The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SAN GORGONIO MEMORIAL HOSPITAL 600 NORTH HIGHLAND SPRINGS AVENUE BANNING, CA 92220 March 12, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on observation, interview, and record review, the facility failed to comply with CFR 489.24 by failing:

1. To ensure a list of physicians who were on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition was complete and maintained. This had the potential to result in the facility being unaware as to who was on-call for each specialty service (Refer to A2404);

2. To ensure a pregnant patient, greater than 20 weeks gestation (full term pregnancy is 40 weeks gestation) seen in the Emergency Department (ED), was provided with a thorough medical screening examination (MSE) to determine whether an emergency medical condition (EMC) existed for one sampled patient (Patient 2). This resulted in Patient 2 being discharged from the facility with an incomplete medical screening examination (Refer to A2406);

Immediate Jeopardy was called related to this issue on March 11, 2015, at 12:18 p.m., and lifted with an acceptable plan of correction and verification of implementation of the plan, on March 12, 2015, at 4:15 p.m.

3. To ensure a complete medical screening examination (MSE) was obtained based on the patient's current complaints and obstetrical history for one sampled patient (Patient 1). This had the potential to result in the death of Patient 1's infant (Refer to A2406);

4. To ensure medical screening examinations for pregnant patients seen in the Emergency Department (ED) included obtaining a pregnancy history and fetal heart tones for three sampled patients (Patients 5, 8, and 9). This resulted in incomplete medical screening exams (Refer to A2406);

5. To ensure the on-call obstetrical physician reviewed and countersigned the medical screening examination performed by an Obstetrical (OB) nurse within 72 hours per facility standardized procedure for three sampled patients (Patients 1, 15 and 16). This had the potential to result in incomplete/inaccurate medical screening exams not being detected by the OB physician in a timely manner (Refer to A2406);

6. To ensure the Medical Staff ByLaws/Rules and Regulations indicated that Obstetrical (OB) Registered Nurses (RNs), who met established guidelines, may perform the medical screening examination (MSE) for obstetrical patients; the physician must be notified of the MSE results and makes the decision on the patient's disposition; and the physician must certify the nurse's MSE within 72 hours of the patient being seen by the OB RN. This resulted in OB RNs performing MSE on OB patients without being determined qualified by hospital bylaws or rules and regulations and approved by the Governing Body of the hospital (Refer to A2406);

7. To ensure the triage Registered Nurse (RN) followed the facility's procedure regarding the evaluation of a patient's medical condition for five sampled patients (Patients 27, 28, 29, 30, and 31). This had the potential to directly impact the safety and provision of adequate care provided for patients in the ED (Refer to A2406);

8. To ensure a "Transfer Request/Refusal Consent" was completed for one sampled patient (Patient 22). This had the potential to result in Patient 22 not consenting to and being unaware of the risks and benefits of a transfer to another facility (Refer to A2409); and

9. To ensure the physician had signed a certification that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred, and/or the certification contained a summary of the risks and benefits upon which the transfer was based, for three sampled patients (Patients 3, 6, and 21). This had the potential to result in the patients being unaware of the risks and benefits of a transfer to another facility (Refer to A2409).
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on observation, interview and record review, the facility failed to ensure a list of physicians, who were on call to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition, was complete and maintained. This had the potential to result in the facility being unaware as to who was on-call for each specialty service.

In addition, the facility policy and procedure did not address how to respond to situations in which a particular specialty was not available/no physician on-call or the on-call physician cannot respond because of circumstances beyond the physician's control.

Findings:

On March 11, 2015, at 8:45 a.m., a tour of the Emergency Department was conducted with Registered Nurse (RN) 1.

RN 1 stated the physician on-call schedule was kept at the Unit Secretary's desk.

The "Emergency Department Backup Schedule (on-call specialty physician's schedule)" dated March 2015, included:
- Primary Care
- Surgery
- Vascular
- Peds/Nursery
- Cardiology
- Gastroenterology
- OB/GYN

There was no indication of who was on-call for Pulmonology, Urology, Orthopedics, and Anesthesiology.

On March 11, 2015, at 9:15 a.m., an interview was conducted with Unit Secretary (US) 1. He stated the on-call schedule, "Emergency Department Backup Schedule" was provided monthly by the medical staff for specialty physicians . US 1 stated there were separate sheets for the Medical Groups Hospitalists, the Medical Groups Cardiology and the Medical Groups Pulmonology on-call schedule. He stated the Medical Groups Cardiologists would cover patients not in the medical group but this did not always happen with the Medical Groups Pulmonologists. US 1 stated the "Urology Phone Triage Schedule" was provided to the Emergency Department (ED) once a month and was also on a separate sheet. US 1 stated the Orthopedic on-call schedule was one physician and he took call on Tuesdays and every fifth weekend but had recently canceled himself for two consecutive Tuesdays in March 2015. He stated the Orthopedic on-call schedule was a separate sheet that contained the entire calendar year's schedule, and was not updated with the changes made to the orthopedic on-call schedule. In addition, the Anesthesiology schedule was a separate sheet and was provided to the ED once a week with a Wednesday start day.

US 1 stated an on-call group was listed for the Surgery specialty. Us 1 stated he would call Physician B and Physician B would tell them who to call for Surgery coverage at that time.

