HospitalInspections.org

Based on observation, record review, policy review and interview the hospital failed to:
- Provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#21) of 27 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed from 03/01/-24 through 09/30/24.
- To ensure that an emergency medical condition (EMC) was stabilized for one patient (#14) of 27 ED and L&D records reviewed.
- Accurately document the patient's name, age, sex, date, time, means of arrival, complaint, disposition of the patient and disposition time on the ED and L&D central logs reviewed from 03/01/24 through 09/30/24.
- Conspicuously post signs in the ED and L&D departments specifying the rights of individuals with respect to examination and treatment for EMCs, and information indicating whether or not the hospital participated in the Medicaid program.

These failed practices had the potential to cause harm to all patients who presented to the ED and L&D seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act" (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," reviewed 02/2024, showed:
- Medicare participating hospitals must meet the EMTALA statute.
- EMTALA requires hospitals with EDs to provide a MSE to any individual who comes to the ED and requests an examination and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an EMC.
- The provisions of EMTALA apply to all individuals who attempt to gain access to a hospital for emergency care.
- The patient should receive a medical screening examination.
- The appropriate means of stabilization for the patient condition must be implemented.

Review of the hospital's policy titled, "MSE," reviewed 02/2024, showed:
- Persons presenting to or being brought to the ED for unscheduled procedures or evaluation will receive a MSE by a physician utilizing ancillary services routinely available to the ED, including examination, testing, treatment and services of appropriate on-call physicians where indicated.
- Patients should not be denied evaluation, screening, testing, treatment or stabilization on the basis of their presenting complaint or condition.
- Persons presenting to the ED or presenting to any area of the hospital and being brought to the ED and requesting treatment or examination should be provided a MSE in the ED.
- In the case of the obstetrical (OB, relating to childbirth and the processes associated with it) patient who is 20 or more weeks gestation (a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days) with complications of pregnancy, the screening should be performed in the L&D department.

Review of the hospital's document titled, "Missouri Delta Medical Center Medical Staff - Rules and Regulations," approved 02/06/92, showed:
- The hospital will provide an appropriate MSE within its capability, including ancillary services routinely available to the ED, for persons on the hospital's property requesting services, for whom services are requested, and if an individual is unable to request services a request shall be deemed to have been made if a prudent layperson observer would believe, based on the individuals appearance or behavior, the individual needs services for a medical condition.
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual at risk of serious injury, serious impairment to bodily function or serious dysfunction of any bodily organ or part.
- If an EMC is found to exist, the hospital will provide necessary stablizing treatment.
- Stabilizing treatment is considered as the treatment necessary to assure, within a reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a hospital.

