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Based on observation, interview, and record review, Facility A failed to comply with CFR 489.24, by failing to:

1. a. Ensure a medical screening exam, (MSE-the process of determining whether an emergency medical condition exists) was completed for one pregnant patient, (Patient 1), who presented to the Emergency Department (ED). This failure resulted in the patient being taken to another facility for treatment at the risk of delivering the infant en route. (Refer to A 2406),

b. Ensure a MSE was completed for Patient 2, who presented to the ED with a chief complaint of chest pain and cold sweats. (Refer to A2406),

c. Ensure a MSE was completed for Patient 6, who presented to the ED with a chief complaint of hearing voices and having suicidal ideations. (Refer to A 2406) and;

2. Ensure Registered Nurse (RN) 10, was qualified to perform the MSE as required per Hospital Rules and Regulations, and facility policy. RN 10, who performed an MSE on a pregnant patient (Patient 17), did not have demonstrated competencies verified prior to performing a MSE. (Refer to A 2406).

Based on observation, interview, and record review, the facility (Facility A), failed to maintain an accurate central log for the Emergency Department (ED). The ED Central Log did not contain the name and disposition of one obstetric (OB) patient (Patient 1), who presented to the ED on January 5, 2016, seeking assistance. As a result the facility was unable to track the care provided to Patient 1.

Findings:

On January 12, 2016, the record for Patient 1, obtained from Facility B, was reviewed. The record contained a copy of the "OB Patient Registration Form," from Facility A. The Registration Form indicated Patient 1 presented to Facility A on January 5, 2016, at 1:45 a.m., with complaints of, "A lot of pain/ pressure in lower stomic (stomach)."

On January 12, 2016, at 11:15 a.m., an unannounced visit was made to Facility A. The ED and OB Central Logs were reviewed. Patient 1 was not listed on either log.

On January 12, 2016, at 3 p.m., a copy of the ED security video for January 5, 2015, was reviewed with the Director of Security (DS) and the Director of Quality Services. The DS stated the time stamp on the video was 34 minutes fast. The video revealed the following:

- At 2:19 a.m. (actual time 1:45 a.m.), a man and a woman (who appeared to be pregnant) entered the ED. The security guard gave the woman paperwork to fill out, and assisted the woman into a wheelchair. The woman was next observed filling out the paperwork.

- At 2:24 a.m. (1:50 a.m.), the man handed the paperwork to a staff member (Patient Access Representative 1) observed sitting behind a semi circular desk in the lobby.

- At 2:27 a.m. (1:53 a.m.), Patient Access Representative (PAR) 1 gave the paperwork back to the couple and they went to sit in the waiting area.

- At 2:28 a.m. (1:54 a.m.), the man went back to the desk to talk to PAR 1.

- At 2:32 a.m. (1:58 a.m.), the man assisted the pregnant woman from the wheelchair and the couple left the ED.

On January 13, 2016, at 10:53 a.m., the Director of Patient Access (DPA) was interviewed. The DPA stated when an OB patient presented to the ED the PAR would do a quick registration on the patient and enter the patient into the computer. She stated at that time the patient's name would appear on the tracking board (electronic central log). The DPA stated if a patient left without being seen (LWBS) or left without being triaged (LWBT), the patient would still be on the electronic log, but be listed as LWBS or LWBT, so that it could be tracked.

On January 13, 2016, at 11:20 a.m., PAR 1 was interviewed. PAR 1 stated she was not a nurse and her job was not clinical. PAR 1 stated it was her job to register patients as they came in to the ED. However, PAR 1 stated, if it was an OB patient, then she would not register them unless she knew for sure that the patient was going to have a baby.

PAR 1 stated she would review the paperwork, to make sure everything was filled out, and then call the OB Department to report to them that an OB patient would be coming soon. She stated after the patient was seen in the OB department, then they would fax the registration form back to the PAR on duty, and the patient would be entered into the computer at that time.

PAR 1 stated she worked the night shift on January 5, 2016. PAR 1 stated she remembered Patient 1 and her boyfriend presented to the ED on that night. PAR 1 stated Patient 1's boyfriend complained that Patient 1 was overdue and they hoped that she could be induced. PAR 1 stated she did not register Patient 1 into the computer, because she did not know if Patient 1 would be admitted or not. PAR 1 stated she remembered that at some point Patient 1's boyfriend informed her that they were going to go to another hospital, and they left. PAR 1 added, it's the patients choice if they want to go somewhere else.

