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MEDICAL CENTER OF THE ROCKIES 2500 ROCKY MOUNTAIN AVE LOVELAND, CO 80538 July 20, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on staff interview and review of medical records and policies/procedures, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The facility failed to meet the following requirements under the EMTALA regulations:

Tag A 2404 On-Call Physicians
The on-call physician failed to follow the facility's policies/procedures and appropriately respond when an obstetric patient presented with an emergent medical condition.

Tag A 2406 Appropriate Medical Screening Examination
The "systems assessment" portion of the medical screening examination was not completed as required.

Tag A 2407 Stabilizing Treatment.
An obstetric patient failed to be stabilized prior to discharge.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interviews, review of medical records and facility policies/procedures, the hospital failed to respond to the needs of one (#1) of 10 obstetric (OB) patients reviewed in the medical records. Specifically, the on-call physician failed to follow the facility's policies/procedures and appropriately respond when an OB patient presented with an emergent medical condition.

The findings were:

The facility's policy and procedure entitled, "EMTALA in Obstetrics," stated the following in pertinent part:
"E. The obstetric nurse will notify the primary obstetric provider or attending/consulting obstetric provider on call promptly if any of the following findings are present or suspected:
1. Vaginal bleeding
2. Acute abdominal pain
3. Temperature of 100.4 or higher
4. Preterm labor/threatened AB
5. Preterm rupture of membranes
6. Hypertension
7. Indeterminate or abnormal (Category II or III) fetal heart tracing
G. The obstetric nurse will utilize the Labor and Delivery Discharge Screening Tool to then determine if a patient may be discharged . If the score is 7 or less on the evaluation tool the patient may be dismissed with a telephone order from the primary obstetric provider or attending/consulting obstetric provider on call...
K. No patient with a score of 8 or greater shall be transferred or referred to another facility except for care not available at that facility or by patient initiated transfer or departure against medical advice."

Sample patient #1, a [AGE]-year-old female, presented to the L&D on 6/19/11 at approximately 11:43 p.m. for a preterm labor check. The following was documented in nursing notes and stated in pertinent part:
6/19/11 23:45 (11:45 p.m.) - "G4P3 (gravida/para) with EDC (estimated date of confinement - due date) 10/9/11 at 24 and 1/7 weeks to unit with C/O (complaints of) "strong" UC's (uterine contractions) since 2200 (10:00 p.m.). Pt. has had "mild cramping" and yellow mucousy discharge with pink streaks since Friday (6/17/11)."

6/20/11 00:05 (12:05 a.m.) - "(On-call physician name) updated on pt. status, aware of gestational age, complaint of UC's and Prenatal history. MD aware of UC pattern and audible fetal heart tones. Aware of pt. complaint of pink discharge. Orders received for labs..."

6/20/11 01:40 (1:40 a.m.) - "Spoke to (on-call physician name). Reported lab results including: CRP (C-Reactive Protein), WBC (White Blood Cells), and [DIAGNOSES REDACTED] counts. (Note: All these lab results were out-of-range and elevated.) Also reported pt. UC pattern and pain level...Instructed to notify if UC's become closer together or stronger."

6/20/11 02:55 (2:55 a.m.) - "Spoke to (on-call physician name). Reported one UC in last hour. Received orders to discharge patient and have her follow up in clinic first thing in morning."

6/20/11 03:00 (3:00 a.m.) - "Pt. up to br (bathroom). Pt. reports blood "dripping in toilet" and blood streaks on toilet paper when wiping. Pt. instructed to return to bed. (On-call physician name) paged."

6/20/11 03:05 (3:05 a.m.) - "Spoke to (on-call physician name). Reported bleeding from vagina. Asked to verify whether or not patient had previa on previous u/s (ultrasound). Told (on-call physician name) that there was no previa on u/s. Orders remain to discharge pt. to home with f/u (follow-up) in office in a.m."

6/20/11 03:08 (3:08 a.m.) - "(On-call physician name) called unit, states s/he wants pt. to be instructed to go to (sister hospital name-approximately 15 miles) immediately for evaluation."

6/20/11 03:10 (3:10 a.m.) - "Discharge instructions given to patient who verbalizes understanding. Pt. to f/u in office tomorrow knows to call as soon as office opens in a.m."

6/20/11 03:13 (3:13 a.m.) - "Pt. instructed to drive to (sister hospital name) in own vehicle for further evaluation per MD order. Pt. verbalizes understanding of this instruction."

