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.

ADVENTHEALTH OCALA 1500 SW 1ST AVE OCALA, FL 34474 June 15, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
REFERENCE A 2405
Based on interview, review of patient records, and review of the Central Log, the facility failed to maintain a log which included one (Patient # 1) of 25 sampled patients presenting to the hospital emergency department.

REFERENCE A 2406
Based on interview, review of medical records, and policies and procedures, the hospital failed to provide a Medical Screening Examination for one (Patient #1) of 25 patients presenting to the hospital's Emergency Department to determine if an emergency medical condition existed.

REFERENCE A 2407
Based on interview, record review, and review of policies and procedures, the hospital failed to provide a Stabilizing Treatment within the capability of the hospital for one (Patient #1 ) of 25 patients presenting to the hospital's Emergency Department.



Munroe Regional Medical Center presented a credible allegation of compliance:
An initial investigation conducted promptly by the hospital on the morning of 5/9/2017.
05/09/2017 the Chief Medical Officer and Chief Nursing Officer reviewed the situation with the on-call obstetrician and emphasized the on-call physician's EMTALA and contractual obligation to come to the Hospital when specifically requested to provide further examination and, if a patient has an emergency medical condition, treatment to stabilize the emergency condition.

The RN (Registered Nurse) Director of Maternal/child Services reviewed the L & D (Labor and Delivery) policy on the screening process for walk-in patients who have delivered. the policy was revised on 6/2/2017 to include: Weekly review of the L & D logs to review any returning post-partum patient to determine a medical screening exam was completed times 3 months 5/10/2017 through 8/10/2017.

The RN Director of Emergency Services reviewed the ED (Emergency Department) policy with respect to obstetric patients who have delivered. Policy revision dated 6/2/2017 includes post partum patients should receive the medical screening examination in the ED; and
The ED physician and staff are responsible for contacting the on-call obstetrician/gynecologist if needed for further examination and treatment of a post partum patient.

On 6/2/2017, the RN Director of Maternal/Child Services provided education to L & D nursing staff on the following:
The process clarification and policy, emphasizing that in post partum patient should be sent by the ED to L & D for a medical screening examination; post partum patients must receive the medical screening examination in the ED prior to proceeding to any other department of the Hospital; and
The Chain of command and expectations for documenting actions taken.

The RN Director of Emergency Services provided education to the ED nursing staff on the process clarification policy that no post partum patient should be sent by the ED to L & D for a medical screening examination; post partum patients must receive the medical screening examination in the ED prior to proceeding to any other department of the Hospital.

The Medical Director of Emergency Services provided education to the ED physician on the process clarification that no post partum patient should be sent by the ED to L & D for a medical screening examination/ post partum patients must receive the medical screening examination in the ED prior to proceeding to any other department of the Hospital.

The Chief Nursing Officer was provided re-education on EMTALA and on the Chain of Command in a meeting with the Nursing Directors and House Supervisors on 6/11/2017.

The Chief Medical Officer provided re-education on the EMTALA obligations of on-call physicians in the OB/GYN department meeting with obstetricians on staff at the Hospital. the Chief Medical Officer emphasized it is never permissible for an on-call physician to recommend that the patient be discharged and follow up in a physician office unless there has been an appropriate medical screening examination by qualified medical personnel and a medical determination made and documented that no emergency medical condition exists. This re-education occurred on 5/24/2017.

All L & D staff and House Supervisors completed an EMTALA education module that covers all of the EMTALA obligations on 5/10/2017.

The RN Director of of Maternal/Child Services and the Director responsible for House Supervisors are tracking completion of education by staff members. Any staff who miss the scheduled sessions will receive the education upon their return to the Hospital and prior to the start of their next scheduled shift.

The RN Director of Maternal/child Services established an audit process for reviewing the L & D logs each week for the next three months to track that:
Any patients who come to the hospital post partum receive the medical screening examination in the ED: and
Variances are placed in the incident-reporting system when L & D staff have difficulty reaching an on-call obstetrician.

