HospitalInspections.org

On the days of the EMTALA (Emergency Medical Treatment And Labor Act) survey based on observations, record reviews, interviews, review of the hospital's emergency department policies and procedures, review of the hospital's emergency department policies and procedures, and review of the hospital's Governing Body and Medical Staff Bylaws, the following deficiency was cited:

The findings are:

Cross Reference to A 2406: The hospital failed to ensure that 1 of 1 patient who presented to the hospital's emergency department in a private vehicle received a medical screening examination based on the hospital's nursing staff informing the patient and the patient's spouse that they should seek an alternative medical option rather than the emergency department (Patient #1); and it was determined the hospital failed to ensure that obstetrical patients presenting to the hospital's emergency department with gestation 20 weeks or greater received an appropriate medical screening examination to rule out an emergency medical condition by a qualified medical personnel approved by the governing board for 1 (Patient #22 ) of 3 obstetrical patient charts reviewed for obstetrical services. The hospital failed to ensure that Medical Staff ByLaws, Medical Staff General Rules and Rules and Regulations, and Obstetrical Gynecology Department Rules and Regulations identified and approved Obstetrical Registered Nurses as qualified medical personnel authorized to conduct/perform medical screening examinations.

Based on observations, record reviews, interviews, review of videos, review of the hospital's Medical Staff Bylaws, and review of the hospital's Emergency Medical Treatment And Labor Act (EMTALA), review of the hospital's Labor and Delivery policies,
the hospital failed to ensure that 1 of 1 patient who presented to the hospital's emergency department in a private vehicle received a medical screening examination based on the hospital's nursing staff informing the patient and the patient's spouse that they should seek an alternative medical option rather than the emergency department (Patient #1); and it was determined the hospital failed to ensure that obstetrical patients presenting to the hospital's emergency department with gestation 20 weeks or greater received an appropriate medical screening examination to rule out an emergency medical condition by a qualified medical personnel approved by the governing board for 1 (Patient #22 ) of 3 obstetrical patient charts reviewed for obstetrical services. The hospital failed to ensure that Medical Staff ByLaws, Medical Staff General Rules and Rules and Regulations, and Obstetrical Gynecology Department Rules and Regulations identified and approved Obstetrical Registered Nurses as qualified medical personnel authorized to conduct/perform medical screening examinations.

The findings are:

Patient #1
Video Inside Door View
On 2/14/2020 from 08:30 AM to 09:30 AM, review of the hospital's emergency department entrance videos dated 2/10/2020 with the hospital's Compliance Officer revealed:
08:00 AM: The emergency department's inside door view revealed that at 08:00 AM on 02/10/2020, a car was sitting outside the emergency department's front entrance door. There was a female standing in front of the door inside the emergency department. A male nurse was taking a wheelchair through the front door, and the female walked out with the male nurse and stood at the back door of the car.
8:05 AM: The video showed the male nurse returned to the emergency department. The video showed other people walking in and out the emergency department entrance door.
8:16 AM: The video showed a security guard standing at the metal detector looking through the purses of 2 females who entered the emergency department and went through the metal detector.
8:17 AM to 8:21 AM: The video showed seven persons entered the emergency department door and went through the metal detector.
8:22 AM: The Security Officer was observed going to the car parked in front of the emergency department's entrance.
8:23 AM: The Security Guard left the vehicle and entered the emergency department.
8:26 AM: The video showed the Security Guard went to the car parked in front of the emergency department's entrance, and then returned to the emergency department.
8:29 AM: The female stood outside the car and was on the telephone. The video showed the Security Guard transported another wheelchair to the car, locked the wheels of the wheelchair, and brought the other wheelchair back into the emergency department.
8:35 AM: The video showed the Security Guard and a nurse went to the car.
8:37 AM: The Security Guard and nurse entered the emergency department and the female gets into the car and leaves the emergency room entrance.