Based on observation, interview, and record review Facility A failed to:

1. a. Ensure a medical screening exam (MSE-the process of determining whether an emergency medical condition exists) was completed for one pregnant patient, (Patient 1), who presented to the Emergency Department (ED). This failure resulted in the patient being taken to another faciity for treatment, at the risk of delivering the infant en route,

b. Ensure a MSE was completed for Patient 2, who presented to the ED with a chief complaint of chest pain and cold sweats,

c. Ensure a MSE was completed for Patient 6, who presented to the ED with a chief complaint of hearing voices and having suicidal ideations, and;

2. Ensure Registered Nurse (RN) 10, was qualified to perform the MSE as required per Hospital Rules and Regulations, and facility policy. RN 10, who performed an MSE on a pregnant patient (Patient 17), did not have demonstrated competencies to conduct an MSE.

The failure of the facility to provide an appropriate MSE for individuals who presented to the ED, to stabilize those individuals as indicated, and to adequately educate staff could interfere with the provision of medical care and result in unrecognized complications.

Findings:

1. a. The Department received an anonymous complaint on January 12, 2016, at 1:48 p.m., stating a full term pregnant patient, (Patient 1) presented to Facility A with complaints of abdominal pain. The complainant further stated at Facility A no vital signs were taken, the patient did not receive a MSE, and Patient 1 subsequently went to Facility B where the patient delivered an infant the same day.

On January 12, 2016, the record for Patient 1, obtained from Facility B, was reviewed. The record contained a copy of the "OB (obstetric) Patient Registration Form," from Facility A. The registration form indicated Patient 1 presented to Facility A on January 5, 2016, at 1:45 a.m., with complaints of "A lot of pain/pressure in lower stomic (stomach)."

On January 12, 2016, at 11:15 a.m., an unannounced visit was made to Facility A. The ED and OB Central Logs were reviewed. Patient A was not listed on either log.

On January 12, 2016, at 3 p.m., a copy of the ED security video for January 5, 2016, at Facility A was reviewed with the Director of Security (DS) and the Director of Quality Services. The DS stated the time stamp on the video was 34 minutes fast. The video revealed the following:

-At 2:19 a.m., (actual time 1:45 a.m.), a man and a woman, (Patient 1, who appeared to be pregnant) entered the ED. The security guard gave the woman paperwork to complete, and assisted the woman into a wheelchair. The woman was next observed seated in the wheelchair in front of a semi circular desk, completing the paperwork. The Patient Access Rep(resentative) (PAR) 1, was seated behind the desk. To the immediate right of PAR 1, sat a triage nurse, Registered Nurse (RN) 1 who had his back to PAR 1 as he was interacting with another patient (triage-the process of determing the severity of a patient's medical needs).

-At 2:24 a.m., (1:50 a.m.), the man handed the paperwork back to PAR 1.

-At 2:27 a.m., (1:53), PAR 1 gave the paperwork back to the couple and they went to sit in the waiting area.
-At 2:28 a.m., (1:54 a.m.), the man went back to the desk to talk to PAR 1.

-At 2:30 a.m., (1:56 a.m.), another triage nurse, (RN 2) walked up to the desk and interacted with RN 1. The two nurses were directly to the right of PAR 1.

-At 2:32 a.m., (1:58 a.m.), the man assisted the pregnant woman from the wheelchair. PAR 1was observed watcing the couple as they couple left the ED. No staff were observed interacting with the couple as they left Facility A. At no time was PAR 1 observed to speak/interact with either RN 1 or RN 2. At no time were RN 1 or RN 2 observed taking note of, or interacting with the couple, either the man or with Patient 1, who were less than 4 feet away from them.

An interview was conducted with PAR 1 on January 13, 2016, at 11:20 a.m. PAR 1 stated she worked the night shift on January 5, 2016, and remembered Patient 1, who was with her boyfriend. PAR 1 stated Patient 1's boyfriend said the patient was overdue and they hoped she would be induced. PAR 1 stated she remembered that at some point Patient 1's boyfriend informed her that they were going to go to another hospital, and they left. PAR 1 said she told the couple that a nurse would be here soon.

PAR 1 stated, she didn't believe the patient was in labor and didn't remember if Patient 1 complained of a lot of pain. PAR 1 further stated she did not remember if she told the triage nurses (about Patient 1)." PAR 1 further stated it's the patients choice if they want to go somewhere else. PAR 1 stated she did not register Patient 1 into the computer, because she did not know if the patient was going to be admitted to the facility or not.

An interview was conducted with the Triage Nurse on January 13, 2016, at 9:15 a.m. The Triage Nurse was seated behind the semi circular desk next to the PAR. The Triage Nurse stated the PAR should always notify the triage nurse about any pregnant patients which are greater than 20 weeks pregnant. The Triage Nurse further stated if the patient is in obvious labor they should be taken directly to the OB unit, if not she would take their vital signs, get their due date, and their chief complaint to determine if their problem was or was not OB related.

