HospitalInspections.org

Based on interview and record review, the facility failed to keep an accurate record of patients requesting to be seen at the Emergency Department. The facility's ED physician halted the registration clerk from entering the Patient's information and instructed Patient #1's mother to seek treatment at another facility.

Findings include:

Review of the facility provided policy, "Creation Of A Medical Record", (Approved 03/2023) reflected,
Purpose:
The purpose of this policy is to ensure that EMTALA law is followed and that a medical record is created for every patient who enters our facility through the Emergency Department.
Policy:
1. When a patient enters the hospital through the Emergency Department to be examined, the
patient should be triaged, and a medical record created.
2. On rare occasions when a patient enters the Emergency Department and leaves prior to triage
and/ or a physician assessment a Left Without Being Seen Form will be utilized. In this case if a
patient has signed in; a medical record will still be created giving the patient a medical record
number and the Left Without Being Seen Form will be attached to the medical record.
3. If a patient refuses to sign the Left Without Being Seen Form, it should be signed by two
staff members and the fact that the patient refused to sign will be documented.
4. Every encounter will be logged in the Emergency Department Logbook.

During an interview, on the afternoon of 10/04/23, in the administrative conference room, Staff #4, Ward clerk confirmed she was on duty when Patient#1's mother attempted to bring her daughter into the ED. Staff #4 stated, "A woman came up to the desk and asked where she could get a wheelchair for her daughter. When I asked what she was coming in for, so I could determine if I needed to call the nurse, the mother stated, 'My daughter is just a few weeks pregnant, and she is bleeding for the past couple of days.' The doctor said, 'I'll go talk to her, hold off till I talk to her.' I couldn't hear what he was saying to her, then she left."

Review of the facility provided Emergency Room Logbook, dated 9/12/2023, did not have Patient #1 listed, in spite of the fact she had attempted to seek medical treatment in the facility's emergency room.

Based on interview and record review, the facility failed to provide emergency medical screening examination for a patient requiring an Ultrasound. Patient #1 had presented to the facility emergency department with a possible medical emergency and was discouraged from staying, due to lack of an ultrasound technician. Patient #1 was ultimately found to have been in active labor. The failure to exam this, and possibly other patients, places patients at risk of delayed treatment for medical emergencies resulting in injury, pain, and possible death.

Findings include:

During an interview, on the afternoon of 10/04/23 in the administrative office, Staff #6, MD stated, "I saw her (patient #1's mother) coming in, I overheard her telling registration she was having lower abdominal pain. When I went to see the person, she was middle-aged, and only a few weeks pregnant or I thought I heard 3 to 6 weeks. I knew we would have to do an Ultrasound to rule out an ectopic pregnancy. I informed, who I thought she needed to see, the patient. I told her we would be glad to see her, but we didn't have an Ultrasound technician. I did say go to Monahan's, they have an Ultrasound tech on call, she turned around and left. Hindsight, I could have done a physical exam, but I thought she was the patient."

When asked if the facility had provided training concerning EMTALA, Staff #6 stated, "No, it was covered briefly in school ...it is for dealing with heart attacks and things like strokes."

Review of Staff #6's licensure reflected he is currently certified with the American
Board of Family Medicine (ABFM).

Review of Patient #1's medical records from Hospital #2 (located 52 miles away from Pecos County Memorial Hospital), dated 9/13/2023 at 9:57 am reflected,
"History of Present Illness: Abdominal pain/pregnancy 15-year-old Latin American female presents with complaints of lower abdominal pain and being pregnant of unknown gestation. They only found out she was pregnant 2 weeks ago. The patient has not had any prenatal care. The patient is having significant abdominal pain. She denies any bleeding or rupture of membranes.
Nurse Practioner' s Procedure Note: 15-year-old female presented with lower abdominal pain and cramping. The mother was visibly pregnant with a pregnancy above the umbilicus. Patient was in significant pain and distress. I went to do a manual exam of the fingers [sic] and felt the baby's head crowning and was able to see the amniotic sac just inside the vaginal vault. The patient was attempting to push, and the amniotic sac had not yet ruptured. I have put on some sterile gloves and used a pair of sterile scissors to rupture the amniotic sac. We then encouraged the patient to take deep breaths and then slowly breathe out while pushing. The patient was able to do this. After approximately 15 to 20 minutes the baby was born at 1929 (9:29 pm.) The baby started to move immediately and cried out. The baby was slightly blue in color. The umbilical cord was then clamped on both ends and cut. I was then able to deliver the placenta without any complications. There were no obvious lacerations to the vaginal region.