The RN Director of Maternal/child Services is responsible for following up on issues or concerns with the appropriate L & D staff member or on-call physician.

The Director of Maternal/child Services will analyze and aggregate the audit data and report it to the Patient Safety Committee, Quality Council, Medical Executive committee, and the Board.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, review of patient records, policies and procedures, and the central log, the facility failed to maintain a log which included one (Patient #1) of 25 patients sampled seeking treatment in the hospital's Emergency Department.

Findings:

Review of the Emergency Department (ED) log from 5/7/2017 through 5/11/2017 revealed that Patient #1 was not in the Emergency Log.

Review of the medical record revealed that Patient #1 (MDS) dated [DATE] at approximately 2:00 AM. The patient approached staff in the registration area and requested medical treatment. The form presented to the hospital and signed by the midwife showed Patient #1 was sent by the midwife for a 3rd degree perineal tear following a home birth.

Documentation by the ED Registered Nurse (RN) on 5/9/2017 at 2:00 AM revealed that an ED-OB (Emergency Department)-(Obstetrics) hand off sheet showed Patient #1 was sent to the ED for sutures following a home birth. Patient #1 was transported to the Labor/Delivery/Recovery (LDR) unit at 2:14 AM without a medical screening in the ED.

During a telephone interview on 5/22/2017 at 5:46 PM, Staff X (Staff in the ED who had Patient #1) stated there was no policy for a patient presenting to the ED after giving birth at home.

During an interview on 5/22/2017 at 11:05 AM, Staff P stated that Patient #1 should have been seen in the ED before being sent to LDR Unit. Staff P stated they never had a patient from home present to either the ED or LDR after giving birth at home.

During an interview on 5/22/2017 at 3:15 PM, Staff Z stated she called the LDR regarding the patient. Patient #1 was not put in the emergency log or seen by a physician/mid-level provider before going to the LDR unit.

During an interview on 5/22/2017 at 1:15 PM, Staff Y stated that any post partum patient should be seen in the ED first. Patients who have any kind of vaginal tear need to have an evaluation in the ED first. All patients presenting to the ED are to have a medical screening exam and, if needed, the on-call physician for the specialty needed is then called.

During an interview on 5/22/2017 at 10:55 AM, Staff O stated that a post partum patient should be seen in the ED before being sent to the LDR unit. When a patient needs a vaginal repair, the patient would go to the operating room for the laceration repair. Most post partum patients are admitted through the ED and then go to the operating room (OR).

Review of the facility's Policy and Procedure, titled "Medical Screening and Treatment/Transfer Policy (EMTALA)" revealed Emergency Department Log, each hospital must maintain a central log to track the care provided to each individual who comes to the hospital seeking care for an emergency condition. The log entry must be made at the first point of contact and must contain the name of the patient, and the disposition of the patient as patient stabilized.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, review of medical record, and policies and procedures, the hospital failed to provide a Medical Screening Examination for one (Patient #1) of 25 sampled patients presenting to the hospital's Emergency Department (ED) to determine if an emergency medical condition existed. This failure presented a substantial probability of adversely affecting the health and safety of all patients presenting to the Emergency Department.

Findings:

Review of the medical record revealed that Patient #1 (MDS) dated [DATE] at approximately 2:00 AM. The patient approached registration area and informed the Emergency Department staff requesting medical treatment. The form signed by the midwife showed Patient #1 was sent by the midwife for a 3rd degree perineal tear following a home birth.

Documentation by the ED Registered Nurse (RN) on 5/9/2017 at 2:00 AM revealed that an ED-OB( Emergency Department)-(Obstetrics) hand off sheet showed Patient #1 included the birth of the baby at home and the need to have sutures. A form signed by a midwife stated the patient had a 3rd degree perineal tear, time of delivery 2245 on 5/8/17. Patient #1 was transported to the Labor/Delivery/Recovery (LDR) unit at 2:14 AM. There was no documentation in the patient's medical record to indicate Patient #1 was medically screened in the ED by a physician/mid-level prior to being sent to the Labor/Delivery/Recovery Unit.

