HospitalInspections.org

Based on the hospital's Emergency Medical Treatment and Labor Act (EMTALA) policy, medical record review, emergency medical services (EMS) record review, the hospital's Dedicated Emergency Department (DED) log and interview, the hospital failed to ensure all patients presenting to the hospital's DED received an appropriate medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 2 (Patient #1) obstetrical (OB) patients presenting to the hospital's DED via Emergency Medical Services (EMS) seeking medical attention.

Refer to the findings in deficiencies A 2406.

Based on medical staff regulation by-laws, policy review, medical record review, document review and interview, the hospital (Hospital #1) failed to ensure all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention received an appropriate Medical Screening Examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 2 (Patient #1) obstetrical (OB) patients presenting to the DED via Emergency Medical Services (EMS) seeking medical attention.

The findings included:

1. Review of Hospital #1's medical staff by-laws revealed, "...Persons Qualified to perform Screening Exams...To comply with... regulations concerning emergency patients, qualified personnel to do screening medical evaluations may include doctors, physician assistants (PA) or nurse practitioners (NP). Additionally obstetrical patients may be medically screened by certified nurse midwives and obstetrical registered nurses qualified as per criteria established for this purpose..."

Review of Hospital #1's "EMTALA [Emergency Medical Treatment And Labor Act] (Screening, Stabilization and Management of Emergency Transfers)" policy revealed, "It is the policy of [Name of Hospital #1] to provide an appropriate Medical Screening Examination to individuals presenting at its Dedicated Emergency Departments requesting examination or treatment of a medical condition, and to individuals presenting on Medical Center Property requesting examination or treatment of an Emergency Medical Condition, and if one exists, either to stabilize the emergency condition or to transfer the individual appropriately and in conformity with legal and regulatory requirements... This policy applies to anyone who requests or requires care who presents on [Name of Hospital #1] Property specifically including not only the Emergency Department but Obstetrical units...
SCREENING AND STABILIZATION REQUIREMENTS...All individuals who come to the DED...shall receive an appropriate Medical Screening Examination...Medical screening examinations will be performed by the Emergency Department, Nurse practitioner, Physician's Assistant, or the Labor and Delivery Registered Nurse...as set forth I [in] the Medical Staff Rules and Regulations [By Laws]...A list of Labor and Delivery Registered Nurses who have demonstrated competency and are approved to perform the medical screening exam will be maintained by the Women's Services Nursing Manager...
Exam to be Provided within Capabilities of the Medical Center...must include all services within the capabilities of the Medical Center...
Treatment, Discharge or Transfer of Stabilized Patients...Once the Medical Screening is completed and there is a determination the patient does not have an Emergency Medical Condition or the Emergency Medical Condition has been Stabilized, the patient may be...Treated...Discharged...Transferred for continued care. Appropriate Transfer procedures shall be followed...
Transfer of Patients with and Emergency Medical Condition...
1...If the patient has an Emergency Medical Condition, the patient is to be treated in the DED until the condition is Stabilized or the patient can be appropriately Transferred.
2. If the patient's emergency condition cannot be Stabilized within the Capability and Capacity of the medical Center, the patient may be Transferred in compliance with state and federal laws...
'Appropriate Transfer' means a Transfer of an individual with an Emergency Medical Condition that is implemented in accordance with EMTALA standards...the Transferring hospital provides the medical treatment within its Capacity which minimizes the risks to the individual's health and, in the case of a women in labor, the health of the unborn child...
'Emergency Medical Condition' refers to both labor and non-labor related emergency condition...Labor means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta...Non-labor related Emergency Medical Condition means...A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in: 1. placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy...The Medical Screening Examination is an ongoing process, including monitoring of the individual, until the individual is wither Stabilized or Transferred...
Women in Labor. Stabilization means the delivery of the child and the placenta..."

Review of Hospital #1's "OBSTETRICAL TRIAGE" policy revealed, "...PURPOSE: To outline the nursing management of obstetric patients during initial assessment and and triage. The patients are seen in Labor and Delivery. Patients triaged are usually 20 weeks gestation to 6 weeks postpartum...Initial assessments of patients arriving in Labor and Delivery triage includes the following...Maternal physical status...Fetal status...Labor status...The provider is notified after the initial assessment, unless earlier notification is warranted...Certified Nurse Midwives are approved and designated by the Medical Center Medical Board as Qualified Medical Personnel ("QMPs") as defined by EMTALA and may provide medical screening examinations and certification of false labor...
Maternal Transfer: Call Maternal Referral [at Hospital #2]...Physician to obtain approval from OB at receiving facility for transfer of care...Consent to transfer..."