Review of the hospital's policy titled, "Obstetrics (the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Policy and Procedure Management of Severe Hypertension (elevated blood pressure [BP, normal adult blood pressure is between 90/60 and 120/80]) Preeclampsia (a disorder of pregnancy characterized by the onset of high BP and often a significant amount of protein in the urine which increases the risk of the mother and the baby)," reviewed 02/2024, showed:
- The purpose of the policy was to define Missouri Delta Medical Center's policy regarding the multidisciplinary team management of pregnant and postpartum (the time that begins right after a woman gives birth and lasts about six weeks) patients with severe hypertension.
- This is an organization-wide policy. It applies to all services and settings that provide maternal (characteristics of a mother) care.
- Preeclampsia is characterized by a new onset of hypertension and proteinuria (elevated protein in the urine) after 20 weeks of gestation in a previously normotensive (an individual with a normal BP) woman.
- Hypertension is diagnosed with two BP readings of greater than or equal to a systolic pressure (the pressure against the artery during the heartbeat, when the heart is pushing blood out) of 140 or a diastolic pressure (the pressure against the wall of the artery when the heart rests, between beats) of 90 at least four hours apart.
- Proteinuria is a protein/creatinine (a measure of the protein and creatine [a waste product] in urine) ratio of 0.3 or greater.
- Eclampsia (a new onset of seizures [sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness] or coma in a pregnant/postpartum woman with preeclampsia) up to six weeks postpartum.
- Severe hypertension is a systolic BP of 160 or greater, a diastolic BP of 110 or greater or both in a woman in the postpartum period.
- Standardized, evidence-based clinical guidelines will be implemented for the management of patients with severe hypertension, preeclampsia and eclampsia.
- Women in the postpartum period with acute (sudden) onset, severe systolic hypertension, severe diastolic hypertension or both require urgent antihypertensive (medication used to reduce high blood pressure) therapy.
- Prompt treatment within 30 to 60 minutes of detection is recommended. Control of severe hypertension is the first priority.
- A systolic BP greater than 160 or a diastolic pressure of greater than 105 to 110 is treated with intravenous (in the vein) antihypertensive medications to protect the patient from a stroke. The goal is a diastolic pressure of 90-100 to maintain circulation.
- Magnesium sulfate (a medication used to prevent seizures in pregnancy/postpartum) administration is a first line drug to prevent seizures in women who have preeclampsia with severe features (signs or symptoms of significant organ dysfunction). Starting magnesium sulfate should not be delayed in the setting of acute severe hypertension. It is recommended for women with severe hypertension with or without proteinuria, hypertension with neurologic (neuro, relating to or affecting the nervous system including headache) signs or symptoms or eclampsia.
- A team debrief is conducted by at least the primary registered nurse (RN) and primary physician and input is obtained from all or as many participants as possible in the care and treatment of a patient with severe hypertension, preeclampsia and/or eclampsia occurrence, including the ED.
- The team debrief provides an opportunity for teams to review and document the sequence of events, success and barriers to a swift and coordinated effort for severe hypertension, preeclampsia and eclampsia occurrence.
- Staff education will be provided to all staff and providers who treat pregnant and postpartum patients about hypertension and preeclampsia procedures. Education will occur at orientation, whenever changes to the procedures occur and every two years.
- Severe hypertension, preeclampsia and eclampsia drills will be conducted at least annually to determine system issues as part of the ongoing quality improvement efforts. Drills include representatives from each discipline who treats pregnant/postpartum patients and include a team debrief after the drill.
- Severe hypertension, preeclampsia and eclampsia cases that meet criteria will be reviewed to evaluate the effectiveness of care, treatment and services provided. The outcomes of the review will be reported to the appropriate clinical, medical staff and organizational quality improvement committees and as described in the organizations Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program/plan.

Review of the hospital's policy titled, "Log Book-Control Register," reviewed 02/2024, showed:
- An electronic patient register containing pertinent information should be continuously maintained for individuals seeking medical care through the ED.
- OB patients should be logged in a register maintained by the OB department.
- Information contained in the log should include, patient name, age, sex, date, time, means of arrival, patient complaint, disposition of the patient and disposition time.

Although requested, the hospital did not provide a policy for EMTALA signage.

Please refer to 2402, 2405, 2406 and 2407 for further details.

Based on observations and interview, the hospital failed to conspicuously post signs in the Labor and Delivery (L&D) and the Emergency Department (ED) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMCs), and information indicating whether or not the hospital participated in the Medicaid program. These failures had the potential to affect all patients that presented to the L&D unit and ED for emergency medical treatment. The hospital's average monthly ED census over the past six months was 1,777. The hospital's L&D average monthly triage (process of determining the priority of a patient's treatment based on the severity of their condition) census over the past six months was 410.

Findings included:

Although requested, the hospital did not provide a policy for Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) signage.

Observation on 09/30/24 at 11:20 AM, in the L&D unit, showed no EMTALA signage in the L&D triage room.

Observation on 10/03/24 at 10:30 AM, in the ED, showed no EMTALA signage in the ED treatment rooms.

During an interview on 09/30/24 at 11:20 AM, Staff I, L&D Manager, stated she agreed there was no EMTALA signage in the L&D triage room.

During an interview on 10/02/24 at 11:50 AM, Staff E, ED Director, stated he agreed there was no EMTALA signage in the ED treatment rooms.

During an interview on 10/02/24 at 2:24 PM, Staff W, President, stated EMTALA signs should be in each L&D triage room and ED treatment room.

During an interview on 10/02/24 at 2:42 PM, Staff G, Nursing Vice President (VP), stated EMTALA signs should be in each L&D triage room and ED treatment room.