Documentation by the Labor/Delivery/Recovery Unit nurse on 5/9/2017 at 2:15 AM revealed that the patient arrived to the Unit after a home birth (assisted by a mid-wife). At 2:16 AM a physical by the LDR RN was performed on Patient #1 that revealed the perineum appears to have a 3rd degree laceration from perineum extending into the vagina. At 2:20 AM, a call/page was made to the on-call physician for walk-in's. The physician was informed of the need for repair of a possible 3rd degree laceration following a vaginal home birth. The physician refused to come in and repair the laceration. The physician gave orders for the patient to follow up in the office in the morning. The Labor/Delivery/Recovery nurse stated again to the on-call physician that he was requested to come in to the facility to repair the laceration. The on-call physician stated again no. The charge nurse of the LDR Unit was aware of the situation. A call was placed to the hospital house supervisor regarding what the on-call physician had told the RN in the Labor/Delivery/Recovery Unit. At 5:02 AM, both verbal/written instructions were given to Patient #1 to go to the on-call physician's office in the morning for the laceration repair. Patient #1 stated she would not be seeing this physician. A repeat phone call was made to the on-call physician that Patient #1 was refusing to leave until the laceration was repaired. The physician was told that the ED was not willing to do the repair, as it was not in their area of expertise. The on-call physician stated he had explained to the RN in the Labor/Delivery/Recovery Unit to send patient home and follow up in the morning in his office. The RN again explained that the patient was requesting the laceration be repaired. The physician stated that an episiotomy was not an emergency. Patient #1 was given information and discharged home.

A review of the medical record showed: Review of symptoms: Drainage at perineum site small. Perineum revealed a 3rd degree laceration to perineum extending to the vaginal area. BP (Blood Pressure) 142/76, and pulse 110, shows small amount of drainage and no clots. Discharge vitals include BP 125/63 and pulse of 105. Review of post care instructions shows that the peripad was changed and had small amount of drainage. Further discharge instructions included patient to go the on-call physician's office to have laceration repaired and patient refused.

Patient #1 followed up on 05/09/2017 with another obstetrician who took the patient to surgery and repaired the perineal tear in the Munroe Regional Medical Center operating room and discharged her home the same day.

During an interview on 5/22/2017 at 11:05 AM, Staff P stated that Patient #1 should have been seen in the ED before being sent to LDR Unit. Staff P stated they never had a patient from home present to either the ED or LDR before.

During a telephone interview on 5/22/2017 at 2:55 PM, Staff S (The RN who was taking care of Patient #1 in the LDR Unit) stated that on 5/9/2017 at 2:15 AM, after Patient #1 was brought to the LDR after having a baby at home by a midwife. She had called the on-call physician and he stated would not come in for the repair. The discharge instructions by the on-call physician was for Patient #1 to come to the office in morning for repair of the laceration. Staff S stated that she had also called the house supervisor and was waiting for her to call back.

During a telephone interview on 5/23/2017 at 11:30 AM, Staff U (Supervisor on-call on 5/9/2017) stated that they had a conversation with Labor/Delivery/Recovery Unit charge nurse regarding Patient #1. Patient #1 could stay in the LDR Unit until morning and get the laceration repair. Staff U had spoken to the physician on-call. The physician on-call still stated it was not an emergency and the patient could be discharged home and seen in his office in the AM for the laceration repair. Staff U stated to the physician on-call that LDR staff were uncomfortable and needed Patient #1 to be seen. The vital signs were within normal parameters and drainage was minimal. Patient # 1 decided to leave.