An interview was conducted with RN 1 on January 14, 2016, at 11:30 a.m. RN 1 stated he never saw Patient 1 on January 5, 2016, and that "absolutely" he would have wanted to be notified if a pregnant patient came to the ED seeking treatment. RN 1 further stated he would have questioned the patient about the pregnancy and the patient's symptoms. The patient would then be transported to the OB department for a MSE.

An interview was conducted on January 12, 2016, at 3 p.m., with the Director of Patient Access, who stated the patient access representatives do not receive full EMTALA training (Emergency Medical Treatment and Active Labor Act).

An interview was conducted with ED Physician 1 on January 12, 2015, at 1 p.m., who stated pregnant patients should be screened immediately to determine if they have an emergency medical condition. If the patient is over 20 weeks gestation, they should then be taken to the OB unit.

An interview was conducted with the ED Director on January 14, 2016, at 8:45 a.m., who stated Patient 1 did not receive a MSE.

Further investigation failed to show Patient 1 was logged into the ED or OB logs, or that the patient received a MSE. Patient 1 subsequently went to Facility B, 26 miles away.

A review of Facility A's ED policy, "Patient Registration (Revised/Reviewed: 3/2014)," was conducted. The policy indicated, "All patients will be evaluated by the Triage Nurse prior to being seen by the Admitting Department Clerk" (also known as a patient access representative).

A review of Facility A's ED policy, "Guidelines for Triage of OB Patients Presenting to the ED with a Potential Medical Emergency (Revised/Reviewed: 3/2014)" was conducted. The policy indicated, "The purpose of the triage is to quickly determine if the woman is experiencing an emergent or life-threatening problem related to her pregnancy or suffers from a medical condition that affects her pregnancy...The ED Triage Nurse will triage the patient to determine whether the pregnant patient has an emergency medical condition."

A review of Patient 1's record from her admission to Facility B was conducted. Patient 1 presented to the ED at Facility B on January 5, 2016, at 3 a.m., one hour after the patient left Facility A. A review of the OB flow sheets indicated upon arrival, Patient 1 was having contractions every six minutes with a duration of 60 to 70 seconds. Patient 1 was determined to be 41 6/7 weeks pregnant (A full term pregnancy is 40 weeks duration).

A review of the physician's consultation at Facility B dated January 5, 2016, at 4:35 a.m., indicated Patient 1's baby may have intrauterine growth retardation or be small for its gestational age (complications of being post due).

Patient 1 delivered her child on January 5, 2016, at 6:23 p.m.

b. A review of Patient 2's "Patient Registration Form" dated November 26, 2015, at 8:32 p.m., was conducted. The reason for the visit to the ED was documented by the patient as, "Pain to chest/cold sweats." The Conditions Of Admission were signed by Patient 2 on November 26, 2015, at 8:32 p.m. The document was witnessed and scanned into the patient's record.

A review of the facility's ED policy, "Patient Registration (Revised/Reviewed: 3/2014)," was conducted. The procedure indicated, "The Admitting Department Clerk (also known as a patient access representative) will immediately notify the Triage Nurse if any individual presents with: Chest Pain..."
There was no documentation in Patient 2's record to indicate the patient was triaged or received a MSE, when the patient's chief complaints were chest pain and cold sweats.

On January 13, 2016, at 9:15 a.m., PAR 2 was interviewed. PAR 2 stated, when a patient presented to the ED, and filled out the Patient Registration Form and the Conditions of Admission, the patient would give the documents to the PAR seated behind the desk. The PAR would enter the information into the computer, and put together a chart. The PAR would then give the chart to the Triage Nurse. PAR 2 stated if the complaint was an urgent or emergency condition, such as chest pain or shortness of breath, the triage nurse would see the patient first. When PAR 2 was asked who determined if the patient needed to see the triage nurse first, she answered, "We do, the PARs."

A review of Facility A's ED policy, "Patient Registration (Revised/Reviewed: 3/2014)," was conducted. The policy indicated, "All patients will be evaluated by the Triage Nurse prior to being seen by the Admitting Department Clerk."

A review of the ED Log was conducted. The log indicated Patient 2 arrived on November 26, 2015, at 8:32 p.m., and was discharged on November 27, 2015, at 1:21 a.m., five hours later. The ED log indicated Patient 2's disposition as LWBT (left without being triaged-the process of determining the severity of a patient's chief complaint or reason for the visit).

An interview was conducted with the Associate Chief Nursing Officer on January 14, 2016, at 9:30 a.m., who stated a patient with a chief complaint of chest pain should be triaged upon arrival to the ED.

c. A review of Patient 6's "Patient Registration Form," dated January 9, 2016, at 3:20 p.m., was conducted. The reason for the visit to the ED was documented by the patient as, "Hearing voices feeling don't want to live." The Conditions Of Admission were signed by Patient 6 on January 9, 2016, at 3:21 p.m. The document was witnessed and scanned into the patient's record.

