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Based on hospital policy review, Labor and Delivery (L&D) medical record reviews, and physician and staff interviews, the hospital failed to comply with §489.24 by failing to provide an appropriate medical screening examination for 1 of 5 sampled patients (Patient #4) presenting to the hospital's L&D department.

The findings include:

1. Based on hospital policy review, Labor and Delivery (L&D) medical record reviews, and physician and staff interviews, the hospital failed to comply with §489.24 by failing to provide an appropriate medical screening examination for 1 of 5 sampled patients (Patient #4) presenting to the hospital's L&D department.

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on hospital policy review, Labor and Delivery (L&D) medical record reviews, and physician and staff interviews, the hospital failed to comply with §489.24 by failing to provide an appropriate medical screening examination for 1 of 5 sampled patients (Patient #4) presenting to the hospital's L&D department.

Findings Included:

1. Review on 11/01/2017 of hospital policy entitled "Birthing Center Observation/OB Check" with an approval date of 07/06/2015 revealed "Policy: 1. All patients presenting to (Named Facility) with questionable labor or pregnancy-related complaints, or complaints that might be pregnancy-related, and who are 20 weeks gestation or greater, will be brought to the Birthing Center for observation, assessment and evaluation ...6. In the Birthing center, trained labor and delivery nurses are the Qualified Medical Personnel to conduct the medical screening exam on patients over 20 weeks gestation to determine the presence of labor with 24 hour/day backup from on call obstetricians/midwives. If the RN determines that active labor is not present, but after communication with the physician, questions remain about the presence of another emergency medical condition, the patient will be evaluated by a physician."

Closed medical record review of Patient #4 revealed she was a 22 year old female gravida 2 (number of pregnancies); Para 0 (pregnancies carried beyond 20 weeks), Spontaneous abortion 1, and 32.3 weeks in gestation. Patient #4 presented to Labor and Delivery on 10/23/2017 at 1354 and was triaged at 1408 with reported "gestational diabetes, fall at 1230 on 10/23/2017."Record review revealed Patient #4 had fallen while chasing a dog "She fell onto knees then to hands and abd (abdomen). Small abrasion noted to right knee ..." Record review revealed the patient had fallen at 1230 the day of presentation, denied contractions, leakage of fluid, and vaginal bleeding. Record review revealed the patient was placed on a Continuous External Fetal monitor, which, at 1408 indicated a fetal heart rate of 140 beats per minute. The patient's vital signs [not visible on printed record] obtained at 1412 were BP 124/75; heart rate 110; SpO2 96% (blood oxygen level). A "Falls Risk Score" indicated "Low Risk" for falls, and review of a pain assessment indicated "denies pain/discomfort." Record review revealed no vaginal exam performed. Record review revealed MD #4 was notified of the patient's presentation and condition at 1457 and ordered monitoring " ...until 4 hours post fall. If baby has reactive NST ok to discharge home ..." Record review revealed all orders were electronically signed by MD #4 on 10/23/2017 at 1712. Record review revealed the patient was discharged at 1519 with discharge instructions that included Pre-Term Labor (PTL) precautions. Record review revealed no discharge diagnosis or physician notes documented in the medical record.

Interview on 11/01/2017 at 1235 with RN #1 revealed she was the nurse for Patient #4 on 10/23/2017. Interview revealed the L&D unit sees all patients greater than 20 weeks in gestation. Interview revealed RN's did a "quick look" initially to check for signs of distress which included checking vital signs, and placing the patient on an external fetal monitor. Interview revealed that if a patient has an urgent condition, the physician is called immediately to come and see the patient, and if not RN's check the abdomen, and run a 30-45 minute "strip" prior to discussing the patient with the physician. Interview revealed that if the MD is not in the hospital RN's obtain orders via telephone, enter them into the facility's electronic system, and the physician can then sign the orders from their offsite location. Interview revealed RN's work the patients up and if all results were normal, they called the physician, let them know, and sent the patients home. Interview revealed RN's do not write diagnosis into the medical record. Interview revealed that when she spoke with MD #4 about Patient #4, the physician indicated the patient had been stable and could be discharged prior to the four hours from the time of the fall as indicated initially.

Interview on 11/01/2017 at 1410 with MD #4 revealed she had not come in to the hospital to evaluate Patient #4. Interview revealed she had discussed the patient fall, then current symptoms, and fetal monitoring results with RN #1 and believed Patient #4 was stable to be discharged when she gave the order. MD #4 revealed "Unfortunately I can't see any documentation in the chart from me. I should have done that."

NC00132705