2. Medical record review revealed Patient #1 was a 40 year old pregnant female with the diagnoses of Placenta Previa (condition in which the placenta partially or completely covers the cervix opening that can result in pregnancy complications) and Placenta Percreta (condition in which the placenta penetrates the wall of the uterus and attaches to other organs that an result in pregnancy complications).

Review of a prenatal physician's clinic visit note dated 5/7/18 revealed Patient #1 was seen for evaluation and management of Placenta Previa and Placenta Percreta. The note revealed the delivery timing is to balance the risk to mother of hemorrhage versus risk to infant of premature birth. The note revealed a likelihood of requiring a large volume blood transfusion and emphasized to patient the seriousness of this condition. Patient given strict precautions to call/come to hospital for any vaginal bleeding.

Review of a prenatal physician's clinic visit note dated 5/8/18 revealed potential complications discussed with Patient #1 included hemorrhage, transfusion need, hysterectomy, injury to vascular structures and/or maternal death.

3. Review of Hospital #1's DED log revealed Patient #1 arrived in the DED on 5/31/18 at 1:46 AM. Hospital #1's "Initial" DED note revealed the patient was transferred to Hospital #1's Women's Services Obstetrics (OB) Department at 1:48 AM.
There was no additional facility documentation for Patient #1. There was no documentation Patient #1 received a Medical Screening Examination (MSE) or treatment at Hospital #1 to determine if an EMC existed.

In an interview on 7/9/18 at 3:00 PM in the conference room, the Manager of Women's Services (MOWS) verified there was no additional medical records for Patient #1.

In an interview on 7/9/18 at 3:40 PM in the conference room, the Director of Women's Services (DOWS) verified there was no additional medical records for Patient #1.

4. Review of an EMS report dated 5/31/18 revealed an emergency call was received at 1:18 AM for Patient #1, a 40 year old pregnant female. The EMS report revealed the ambulance arrived at the home of Patient #1 at 1:23 AM. The report revealed, "...female pt [patient] bleeding from vagina 35 weeks pregnant. Arrived on scene and presented with 40 year old female...standing in bathroom tub with copious amounts of blood in the toilet and in the tub and Fist size clots in the floor of the tub...Due to the extreme amount of hemmoraging [Hemorrhaging] from vaginal area and pt not sure if she could feel the baby moving or not it was determined to transport to [name of Hospital #1] ob to be evaluated and get bleeding under control. Pt states she is high risk due to placental previa and is scheduled for a c [Cesarean] section in the next two weeks...[Name of Hospital #1] ER contacted via phone and advised of the situation and asked to relay this message to the ob floor. Arrived at [Name of Hospital #1] and pt was registered in in [in] the ER and then we proceeded to the 2nd floor to the ob department. Arrived in the ob department and greeted by multiple nurse and began taking pt into room when we were told to wait and a nurse at the desk hangs up the phone and says take her [Patient #1] on to [Name of Hospital #2] they would not be seeing her there [at Hospital #1]...Pt secured into our unit [ambulance] once again and we began transporting emergency to [name of Hospital #2]...Pt arrived at [Name of Hospital #2]...and placed in ob room...Care and report given to ob staff." The report documented EMS arrived at Hospital #2 at 2:24 AM, and Patient #1's care was turned over to the OB DED upon arrival.

5. Medical record review for Hospital #2 revealed Patient #1 arrived via ambulance in an urgent condition on 5/31/18 at 2:29 AM.

Review of Hospital #2's History and Physical dated 5/31/18 revealed Patient #1 had a known Complete Placenta Previa and Placenta Percreta and was taken to the operating room for an urgent Cesarean Hysterectomy.