Based on observation, policy review and interview the hospital failed to maintain an accurate central log for patients who presented to the Emergency Department (ED) and Labor and Delivery (L&D) for care of central logs reviewed from 03/01/24 through 09/30/24.

Findings included:

Review of the hospital's policy titled, "Log Book-Control Register," reviewed 02/2024, showed:
- An electronic patient register containing pertinent information should be continuously maintained for individuals seeking medical care through the ED.
- Obstetrical (OB, relating to childbirth and the processes associated with it) patients should be logged in a register maintained by the L&D department.
- Information contained in the log should include, patient name, age, sex, date, time, means of arrival, patient complaint, disposition of the patient and disposition time.
Review of the hospital's document titled, "Activity Log," dated 03/01/24 through 09/30/24 showed 28 ED patients without complaints and 40 ED patients without disposition locations documented.
Review of the hospital's undated and untitled document showed:
- 633 patients without a means of arrival;
- 170 patients without a disposition time;
- 159 patients without disposition locations;
- 13 patients without complaints;
- 13 patients without an age;
- 13 patients without a time;
- 11 patients without a date; and
- Two patients without names.

During an interview on 10/02/24 at 2:24 PM, Staff W, President, stated it was unacceptable that the central logs were not completed. He expected the central logs to be completed per the hospital's policy.

During an interview on 09/30/24 at 11:20 AM and 10/02/24 at 2:42 PM, Staff G, Nursing VP, agreed the central logs were incomplete. She expected the central logs were completed per the hospital's policy.

During an interview on 10/02/24 at 11:50 AM, Staff E, ED Manager, stated he expected the central logs were completed per policy.

During an interview on 09/30/24 at 11:21 AM, Staff I, L&D Manager, stated she was not aware the central logs were incomplete.

Based on interview, record review and policy review the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#21) of 27 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act" (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) reviewed 02/2024, showed:
- Medicare participating hospitals must meet the EMTALA statute.
- EMTALA requires hospitals with EDs to provide a MSE to any individual who comes to the ED and requests an examination and prohibits hospitals with EDs from refusing to examine or treat individuals with an EMC.
- The provisions of EMTALA apply to all individuals who attempt to gain access to a hospital for emergency care.
- The patient should receive a medical screening examination.

Review of the hospital's policy titled, "MSE," reviewed 02/2024, showed:
- Persons presenting to or being brought to the ED for unscheduled procedures or evaluation will receive a MSE by a physician utilizing ancillary services routinely available to the ED, including examination, testing, treatment and services of appropriate on-call physicians where indicated.
- Patients should not be denied evaluation, screening, testing, treatment or stabilization on the basis of their presenting complaint or condition.
- Persons presenting to the ED or presenting to any area of the hospital and being brought to the ED and requesting treatment or examination should be provided a MSE in the ED.

Review of the hospital's document titled, "Missouri Delta Medical Center Medical Staff - Rules and Regulations," approved 02/06/92, showed the hospital will provide an appropriate MSE within its capability, including ancillary services routinely available to the ED for persons on the hospital's property requesting services, for whom services are requested, and if an individual is unable to request services a request shall be deemed to have been made if a prudent layperson observer would believe, based on the individuals appearance or behavior, the individual needs services for a medical condition.

Review of Patient #21's Hospital B Medical Record dated 04/15/24, showed:
- At 2:08 PM, he was a 50-year-old male who presented to the ED and stated he had a bowel movement, got weak and fell into his bathroom counter causing left rib pain. He verbalized diarrhea and feeling bad all over with generalized weakness.
- His past medical history included kidney failure, dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions), high blood pressure, seizures (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) and diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing).
- At 7:08 PM, his potassium (mineral in the blood or body fluid, normal is 3.3 to 5.0) level was 5.4. A comment showed the potassium result may be elevated due to moderate hemolysis (the destruction of red blood cells). No treatment was given.
- At 7:45 PM, a stat (immediately) potassium level was ordered.
- At 8:47 PM, his potassium level was 2.7. A comment showed slight hemolysis. Any hemolysis had the potential to falsely elevate potassium levels.
- At 9:03 PM, he was discharged home.