During an interview on 5/22/2017 at 1:15 PM, Staff Y stated that any post-partum patient should be seen in the ED first. Patients who have any kind of vaginal tear need to have an evaluation in the ED first. All patients presenting to the ED are to have a medical screening exam and, if needed, the on-call physician for the specialty needed, is then called.

A review of the on-call physician for week of 5/8/2017 to 5/14/2017 and review of the on-call schedule for Labor/Delivery/Recovery and ED validated that on 5/9/2017 Staff V was the physician on-call for walk-in's.

Review of the facility's Policy and Procedure, titled "Medical Screening and Treatment/Transfer Policy (EMTALA)" revealed Emergency Department Log: Each hospital must maintain a central log to track the care provided to each individual who comes to the hospital seeking care for an emergency condition. The log entry must be made at the first point of contact and must contain the name of the patient, and the disposition of the patient as patient stabilized.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, review of medical records, and policy and procedures, the hospital failed to provide a Stabilizing Treatment within the capability of the hospital for 1 (Patient # 1) of 25 patients presenting to the hospital's Emergency Department.

Findings:

Review of the medical record revealed that Patient #1 (MDS) dated [DATE] at approximately 2:00 AM. The patient approached registration area and informed the staff in registration requesting medical treatment. The form signed by the midwife showed Patient #1 was sent by the midwife for a 3rd degree perineal tear following a home birth.

Documentation by the ED Registered Nurse (RN) on 5/9/2017 at 2:00 AM revealed that an ED-OB (Emergency Department)-(Obstetrics) hand off sheet showed Patient #1 was sent to the ED for sutures following a home birth. Patient #1 was transported to the Labor/Delivery/Recovery (LDR) unit at 2:14 AM.

There is no documentation in patient's medical record to indicate Patient #1 was medically screened in the ED by a physician/mid-level prior to being sent to the Labor/Delivery/Recovery unit.

Documentation by the Labor/Delivery/Recovery unit nurse on 5/9/2017 at 2:15 AM revealed that the patient arrived to the unit after having a home birth by a mid-wife. At 2:16 AM a physical by the LDR RN was performed on Patient #1 that revealed the perineum appears to have a 3rd degree laceration from perineum extending in to the vagina. At 2:20 AM, a call/page was made to the on-call physician for walk-in's and was informed of need for repair of possible 3rd degree laceration following a vaginal home birth. The physician refused to come in and repair the laceration. The physician gave orders for the patient to follow up in the office in the morning. The Labor/Delivery/Recovery nurse stated again to the on-call physician that he was requested to come in to the facility to repair the laceration. The on-call physician stated again, no. The charge nurse of the LDR unit was aware of the situation. A call was placed to the hospital house supervisor regarding what the on-call physician had told the RN in the Labor/Delivery/Recovery Unit. At 5:02 AM, both verbal/written instructions were given to Patient #1 to go to the on-call physician's office in the morning for the laceration repair. Patient #1 stated she would not be seeing this physician. A repeat phone call was made to the on-call physician that Patient #1 was refusing to leave until the laceration was repaired. The physician was told that the ED was not willing to do the repair, as it was not their area of expertise. The on-call physician stated he had explained to the RN in the labor/delivery/recovery unit to send patient home and follow up in the morning in his office. The RN again explained that the patient was requesting the laceration be repaired. The physician stated that an episiotomy was not an emergency. Patient given information and discharged home.

Continued record review showed Patient #1 was admitted for outpatient surgery on 05/09/2017 at 11:30 AM Munroe Regional Medical Center for repair of a third degree obstetric laceration. She was discharged home the same day with a follow up appointment with the same physician.

During an interview on 5/22/2017 at 9:54 AM, Staff G stated that if a patient goes to LDR, the patient is usually over 20 weeks pregnant, a staff member will take the patient by wheelchair. If a patient presents to the ED and is under 20 weeks pregnant the patient will be seen in the ED. Patient #1 was not seen in the ED post delivery and this was found after Patient #1 went to the LDR Unit. Patient #1 should have been seen in the ED first, the ED physician/mid-level will communicate with on-call OB physician and a determination will be made to repair the laceration.