Review of "American College of Obstetricians and Gynecologists https://www.acog.org" reflected, "An ectopic pregnancy occurs when a fertilized egg implants and grows in a location that cannot support the pregnancy. Almost all ectopic pregnancies-more than 90%-occur outside of the uterine cavity in a fallopian tube, but they can also implant in the abdomen, cervix, ovary, and cesarean scar. An ectopic pregnancy in any location is life threatening. This is because as the pregnancy grows, it can cause the structure where it is implanted to burst, or rupture. A rupture can cause major internal bleeding and is a life-threatening emergency that requires urgent surgery ...
Patients with an ectopic pregnancy must have timely access to all treatment options.
An untreated ectopic pregnancy is life threatening; withholding or delaying treatment can lead to death."

Review of the facility provided policy, "Medical Screening in the Emergency Department" (Approved 03/2023) reflected,
"1. If any individual {whether or not eligible for Medicare benefits and regardless of ability to
pay) comes by him or herself or with another person to the emergency department and a request is made on the individual's behalf for examination or treatment of a medical condition by qualified medical personnel (as determined by the hospital in its rules and regulations) the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department. including ancillary services routinely available to the emergency department.
2. A medical screening examination must be provided to any individual regardless of diagnosis,
financial status, race, color, national origin, or handicap.
3. Individuals coming to the emergency department must be provided a medical screening
examination beyond initial triaging. Triage is not equivalent to a medical screening examination.
Triage merely determines the "order" in which patients will be seen, not the presence or absence of an emergency medical condition.
4. If the medical screening examination is appropriate and does not reveal an emergency medical condition, the hospital has no further obligations under 42 CFR 489 .24.
5. A medical screening examination is the process required to reach with reasonable clinical
confidence, the point at which it can determine whether a medical emergency does or does not exist. This screening process MUST be done in a nondiscriminatory manner (i.e., a different level of care must not exist based on payment status, race, national origin) and this screening process is reasonably calculated to determine whether an emergency medical condition exists to meet our obligations under the Emergency Medical Treatment and Labor Act (EMTALA).
6. Depending on the patient's presenting symptoms, the medical screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures. clinical laboratory tests, CT scans.
7. The medical screening examination is not an isolated event. It is an ongoing process. The
medical record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this
evaluation prior to discharge or transfer ...LOCATION OF SCREENING EXAM
1. If an individual is on hospital premises (not technically in the emergency department) And
requests emergency care, he or she is entitled to a medical screening examination.
2. The hospital may use areas to deliver emergency services which are also used for other
inpatient or outpatient services.
3. Medical screening examinations or stabilization may require ancillary services available only in areas or facilities of the hospital outside of the emergency department. As long as the patient is directed to a hospital-owned facility which is contiguous (i.e., any area within the hospital of a hospital-owned facility on land that touches land where a hospital's emergency department sits) or is part of the hospital "campus and is owned by the hospital and is operating under the hospital's provider number. the hospital is complying with 1867. This means that if a patient is directed off campus for an evaluation, i.e., an MRI, it must be done as a formal transfer ..."

Review of the facility provided Medical Staff By-Laws, (undated) reflected, "Classifications of Emergency Problems
A. Emergent - These problems are deemed immediately life/limb threatening and require immediate therapeutic intervention in order to preserve function. The following are a list of some of these problems ...Pregnancy assoc. with active vaginal bleeding, and/or intermittent abdominal or back pain."

