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.

Based on document review and interview it was determined the Hospital failed to ensure compliance with 42 CFR 489.20 and 489.24.

Findings include:

1. The Hospital failed to ensure an on-call physician was available to provide additional evaluation and treatment of a patient presenting with an emergency medical condition (reference tag A 2404).

2. The Hospital failed to ensure all patients who presented to the Emergency Department (ED) were entered into the ED log. (reference tag A 2405).

Based on document review and interview it was determined for 1 of 1 (Pt. #1) patient presenting for emergency Obstetric Gynecology (OB) services, the Hospital failed to ensure an on-call physician was available to provide additional evaluation and treatment of a patient presenting for an emergency condition.

Findings include:

1. On 9/9/14 at approximately 9:00 AM, Hospital policy titled, "Emergency Medical Treatment (EMTALA" (reviewed 1/14) was reviewed and required, "H. On-Call Physicians...on call physicians are to respond in a timely fashion..."

2. On 9/9/14 the Hospital's policy titled, "Professional Staff Bylaws & Rules and Regulations" (revised 6/12/14) was reviewed and required, "18. all patients will be seen as soon as possible following admission, depending on the patient's updated medical record entry documenting the repeat physician examination is added to the original history and physical and entered into the medical record...20. On-call physicians can't refuse patients when on call if we are able to provide the service needed...the physician on call can't refuse to accept the patient after discussing the case with the attending physician and the patient..."

3. The Hospital's "Maternity and Neonatal Service Plan" (reviewed 8/13) was reviewed on 9/9/14 and required, "a board certified or board eligible obstetrician is available in house 20 hours a day (7:00 PM-7:00 AM, 9:00 PM-5:00 AM), and available on call 24 hours a day. The medical staff is community based and available within 30 minutes."

4. On 9/9/14 at approximately 9:45 AM the Hospital OB/Gyne call schedule was reviewed for 8/24/14. The OB call physician at the time Pt. #1 was admitted was MD #1. The OB on call physician for 7:00 AM to 7:00 PM was listed as MD #2.

5. On 9/9/14 the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female who was triaged on the OB unit on 8/24/14 at approximately 4:47 AM with a complaint of abdominal pain, vaginal bleeding, and lack of fetal movement. Pt. #1 received a nursing triage (untimed): Pt. #1's vital signs as documented on a fetal monitor strip on 8/24/14 at 4:50 am were: blood pressure 105/68, respiration 20, heart rate 129. Pt. #1 had a medical screening exam at 5:20 AM by MD #1 during which no fetal tones or movement were elicited. Genitalia exam included cervical dilation at 1centimeter (cm), fetus at station -2, effacement 50%, with questionable rupture. MD #1 documented Pt. #vomited during history and physical and voiced that she passed 2 clots of blood while urinating. The clots were unobserved by the staff. A subsequent abdominal ultra sound (US) test was performed on 8/24/14 at approximately 6:40 AM which determined Pt. #1 was "37 weeks and 2 day pregnant with fetal demise."

6. On 9/9/14 at approximately 12:50 PM an interview was conducted with MD #1. MD #1 stated that he assessed and cared for Pt. #1 on 8/24/14 from the time of her arrival until approximately 7:30 or 8:00 AM; that was the last time he saw Pt. #1. MD #1 stated, "prior to leaving the Hospital he had given hand-off by telephone to MD #2 for continuation of care." MD #1 stated he left the Hospital at approximately 8:15 AM. The medical record lacked documentation of the hand-off or the time MD #1 left the Hospital.

7. Additional review of Pt. #1's medical record included that on 8/24/14 at 9:00 AM, OB-RN (E #3) documented Pt. #1 was educated on the induction process, and also informed Pt. #1 MD #2 would be in to start the process. E #3 called MD #2 at 10:30 AM and documented MD #2 stated, "she would be in to assess the patient, to explain to the patient further what would happen in the induction process, and to start the induction." MD #2 was called again a second time at 11:15 AM. According to nursing documentation, MD #2 spoke with Pt. #1 mother on the phone, but did not come to the Hospital. During an interview with MD #2 on 9/9/14 at approximately 11:30 AM, MD #2 stated that Pt. #1 had signed out AMA (against medical advice) prior to her arrival at the Hospital. Documentation in the clinical record indicate Pt. #1 signed AMA on 8/24/14 at 11:40 AM. The clinical record lacks documentation of physician assessment by MD #2 of Pt. #1's condition between 7:30 AM and 11:40 AM (approximately 4 hours), the time Pt. #1 signed AMA. The last vital signs documented at 7:00 AM were: blood pressure 106/55, respirations 18, heart rate 97, oral temperature 98.4, and oxygen saturation 100%.

8. On 9/9/14 at approximately 11:30 AM during an interview, MD #2 stated she arrived at the Hospital after Pt. #1 had signed out AMA. MD #2 also stated she did not believe an emergency condition existed.
Based on document review and interview it was determined for 1 of 1 (Pt.#1) medical record reviewed of a patient seeking emergency services for fetal demise, the Hospital failed to ensure all patients requesting emergency services were entered on a central log.

Findings include:

1. On 9/8/14 the Hospital's policy titled "Emergency Medical Treatment (EMTALA)" (revised 1/14) was reviewed and required, "...a centralized log of all patients presenting to the ED shall be maintained and include the name of the patient, chief complaint..."

2. On 9/8/14 the Hospital policy titled "Assessment of the OB patient in the ER" (revised 12/07) was reviewed and required, "...all pregnant patients will enter the ED for a medical determine the presence of an emergency medical condition including use of hospital personnel and on-call physician...ED log, triage and recording of final patient disposition."

3. On 9/8/14 at approximately 12:45 PM during a tour of the ED, the surveyor requested to see the ED log of Pt. #1's arrival to the ED on 8/24/14. The surveyor was informed by the ED Nurse Manager ( E #4) that Pt. #1 was not logged on the ED log, but was sent directly to the OB triage area.

4. On 9/8/14 at approximately 3:00 PM the ED log for 8/24/14 was reviewed and lacked documentation of Pt. #1's arrival, triage, or disposition.

5. On 9/9/14 at approximately 12:00 PM the surveyor requested the OB log for patients arriving to the OB unit for triage and assessment. The OB log was not produced for review.

6. On 9/10/14 at approximately 3:00 PM the Vice President of Talent Management and Chief Administrative Officer verified there was no OB log.