On March 11, 2015, the on-call schedules for December 2014, January and February 2015, were requested from the facility.

The only on-call schedules provided by the Director Medical Staff were "Emergency Department Backup Schedule(s)" for December 2014, January and February 2015. There were no additional schedules provided for Pulmonology, Urology, Orthopedics, and Anesthesiology.

During an interview with the Director Medical Staff, on March 12, 2015, at 3:50 p.m., she stated she only had on-call physician schedules for "Emergency Department Backup Schedule(s)", the Medical Groups Hospitalists, and the Medical Groups Cardiologist/Pulmonologist.

The facility was unable to provide the Pulmonology, Urology, and Anesthesiology on-call schedules for December 2014; January and February 2015; and, the Orthopedic on-call schedule for December 2014.

During an interview with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Director Emergency Department (DED), on March 12, 2015, at 4 p.m., they stated there were uncovered days for the on-call physician schedules due to limited number of physicians in said specialties such as Orthopedics, Gastroenterology, and Vascular. The CEO and CNO reviewed the "Emergency Department Backup Schedule(s)" and verified the on-call schedules for Pulmonology, Urology, Anesthesiology, and Orthopedics were not included on the "Emergency Department Backup Schedule(s)." In addition, for Surgery a group was listed rather than an individual.

The facility policy and procedure titled "EMTALA and COBRA Compliance" with a review date of November 2011, revealed, "... The ED will maintain an "on-call" list of specialty services available to the ED physician for consultation to assist in the determination of the presence of an emergency medical condition and to provide any consultation, treatment or intervention to stabilize a patient with an existing emergency medical condition..."

The facility policy and procedure did not address how to respond to situations in which a particular specialty was not available, no physician on-call or the on-call physician was unable to respond because of circumstances beyond the physician's control.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed:

1. To ensure a pregnant patient, greater than 20 weeks gestation (full term pregnancy is 40 weeks gestation) seen in the Emergency Department (ED), was provided with a thorough medical screening examination (MSE) to determine whether an emergency medical condition (EMC) existed for one sampled patient (Patient 2). This resulted in Patient 2 being discharged from the facility with an incomplete medical screening examination.

Immediate Jeopardy was called related to this issue on March 11, 2015, at 12:18 p.m., and lifted with an acceptable plan of correction and verification of implementation of the plan, on March 12, 2015, at 4:15 p.m.

2. To ensure a complete medical screening examination (MSE) was obtained based on the patient's current complaints and obstetrical history for one sampled patient (Patient 1). This had the potential to result in the death of Patient 1's infant.

3. To ensure medical screening examinations for pregnant patients seen in the Emergency Department (ED) included obtaining a pregnancy history and fetal heart tones for three sampled patients (Patients 5, 8, and 9). This resulted in incomplete medical screening exams.

4. To ensure the on-call obstetrical physician reviewed and countersigned the medical screening examination performed by an Obstetrical (OB) nurse within 72 hours per facility policy and procedure for three sampled patients (Patients 1, 15 and 16). This had the potential to result in incomplete/inaccurate medical screening exams not being detected by the OB physician in a timely manner.

5. To ensure the Medical Staff ByLaws/Rules and Regulations indicated that Obstetrical (OB) Registered Nurses (RNs), who met established guidelines, may perform the medical screening examination (MSE) for obstetrical patients; the physician must be notified of the MSE results and makes the decision on the patient's disposition; and the physician must certify the nurse's MSE within 72 hours of the patient being seen by the OB RN. This resulted in OB RNs performing MSE on OB patients without being determined qualified by hospital bylaws or rules and regulations and approved by the Governing Body of the hospital.

6. To ensure the triage Registered Nurse (RN) followed the facility's procedure regarding the evaluation of a patient's medical condition for five sampled patients (Patients 27, 28, 29, 30, and 31). This had the potential to directly impact the safety and provision of adequate care provided for patients in the ED.

7. To ensure a RN met the facility required qualifications for personnel who worked in the Emergency Department (ED). This had the potential to directly impact the safety and provision of adequate care provided for patients in the ED.

Findings:

1. On March 11, 2015, at 9 a.m., a tour of the ED was conducted with Registered Nurse (RN) 1.

On March 11, 2015, the record for Patient 2 was reviewed. Patient 2 presented on March 11, 2015, at 6:55 a.m., complaining of right sided back pain and chest wall pain.

The "ED Triage Report" dated March 11, 2015, at 6:56 a.m., indicated Patient 2 was assigned an acuity of "4 (Emergency Severity Index - ESI - five level triage system - 4: non-urgent)."

On the "ED Triage Report," there was no documentation to indicate whether Patient 2 was pregnant and no documentation to indicate a last menstrual period (LMP).

The "Emergency Nursing Record: Adult General" dated March 11, 2015, at 7:05 a.m., indicated "... presents with chest soreness since last night. Pt (Patient) states pain started as sharp in her back. Pt is 8 months pregnant. ..."

An electrocardiogram (EKG - test that checks for problems with the electrical activity of the heart) was done at 7:08 a.m.

The "Emergency Department Record" dated March 11, 2015, indicated Patient 2 was seen by the ED Practitioner at 7:10 a.m. The "Diagnosis" was chest pain and "pregnancy."

There was no documentation to indicate pregnancy history, the estimated delivery (due) date (EDD), or whether Patient 2 was seeing a physician for her pregnancy. There was no documentation to indicate if the fetal (infant's) well being was evaluated to include fetal heart tones.