Based on record review and interview, the facility failed to initiate an appropriate transfer for a pregnant patient experiencing bleeding and was ultimately discovered to be in active labor. (Patient #1) This failure placed the patient and unborn infant at risk of injury, hypoxia, and possible death.

Findings include:

Review of the facility provided policy, "Patient Transfer Procedure For Emergency Room" (Approved 03/23) reflected,
Purpose: To provide an efficient process to set up patient transfer from our facility to
another.
Policy: All patients transferred out of the ER area will follow the hospital policy for transfer as
described below.
Procedure:
1. The patient must be evaluated by a physician. or by a midlevel practitioner acting under the
direct supervision of a physician. All class I traumas are to be directly examined by the
physician.
2. There must be written orders initiating the transfer, or verbal orders that are counter
signed, as soon as possible.
3. There must be a Memorandum of Transfer completed prior to the transfer. The Memorandum of Transfer will be signed by the transferring physician or hospital staff member acting under the
physician's order and by a member of the hospital's administration. {Administrator, Acting Administrator, House Supervisor or ER Supervisor)
4. There must be a copy of those portions of the patient's medical record that are relevant to
the transfer and continuing care. Minimum requirements are:
a. Brief description of medical history and physical exam
b. Provisional diagnosis and recorder's observations of physical assessment of the patient's
condition at the time of transfer.
c. Results of diagnostic tests
d. Copies of X-ray s
e. Copy of trauma flowsheet (if trauma)"

During an interview, on the afternoon of 10/04/23 in the administrative office, Staff #6, MD stated, "I saw her (patient #1's mother) coming in, I overheard her telling registration she was having lower abdominal pain. When I went to see the person, she was middle-aged, and only a few weeks pregnant or I thought I heard 3 to 6 weeks. I knew we would have to do an Ultrasound to rule out an ectopic pregnancy. I informed, who I thought she needed to see, the patient. I told her we would be glad to see her, but we didn't have an Ultrasound technician. I did say go to Monahan's, they have an Ultrasound tech on call, she turned around and left. Hindsight, I could have done a physical exam, but I thought she was the patient."

Review of Patient #1's medical records from Hospital #2 (located 52 miles away from Pecos County Memorial Hospital), dated 9/13/2023 at 9:57 am reflected, "History of Present Illness: Abdominal pain/pregnancy
15-year-old Latin American female presents with complaints of lower abdominal pain and being pregnant of unknown gestation. They only found out she was pregnant 2 weeks ago. The patient has not had any prenatal care. The patient is having significant abdominal pain. She denies any bleeding or rupture of membranes.
Procedure Note: 15-year-old female presented with lower abdominal pain and cramping. The mother was visibly pregnant with a pregnancy above the umbilicus. Patient was in significant pain and distress. I went to do a manual exam of the fingers and felt the baby's head crowning and was able to see the amniotic sac just inside the vaginal vault. The patient was attempting to push, and the amniotic sac had not yet ruptured. I put on some sterile gloves and used a pair of sterile scissors to rupture the amniotic sac. We then encouraged the patient to take deep
breaths and then slowly breathe out while pushing. The patient was able to do this. After
approximately 15 to 20 minutes the baby was born at 1929 (9:29 pm.) The baby started to move immediately and cried out. The baby was slightly blue in color. The umbilical cord was then clamped on both ends and cut. I was then able to deliver the placenta without any complications. There were no obvious lacerations to the vaginal region.

Review of Patient #1's Hospital #2's ED timeline reflected,
"1909 - Patient presented to ER in active labor. LMP (last menstrual period) in December unknown to patient. Crowning upon exam.
1919 - Patient began pushing.
1929 - Baby boy delivered vaginally. Cord clamped and cut Baby transferred to warmer and bulb suctioned nose and mouth. Baby crying with no s/s (signs or symptoms) of distress. Blow by oxygen to baby at this time. [sics]"