6/20/11 03:20 (3:20 a.m.) - "Pt. discharged in wheelchair to own vehicle. FOC (father of child) at side. Report called to (sister hospital name) charge RN."

The L&D Discharge Screening Tool for sample patient #1 was completed by the nurse after the patient had been discharged . The patient was rated as follows with a total of 14 points:
Multi-parity: 1 point
Duration of last labor: 1 point
Vaginal bleeding without UC's: 8 points
Gestation 20.0-27.6 weeks: 4 points.
The instructions on the "L&D Discharge Screening Tool" stated the following: "A patient with a score of 8 or greater shall not be transferred or referred to another facility except for care not available at MCR (Medical Center of the Rockies) or by patient initiated transfer or departure against medical advice. Obstetric Provider must evaluate patient in person if transfer initiated. Regardless of score the Obstetric RN may request an Obstetric Provider exam at any time."

An interview was conducted on 7/19/11 at approximately 9:30 a.m. with the CNO (Chief Nursing Officer) and the Director of Quality Resources & Risk Management. The Director of Quality was also appointed to be the interim Director of Obstetrics (OB). The CNO stated that the RN caring for the patient did not utilize all her/his resources to get the on-call physician to physically respond to the hospital. The hospital has a chain-of-command at the disposal of all nursing staff; however, the nurse was acting independently and failed to utilize this very important resource. However, the on-call physician was aware of the hospital's policies/procedures but elected to not respond in person. The CNO stated that a preliminary procedure could have been performed at the hospital and the patient flown in utero to a contracted hospital in Denver that had the capability of caring for the premature infant. The sister hospital where the patient was referred to did not have the capability of caring for a premature infant of 24+ weeks. The CNO further stated that a RCA (Root Cause Analysis) has been performed and peer review is scheduled to be done on 8/4/11.

In summary, the on-call physician was aware that the patient was actively bleeding and was 24 and 1/7 weeks pregnant. The on-call physician failed to follow the protocol for a patient that presented to L&D with an emergent medical condition with a score of >8. The on-call physician failed to meet the needs of the patient.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on staff interviews and review of medical records and facility policies/procedures, the facility failed to provide a complete initial MSE (Medical Screening Examination) for two (#1 and #7) of 10 obstetric (non admission) medical records reviewed. Specifically, the "systems assessment" portion of the MSE was not completed as required.

The findings were:

The facility's policy and procedure entitled, "EMTALA in Obstetrics," stated the following in pertinent part: "All pregnant patients seeking urgent or emergent care (non-scheduled patients) that present to the L&D (labor and delivery) area will have an obstetrical medical screening examination upon arrival to the L&D area by an obstetric nurse, who possesses the necessary skills and has documented competency. The examination will include but not be limited to: ...
6. Systems assessment..."

Sample patient #1 presented to L&D on 6/19/11 at approximately 11:43 p.m. with the reason for visit: "Pre Term Labor Check." All of the required elements of the L&D examination were performed except for the "systems assessment" portion.

Sample patient #7 presented to L&D on 7/18/11 at approximately 2:28 a.m. with the reason for visit: "Labor Check." There was no documentation that a "systems assessment" was completed on the patient; however, all of the other elements of the MSE had been performed.

Interviews were conducted with the CNO (Chief Nursing Officer) and the APRN (Advance Practice Registered Nurse) on 7/19/11 at approximately 4:15 p.m. and on 7/20/11 at approximately 8:20 a.m. regarding the lack of complete MSEs. The APRN reviewed the medical records for sample patients #1 and #7 and verified that the "systems assessment" had not been completed. The CNO stated that there would be an action plan instituted immediately regarding the auditing for complete MSEs in the L&D medical records.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview, review of medical records and facility's policies/procedures, the hospital failed to stabilize one (#1) of 10 obstetric (OB) patients prior to discharge. Specifically, the OB patient was actively bleeding when the on-call physician discharged the patient and told the patient to drive to another sister hospital.

The findings were:

The facility's policy and procedure entitled, "EMTALA - Stabilization," stated the following in pertinent part:
"b. Stable For Discharge - A patient is considered stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic workup and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions."