Patient 2 was discharged from the facility on March 11, 2015, at 7:28 a.m.

During an interview with Registered Nurse (RN) 2, on March 11, 2015, at 10:15 a.m., RN 2 reviewed the record and was unable to find documentation of Patient 2's LMP, EDD, pregnancy history, and an evaluation of fetal well being to include fetal heart tones. RN 2 stated he had spoken to Patient 2 and this was her fourth pregnancy and she was due April 1, 2015. RN 2 stated he had not obtained the patient's pregnancy history, if she was receiving prenatal care and by whom, and had not evaluated fetal well being to include fetal heart tones. RN 2 stated he would not necessarily obtain fetal heart tones. He stated it was up to the ED Practitioner if the patient would be seen in Obstetrics for an evaluation of the infant's well being.

During an interview with RN 1, on March 11, 2015, at 10:12 a.m., she reviewed the record for Patient 2 and stated a pregnancy history and fetal heart tones should have been obtained.

During an interview with the Director Emergency Department (DED) and Chief Nursing Officer (CNO), on March 11, 2015, at 10:50 a.m., they reviewed the record for Patient 2. The DED stated when a patient was pregnant the infant should be assessed along with the mother. The DED stated an obstetrical history should have been obtained. Patient 2's obstetrical care provider should have been called and fetal well being should have been assessed.

The facility policy and procedure titled "Obstetrical Patient Triage & Medical Screening Examination in the ED" revised December 2011, revealed "... Assessment of Fetal Well Being: ... Greater than or equal to 20 weeks' gestation - assessment of FHT's (fetal heart tones) by application of a monitor to the maternal abdomen will be performed by a qualified OB nurse and reported to the ED LIP (Licensed Independent Practitioner) and the OB provider on call ... Management of the pregnant patient in the ED ... Request evaluation by qualified OB nurse to determine fetal well being as needed. ... Gestational age is to be calculated ... Do not base decision-making on patient stated length of pregnancy. Communication between ED and OB is essential to assure appropriate triage. Call OB discuss patient status and decide appropriate disposition, as necessary. ..."

The Chief Nursing Officer (CNO) and the Director Emergency Department (DED) were notified Immediate Jeopardy was declared on March 11, 2015, at 12:18 p.m. The Immediate Jeopardy was identified due to the facility's failure to ensure a pregnant patient, greater than 20 weeks gestation, was provided with a thorough medical screening examination (MSE) to determine whether an emergency medical condition existed for one sampled patient (Patient 2). This resulted in Patient 2 being discharged from the facility with an incomplete MSE.

On March 11, 2015, at 6 p.m., an acceptable plan of correction was received from the facility, which indicated the following:

a. The facility had made two attempts to contact Patient 2, at the telephone number provided, requesting her to return to the facility OB Unit for an evaluation of fetal well being. Facility will continue this effort until contact has been made with Patient 2;

b. All pregnant patients will have a basic pregnancy assessment completed prior to discharge from the ED;

c. All ED staff, ED Practitioners, and OB staff will receive education on the triage care and assessment of OB patients. The training will start immediately and continue until 100% completed; and

d. An email has been sent to all ED Practitioners by the ED Medical Director.

On March 12, 2015, at 1:50 p.m., tours of the Emergency Department and Obstetrical Services were conducted. Interviews were conducted with the staff and ED Practitioners to evaluate understanding of the process. Education records and an email sent to the ED Practitioners were reviewed.

On March 12, 2015, at 4:15 p.m., the Chief Executive Officer (CEO), CNO, and DED were notified the Immediate Jeopardy was lifted.

2. On March 9 and 11, 2015, the record for Patient 1 was reviewed. Patient 1 presented to the facility Obstetrical (OB) Unit on August 19, 2014, at 11:35 p.m., complaining of decreased fetal movement, cramping and increased vaginal discharge at 20 and 2/7 weeks gestation (full term pregnancy 40 weeks gestation).

The "LD-Flowsheet" dated August 19, 2014, indicated Patient 1 was placed on a fetal monitor (monitors uterine contractions and fetal heart tones) on August 20, 2014, at 12:12 a.m. Fetal heart tones were 140 to 150 beats per minute and a urine sample was obtained.

Patient 1 was a gravida (number of pregnancies) two (2), para (number of live births greater than 20 weeks gestation) one (1), with a history of preterm labor, a "shortened cervical length," treatment with vaginal progesterone, and loss of one or more fetuses during the first pregnancy.

The OB Physician was provided a report of Patient 1's history and complaints on August 20, 2014, at 12:12 a.m., which included "Complains of decreased fetal movement and cramping with increased discharge similar to the previous demise."

The "Physicians Orders" dated August 20, 2014, at 12:12 a.m., indicated apply a fetal monitor for fetal heart tones and uterine contractions, "ok to discharge home," and to follow up with OB Physician at next regular appointment.

There was no documentation to indicate the urine sample was sent for analysis to determine if Patient 1 had a urinary tract infection. There was no documentation to indicate a pelvic ultrasound, sterile speculum examination, or a vaginal exam was done to determine if Patient 1's cervix was open.

Patient 1 was discharged home on August 19, 2014, at 12:30 a.m. (55 minutes after presenting to the facility and 18 minutes after being placed on the fetal monitor).

