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Based on a review of facility documentation, and staff interview (EMP), it was determined that the facility failed to ensure that every individual presenting to the Emergency Department (ED) for treatment was entered into the Emergency Department Central Log for one of 16 medical records reviewed.(MR1)

Findings include:

1) A review of facility Emergency Department (February 1, 2014-August 11, 2014) patient Log revealed that the ED maintains two Logs. One is a handwritten, hard copy book, and one is computer generated. Both Logs were reviewed.
A review of the Log (hard copy), revealed no documented evidence that the patient (MR1) was placed on the Log as a presentation to the ED on May 31, 2014. It was noted that there were five patients that had presented to the ED, or were waiting for treatment/discharge at the time the ambulance carrying patient MR1 presented to the parking lot of Windber Emergency Department on May 31, 2014.
A review of the computer generated Log dated May 31, 2014, revealed patient (MR1) was noted on the Log, but documentation was not completed. There was no documentation of Clinical Impression, Disposition, and Disposition Date/Time.
An interview with EMP3 was conducted on August 12, 2014, at approximately 1:00 PM. EMP3 revealed that on Monday, June 2, 2014, a medical record was generated for the patient (MR1), in order to establish a record of the patient that presented for Medical Command. EMP3 further revealed that because the facility generated a medical record on June 2, 2014, the patient was automatically pulled into the computer generated Log. EMP3 also stated that there are no ED policies or Registration policies that relate to the Emergency Department Log.

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure each patient presenting to the Emergency Department was provided with an appropriate medical screening examination by a physician, or other qualified medical personnel, for one of 16 medical records reviewed (MR1).



Findings Include:

A review of policy entitled "EMTALA", revised February 2014, revealed, "Windber Medical Center will comply with all aspects of the Emergency Medical Treatment and Active Labor Act (EMTALA). Purpose: To provide a safe environment for all individuals who present to the hospital in an emergency medical condition, regardless of where in the hospital the individual appears. Procedure: 1. Any individual who presents to the emergency department, or any other location within the hospital, requesting examination or treatment for a medical condition will be provided with an appropriate medical screening examination within the Emergency Department to determine if he/she is suffering from an emergency medical condition. 2. An 'emergency medical condition' is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the mother or her unborn child) in serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Ultimately this determination is a medical one. 3. The person performing the medical screening exam must be a physician or an appropriately credentialed physician assistant. 4. Following a medical screening exam, if the individual is determined to be suffering from an emergency medical condition, he/she will be provided with appropriate medical treatment until stable or able to be safely transferred to another hospital if applicable. If the individual does not have an emergency medical condition, the hospital will provide care as appropriate based on the best judgment of the medical screening person. 5. A pregnant woman who presents in active labor must be treated and kept until delivery is completed (including delivery of the placenta), unless a transfer compliant with EMTALA regulations is appropriate. 6. Regardless of an individual's presenting complaint, an 'appropriate transfer' (i.e. a transfer before complete stabilization) must meet the following criteria: a. The patient has been treated and stabilized as far as possible within the limits of WMC's capabilities (or the patient is requesting transfer.) b. The patient needs treatment at a facility capable of providing a higher level of care, and the medical risks of transferring him are outweighed by the medical benefits of the transfer. C. The transferring physician certifies the transfer in writing providing an express summary of the risks and benefits upon which it is based. D. The receiving hospital has been contacted and agrees to accept the transfer, and has the facilities to provide the necessary treatment to him ... ."

1) Review of facility documentation dated March 27, 2014, revealed, "TO: All EMS Services SUBJECT: Discontinuation of OB Services. It is with regret we announce the discontinuation of Windber Medical Center's Obstetrical Services (OB) Department effective at midnight, March 30, 2013. Following that date we will no longer be admitting Obstetrical patients or delivering babies. The ER will continue to maintain the capacity to deliver a baby for emergent walk-in patients where birth of the infant is imminent. Following the delivery, the patient and new born would then be transferred to a hospital with OB admission capabilities. WMC Emergency Department and Medical Command physicians will continue to remain available to provide advice and medical command to EMS crews transporting Obstetrical patients to other facilities. In the event a patient requires immediate emergency attention the EMS crew determines it is essential for the health and welfare of the patient to stop at Windber Emergency Department, the ER Physicians and Nursing staff will be available to assist with stabilization of the patient at our ER. Once stabilized the patient would be transferred to a hospital with OB admission capabilities ... ."


2) Review of MR1 dated May 31, 2014 at 19:02 revealed, " Windber Medical Center Medical Command ... Gunshot wound to head 9 mo pregnant ... ETA 30 sec ... Ambulance NEMS ... Additional Orders Advised of ambulance en route as above - attempted to re-establish contact with ambulance, arrived to parking lot in meantime. I went out to ambulance and attempted to ascertain condition of pt - asked if pulses present/airway needed otherwise needed to go to Trauma Center - only report given by medic was 'just lost distal pulses', baby still moving and desire to have our hospital get the baby out. Advised medic we have no one available to do that (getting baby out) and they should proceed to Trauma Center, initiate CPR,if no pulses and I offered help with airway if they felt that was needed. Medic advised me there was no time for that, and that if we were not going to take the baby, they were leaving. Reiterated we have no staff/facilities to do that and re-offered help with airway, but stated they were leaving. I contacted Dr. ... at Trauma Center and advised them ... en route with above patient - 9 mos. Pregnant, child possible still viable ... Late Note 8:45 PM Discussed with Dr. ... at Trauma Center, child appears viable, Dr. felt we made proper decision to divert ambulance to ... ."

MR1 failed to reveal documented evidence that a medical screening examination had been performed.


3) An interview was conducted with EMP6 who stated that the "facility has a policy that permits the PA or the nurse to answer the initial Medic Command call. EMP15 took the Medical Command call as I was not immediately available. EMS requested Medical Command and I was notified. There was a very short window, only 30 second ETA.
The nurse was on the phone to me and said that you need to come over, we have a female, gunshot wound, who's nine months pregnant. As I'm on the way, I'm thinking, why are they coming here. They need to go to the Trauma Center to give the baby the best chance. They had to pass by our hospital in order to get to the Trauma Center, seven miles away. It was at that point that we could see the ambulance in the parking lot. EMP15 and I went out, I felt we needed them to go directly to the Trauma Center. I asked them why they brought the patient here, and they said, 'The baby needs to come out now. You're a hospital, right?'
I told them that I could help with the airway. They said that they didn't have time for that. I explained that we didn't have anyone here who could take the baby out. They said that if I was not going to take the baby out, they will go downtown. We are not a Trauma Center, this situation was beyond our capabilities. They asked I could go along in the ambulance, I said I can't leave, I am the only physician here. I asked if they needed help with the airway. I could see the baby was still moving and mother had facial and neck injuries. I had to weigh in a quick manner how to handle this. We don't have OB services here. We had a General Surgeon and a Gyne, not an OB, on call. It would take at least 30 minutes at minimum if everyone responded immediately. They could get the patient to the Trauma Center quicker than we could get the baby out."