Review of Patient #21's medical record dated 04/16/24, showed:
- At 12:16 AM, he presented to the ED with a complaint of involuntary movement.
- He arrived via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) after he had just gotten home from Hospital B for the same complaint and called EMS. He had a history of twitching and was scheduled for a Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) and an electroencephalography (EEG, a recording of brain activity, often used to evaluate presence of seizure activity) that morning but transportation services did not pick him up. He fell and hit his left rib area.
- At 1:36 AM, his vital signs (VS, measurements of the body's most basic functions: include blood pressure (BP) normal between 90/60 and 120/80; pulse/heartbeats (HR) normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature (T) normal 97.8 to 99 degrees) were BP 170/89, HR 86, RR 18 and T 98.1.
- The ED fall assessment showed no falls in the last three months.
- At 1:36 AM, his pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was six for rib pain.
- He lived at home independently.
- He had diffuse sporadic jerking, more so when Staff Q, Physician, talked to him during the exam. Before the exam Staff Q walked around the room and did not see any jerking.
- Laboratory tests from a previous hospital show a potassium of 5.4, otherwise unremarkable.
- The impression was patient was given Kayexalate (a medication that helps the body get rid of extra potassium) and discharged home. There was no plan to repeat laboratory testing. He needed to go to dialysis the next day.
- The discharge diagnosis was anxiety, hyperkalemia (high potassium level in the blood) and twitching.
- At 1:52 AM, he was discharged home.

During a telephone interview on 10/01/24 at 9:10 AM, Staff N, ED Medical Director, stated Patient #21's care in the ED did not meet MSE expectations. A patient should never be treated based on an outside hospital's laboratory results. The results should have been re-evaluated before he received treatment. She stated outside laboratory results "should never be trusted." Kayexaleate administration was inappropraite for a potassium level of 5.4 without the presence of EKG changes. She expected Patient #21 would have been admitted to the hospital with an order for a neurology (a branch of medical science that is concerned with disorders and disease of the nervous system) consultation. The hospital was capable of providing a telehealth (remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) neurology consultation. An ED visit did not provide sufficient time to evaluate Patient #21's electrolytes (minerals in the blood and other body fluids that carry an electric charge) imbalance and symptoms, considering he had two ED visits.

During an interview on 10/01/24 at 4:00 PM, Staff L, Chief of Staff, stated he could "argue either way" Patient #21 received a completed MSE. The completed history and physical assessment documentation qualified as a completed MSE. He stated that retrospectively the MSE was not "the best" and was not a completed evaluation. Next time, "for goodness sakes, the provider should do more. If he were in Staff Q's, Physician, shoes, he would have ordered more laboratory testing."

During a telephone interview on 10/01/24 at 11:28 AM, Staff Q, Physician, stated he received a report for Patient #21 from the patient, EMS, nursing staff and a "stack of papers." He was unfamiliar with the electronic medical record (EMR) system for the outside hospital but "did his best" to look at the paperwork. He did not see any indication that the report he received was "wrong." He decided to treat Patient #21 based on the outside hospital's laboratory results, the results were "only a few hours" old. He did not repeat the laboratory tests because he was "conscious of expenses." He did not see that any treatment was given at Hospital B and the patient's potassium level "drastically" dropped to 2.7 before he ordered the Kayexalate administration. His orders were based on "what he saw." He learned his lesson and will double-triple check in the future. It was not an intentional mistake and should not have happened. He did not consider ordering a neurology consult, the patient was not "convulsing, spoke in complete sentences and he followed the EMS and nursing story." The patient looked "anxious." He believed the patient's activity level in the ED was equal to the patient's "baseline and he needed extensive help to get from one place to another."

During an interview on 10/02/24 at 2:24 PM, Staff W, President, stated he expected a complete MSE as indicated to meet the patient's needs. Outside medical records could be used on an "adjunct basis." He expected new laboratory work to be completed in the ED. If the outside medical records were used in the care of a patient, those records were scanned into the patient's medical record. "All information needed to be in the medical record."

