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HIGHLANDS REGIONAL MEDICAL CENTER 3600 S HIGHLANDS AVE SEBRING, FL 33870 May 1, 2012
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on record review, policy review and staff interview, it was determined the facility's medical staff failed to ensure compliance regarding care in the Emergency Department for 1 (#1) of 10 sampled patients. This practice does not ensure in provision of quality patient care.


Findings include:

The policy "emergency room - Obstetrics Patients", #003 - OB - 029, revised 3/11 requires that patients with a pregnancy of greater than 20 weeks will be registered and transported to the Women's and Children's center. Review of the medical record of patient #1 revealed she presented to the facility's ED with the complaint of nausea, vomiting and stabbing lower abdominal pain. She was 35 weeks pregnant. The patient was not assessed by the ED nurses until. The facility's policy "Triage/Evaluation of Patient", #003 - ED - 03, revised 3/11 presenting with abdominal distress with proceed to Obstetrics (OB) with a staff member. There was documentation by both the nursing staff, physician assistant and ED physician that they did not believe the patient was in labor. The PA wrote and order for Fetal Heart Tones (FHT) at 6:00 p.m. The nursing director for OB was asked to evaluate the patient. The ED nurse documented the FHT were 128 and that contractions were felt. There was no documentation of a vaginal examination. The OB nurse manager was interviewed on 5/1/12 at approximately 9:15 a.m. She admitted she only listened to the FHTs with a Doppler. She stated she did not perform a vaginal examination. She stated that she did feel contractions and recommended the patient be transferred to the OB department. The facility's policy "Rule Out Labor for Outpatients", no number, effective 4/18/12, approved by the OB nursing director and the Medical Executive Committee, requires that the nurse is to perform assessment of membrane status and Vaginal Examination. Documentation in the medical record noted that a page was placed to the OB physician on call at 6:23 p.m. and again at 6:37 p.m. The physician's partner was paged at 7:12 p.m. There was no further documentation of attempts to reach the physician. There is documentation that the physician returned the call at 9:00 p.m. The facility's Medical Staff Rules and Regulations require the on call physicians are to respond within 30 minutes. The PA documented that he and the ED physician wished to consult with the physician before moving the patient to the OB department. There is documentation at 8:30 p.m. that the patient was found holding the baby who was self delivered by the patient in the ED examination. The delivery was unwitnessed by the ED staff. The PA was interviewed on 4/30/12 at approximately 3:00 p.m. He stated that he did not think the patient was in labor. He had discussed the case with the ED physician and decided a consultation with the on call physician should be requested. He stated that he believed the patient's main problem was the vomiting and subsequent dehydration that needed to be addressed. Intravenous fluids and antiemetic medications can be provided in the OB department. The Risk Manager and CNO were interviewed on 4/30/12. They indicated they had investigated the event and recognized their policies had not been followed, but believed that the failure of the OB physician to respond resulted in a delay of treatment.