Video Front Outside View
8:00 AM: Car parked in front of the emergency department door.
8:01 AM: Nurse with a wheelchair was at the car with the female driver. The nurse was at the passenger door with an arm resting on top of the car door. The nurse was talking with the female driver and the passenger.
8:05 AM: Nurse returned to the emergency department. The female driver went to the passenger door and appeared to be in conversation with the male passenger.
8:15 AM: The female driver appeared to bend down and continues conversation with the male passenger.
8:22 AM: Security Guard approached the car and talked to the woman who gestured with her hands.
8:23 AM: Security Guard entered the emergency department, and the female driver bent down in conversation with the passenger.
8:24 AM: Security Guard transported another wheelchair to the car and removed the other wheelchair.
8:26 AM: Female driver was talking on a cell telephone, and the Security Guard was at the passenger door.
8:27 AM: Security Guard entered the emergency department and the female driver was engaged in conversation on the cell telephone and then handed the cell telephone to the passenger.
8:35 AM: Security Guard and Nurse went to the car. The female driver was gesturing with her hands.
8:37 AM: Female driver gets in the car and drives away. Security Guard and nurse return to the emergency department.

Interviews
Registered Nurse #1
On 2/12/2020 at 2:00 PM, a face to face interview with Registered Nurse (RN) #1 revealed, "I ' ve been here about 13 years. On 2/10/2020, I was making morning rounds. A lady walked in the front door and asked if someone could assist her husband in a wheelchair. I went to the passenger car door, and introduced myself to him. He said his name was Joe. I asked why were they there, and the woman said, 'Altered mental status'. The gentleman was alert and oriented. He knew his name, date of birth, the year, who the president was, where he was, and why he was here. I asked him to stand so I could help him get in the wheelchair, and he said, "No", and he said he didn ' t want to be in the emergency room. He said he 'didn ' t want to be seen by my doctors and he didn ' t want to get in the wheelchair'. I had a brief conversation with her(driver). He was alert and oriented, but he wouldn ' t come in with me. I explained to her that I couldn ' t force him out of the vehicle. She stayed there. I went and got the charge nurse and explained the situation."

Security Guard #1
On 2/13/2020 at 9:40 AM, a face to face interview with Security Guard #1 revealed, "I was working the metal detector and monitoring the front door. I saw a car outside the front door, and there was a gentleman in the passenger seat. There was a woman outside the car. I went outside to ask if they were okay or needed help. I asked the gentleman to come inside to talk to us, and he told me, 'No'. I did take them another wheelchair because the one that was there was missing a footrest. I think she was on the telephone with her son trying to convince him to come in. I explained to the other nurse what was going on. He/she went out with me, and asked the passenger if he wanted to come in, and he said, 'No'. He was carrying on a conversation with someone on the telephone. It was obvious he did not want to go into the emergency department. I do remember one other thing. One time when I was walking out, the lady grabbed the passenger ' s legs and rotated them out of the car. The passenger rotated his legs back in the car."

Registered Nurse #2
On 2/13/2020 from 10:00 AM to 10:10 AM, a telephone interview with Registered Nurse #2 revealed, "I ' ve been employed here about 10 years and worked in the Emergency Department the whole time. When asked if he/she remembered a couple coming to the emergency department on Monday 2/10/2020 around 8:00 AM and parked in front of the emergency department door, Registered Nurse #2 verified that he/she did recall the incident, and stated, "Yes. I was asked to come up front. Someone had been parked there a long time. A female brought a male in a car to the front door. I asked him if he needed help, and he said, 'No'. I asked him if he needed help getting in the wheelchair, and he said 'No'. I asked her to move the car, and she didn ' t say anything. I asked her to move over to a parking spot, and we could talk. I told her she was welcome to go to her physician ' s office or there are other resources to offer. I could tell she was upset. She got in the car and drove out of the way. I don ' t know where she went." Registered Nurse #2 verified that he/she had EMTALA training, and stated, "I feel like we have it yearly on our competencies."