During an interview on 10/02/24 at 2:42 PM, Staff G, Nursing Vice President (VP), stated a complete MSE included the imaging, laboratory work, consultations, etc., needed to determine the presence or absence of an EMC. The care Patient #21 received in the ED did not meet her expectations and Patient #21 did not receive a complete MSE. Staff Q, Physician, was decredentialed after the event with Patient #21. Laboratory results from an outside hospital could be used to assist with an assessment to "identify trends," but were not to be the basis for ED treatment. Those records were to be scanned into the medical record if used in the assessment of the patient. In addition to the expectation that new blood work was completed prior to medication administration for hyperkalemia, she expected a patient's potassium level was evaluated after treatment was given prior to the patient's discharge home. She stated the patient required an admission for further observation and assessment.

During an interview on 10/02/24 at 11:50 AM, Staff E, ED Director, stated his epectations were not met when Patient #21 received treatment based on laboratory results from Hospital B. If laboratory results from another hospital were included in the assessment of a patient, those records were to be scanned into the patient's medical record. The ED had the capability to obtain an emergent MRI and EEG. He agreed Patient #21 did not receive a complete MSE. If the patient fell during transfer to his car after his discharge from the ED, the patient should have been re-evaluated for a possible unsafe discharge.

During an interview on 10/02/24 at 3:09 PM, Staff T, RN, stated she "kind of remembered a stack of papers" with Patient #21. She stated that "normally" the labs were obtained at the hospital. She did not recall if the patient fell. "A technician assisted Patient #21 to his car." If he fell, she expected the technician to bring the patient back into the ED for further assessment. She expected a telehealth neurology consult for Patient #21. If neurology recommended admission, the patient was admitted to the hospital.

Based on interview, record review and policy review the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#14) of 27 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED and L&D unit seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act" (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition), reviewed 02/2024, showed:
- Medicare participating hospitals must meet the EMTALA statute.
- EMTALA prohibits hospitals with emergency departments from refusing to examine or treat individuals with an EMC.
- The provisions of EMTALA apply to all individuals who attempt to gain access to a hospital for emergency care.
- The appropriate means of stabilization for the patient condition must be implemented.

Review of the hospital's policy titled, "Medical Screening Examination (MSE)," reviewed 02/2024, showed in the case of the obstetrical (relating to childbirth and the processes associated with it) patient who is 20 or more weeks gestation (a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days), with complications of pregnancy, the OB screening should be performed in the L&D department.

Review of the hospital's document titled, "Missouri Delta Medical Center Medical Staff - Rules and Regulations," approved 02/06/92, showed:
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual at risk of serious injury, serious impairment to bodily function or serious dysfunction of any bodily organ or part.
- If an EMC is found to exist, the hospital will provide necessary stablizing treatment.
- Stabilizing treatment is considered as the treatment necessary to assure, within a reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a hospital.