A review of the facility's ED policy, "Patient Registration (Revised/Reviewed: 3/2014)," was conducted. The procedure indicated, "The Admitting Department Clerk (also known as a patient access representative-PAR) will immediately notify the Triage Nurse if any individual presents with: Psychiatric disturbances or substance abuse..."

There was no documentation in Patient 6's record to indicate the patient was triaged or received a MSE, when the patient's chief complaint was of a psychiatric nature, "Hearing voices feeling don't want to live."

A review of Facility A's ED policy, "Patient Registration (Revised/Reviewed: 3/2014)," was conducted. The policy indicated, "All patients will be evaluated by the Triage Nurse prior to being seen by the Admitting Department Clerk."

On January 13, 2016, at 9:15 a.m., PAR 2 was interviewed. PAR 2 stated, when a patient presented to the ED, and filled out the Patient Registration Form and the Conditions of Admission, the patient would give the documents to the PAR seated behind the desk. The PAR would enter the information into the computer, and put together a chart. The PAR would then give the chart to the Triage Nurse. PAR 2 stated if the complaint was an urgent or emergency condition, such as chest pain or shortness of breath, the triage nurse would see the patient first. When PAR 2 was asked who determined if the patient needed to see the triage nurse first, she answered, "We do, the PARs."

A review of the ED log was conducted. The log indicated Patient 6 arrived on November 9, 2016, at 3:20 p.m. and was discharged on January 9, 2016, at 3:32 p.m. The ED log indicated Patient 6's disposition as LWBT (left without being triaged).

An interview was conducted with the Associate Chief Nursing Officer on January 14, 2016, at 9:30 a.m., who stated a patient with the chief complaint of hearing voices and having suicidal ideations should be triaged upon arrival to the ED.




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2. The record for Patient 17 was reviewed. Patient 17 presented to the facility Labor & Delivery Department (L&D) on January 5, 2016, at 3:15 a.m., with complaints of uterine contractions.

RN 10 assessed Patient 17 on January 5, 2015, at 3:33 a.m. Patient 17 was pregnant with her fourth baby, and had a due date of April 27, 2016, (indicating she was pre-term at just 23 6/7 weeks). Patient 10 was placed on a fetal monitor (measures both contractions and fetal heart rate) and was having mild contractions every 10 minutes, lasting 60 seconds. The babies heart rate was 130 beats per minute, and was interpreted as reactive (good). RN 10 also performed a vaginal exam and assessed Patient 17's cervix (opening to the uterus) as closed and thick.

RN 10 notified the physician on January 5, 2016, at 4 a.m. Orders were received to medicate Patient 17 with Turbutaline (used to prevent pre-term labor), every 30 minutes, as needed for uterine contractions.

Patient 17 was discharged home on January 5, 2016, at 5:05 a.m., with instructions to follow up with her doctor. There was no further documentation of the physician being updated on Patient 17's condition prior to discharge, and there was no physician order to discharge Patient 10.

The list of RN's that were qualified to perform MSE's was reviewed. The list did not reflect RN 10's name.

The facility Rules and Regulations were reviewed, and indicated, "... The Obstetric and Gynecology Division approves the use of specially trained Registered Nurses for the purpose of Medical Screening Exams in accordance with the Medical Screening Exam Policy for obstetrical patients..."

The facility policy and procedure titled, "Obstetrics Standardized Procedures: Medical Screening Examination in Labor and Delivery," dated December 2015, was reviewed. A Medical Screening Exam was defined as, "A process of medical evaluation to identify or rule out the existence of labor or any other emergency medical conditions." A qualified RN was defined as, "A Registered Nurse who is certified to perform emergency medical examinations as defined in the OB Department Rules and Regulations who meet the following requirements."

- Demonstration of competence in skill and knowledge for evaluation and care of the women in labor using a Competency Validation Tool;

- Successful completion of a written examination for the performance of a MSE;

- Three previous MSE's performed in the last 12 months without any identified opportunity for improvement; and,

- Annual review of policy/procedure for MSE during Skills Day.

On January 14, 2016, at 11:45 a.m., the Assistant Chief Nursing Officer (ACNO) was interviewed. The ACNO stated she was also the Acting Director of L&D. The ACNO stated a L&D nurse must be checked off annually to verify competencies to perform a MSE. The ACNO stated if an RN had not been checked off, then they were not allowed to perform a MSE. The ACNO looked up the competencies that had been validated for RN 10, and stated RN 10 was not cleared to do a MSE, and therefore was not qualified to perform the MSE for Patient 17.