Patient 1 presented to Facility B on August 20, 2014, at 5:24 p.m.(16 hours and 54 minutes after leaving Facility A) complaining of contractions, vaginal pressure, and low back pain.

The "Patient Notes" dated August 20, 2014, at 5:24 p.m., indicated Patient 1 had a "shortened cervix" with her last pregnancy and she was currently taking progesterone injections (female hormone to help nuture the fetus) at this time.

A vaginal exam was done at 5:56 p.m., which indicated "unable to determine cervical dilation D/T (due to) feeling bulge low in vaginal vault."

The OB Physician performed a vaginal exam at 6 p.m., which confirmed the bulging membranes (fluid surrounding the fetus in utero) and the inability to feel the cervix.

Patient 1 was admitted to Facility B on August 20, 2014, at 6 p.m., with the diagnosis of [DIAGNOSES REDACTED]

An obstetrical ultrasound was done on August 20, 2014, at 9:50 p.m., which indicated a single intrauterine gestation at 20 and 5/7 weeks and "cervical funneling."

Patient 1 expressed an urge to "push" on August 21, 2014, at 6:50 a.m.

Patient 1 delivered a baby boy on August 21, 2014, at 2:04 p.m. The infant was born alive with a heart rate and muscle tone but passed away on August 21, 2014, at 3:05 p.m.

During an interview at Facility A with Registered Nurse (RN) 3, on March 11, 2015, at 2:50 p.m., Patient 1's record was reviewed. RN 3 stated Patient 1 would be considered "high risk" based on her obstetrical history. RN 1 stated the facility's policy was to monitor all outpatients for a minimum of one hour. RN 3 stated a physician's order was required to send a urine sample for a urinalysis to determine if a patient had a urinary tract infection. RN 3 stated based on Patient 1's history, she would have asked the physician for an order for an OB ultrasound to determine if the patient's cervix was open. In addition, RN 3 stated if the physician had said no to the OB ultrasound she would have requested the OB Physician to "come in and see the patient." RN 3 stated, as part of the patient's assessment/examination, they would need to determine if Patient 1's cervix was "open."

The facility standardized procedure titled "Obstetrical Medical Screening Examinations" revised May 2011, revealed "... Every patient that presents to (Name of Facility A) will be provided with a medical screening examination within the hospital's capability. This exam is to determine whether a medical emergency does or does not exist. ... The following assessment and treatment procedures, as part of the medical screening examination, may be initiated by the Obstetrical Registered Nurse who has documented competencies on file: ... sterile vaginal examination in the [DIAGNOSES REDACTED]l bleeding to determine dilatation, effacement, station and presentation ... urinalysis ..."

3a. On March 11, 2015, the record for Patient 5 was reviewed. Patient 5 presented on January 7, 2015, at 3:30 p.m., with the chief complaint of pregnancy with sharp pain from the "vagina up."

The "ED Triage Report" dated January 7, 2015, at 5:17 p.m., indicated Patient 5 was complaining of pelvic pain for four days and was 19 weeks pregnant.

On the "ED Triage Report," there was no documentation to indicate Patient 5's last menstrual period or estimated delivery (due) date.

The "Emergency Nursing Record: Adult General" dated January 7, 2015, indicated Patient 5 was placed in a room at 5:30 p.m.. A pregnancy test was done which was positive and a pelvic ultrasound was ordered.

There was no documentation of an obstetrical history to include last menstrual period, number of pregnancies, number of deliveries/losses, and pregnancy complications. There was no documentation to indicate whether FHT's were obtained via Doppler.

The "Emergency Department Record" dated January 7, 2015, indicated Patient 5 was seen by the ED Practitioner at 5:34 p.m., was pregnant, had a cesarean section scar, and was being seen by an OB Physician.

There was no indication an obstetrical history to include number of pregnancies, number of deliveries/losses, and pregnancy complications was obtained. There was no indication Patient 5's OB Physician was notified of the patient's complaints.

The pelvic ultrasound done on January 7, 2015, at 5:51 p.m., indicated a fetal heart rate of 133 beats per minute (2 hours and 21 minutes after Patient 5 presented to the facility) and a "single live intrauterine gestation consistent with 21 weeks and 6 days gestation."

Patient 5 was discharged home on January 7, 2015, at 8:50 p.m.

During an interview with the Director Emergency Department (DED), on March 12, 2015, at 4:20 p.m., she reviewed the record and was unable to find documentation of a last menstrual period, estimated delivery date, number of pregnancies, number of births greater than 20 weeks gestation, and an OB history to include information about Patient 5's cesarean section scar. The DED stated an Obstetrical history should have been part of Patient 5's assessment.

b. On March 11, 2015, the record for Patient 8 was reviewed. Patient 8 presented on March 1, 2015, at 10:50 p.m., with the chief complaint of abdominal pain.

The "ED Triage Report" dated March 1, 2015, at 11:07 p.m., indicated Patient 8 was complaining of abdominal pain and had been at the facility on February 24, 2015, when a pelvic ultrasound was done which revealed "placenta was not '100% not attached'."

On the "ED Triage Report" there was no indication of Patient 8's last menstrual period or estimated delivery date.

