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Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases] by failing to provide an appropriate medical screening exam (MSE) for 1 patient (P-1), who came to the emergency department requesting examination and/or treatment for a medical condition, out of 21 patients reviewed for EMTALA requirements. This failed practice resulted in the potential for the patient to experience deterioration of an unidentified emergency medical condition, which posed a risk to her health and safety.
Findings include:

See A-2406 Failure to complete an adequate medical screening exam

Based on interview and record review, the facility failed to provide an appropriate medical screening exam (MSE) for 1 patient (P-1), who came to the emergency department requesting examination and/or treatment for a medical condition, out of 21 patients reviewed for EMTALA requirements. This failed practice resulted in the potential for the patient to experience deterioration from an unidentified emergency medical condition, which posed a risk to her health and safety. Findings include:

On 2/13/2024 at 1130, medical record review revealed P-1 was evaluated at the facility's ED (Emergency Department) on 8/26/2023 at 2009 with a complaint of "miscarriage yesterday.", P-1 stated she has "lost a lot of blood and feels lightheaded, having sharp abd [abdominal] pain, and is soaking a pad every 5 minutes."

P-1 had also been evaluated at this hospital on 8/25/2023 at 0919 for a similar complaint and again on 8/25/2023 at 2029 for headache. Laboratory and ultrasound testing on 8/25/2023 demonstrated a 9-10 week "single intrauterine gestation [pregnancy] without fetal heart tones consistent with fetal demise." The on-call OB/GYN physician was contacted on or about 8/25/2023 at 1246, and P-1 was ultimately discharged with plans to follow-up in one week and instructions to "come back to the Emergency Department if your problem is not improved."

During the return visit on 8/26/2023 at 2009, documentation by Physician Staff V described that "she was seen yesterday twice, diagnosed with IUFD [intrauterine fetal demise, a condition in which the fetal heart stops and the fetus is determined not to be viable before onset of labor] and discharged home with supportive therapies. She returns today stating that she was starting to have some bleeding" and "had a significant amount of vaginal output [including] multiple clots" and "presents today with ...concern for persistent bleeding, contraction type discomfort in the pelvis." Physician Staff V documented P-1 ' s physical examination as including "lower abdominal discomfort to palpation" and "pelvic exam deferred" (with no further explanation of why or whether other means were available to assess cervical dilation or briskness of bleeding). Physician Staff Vs "medical decision making" documentation included "Bedside ultrasound by myself on arrival confirms that there is no evidence of uterine fetal tissue, and lab results on 8/25/2023 at 21:08 included white blood cell count 13.8 (a laboratory marker of inflammation or infection, hospital reference range 3.6 to 10), in comparison to 12.0 on 8/25/2023 at 21:15. The medical record did not contain documentation of further ultrasound findings or archival of images from the ultrasound exam during this visit. The record did not contain evidence that the on-call OB/GYN was consulted or documentation to support why involvement of the on-call specialist would not be required during this presentation, in contrast to P-1's evaluation on 8/25/2023 at 0919. P-1 was discharged with a diagnosis of "complete miscarriage" on 8/27/2023 at 0014 with instructions to follow up with her OB/GYN on 8/30/2023.

On 2/15/2023 at 0740, an interview was conducted with Physician Staff V, the emergency department physician who evaluated P-1 during the 3rd visit to the ED on 8/26/2023. Physician Staff V stated he performed a bedside ultrasound, repeated laboratory tests and provided medications. P-1 was given discharge instructions and told to return to the ED if necessary. Physician Staff V verified that he relied upon his point of care ultrasound (POCUS) findings to determine whether or not an emergency medical condition was present for P-1. Physician Staff V confirmed that he was not credentialed by the hospital ' s governing body to perform obstetrical ultrasound to evaluate for retained products of conception but that he had been trained to do so. He stated that the hospital did not have a process for archiving POCUS images used for medical decision making, nor a process for documenting such exams. Physician Staff V confirmed he did not contact the OB/GYN and verified a pelvic exam or other assessment of cervical dilation and briskness of bleeding was not completed and admitted there is "always room for improvement" and that he "could contact OB/GYN physicians in the future."

On 2/14/2024 at 1230, during review of policy "Healthcare EMTALA/Physician on Call Policy" last revised on 2/1/2022 under section titled "Policy, letter A, #1. An appropriate medical screening examination should address the
presenting symptoms and comply with current policies and procedures for assessment of those presenting symptoms, including but not limited to a history of the presenting problem; a documented physical examination of the involved area or system; and the use of on-call physicians..." The policy also required that qualified medical personnel "conduct and document an appropriate medical screening examination reasonably calculated to identify an emergency medical condition" and defined emergency medical condition as "a condition manifesting itself by acute and severe symptoms of sufficient severity (including severe pain, psychiatric disturbances and/ or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in (1) placing the health of the individual (including the health of an unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part; or (2) with respect to a pregnant woman who is having contractions, that there is insufficient time to safely transfer the woman to another hospital before delivery, or the transfer may pose a threat to the health or safety of the woman or the unborn child. A woman having contractions is presumed to be in labor unless qualified medical personnel certify, after a reasonable time of observation, that the woman is in false labor." Subsection A, 3, a, i of the same policy defined that discharge was appropriate only when "the person does not need continued care, or no material deterioration is likely to result if the patient receives continued care as an outpatient or later as an inpatient and the patient is given a plan for appropriate follow-up care."

On 2/13/2024 at 1608, an interview was conducted with Physician Staff K, the OB/GYN performed a D&C for P-1 on 8/29/2023 for retained products of conception. Physician Staff K confirmed the OB/GYN was not notified that P-1 had come to the ED for the third visit on 08/26/2023 and "if they had been notified, they would have come to the ED to see her."

Review of the document titled "Operative/Procedure Reports" dated 08/29/2023 at 18:29 and signed by OB/GYN Staff K revealed "A 10 french curved curette was used with suction and large amount of products of conception, sharp curettage done..."

Based on record review, policy review, and interviews, the hospital failed to provide an appropriate medical screening examination, within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, for P-1 during her third visit on 8/26/2023 at 2009. The hospital's policies also set forth specific requirements to define an appropriate MSE, including examination, documentation, consultation, observation, and certification requirements, which were not met.