Review of the hospital's policy titled, "OB Policy and Procedure Management of Severe Hypertension (elevated blood pressure [BP, normal adult blood pressure is between 90/60 and 120/80]) Preeclampsia (a disorder of pregnancy characterized by the onset of high BP and often a significant amount of protein in the urine which increases the risk of the mother and the baby)," reviewed 02/2024, showed:
- The purpose of the policy was to define Missouri Delta Medical Center's policy regarding the multidisciplinary team management of pregnant and postpartum (the time that begins right after a woman gives birth and lasts about six weeks) patients with severe hypertension.
- This is an organization-wide policy. It applies to all services and setting that provide maternal (characteristics of a mother) care.
- Preeclampsia is characterized by a new onset of hypertension and proteinuria (elevated protein in the urine) after 20 weeks of gestation in a previously normotensive (an individual with a normal BP) woman.
- Hypertension is diagnosed with two BP readings of greater than or equal to a systolic pressure (the pressure against the artery during the heartbeat, when the heart is pushing blood out) of 140 or a diastolic pressure (the pressure against the wall of the artery when the heart rests, between beats) of 90 at least four hours apart.
- Proteinuria is a protein/creatinine (a measure of the protein and creatine [a waste product] in urine) ratio of 0.3 or greater.
- Eclampsia is a new onset of seizures (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness or coma) in a pregnant/postpartum woman with preeclampsia up to six weeks postpartum.
- Severe hypertension is a systolic BP of 160 or greater, a diastolic BP of 110 or greater or both in a woman in the postpartum period.
- Standardized, evidence-based clinical guidelines will be implemented for the management of patients with severe hypertension, preeclampsia and eclampsia.
- Women in the postpartum period with acute (sudden) onset, severe systolic hypertension, severe diastolic hypertension or both require urgent antihypertensive (medication used to reduce high blood pressure) therapy.
- Prompt treatment within 30 to 60 minutes of detection is recommended. Control of severe hypertension is the first priority.
- A systolic BP greater than 160 or a diastolic pressure of greater than 105 to 110 is treated with intravenous (in the vein) antihypertensive medications to protect the patient from a stroke. The goal is a diastolic pressure of 90-100 to maintain circulation.
- Magnesium sulfate (a medication used to prevent seizures in pregnancy/postpartum) administration is a first line drug to prevent seizures in women who have preeclampsia with severe features (signs or symptoms of significant organ dysfunction). Starting magnesium sulfate should not be delayed in the setting of acute severe hypertension. It is recommended for women with severe hypertension with or without proteinuria, hypertension with neurologic (neuro, relating to or affecting the nervous system including headache) signs or symptoms or eclampsia.
- A team debrief is conducted by at least the primary registered nurse (RN) and primary physician and input is obtained from all or as many participants as possible in the care and treatment of a patient with severe hypertension, preeclampsia and/or eclampsia occurrence, including the ED.
- The team debrief provides the team an opportunity for teams to review and document the sequence of events, success and barriers to a swift and coordinated effort to severe hypertension, preeclampsia and eclampsia occurrence.
- Staff education will be provided to all staff and providers who treat pregnant and postpartum patients about hypertension and preeclampsia procedures. Education will occur at orientation, whenever changes to the procedures occur and every two years.
- Severe hypertension, preeclampsia and eclampsia drills will be conducted at least annually to determine system issues as part of the ongoing quality improvement efforts. Drills include representatives from each discipline who treats pregnant/postpartum patients and include a team debrief after the drill.
- Severe hypertension, preeclampsia and eclampsia cases that meet criteria will be reviewed to evaluate the effectiveness of care, treatment and services provided. The outcomes of the review will be reported to the appropriate clinical, medical staff and organizational quality improvement committees and as described in the organizations Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program/plan.

Review of Patient #14's medical record dated 07/26/24 showed:
- At 4:23 PM, she was an 18-year-old female who presented to the L&D triage unit via a wheelchair and complained of a headache since 11:00 AM, her BP was high, and her feet were still swollen.
- Her past medical history included epilepsy (a neurological disorder that can cause unpredictable seizures).
- At 4:34 PM, her BP was 157/102.
- At 4:45 PM, blood work was obtained. She verbalized occasional blurred vision, denied seeing spots and epigastric (the upper part of the abdomen just below the rib cage) pain. She verbalized taking ibuprofen (a medication that is used for treating pain, fever, and inflammation) for the headache without improvement. Her pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was five to six in the front of her head and behind her eyes. She had mild generalized edema (swelling); deep tendon reflexes (the strength of a reflex, two plus is normal) were three plus in her left knee and two plus in her right knee.
- At 4:52 PM, her urine protein-creatinine ratio was 0.59. Her platelets (cell fragments in the blood that initiate clot formation and stop or prevent bleeding) were 461.
- At 5:03 PM, her BP was 136/86.
- At 5:06 PM, her BP was 165/96.
- At 5:15 PM, her BP was 151/89.
- At 5:30 PM, her BP was 150/91.
- At 5:38 PM, Staff Y, Physician, was notified of the patient's BPs and laboratory results.
- At 5:40 PM, her BP was 135/91.
- At 5:50 PM, her BP was 132/92. An oral antihypertensive medication was administered. The patient was instructed to try Tylenol for the treatment of her headache.
- At 6:03 PM, her BP was 130/91.
- At 6:20 PM, her BP was 131/92. She was discharged with instructions to alternate ibuprofen and Tylenol (medication that treats minor pains and fever) for a headache, to take the antihypertensive medication twice daily as prescribed and postpartum hypertension education was provided.