The "Emergency Nursing Record: Adult General" dated March 1, 2015, indicated Patient 8 was placed in a room at 11:45 p.m., a urinalysis was obtained and a pelvic ultrasound was ordered.

There was no indication an obstetrical history to include her last menstrual period, number of pregnancies, number of deliveries/losses, pregnancy complications, and if FHT's were obtained via Doppler.

The "Emergency Department Record" dated March 1, 2015, indicated Patient 8 was seen by the ED Practitioner at 11:42 p.m., was pregnant and had been seen on February 24, 2015, with the same complaint.

There was no indication an obstetrical history to include number of pregnancies, number of deliveries/losses, and pregnancy complications was obtained.

The pelvic ultrasound indicated a fetal heart rate of 150 beats per minute.

Patient 8 was discharged home on March 2, 2015, at 2:58 a.m.

During an interview with the DED, on March 12, 2015, at 4:20 p.m., she reviewed the record and was unable to find documentation of a last menstrual period, estimated delivery date, number of pregnancies, number of births greater than 20 weeks gestation, and an OB history. The DED stated an Obstetrical history should have been part of Patient 8's assessment.

The facility policy and procedure titled "Obstetrical Patient Triage & Medical Screening Examination in the ED" revised December 2011, revealed "... Assessment of Fetal Well Being ... Less than 20 weeks gestation - assessment for the presence of Fetal Heart Tones (FHT) using a hand-held Doppler monitor may be performed by ED nurses that have demonstrated competency in assessing FHT's. The FHT will be reported to the ED LIP and documented in the Emergency Nursing Record. ... Gestational age is to be calculated ... Do not base decision-making on patient stated length of pregnancy. Communication between ED and OB is essential to assure appropriate triage. Call OB discuss patient status and decide appropriate disposition, as necessary. ..."

c. On March 11, 2015, the record for Patient 9 was reviewed. Patient 9 presented on February 2, 2015, at 3:03 p.m., with the chief complaint of needing a RhoGAM (rhod immune globulin human used to prevent an immune response to Rh positive blood in people with an Rh negative blood type) shot at approximately 28 weeks gestation.

The "ED Triage Report" dated February 2, 2015, at 3:11 p.m., indicated Patient 9 was at the facility for a "RhoGAM Shot" and was assigned an ESI of "4 (Non-urgent)."

On the "ED Triage Report" there was no indication of Patient 9's last menstrual period or estimated delivery date.

The "Emergency Nursing Record: Adult General" dated February 2, 2015, indicated Patient 9 was placed in a room at 3:46 p.m., was given RhoGAM 300 milligram intramuscularly (IM) at 5:10 p.m., and was discharged home at 5:25 p.m.

There was no indication an obstetrical history was obtained to include LMP, EDD, number of pregnancies, number of deliveries, pregnancy complications and an assessment of fetal well being.

The "Emergency Department Record" dated February 2, 2015, indicated Patient 9 was seen by the ED Practitioner at 3:58 p.m. and was given the diagnosis of [DIAGNOSES REDACTED]"

There was no indication an obstetrical history was obtained to include LMP, EDD, number of pregnancies, number of deliveries, pregnancy complications and an assessment of fetal well being.

During an interview with the DED, on March 12, 2015, at 4:20 p.m., she reviewed the record and was unable to find documentation of a last menstrual period, estimated delivery date, number of pregnancies, number of births greater than 20 weeks gestation, and an OB history. The DED stated an Obstetrical history should have been part of Patient 9's assessment. In addition, the DED stated an assessment of fetal well being was not done and should have been done prior to Patient 9 being discharged from the facility.

The facility policy and procedure titled "Obstetrical Patient Triage & Medical Screening Examination in the ED" revised December 2011, revealed "... Assessment of Fetal Well Being ... Greater than or equal to 20 weeks gestation - assessment of FHT's (fetal heart tones) by application of a monitor to the maternal abdomen will be performed by a qualified OB nurse and reported to the ED LIP (Licensed Independent Practitioner) and the OB provider on call per OB Department protocol. ..."

4a. On March 9 and 11, 2015, the record for Patient 1 was reviewed. Patient 1 presented to the facility Obstetrical (OB) Unit on August 19, 2014, at 11:35 p.m., complaining of decreased fetal movement, cramping and increased vaginal discharge at 20 and 2/7 weeks gestation (full term pregnancy 40 weeks gestation).

The "LD-Flowsheet" dated August 19, 2014, indicated Patient 1 was placed on a fetal monitor (monitors uterine contractions and fetal heart tones) on August 20, 2014, at 12:12 a.m. Fetal heart tones were 140 to 150 beats per minute, and a urine sample was obtained.

Patient 1 was a gravida (number of pregnancies) two (2), para (number of live births greater than 20 weeks gestation) one (1) with a history of preterm labor, a "shortened cervical length," treatment with vaginal progesterone, and loss of one or more fetuses during the first pregnancy.

The OB Physician was provided a report of Patient 1's history and complaints on August 20, 2014, at 12:12 a.m., which included "Complains of decreased fetal movement and cramping with increased discharge similar to the previous demise."

The "Physicians Orders" dated August 20, 2014, at 12:12 a.m., indicated apply a fetal monitor for fetal heart tones and uterine contractions, "ok to discharge home," and to follow up with OB Physician at next regular appointment.

Patient 1 was discharge home on August 19, 2014, at 12:30 a.m.

