and positive AmniSure test result. On 4/16/18 at 2:50 a.m., RN J documented, "Orders received (sic) to keep pt (patient) till (sic) am (morning) and order Usg (ultrasound) or offer pt to go to (Hospital M) in her own vehicle." At 2:53 a.m., RN J documented Patient 1 requested to be discharged and go to Hospital M. RN J documented Physician F was notified, and she received orders to discharge Patient 1. RN J documented Patient 1 was educated regarding the, "urgency of going straight to (Hospital M) with no stops." RN J documented she also urged Patient 1 to stay until 8 a.m., for an ultrasound, but Patient 1 continued to request a discharge. RN J documented Patient 1 understood the risks of leaving with PROM and the importance of going straight to Hospital M.

Patient 1's Discharge Summary from Hospital L, dated 4/2/18 at 2:54 a.m., indicated orders were received from Physician F to discharge Patient 1. "Pt instructed to go directly to (Hospital M) in (a town thirty minutes away). Pt verbally understands." The following portions of the medical record were left blank and did not contain documentation from the provider: The MSE Discharge Status, MSE Discharge Criteria, MSE Discharge teaching, and MSE Summary.

According to the National Institute of Health, initial management of preterm PROM includes, "Admit to Labor and Delivery," and a woman presenting with suspected preterm PROM should focus on confirming the diagnosis, validating gestational age, documenting fetal well-being, and deciding on the mode of delivery. Management of pregnancies complicated by preterm PROM should be undertaken in hospital because it is not possible to accurately predict which pregnancies will develop complications. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588/)

Review of Hospital L's policy and procedure titled, "EMTALA - Screening, Stabilization And Transfer Of Individuals With Emergency Medical Conditions All Departments & Locations" (revised 1/23/17), indicated a medical screening examination (MSE) was a, "screening process performed by a physician or another QMP (Qualified Medical Person) required to determine, with reasonable clinical confidence, whether an EMC (Emergency Medical Condition) exists...." The policy indicated it applied to, "B.1. Any individual who presents at Hospital's Emergency Department....and requests examination or treatment for a medical condition..." The policy indicated, "III. Procedures: ...B. Medical Screening Examination: 1. An MSE must be provided for: a. Every individual described in Section 1B." The policy indicated, "B.3. MSE Process: a.....The MSE is performed by a physician or by a Qualified Medical Practitioner....and must be documented in the medical record."

Review of Hospital L's policy and procedure titled, "Triage and Treatment of Obstetric Patient Presenting to the Emergency Department," subtitled, "Policy:" (revised 8/17/17), indicated "All patients who present to the Emergency Department for care will be given timely medical screening examinations (MSE) and appropriate interventions....Patients in labor will proceed directly to Labor & Delivery, ideally via a wheelchair..." The policy indicated, under subtitle, "Procedure: ...B.5. Patients greater than 20 weeks GA (gestation) with the following conditions will be medically screened and treated in Labor & Delivery: a. Symptoms of preterm labor...c. Preterm premature rupture of membranes..."

Review of policy titled, "Maternal Admission/Discharge Criteria," subtitled, "Policy:" (revised 10/16/17), indicated: "The following patients are considered appropriate for admission to New Beginnings: ...."B. Pregnant patient who has a complication of pregnancy." Documentation under subtitle, "Transfer/discharge Criteria:" indicated, "The following criteria are recommended for transfer/discharge to/from New Beginnings...B. Women who need more intensive monitoring or who would benefit from a higher level of care may be transferred to ICU (intensive care unit) or another acute medical facility...."