HospitalInspections.org

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Based on review of the Emergency Department (ED) log on 10/12/11, the facility failed to maintain a central log that includes all patients who presented to Triage in the ED.

Findings:

Review of the electronic central ED log on 10/12/11 for the months of June 2011 to October 2011 revealed the central log was incomplete and did not include patients that were seen by the Triage nurse in the ED and sent to Labor and Delivery (L&D). The L&D department log for the same period presented on 10/13/11 did not specify which patients came from the ED.

Review of medical records for Patients #22 and #24 indicated these patients presented to the ED on 09/29/11, but the ED log did not document that these patients were seen by the Triage nurse.

The Outpatient/Observation record for Patient #22 documented she had presented to the ED on 09/29/11 and was transported from the ED via a wheelchair to L&D at 1320. The ED log does not mention this patient.

Review of the Outpatient/Observation record for Patient #24 indicated this pregnant woman presented to the ED on 10/08/11 and was taken in a wheelchair to L&D. The ED log does not mention this patient.

On 10/12/11 at 1030 during an onsite inspection of the ED the Registrars on duty stated "when a patient presents to the ED for treatment we send them over to the Triage nurse."

The facility's policy entitled "Function of the Triage Nurse" dated 01/2011 states: "The Triage RN is the first professional contact with the patient and family at which time she/he makes initial assessment of the patient's condition."

The facility's policy entitled "Triage and Chart Flow System" dated 01/2011 states: "The triage RN is the first person to assess all the ambulatory patients who arrive to the Emergency Department. The nurse determines urgency and priority of all patients and determines the resources required (e.g., L&D, Trauma Room, etc.)." This assessment was not evident in the medical records for Patient #22 and #24 and was not evident in the ED log.

These findings were confirmed by Hospital Administration.
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Based on record review the facility did not consistently document the refusal of examination or treatment and inform the patient of the risks and benefits of leaving Against Medical Advice (AMA) in one (1) out of three (3) medical records reviewed.

Findings:

Review of the medical record for Patient #14, revealed the patient presented to the Emergency Department (ED) on 06/11/11 at 10:56AM with complaints of chest pain and near syncopal episode. The patient was triaged at 10:58AM and seen and examined by the ED physician. The physician noted at 2:56PM that the patient had left Against Medical Advice.

There was no documented evidence contained in the medical record that the patient signed the "Release When Patient Leaves Hospital Against Medical Advice (AMA)" form.

The medical record did not document evidence that the ED physician indicated or explained the risks and benefits of Leaving the Hospital Against Medical Advice to the patient .

This finding was confirmed by Hospital Administration on 10/14/11.
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Based on record review and interview, the facility failed to effectuate an appropriate transfer as required by the provisions of this regulation and the facility's policy for a patient with an emergency medical condition that had not been stabilized. Specifically, the facility discharged a pregnant patient and directed her to present to another facility even though the patient was noted to be in labor in one (1) out of six (6) medical records reviewed.

Findings:

Review of the medical record for Patient #20 revealed the patient presented to L&D on 9/21/11 and was admitted at 2:20AM by the nurse. The record documented the patient was a Gravida 1 Para 0, with an EDC of 10/9/11. The outpatient / triage flow sheet documented that the patient was placed on external fetal monitor at 2:24AM with complaints of contractions / bleeding and a pain level of five (5). The vaginal examination performed by the nurse at 3:30AM documented that the patient was 100% effaced, dilated to 2.5cm and the fetus was presenting at (-1) station. The Intra-Partum Flow Sheet documented that the patient was HIV+, no vaginal bleeding, but there is no documentation contained in the record related to the status of the membrane. That area on the flow sheet is blank. The discharge instructions which included the physician's note documented "a 23 year old G-1 P-0 at 38 weeks in early labor. Patient planned delivery at another hospital. Discharged and patient to go to Stony Brook now. NST reactive consistent with early labor." The nurse's note documented at 3:56AM "patient instructed to go to Stony Brook and a taxi cab was called." There is no documented evidence that the physician completed an examination.

Review of the medical record for the delivering facility revealed that the patient presented to the hospital at 5:11AM and had spontaneous ROM at 5:25AM with delivery occurring at 6:40AM.

An interview conducted on 10/14/11 at 9:30AM with the nurse who provided care to Patient #20 revealed that the fetal monitoring strips indicated that the patient was having contractions two (2) to five (5) minutes apart and the FHR was 130. She stated the patient appeared to be in early labor and to her knowledge the physician did not do an examination.

An interview with the attending OB/GYN, conducted at 11:45AM on 10/14/11 revealed that he has never taken care of a HIV+ obstetrical patient. He stated he knew there are protocols for prophylaxis but he did not know them and the hospital does not have any policies or protocols available for HIV+ patients in labor and the medications are not available on the unit. The physician stated that he did assess the patient but he did not do an internal exam.

An interview at 1:00PM on 10/13/11 with the Chief of OB/GYN revealed that the patient was in labor, was having contractions and would usually be observed to see how she progressed. Intra-Partum HIV+ women are given AZT prior to the rupture of membranes or if they are in active labor. He stated that the facility can provide AZT prophylaxis and that the medication could have been made available but the physician did not request it.

Review of the Medical Board Policy 700.01 entitled "EMTALA" dated 3/7/11 revealed that the physician did not comply with the policy which requires "the medical screening examination must be performed by a physician." The policy "applies to an on-campus department (i.e. Labor & Delivery)" and "once the medical screening exam reveals an emergency medical condition the hospital must provide care within it's capacity before the patient is discharged or transferred." The policy states that "a violation of EMTALA means that the hospital has denied care, limited care, discharged or transferred the patient who has an emergency condition as defined by law."