The OB Physician "authenticated" Patient 1's medical screening examination by reviewing the record and countersigning the chart/certification on October 4, 2015 (45 days after discharge).

During an interview with the Director Obstetrical Services (DOS), on March 12, 2015, at 3 p.m., she reviewed the record and determined the OB Physician had "authenticated" Patient 1's medical screening examination 45 days after the patient had been seen at the facility. The DOS stated Patient 1's medical screening examination by the OB Nurse should have been reviewed and countersigned by the OB Physician within 72 hours of the patient being seen at the facility.

b. On March 11, 2015, the record for Patient 15 was reviewed. Patient 15 was seen in the facility Obstetrical (OB) Unit on February 10, 2015, at 11:52 p.m., with the chief complaint of decreased fetal movement at 35 and 5/7 weeks gestation (full term pregnancy 40 weeks gestation).

The "LD-Flowsheet" dated February 10, 2015, indicated Patient 15 was placed on a fetal monitor (monitors uterine contractions and the infants heart tone to determine fetal well being), and the OB Physician was provided a report on Patient 15's status on February 11, 2015, at 12:28 a.m.

The "Physicians Orders" dated February 11, 2015, at 12:28 a.m., indicated "BPP and Discharge home if NST (non-stress test)/BPP WNL (within normal limits)."

A fetal biophysical profile (BPP) ultrasound was done on February 11, 2015, with the result of 10 out of 10 (BPP includes fetal movement, tone, respirations, fluid, and heart rate - 2 points for each if present).

Patient 15 was discharged home on February 11, 2015, at 3:12 a.m.

The OB Physician "authenticated" Patient 15's medical screening examination by reviewing the record and countersigning the chart/certification on February 24, 2015 (13 days after discharge).

During an interview with the Director Obstetrical Services (DOS), on March 12, 2015, at 3 p.m., she reviewed the record and determined the OB Physician had "authenticated" Patient 15's medical screening examination 13 days after the patient had been seen at the facility. The DOS stated Patient 15's medical screening examination by the OB Nurse should have been reviewed and countersigned by the OB Physician within 72 hours of the patient being seen at the facility.

c. On March 11, 2015, the record for Patient 16 was reviewed. Patient 16 was admitted to the facility on on [DATE], at 3:05 p.m., with the chief complaint of epigastric pain and dizziness at 27 and 2/7 weeks gestation.

The "LD-Flowsheet" dated January 30, 2015, indicated Patient 16 was placed on a fetal monitor at 3:14 p.m.

The "Physicians Orders" dated January 30, 2015, at 3:05 p.m., indicated place Patient 16 on a fetal monitor, provide the patient with fluids by mouth and continue to observe Patient 16.

The "LD-Flowsheet" indicated at 3:45 p.m., the OB Physician was given an update on Patient 16's status and orders were written to transfer Patient 16 to the Emergency Department (ED) for further evaluation.

Patient 16 was discharged from Obstetrics to the ED on January 30, 2015, at 4:10 p.m., and from the ED to home on January 30, 2015, at 7:20 p.m.

The OB Physician "authenticated" Patient 16's medical screening examination by the OB Nurse by reviewing the record and countersigning the chart/certification on February 24, 2015 (25 days after discharge).

During an interview with the Director Obstetrical Services (DOS), on March 12, 2015, at 3 p.m., she reviewed the record and determined the OB Physician had "authenticated" Patient 16's medical screening examination 25 days after the patient had been seen at the facility. The DOS stated Patient 16's medical screening examination by the OB Nurse should have been reviewed and countersigned by the OB Physician within 72 hours of the patient being seen at the facility.

The facility standardized procedure titled "Obstetrical Medical Screening Examinations" revised May 2011, revealed "... The on-call obstetrical physician will review and countersign the chart/certification within 72 hours."

5. On March 12, 2015, the facility Medical Staff ByLaws and Rules and Regulations were reviewed.

There was no indication in the Medical Staff ByLaws and/or Rules and Regulations that OB RNs who have met established guidelines may perform the medical screening examination for obstetrical patients; that the physician must be notified of the medical screening results and make the determination of the patients disposition; and the physician must certify the medical screening examination within 72 hours of the patient being seen by the OB RN per facility standardized procedure.

During an interview with the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO), on March 12, 2015, at 4:10 p.m., they reviewed the Medical Staff ByLaws and Rules and Regulations and were unable to find documentation that OB RNs, who have met established guidelines may perform the medical screening examination for obstetrical patients; that the physician must be notified of the medical screening results and make the determination of the patients disposition; and the physician must certify the medical screening examination within 72 hours of the patient being seen by the OB RN.





6. An interview and policy review was conducted with the Director of the Emergency Department (DED), on March 12, 2015, at 3:35 p.m. The DED stated an RN evaluated a patient's medical condition when the patient arrived. The DED stated after the evaluation, the RN would use a five number/level system to indicate the urgency of a patient's medical condition.

The DED stated the number one (1) would indicate a condition that required immediate life-saving interventions to include a patient that required physical stimuli to arouse, and severe pain, and the number two (2) would indicate a high risk situation (when a patient's condition could deteriorate quickly) for a patient to include severe pain (7 or greater on a scale of 1 through 10), confusion, suicidal, chest pain, or the possibility of loss function to a limb.