Sample patient #1, a [AGE]-year-old female, presented to the L&D on 6/19/11 at approximately 11:43 p.m. for a preterm labor check. The following was documented in nursing notes and stated in pertinent part:
6/19/11 23:45 (11:45 p.m.) - "G4P3 (gravida/para) with EDC (estimated date of confinement - due date) 10/9/11 at 24 and 1/7 weeks to unit with C/O (complaints of) "strong" UC's (uterine contractions) since 2200 (10:00 p.m.). Pt. has had "mild cramping" and yellow mucousy discharge with pink streaks since Friday (6/17/11)."

6/20/11 00:05 (12:05 a.m.) - "(On-call physician name) updated on pt. status, aware of gestational age, complaint of UC's and Prenatal history. MD aware of UC pattern and audible fetal heart tones. Aware of pt. complaint of pink discharge. Orders received for labs..."

6/20/11 01:40 (1:40 a.m.) - "Spoke to (on-call physician name). Reported lab results including: CRP (C-Reactive Protein), WBC (White Blood Cells), and [DIAGNOSES REDACTED] counts. (Note: All these lab results were out-of-range and elevated.) Also reported pt. UC pattern and pain level...Instructed to notify if UC's become closer together or stronger."

6/20/11 02:55 (2:55 a.m.) - "Spoke to (on-call physician name). Reported one UC in last hour. Received orders to discharge patient and have her follow up in clinic first thing in morning."

6/20/11 03:00 (3:00 a.m.) - "Pt. up to br (bathroom). Pt. reports blood "dripping in toilet" and blood streaks on toilet paper when wiping. Pt. instructed to return to bed. (On-call physician name) paged."

6/20/11 03:05 (3:05 a.m.) - "Spoke to (on-call physician name). Reported bleeding from vagina. Asked to verify whether or not patient had previa on previous u/s (ultrasound). Told (on-call physician name) that there was no previa on u/s. Orders remain to discharge pt. to home with f/u (follow-up) in office in a.m."

6/20/11 03:08 (3:08 a.m.) - "(On-call physician name) called unit, states s/he wants pt. to be instructed to go to (sister hospital name-approximately 15 miles) immediately for evaluation."

6/20/11 03:10 (3:10 a.m.) - "Discharge instructions given to patient who verbalizes understanding. Pt. to f/u in office tomorrow knows to call as soon as office opens in a.m."

6/20/11 03:13 (3:13 a.m.) - "Pt. instructed to drive to (sister hospital name) in own vehicle for further evaluation per MD order. Pt. verbalizes understanding of this instruction."

6/20/11 03:20 (3:20 a.m.) - "Pt. discharged in wheelchair to own vehicle. FOC (father of child) at side. Report called to (sister hospital name) charge RN."

The L&D Discharge Screening Tool for sample patient #1 was completed by the nurse after the patient had been discharged . The patient was rated as follows with a total of 14 points:
Multi-parity: 1 point
Duration of last labor: 1 point
Vaginal bleeding without UC's: 8 points
Gestation 20.0-27.6 weeks: 4 points.
The instructions on the "L&D Discharge Screening Tool" stated the following: "A patient with a score of 8 or greater shall not be transferred or referred to another facility except for care not available at MCR (Medical Center of the Rockies) or by patient initiated transfer or departure against medical advice. Obstetric Provider must evaluate patient in person if transfer initiated. Regardless of score the Obstetric RN may request an Obstetric Provider exam at any time."

A tour of the L&D unit was conducted on 7/19/11 at approximately 8:50 a.m. with the Interim Director and the APRN (Advanced Practice Registered Nurse). The concern was expressed regarding sample patient #1 being discharged and told to go to the sister facility by private vehicle rather than being transferred by ambulance. The Director agreed that a transfer by ambulance to the sister facility would have been more appropriate.

An interview was conducted on 7/19/11 at approximately 9:30 a.m. with the CNO (Chief Nursing Officer) and the Director of Quality Resources & Risk Management. The Director of Quality was also appointed to be the interim Director of Obstetrics (OB). The CNO stated that rather than discharging the patient a preliminary procedure could have been performed at the hospital and the patient flown in utero to a contracted hospital in Denver that had the capability of caring for the premature infant. The sister hospital where the patient was referred to did not have the capability of caring for a premature infant of 24+ weeks.

In summary, according to documentation the patient was actively bleeding and not in a stabilized condition to be discharged and told to drive by private vehicle to another hospital. The hospital had the capability of providing stabilizing treatment; however, the on-call physical failed to physically be present and utilize the services available at the hospital.