Review of Hospital #2's Operative note dated 5/31/18 revealed Patient #1 was diagnosed with Placenta Percreta, Complete Placenta Previa and Antepartum Hemorrhage. The operative note documented an estimated 4000 milliliter (ml) blood loss in addition to 1000 ml blood loss prior to arrival at Hospital #2. The Operative note documented a Cesarean Section (c section), Hysterectomy, Exploratory Laparotomy and Interventional Radiology of a Vascular Embolization procedures were performed. The procedures started at 4:29 AM and were completed at 9:03 AM. Patient #1's baby girl was delivered at 4:45 AM and transported to the Neonatal Intensive Care Unit (NICU). The patient was transported to the Surgical Intensive Care Unit (SICU).

Review of Hospital #2's physician Discharge Summary note dated 6/4/18 revealed Patient #1 presented to the DED on 5/31/18 at 32 weeks and 5 days gestation. On arrival the patient had a large amount of vaginal bleeding and was urgently taken to the Operating Room for surgery. The physician's note revealed the patient's operative course was complicated requiring 4 units of Packed Red Blood Cells (PRBCs) and 4 units of Fresh Frozen Plasma (FFP) during surgery. Postoperatively the patient was transferred to SICU. The patient's condition improved over the course of the hospitalization and the patient was discharged home on 6/4/18.

Review of Hospital #2's physician Discharge Summary not dated 6/26/18 revealed Patient #1's baby girl was born on 5/31/18 at 4:45 AM and transported to the NICU. The baby girl was diagnosed with Prematurity and Newborn Respiratory Distress. Patient #1's baby girl improved over the course of the hospitalization and was discharged home on 6/26/18.

6. In a telephone interview on 7/10/18 at 10:00 AM Physician #1 verified he was familiar with Patient #1 and was the on call OB physician on 5/31/18, when the patient arrived. Physician #1 stated Hospital #1's Charge Nurse (CN) called and said the patient was enroute, they had attempted to reach the mid wife but was able to reach her. Physician #1 stated the CN did not inform him the patient was in the hospital, only "enroute." Physician #1 stated he told the CN the patient should be on "diversion to [Name of Hospital #2]." Physician #1 stated, "In my clinical and professional experience it was important she [Patient #1] be prioritized and taken to [Name of Hospital #2].

In a telephone interview on 7/10/18 at 11:23 AM Registered Nurse (RN) #1 stated she was working the morning of 5/31/18 when Patient #1 was brought to the OB triage via EMS. RN #1 stated there was a note posted on the unit that due to Placenta Percreta, Patient #1 was to deliver at Hospital #2. RN #1 stated she tried to call the Mid Wife several times with no answer and we had no in house physician or mid wife. RN #1 stated there was no need for a mid wife or physician to be in house if there was no one in labor. RN #1 further stated while she was trying to reach Mid Wife #1, Surgery Tech (ST) #1 got on the other phone and called the on call OB physician.

In an interview on 7/10/18 at 11:50 AM in the conference room, Mid Wife #1 stated she received a call from RN #1 that EMS was bringing a patient that was bleeding. Mid Wife #1 stated "I was on my way." Mid Wife #1 verified that she was not on Hospital #1's property when she received the call. Mid Wife #1 stated she lived 20 minutes from the hospital, and it was common practice for her to be at home when she was on call. Mid Wife #1 stated there were alerts, posted notes and emails regarding the complications of Patient #1's pregnancy. Mid Wife #1 verified she was not available to perform a MSE while Patient #1 was at Hospital #1.

In a telephone call on 7/10/18 at 2:10 PM ST #1 stated the ED called and said Patient #1 is on the way up with EMS. Patient #1's name came up on the triage screen reporting the patient was supposed to go to Hospital #2. ST #1 stated that RN #1 tried to call the mid wife, so I called Physician #1 and told him the patient had presented on the ob unit. ST #1 stated that Physician #1 said the patient needed to go to Hospital #2. ST #1 verified that Physician #1 was informed that Patient #1 had arrived on the unit in the hospital.

In an interview on 7/11/18 at 9:15 AM in the conference room, DOWS stated there was no hospital OB RNs that had been qualified to perform a MSE.

In an interview on 7/11/18 at 11:55 AM in the conference room, the Medical Director of Women's Services (MDOWS) stated she was aware of Patient #1's case. The MDOWS stated that she did not feel Hospital #1 had sufficient capabilities, a sufficient operating room or blood supply to meet the needs for patient #1. The MDOWS stated the patient need a C-Section and other surgery procedures that would have required multiple specialty surgeons that were not available to Hospital #1.