The DED stated patient's evaluated to have a medical condition with a number three (3), four (4), or five (5), would indicate a stable medical condition that did not require immediate intervention.

The records for Patient 26, 27, 28, 29, and 31 were reviewed with the DED, on March 12, 2015, at 4 p.m.

a. Patient 26 presented to ED on January 29, 2015, with the chief complaint of a cold, numb left hand (following a surgical procedure), and pain rated as 7 on the scale of 1 through 10 (the number 10 indicated the most severe pain).

The RN's evaluated the patient's condition at a triage level of 3, which indicated the patient's medical condition did not require immediate intervention.

b. Patient 27 presented on January 29, 2015, with the chief complaint of gravely disabled, and on a 5150 hold (a patient is placed on a 5150 hold when determined by qualified professionals there was a threat of harm to the patient and/or others, or when a patient can no longer care for themselves).

The RN evaluated the patient's condition at a triage level of 3, which indicated the patient's medical condition did not require immediate intervention.

c. Patient 28 was brought to the ED by ambulance, on January 25, 2015, with the chief complaint of altered level of consciousness. The provider's medical screening exam indicated Patient 28 only responded to pain.

The RN evaluated the patient's condition at a triage level of 3, which indicated the patient's medical condition did not require immediate intervention.

d. Patient 29 was brought to the ED on January 24, 2015, by the police, with the chief complaint of "I'm trying to kill myself," and possible over dose of pain medication.

The RN evaluated the patient's condition at a triage level of 3, which indicated the patient's medical condition did not require immediate intervention.

e. Patient 30 (a [AGE] year old patient with a history of cancer and family history of heart disease) presented on January 1, 2015, with the chief complaint of chest pain, and arm pain.

The RN evaluated the patient's condition at a triage level of 3 which, indicated the patient's medical condition did not require immediate intervention.

f. Patient 31 (a [AGE] year old patient) was brought to the ED by ambulance, on February 24, 2015, with the chief complaint of fall, left hip pain, and generalized weakness. The ambulance information form indicated there was visible deformity to the patient's left leg.

The RN evaluated the patient's condition at a triage level of 3, which indicated the patient's medical condition did not require immediate intervention.

During an interview with the DED, on March 12, 2015, at 4 p.m., the DED reviewed the records for Patients' 26, 27, 28, 29, and 31.

The DED stated the RN's determination of the severity of Patients' 26, 27, 28, 29, and 31 medical conditions was incorrect. The DED stated the RN should have determined the medical conditions required a higher level of care.

7. The facility's job description for ED RNs' was reviewed with the Chief of Support Services (CSS), on March 12, 2015, at 2 p.m. The job description indicated the ED RN would possess certification to include Advanced Cardiac Life Support (ACLS). The CSS stated the facility accepted only certifications issued by the American Heart Association.

ACLS is a classroom based course in which providers enhance their skills when treating patients who present with cardiac arrest (when the heart stops), and/or with other heart and lung emergencies (Reference from The American Heart Association).

The facility document for RN 2 was reviewed on March 12, 2015. Documentation indicated RN 2 received ACLS certification via an on-line computer class on November 7, 2013.

On March 12, 2015, at 2:30 p.m., the CSS provided a document that indicated RN 2 did not receive classroom training when obtaining the ACLS certification. The document further indicated RN 2's ACLS certification was not issued by the American Heart Association.

During an interview with the DED, on March 12,. 2015, at 4 p.m., the DED stated ACLS certifications must be from the American Heart Association and must include a clinical component.

The DED stated she was unaware RN 2 did not meet the required job qualifications.

The facility document titled "Staff Nurse- Emergency Department" undated, indicated "The Emergency Department Staff Nurse coordinates/provides nursing care for patients...Maintains appropriate licenses and certifications..."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on interview and record review, the facility failed:

1. To ensure a "Transfer Request/Refusal Consent" was completed for one sampled patient (Patient 22).

2. To ensure the physician had signed a certification that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred, and/or the certification contained a summary of the risks and benefits upon which the transfer was based, for three sampled patients (Patients 3, 6, and 21).

This had the potential to result in the patients being unaware of the risks and benefits of a transfer to another facility.

Findings:

1. The record for Patient 22 was reviewed. Patient 22 presented to the Emergency Department (ED) on March 1, 2015, at 8:51 a.m., with a chief complaint of "Suicidal." The Patient Profile Report indicated Patient 22 was transferred to a psych hospital on March 1, 2015.

The "Emergency Department Record," indicated a medical screening exam at 9:06 a.m., with a disposition time of 10:15 a.m., in stable condition. The "Transfer to" and "Accepted by Dr.," was left blank. There was no documentation to indicate the ED Physician had a discussion with the receiving hospital or had an accepting physician.

The "Emergency Nursing Record," indicated a transfer was accepted by a physician, and report was given to another facility, at 12 p.m. The discharge time was 12:50 p.m.

There was no "Transfer Request/Refusal Consent" form completed and signed by the physician, in Patient 22's medical record.

On March 12, 2015, at 3:35 p.m., the Director of Emergency Department, (DED) was interviewed. The DED was unable to locate the transfer record for Patient 22. The DED stated the transfer record should be part of Patient 22's medical record.