Complainant
On 2/14/2020 at 10:20 AM, a telephone call with the Complainant revealed, "This is about my father. He has been receiving chemotherapy. He completed the fourth round of chemo a couple of weeks ago. He hasn ' t tolerated it well. He was scheduled for the fifth round of chemo last week. It was like he was freezing, and he couldn ' t move. He had a follow up with his oncologist, and they decided not to do his last round of chemotherapy. He made a referral to a neurologist. His oncologist advised him and my mother that if his symptoms worsened over the next few days to go to the emergency department. That morning around 8:30 or 9:00, his symptoms had gotten worse. My mother decided to take him to the emergency department. My father did not want to go to the emergency department, and either couldn ' t or wouldn ' t get out of the car. I was talking to my mother, and she had me on speaker phone. I was trying to talk him to go into the emergency department for treatment. After about 10 minutes or so, a woman from the
emergency department told my mother that she had to move her vehicle. My mother explained the situation to her, and at his last visit with his oncologist last week, the oncologist advised her to take him to the emergency department if his symptoms became worse which they did. The woman from the emergency department told my mother that was bad advice from the doctor, and she should take him back to his oncologist. I was on speaker with my dad so I could hear everything."

Patient #22
Observation
On 02/12/2020 at 10:00 AM, observations of Patient # 22 revealed the patient was seated in a wheelchair and being transported through the lobby. At 10:40 AM on 02/12/2020, a face to face interview was conducted with Registered Nurse #4, Registered Nurse #5, and Director #1 in the triage area on the Obstetric (OB) unit. On 02/12/2020 at 10:47 AM, Registered Nurse #4 described the screening process on the OB unit: "If the patient is greater than 12 weeks pregnant, they come to the triage area here on the OB unit. We just had a patient come in 38 weeks pregnant (Patient # 22), and she thought her water broke. I get her on the monitor and get vitals. I am waiting on the results of her positive or negative amniotic fluid strip. I would notify the physician of a reaction or non-reaction, and then the physician would discharge the patient or give admission orders."

Chart Review
On 2/12/2020 at 2:00 PM revealed Patient # 22 is a self pay patient who was arrived on the OB unit on 02/12/2020 at 10:23 AM presenting with "water broke". Documentation revealed a Registered Nurse conducted the Medical Screening Examination (MSE) for Patient #22. Patient #22's chart revealed the patient has a negative amnisure and was discharged home on labor precautions the same day at 11:12 AM.

Interviews
When asked about qualifications and training for the Registered Nurses(RN) to conduct the Medical Screening Examination for obstetrical patients, Director 1 explained, "We do orientation and preceptor. Our RN ' s have to have 2 years experience to be able to conduct the assessment and critical thinking skills in the triage area." RN #5 stated, "Our charge nurse is aware of who has 2 years experience to staff the correct staff." On 02/12/2020 at 11:30 AM, a list of personnel deemed able to conduct the obstetrical Medical Screening Examination was provided, and the hospital's policy, titled, "Assignment Making in L&D", was reviewed. The list of nurses deemed qualified to perform the obstetrical patients medical screening examination had multiple names and was labeled, "L&D(Labor and Delivery)/OB(Obstetrical) Antepartum Employees." RN #5 explained, "Our policy does not state specifically about the 2 years experience, but it is our practice that only nurses with 2 years experience staff the triage area, and all staff are crossed trained for all areas."

On 02/12/2020 at 12:00 PM, review of the hospital ' s policy, titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", revealed, "Patients present to Labor and Delivery seeking medical treatment. A medical screening exam will be performed by the following: A physician member of the SMC staff, A certified nurse midwife or nurse practitioner employed by SMC ..., A registered nurse employed by SMC qualified by training and experience and currently competent to provide OB services in communication with and carrying out the orders of a member of the SMC Medical staff with OB privileges and in accordance with written policies and procedures for Labor and Delivery Outpatient Services."

The Medical Staff Bylaws, reviewed on 02/12/2020 at 3:30 PM, revealed, "Article 10, Emergency Services, 10. B. Medical Screening Examinations: Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified
medical personnel who can perform medical screening examinations within Hospital policies and procedures are defined as; (b) Labor and Delivery: members of the medical staff with OB/GYN(Gynocological) privileges, Residents, Certified Nurse Midwives."