HospitalInspections.org

Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases as evidenced by:

(A2405: Emergency Department) The hospital's failure to ensure a woman who presented to the Maryvale Emergency Department (ED) in active labor was entered into their central ED log. (Patient #1)

(A2406: Medical Screening Examination) The hospital's failure to provide a medical screening examination to a patient who presented to the hospital's offsite Emergency Department (ED) in active labor. The patient was told labor and delivery services were not available there and the patient left and was driven in a private vehicle to an acute care hospital where she delivered precipitously in that ED. (Patient #1)

Based on review of clinical records, hospital policies/procedures, hospital internal documents, and interviews, it was determined the hospital failed to ensure a woman who presented to the Maryvale Emergency Department (ED) in active labor was entered into their central ED log. (Patient #1)

Findings include:

The hospital's policy and procedure titled "Compliance/EMTALA: Registration, Triage, and Medical Screening Exam" includes: "Valleywise Health will maintain a list of each person covered by EMTALA who comes to the ED. This log must state, at a minimum, whether the person refused treatment, was refused treatment, was admitted and treated, stabilized and transferred, or discharged."

Patient #1 was in active labor and taken to the hospital's Maryvale ED on 9/8/2021 at 10:40 p.m. The patient was told by a staff person t they don't provide those services there and that if she stayed, she would have to be transferred to another hospital that delivers babies. The patient left and was taken by private vehicle to another acute care hospital where she delivered the infant in that ED. There was no documentation that Patient #1 presented to the Maryvale ED.

Staff #3 acknowledged during interviews that Patient #1 should have been entered into the electronic medical record system at the time of her arrival.

Based on reviews of clinical records, hospital policies and procedures, security video, and staff interviews, it was determined the hospital failed to provide a medical screening examination to a patient who presented to the hospital's offsite Emergency Department (ED) in active labor. (Patient #1) The patient was told labor and delivery services were not available there and the patient left and was driven in a private vehicle to an acute care hospital where she delivered precipitously in that ED.

The hospital's policy and procedure titled, "Compliance/EMTALA: Registration, Triage, and Medical Screening Exam" included: "Definition...Emergency Medical Condition (EMC): A medical condition manifesting itself by acute 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: a. 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...1. With respect to a pregnant woman who is having contractions: a. That there is inadequate time to affect a safe transfer to another hospital before delivery; or b. That transfer may pose a threat to the health or safety of the woman of the unborn child....4. Medical Screening Exam...a. Valleywise Health will provide a medical screening examination (MSE) to all persons who present at the Valleywise Health Medical Center requesting emergency services, regardless of their ability to pay....d. The purpose of an MSE is to determine whether the person seeking emergency services has an EMC...f. For pregnant women, the MSE will include assessing the stage and progression of labor and determining fetal well-being.

Documentation in Patient #1's clinical record from Hospital #2 revealed the patient presented to their ED on 9/8/2021 on or around 11:15 p.m. The ED report included: The patient...presents to the ED currently in labor...I delivered baby and obstetrics arrived after delivery of the baby and prior to cord clamping, and obstetrics assumed care...Quick progression from barely crowning to delivery in about 10 minutes...." The documentation revealed the patient had no prenatal care and was positive for fentanyl in a urine drug screen. The patient was discharged home on 09/10/2021. Documentation in the infant's clinical revealed a birth weight of five pounds/seven ounces and birth length of 16.9 inches. The Obstetrical History & Physical Note included: "Pregnancy was complicated by substance use and complete lack of prenatal care." The infant was moved to the hospital's "high risk delivery suite" for monitoring of feeding concern and weight loss and for signs of withdrawal. The infant demonstrated signs of withdrawal on 9/11/2021 and was started on morphine as needed. The infant was still in the hospital as of 09/15/2021.

Staff #1 reported Hospital #2 notified Valleywise Health leadership of the incident and were unable to locate any record of the patient in their medical record system. Security video of the Maryvale ED was reviewed and they located footage of Patient #2 being taken into the ED by a male on 9/8/2021 at 10:39 p.m. A review of the video revealed the following:

10:39 p.m. A car pulled up outside the entrance to the ED. A male got out of the car and went inside and took an empty wheelchair located just inside the entrance and exited back out to the car. The male assisted Patient #2 from the passenger side of the vehicle into the wheelchair and wheeled her inside. The patient was obviously pregnant and had her legs drawn up into the wheelchair. There was one female behind the registration desk.
10:40 p.m. The male approached the female staff with the patient in the wheelchair. There was no audio to the video but it appeared he did all of the talking to the staff member. The patient appeared to be uncomfortable and moving about in the wheelchair.
10:41 p.m. The interaction between the female staff and the male was less than one minute, and he turned around and left with the patient.
10:41 to 10:45 p.m. The couple were outside of the entrance. The male was doing something on a cell phone. During that time the patient stood up from the wheelchair and leaned forward , bent at the waist facing the passenger side. She opened the car door and then went down to her knees.
10:45 p.m. A male staff member came out of the main entrance, stopped and gestured toward the patient. There was conversation between the staff member and the male who was still using the cell phone. The staff member then pulled out his cell phone.
10:46 p.m. The staff member left toward the parking lot, and the male got into the car and drove away with the patient in the passenger side.

The female staff member at the reception desk who interacted with the male was identified as a Registration Specialist (Staff #8). A telephone interview was conducted with Staff #8 on 10/6/2021 Staff #8 acknowledged being on duty when Patient #2 arrived. Staff #8 said the male asked if they had doctors there to deliver babies. She told him they do not have a labor and delivery unit there and that the patient would be transferred somewhere else to deliver. She asked him what hospital the patient was scheduled to deliver at. She said she told him it was their choice to stay. I asked her if the patient appeared to be in labor, discomfort, etc. and she said, "Not really ...she was in a wheelchair ...I was focused on him and didn't really pay attention to her." I asked her if she told the Triage Nurse that a pregnant patient came in and she said she did not.

The male staff member who came out and interacted with the couple was identified as a Registered Nurse (Staff #9). An interview was conducted with Staff #9 on 10/7/2021. Staff #9 reported he had just finished his shift and when he walked outside he saw the patient and the male. He said it was obvious she was in pain. He asked if they needed help and the male said no, that they were going to Hospital #2. Staff #9 said he thought they had already been seen inside and had no idea the patient had not been evaluated. The male asked him if he knew how to get to St. Joseph's Hospital, and he did not so he pulled out his phone and looked for it. Staff #9 said he did not know the patient was in labor. They located the address and they left in the vehicle.

In summary, Patient #2 was in active labor and was taken to the hospital's off-site dedicated Emergency Department. The patient was told by non-clinical staff that labor and delivery services were not available there and the patient would be transferred somewhere else to deliver. The patient left and was driven in a private vehicle to an acute care hospital where she delivered precipitously in that ED.