Review of Patient #14's medical record dated 07/27/24, showed:
- At 1:37 PM, she presented to the ED and stated her BP was 150/108, she had a baby a week ago and was at the hospital the day before.
- At 1:41 PM, her BP was 146/95.
- At 2:22 PM, her BP was 145/87. The history of present illness showed she presented to the ED with a chief complaint of elevated BP at home and a headache. She stated her BP at home was 180/110. She was nine days postpartum. She took the antihypertensive medication and ibuprofen. Her headache started the day before and was a four on the pain assessment scale. When she stood that morning, she felt dizzy and thought she might pass out. No deep tendon reflex assessment was performed.
- At 2:32 an EKG showed a normal HR and rhythm.
- At 2:50 PM, a head computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) showed no abnormality.
- At 2:54 PM, her BP was 148/106.
- At 3:04 PM, her platelets were 479, urine protein was one plus and urine white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) count was 30.1.
- At 3:58 PM, her BP was 161/96.
- At 4:02 PM, she was given IV antibiotics.
- At 5:03 PM, her BP was 160/105.
- At 5:41 PM, her BP was 169/106.
- At 5:50 PM, she was given 500 milliliters of IV fluids.
- At 6:31 PM, an IV antihypertensive medication was administered.
- At 6:41 PM, her BP was 162/106.
- At 7:14 PM, she was diagnosed with postpartum hypertension and a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra).
- At 7:32 PM, her BP was 163/108.
- No Obstetrician/Gynecologist (OB/GYN, a specialty physician focused on women's health and delivering babies) consult was completed.
- At 7:33 PM, she was discharged home with a prescription for oral antibiotics and UTI education.
Review of Patient #14's medical record dated 07/28/24, showed:
- At 4:36 AM, she presented to the ED with seizures.
- At 4:43 PM, the history of present illness showed the seizure onset was just prior to her arrival at the ED. She was lying in bed and began having seizure like activity. She had two episodes lasting two to three minutes each.
- At 4:44 AM, IV levetiracetam (antiseizure medication) was administered.
- At 4:55 AM, she was admitted to the L&D unit.
- At 5:02 AM, IV magnesium sulfate was administered.
- On 07/30/24 at 8:55 AM, she was discharged home.

During an interview on 10/01/24 at 1:15 PM, Staff J, OB Medical Director, stated during Patient #14's visits she had BP's greater than 160/110 with severe features of a headache and a protein-creatinine ratio of 0.59, which was diagnostic for severe postpartum hypertension. The care Patient #14 received did not meet her expectations, she was not stabilized. At a minimum she expected Patient #14 to be monitored for at least four hours to observe her BP's four hours apart. Staff J attempted to speak to Staff P, Nurse Practitioner (NP, a nurse with advanced clinical education and training) and she became "defensive." Patient #14 should have been evaluated in the L&D triage (process of determining the priority of a patient's treatment based on the severity of their condition) unit, she did not understand why Patient #14 remained in the ED. She expected, at a minimum, Patient #14 would have been admitted to the hospital, started on the hypertension in pregnancy protocol and IV magnesium sulfate. She agreed the staff needed increased awareness of hypertension in pregnancy/postpartum. She was unsure if any hypertension in pregnancy education was given to the ED providers. She requested the OB/GYN physician on call be contacted for every postpartum patient that presented to the ED. There was no debrief or case review completed for the events related to Patient #14.

During an interview on 10/02/24 at 9:10 AM, Staff N, ED Medical Director, stated Patient #14's ED visit was mismanaged, and the provider missed the diagnosis. She expected the hypertension in pregnancy protocol to be initiated. She expected a case review and team debrief be completed in relation to Patient #14 according to the hospital's policy. She did not know why the case was not identified for a case review. Staff education needed to be provided for pregnancy related hypertension. She expected a face to face follow up with the provider and an entire team awareness about the care of hypertension in pregnancy.

During an interview on 10/02/24 at 2:42 PM, Staff G, Nursing Vice President (VP), stated she had "no idea" why patient #14 was prescribed oral antihypertensives and discharged from L&D triage. The patient had risk factors for hypertension in pregnancy, a headache, a BP of greater than or equal to 160/110 and recurrent BPs of greater than or equal to 140/90 with both visits. She expected Patient #14 to be admitted to the hospital and IV magnesium sulfate administered with both visits. Patient #14's case was not reviewed; education was to be provided. NP's saw the lesser acute patients in the ED, she was not able to state why Patient #14 was not recognized as a high-risk OB patient. The hospital failed to stabilize Patient #14; she should have been admitted to the hospital.