The policy titled, "EMTALA and Cobra Compliance," with a date of November 2011, was reviewed. the policy indicated, "... If an emergency medical condition is found to exist, but the physician determines that the patient's medical condition has been stabilized, the patient may be transferred when the following conditions have been met: ... The patient may be transferred upon completion of the Transfer Request/Refusal Consent form... The acknowledgment of the notification of the transfer by the patient or the legal representative should be reflected in the Transfer Consent section of the transfer record..."

2a. The record for Patient 21 was reviewed. The record indicated Patient 21 presented on February 27, 2015, at 3:29 a.m., with a chief complaint of body pain. The record indicated patient 21 was transferred to another facility for a higher level of care at 4:35 a.m.

The Transfer Request/Refusal Consent was signed by Patient 21 on February 27, 2015, at 4:20 a.m. There was no indication the "risks associated with this transfer" and "benefits associated with this transfer" were provided to the patient. In addition, the "Physician Certification" was not signed by the physician.

On March 12, 2015, at 3:35 p.m., the Director of Emergency Department, (DED) was interviewed. The DED stated the Risks and Benefits associated with the transfer should be listed and explained to the patient prior to the patient signing the transfer form. The DED also stated the physician was suppose to sign the "Physician Certification" section of the Transfer Request/Refusal Consent form. The DED stated the Transfer Request/Refusal Consent form for Patient 21 was not complete.






b. On March 11, 2015, the record for Patient 3 was reviewed. Patient 3 was seen at the facility Obstetrical (OB) Unit, on January 21, 2015, with the chief complaint of uterine contractions at 31 and 1/7 weeks of pregnancy (full term pregnancy is 40 weeks gestation).

The "LD-Flowsheet" indicated Patient 3 arrived at the facility on January 21, 2015, at 1:54 a.m., complaining of uterine contractions every two to three minutes, previous cesarean section, previous urinary tract infection, positive Fetal Fibronectin (fFN - Test for detecting premature labor). Patient 3 was placed on a fetal monitor and a vaginal exam was done.

The Obstetrical (OB) Physician was called at 2:10 a.m., and orders to treat Patient 3's premature labor included terbutaline (medication used to stop uterine contractions) 0.25 mg (milligrams) subcutaneous every 30 minutes times three doses, and intravenous (IV) hydration (fluid given directly into a vein).

The Registered Nurse (RN) provided an update to the OB Physician at 4:43 a.m., which included the information that Patient 3 was continuing to have uterine contractions every four to five minutes. The OB Physician ordered Procardia (calcium channel blocker medication which can be used to treat premature labor) 10 mg by mouth.

The RN provided an update to the OB Physician at 7 a.m., and the OB Physician gave the order to obtain a consent to transfer Patient 3 to a "higher level of care."

The "Transfer Request/Refusal Consent" dated January 21, 2015, indicated Patient 3 signed the "Patient Transfer Acknowledgement" at 7:35 a.m.

There was no indication the "risks associated with this transfer" were provided to the patient and the "Physician Certification" was not completed and was not signed by the physician.

Patient 3 was transferred to Facility B on January 21, 2015, at 8:45 a.m.

An OB Physician "authenticated" Patient 3's "Transfer Request/Refusal Consent" on February 22, 2015 (32 days after Patient 3 was transferred to Facility B), by a stamp in the space for "Signature of Transferring Physician."

During an interview on March 12, 2015, at 3 p.m., the Director of Obstetrical Services (DOS), reviewed the record and was unable to find documentation that the "risks associated with this transfer" was explained to Patient 3. There was no documentation to indicate the "Physician Certification" of the transfer. The DOS stated the physician should have completed the "Physician's Certification" and the physician should have explained to Patient 3 the risks of transfer to Facility B.

c. On March 11, 2015, the record for Patient 6 was reviewed. Patient 6 was seen at the facility Obstetrical (OB) Unit, on February 24, 2015, with the chief complaint of high blood pressure (normal blood pressure 120/80 mmHg) at 36 weeks gestation (full term pregnancy is 40 weeks gestation).

The "LD-Flowsheet" indicated Patient 6 arrived at the facility on February 24, 2015, at 11:20 a.m., and at 11:24 a.m., Patient 6's blood pressure was 184/111 mmHg (normal range 120/80 mmHg)

The Obstetrical (OB) Physician was called at 12:50 p.m., and orders to treat Patient 6's high blood pressure to include starting an IV (intravenous administration of fluids directly into a vein) and administration of Labetalol (medication used to treat high blood pressure) were obtained.

At 3 p.m., the OB Physician contacted a physician at Facility C to arrange the transfer of Patient 6 to a "Higher level of care."

The "Transfer Request/Refusal Consent" dated February 24, 2015, indicated Patient 6 signed the "Patient Transfer Acknowledgement" at 3:15 p.m.

There was no indication the "risks associated with this transfer" and "benefits associated with this transfer" were provided to the patient.

Patient 6 was transferred to Facility C on February 24, 2015, at 3:38 p.m.

During an interview with the Director Obstetrical Services (DOS), on March 12, 2015, at 3:10 p.m., she reviewed the record and was unable to find documentation of the "risks associated with this transfer" and "benefits associated with this transfer" being explained to Patient 6. The DOS stated the physician should have explained the risks and benefits of being transferred to Facility C to Patient 6.

The facility policy and procedure titled "Transport - Maternal" reviewed December 2011, revealed "... Complete a "Transfer Request/Refusal Consent." ..."