HospitalInspections.org

Based on observation and interview, the facility failed to post required signage in 3 areas (triage rooms, patient examination rooms, and labor and delivery triage rooms) of 7 areas observed.

Findings:

On 1-30-2020, a tour of the emergency department and the labor and delivery triage rooms showed that required signage was missing from the triage room in the emergency department, emergency department examination rooms, and the labor and delivery triage rooms.

Interview with Staff #1 and Staff #10 confirmed that in some instances it was possible for a patient to be placed directly into an emergency department triage room and then the examination room, go straight to the emergency department examination room, or bypass the emergency department and be taken directly to a labor and delivery triage room. This would not allow the patient the opportunity to stop and read signage at the emergency department entrances, registration/waiting area, the emergency department hallway by the ambulance entrance, or the labor and delivery waiting area. The possibility existed that the only time the patient would have to review the required signage would be in the triage rooms or the examination rooms.

Based on review of documents and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) to the extent of their capabilities for 1 patient (Patient #1) of 11 patients reviewed. During the evaluation of Patient #1 it was determined that the patient had abnormal findings related to her pregnancy and the fetus, based on an ultrasound, was greater than 20 weeks gestation, and was not assessed per hospital policy.


Findings:

Review of Patient #1's chart revealed the following:

The patient's initial complaint was of flu-like symptoms. The patient did complain of abdominal pain. She had reported that she was pregnant, but didn't know how far along she was. The physician ordered a sonogram that showed the patient had an Amniotic Fluid Index (AFI) of 0.02 centimeters. The AFI was used to determine if the proper amount of amniotic fluid was available for healthy fetal growth and indicated there was very little amniotic fluid. The sonogram estimated the baby to be approximately 34 weeks and 5 days. The sonogram also indicated the baby was in the breech position, had an enlarged right atrium, normal kidneys, and possible Intra-Uterine Growth Restriction (IUGR).

"Impression:

1. Single live intrauterine pregnancy with severe oligohydramnios (low volume of amniotic fluid) with fetus in breech presentation and possibly with intrauterine growth restriction.

2. Enlargement of the fetal right atrium is present as can be seen in Ebstein's anomaly. Follow-up echocardiography in the neonatal period recommended.

3. Abnormal femur length to abdominal circumference and femur length to head circumference ratios."


Review of patient records do not show that an OB consult was ever made. Review of the log from the Women's Care Services showed that this patient was never sent up to the floor for evaluation. Review of the ED record, along with sonogram report, did not show an evaluation of fetal heart tones or an evaluation to see if the patient was in early labor while not experiencing typical pain or symptoms associated with contractions.


Review of the patient's ED After Visit Summary, signed by the patient and printed for her on 12-4-2019 at 5:28 AM, showed the reason for visit was Influenza and the final diagnosis was Urinary Tract Infection and Dehydration. Nothing in the discharge information addressed the abnormal findings on the sonogram or time-frame needed for the patient to be seen by an OB physician. It did say to follow-up with Staff #14.


Review of the physician call schedule for OB showed that Staff #14 was not on call on 12-3-2019 or 12-4-2019. Interview with Staff #14 confirmed that he was not familiar with this patient, had not treated this patient in the past, and was not consulted by the ED physician on this patient.


Review of hospital policy titled, "Care of the Obstetrical Patient in the Emergency Department" showed:

"The obstetrical patient presenting to the Emergency Department (ED) is provided care based upon her current medical condition and in consideration of her gestational age. Fetal heart tone evaluation via Doppler or external fetal monitor will be assessed either by a Registered Nurse with documented competency, mid-level provider, or physician.
...

Patients greater than or equal to 20 weeks gestation with non-obstetric related complaints remain in the ED for treatment and care including documented fetal heart tones prior to discharge."


The flow sheet attached to the policy shows that if the answer is yes to the following:

Greater than 20 wks Pregnant with:

Abdominal Cramping/Pain

Vaginal bleeding or spotting

Vaginal discharge/leaking fluid

Pelvic pressure

Decreased Fetal Movement

Direct Abdominal Trauma


Greater than 20 weeks Pregnant or Less than 2 weeks Postpartum with:

Dysuria with back pain

Fever

Headache

Blood pressure greater than 140/90

Significant Edema

Proteinuria

Active Seizure/status post seizure

then:

*Patient information entered into MedHost for tracking

Call L&D charge nurse at 41-4362 or 41-4300 to inform of patient coming up. Report the following information:

Patient Name

Due Date

Primary Complaint

OB/Clinic providing prenatal care

Patient escorted to Labor & Delivery


Patient records showed that patient complained of influenza symptoms times 4 days and lower abdominal pains times 6 weeks. Influenza screening was negative for the flu.

The patient reported that the primary symptoms were abdominal pain, cramp and vomiting, no nausea, no diarrhea and no dysuria.

Upon arrival at 23:16 (11:16 PM) the patient's temperature was 99.9 degrees Fahrenheit. Patient reported she had taken medication for a fever prior to arrival.

The urinalysis report showed she had protein in her urine.

Despite having symptoms and test results that indicated the patient be sent to the OB floor, the patient was discharged home without OB physician consult.