During an interview on 10/01/24 at 1:45 PM and 10/02/24 at 10:00 AM, Staff I, L&D Manager, stated that there was "more than enough" reason to admit Patient #14 during her evaluation in the L&D triage unit and the ED. She expected the patient's headache was treated and reassessed prior to discharge. An unrelieved headache was a severe feature for hypertension in pregnancy and demonstrated a potential for seizures. She expected a longer evaluation of at least four hours. She agreed the diagnosis and stabilization was missed during both visits. Patient #14's BP in the ED and L&D triage was greater than 160/110 and she needed an admission to the hospital. The third time Patient #14 returned to the hospital with eclamptic seizures. The ED staff lacked experience with pregnancy related complications and needed to refer to the OB department. Patient #14 came to the hospital twice and asked for help. Staff I spoke with Staff E, ED Director, regarding the events with Patient #14 but was unsure of additional follow up. She expected the ED staff were given hypertension in pregnancy education. There was no debrief or case review for Patient #14. The L&D department performed hypertension in pregnancy drills annually, the ED staff were not included in the drills.

During an interview on 10/02/24 at 11:50 AM, Staff E, ED Director, stated the ED was an "opportunity rich environment." There was no hypertension in pregnancy education provided to the ED staff as a response to Patient #14's events. He was not aware of any hypertension in pregnancy education given to the ED staff within the previous two years. He speculated the registration staff failed to recognize Patient #14's hypertension was pregnancy related and failed to request the patient be seen in the L&D unit. He believed the ED nurse felt the patient was in a hypertensive crisis, she did not consider the patient was postpartum and this was a pregnancy related hypertension. He expected the ED staff to "look deeper" into patient's that presented with pregnancy related hypertension. There was no team debrief or case review completed for the events related to Patient #14.

During an interview on 10/02/24 at 10:45 AM, Staff P, NP, stated she frequently used "references" to ensure she understood the expectations for patient care. She consulted the OB/GYN provider and was told to discharge the patient. She "normally documented the consult and conversation in the medical record." She agreed the diagnosis was missed and the patient was not stabilized. She was not debriefed or provided education in response to Patient #14's events. She was expected to follow the hospital's policies. She agreed a deep tendon reflex assessment and urine protein-creatinine ratio testing was appropriate. BPs of greater than or equal to 140/90 required further observation which was not given to Patient #14.

During an interview on 10/02/24 at 12:23 PM, Staff R, RN, stated she rechecked Patient #14's BP immediately after the reading of 165/96 and it was 151/89. Typically, a patient that presented with the symptoms like Patient #14 exhibited was observed for 30 minutes, a urine sample was obtained, BPs were monitored every 15 minutes and the OB/GYN provider was consulted. She agreed Patient #14 should have been assessed for four hours to assess her BPs for severe hypertension. When a patient complained of a headache, the headache was treated and reassessed prior to discharge. Patient #14's headache was not treated or reassessed. The doctors calculate the patient's urine protein-creatinine ratio, she was not aware of what result was diagnostic for preeclampsia. Leadership did not follow up with her in regard to Patient #14 for a debrief.

During an interview on 10/02/24 at 2:24 PM, Staff W, President, stated he expected Patient #14's events to be peer reviewed and escalated to the quality department.

During an interview on 10/02/24 at 12:35 PM, Staff S, Laboratory Director, stated the calculated protein-creatinine ratio for Patient #14 was 0.59.

During an interview on 10/01/24 at 4:00 PM, Staff L, Chief of Staff, stated he was not aware of the events related to Patient #14.

Although requested, the hospital did not provide an interview with Staff X, RN, the RN who cared for Patient #14 in the ED on 07/27/24, she was on medical leave.

Although requested, the hospital did not provide an interview with Staff Y, Physician, the OB/GYN provider who consulted on Patient #14, she had passed away.