During a telephone interview on 5/22/2017 at 3:25 PM, Staff V was asked why he did not come in and do the laceration repair on Patient #1. Staff V stated did not feel it was an emergency and that he had given the RN in Labor/Delivery/Recovery unit orders to discharge and he would do the repair in the morning at his office. Staff V did not feel that he needed to see the patient after given information from the RN. Staff V was aware from the RN that the ED did not feel comfortable doing the repair of the laceration. Staff V again stated he did not feel that this was life threatening. Staff V was asked, was he also the on-call physician for the ED that day and he stated yes.

During a telephone interview on 5/22/2017 at 4:00 PM, Staff T (Registration clerk in the ED on 5/9/2017 at 2:00 AM for Labor and Delivery) also had never encountered a patient who had a baby somewhere other than the facility. This was something new and Staff T did not know where to send her, which is up to the ED nurse.

During a telephone interview on 5/22/2017 at 4:25 PM, Staff X stated they had spoken to the nurse for Patient #1 several times through the early morning. Staff X also stated they had spoken with the administrator on-call that night and spoken with the on-call physician for labor/delivery/recovery unit. Staff X stated that Patient #1 could have stayed in the LDR and have the laceration repaired. Staff X does not know if this was told to the RN or to Patient #1.

During a telephone interview on 5/22/2017 at 5:46 PM, Staff Z (Staff in the ED who had Patient #1 complete the ED- OB Handoff sheet) stated that there was no policy regarding a patient who has a home birth.

During an interview on 5/22/2017 at 10:55 AM, Staff O stated that post partum patients should be seen in the ED before being sent to the LDR unit. When a patient needs a vaginal repair the patient would go to the operating room (OR) for the laceration repair. Most post partum patients are admitted through the ED and then go to the OR.

During an interview on 5/22/2017 at 11:05 AM, Staff P stated that Patient #1 should have been seen in the ED before being sent to LDR Unit. Staff P stated they never had a patient from home present to either the ED or LDR before.

During a telephone interview on 5/22/2017 at 2:55 PM, Staff S (The RN who was taking care of patient # 1 in the LDR) stated on 5/9/2017 at 2:15 AM, after Patient #1 was brought to the LDR after having a baby at home by a midwife, she had called the on-call physician and he stated he would not come in for the repair. The discharge instructions by the on-call physician was for Patient #1 to come to the office in the morning for repair of the laceration. Staff S stated she also called the house supervisor and was waiting for her to call back.

Staff Z stated she called LDR regarding the patient. Patient #1 was not put on the emergency log or seen by a physician/mid-level before going to the LDR unit.

During a telephone interview on 5/23/2017 at 11:30 AM, Staff U (Supervisor on -call 5/9/2017) stated they had a conversation with labor/delivery/recovery room charge nurse regarding Patient #1. Patient #1 can stay in the LDR Unit until morning and get the laceration repair. Staff U had spoken to the physician on-call, Staff V. Staff V still stated it was not an emergency and Patient #1 could be discharged home and seen in his office in AM for the laceration repair. Staff U stated to Staff V that LDR staff were uncomfortable and needed Patient #1 to be seen. The vital signs were with in normal parameters and drainage were minimal. Patient #1 decided to leave.

During an interview on 5/22/2017 at 1:15 PM, Staff Y stated any post partum patient should be seen in the ED first. Patients who have any kind of vaginal tear need to have an evaluation in the ED first. All patients presenting to the ED are to have a medical screening exam, and if needed, the on-call physician for the specialty needed, is then called.

Review of emergency room , Labor/Delivery/Recovery and Post partum Unit polices/procedures did not address a post partum patient as to how to register the patient or of the discharge process for a patient that had a birth at home.