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NMC HEALTH 600 MEDICAL CENTER DRIVE NEWTON, KS 67114 Aug. 28, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and staff interview the hospital failed to follow its policy
and procedure and examine an individual and unborn child that presented to the Emergency Department seeking care and failed to perform a complete assessment (Medical Screening Exam) in 1 patient (patient #5) of 20 cases reviewed.

Findings include:

- Policy "Obstetrical Patients Checking of 349", reviewed on 8/27/12, revealed, "All obstetrical patients shall be evaluated by the emergency physician. For an obstetrical patient who does not have a physician on staff and presents with obstetrical (OB) complaint, call the unassigned obstetrical physician, after the medical screening examination is complete. Fetal heart tones will be assessed. Maternal Child Unit staff may be consulted to assist with fetal monitoring as appropriate.... A registered nurse shall assess the pregnant patient asking for her chief complaint and her last menstrual period or known due date. All obstetrical patients shall be evaluated by the emergency physician. The Emergency Department (ED) physician may consult the attending physician to discuss findings of the Medical Screening Exam (MSE) and determine how the patient may best be cared for, i.e. send to the Maternal Child Unit or keep in the Emergency Department.... A patient that is over 20 weeks pregnant and has, but not limited to the following complaints, may be evaluated in the maternal/child unit: Abdominal pain, leakage of fluid, vaginal bleeding, back pain unrelated to an injury, headache with blurred vision and/or blood pressure above 140 systolic and/or 90 diastolic...."

- Review on 8/27/12 of the hospital's Observation log-Maternal Child, revealed, each OB patient who entered the OB department, with or without an assigned physician, received an obstetrical triage(OBT), except patient #5 and unborn child. The log lacked documentation for patient #5 and unborn child receiving an OBT (an assessment of the patient which includes a medical screening exam).

- Nursing Staff A, who cared for patient #5, interviewed on 8/27/12 at 2:00pm acknowledged they failed to perform a medical screening exam for patient #5 and unborn child as per hospital policy.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on document review, policy review, and interview, an immediate jeopardy situation was found to exist when the hospital failed to perform a medical screening exam for 1 (patient #5) patient and her unborn child who came to the emergency department requesting medical care. Patient #5 then traveled by private auto to another hospital where no fetal heart tones were present and the baby was stillborn. The sample size was twenty closed records.

Findings include:

- Policy "Obstetrical Patients Checking of 349", reviewed on 8/27/12, revealed, "All obstetrical patients shall be evaluated by the emergency physician. Fetal heart tones will be assessed. Maternal Child Unit staff may be consulted to assist with fetal monitoring as appropriate.... A registered nurse shall assess the pregnant patient asking for her chief complaint and her last menstrual period or known due date. All obstetrical patients shall be evaluated by the emergency physician. The Emergency Department (ED) physician may consult the attending physician to discuss findings of the Medical Screening Exam (MSE) and determine how the patient may best be cared for, i.e. send to the Maternal Child Unit or keep in the Emergency Department.... A patient that is over 20 weeks pregnant and has, but not limited to the following complaints, may be evaluated in the maternal/child unit: Abdominal pain, leakage of fluid, vaginal bleeding, back pain unrelated to an injury, headache with blurred vision and/or blood pressure above 140 systolic and/or 90 diastolic.... For an obstetrical patient who does not have a physician on staff and presents with obstetrical complaint, call the unassigned OB physician after the medical screening examination is complete."

- Document review of the Emergency Log and Observation Log-Maternal Child, revealed the hospital failed to perform a MSE in the emergency room and failed to perform a MSE in the OB Department as per policy for patient #5 and unborn child on 8/5/12 at 11:30pm.

- Nurse Manager Staff D interviewed on 8/27/12 at 11:00am confirmed the only documentation from hospital staff about patient #5 on 8/5/12 was on the OB log. Nurse Manager Staff D acknowledged patient #5's name did not appear on the ED log and the hospital failed to create a medical record on 8/5/12 at 11:30pm when the patient and unborn child came to the ED requesting medical care.

Nursing Staff A interviewed on 8/27/12 at 2:00pm acknowledged patient #5 arrived to the ED around 11:30pm. Patient #5 indicated they were pregnant and experiencing abdominal and back pain. The patient was 38 weeks and 4 days pregnant. The ED clerk directed patient #5 to walk unescorted to the OB Unit. Nursing Staff A confirmed the patient complained of abdominal pain around the umbilical area at a level of 2-3 (0 being the least pain and 10 being the worst). Nursing Staff A indicated they did not perform a MSE. Nursing Staff A stated "if they meet the criteria: Vaginal bleeding, leakage of fluid, contractions, or no fetal movement then we call the physician. If we believe it is an emergency or having a problem then we perform the MSE and the Score System." Nursing Staff A stated the Score System (Obstetrical Evaluation Scoring System) is used on OB patients to determine if they must be seen by the attending physician prior to discharge from the ED. Nursing Staff A acknowledged they did not use the Score System for patient #5. Nursing Staff A described patient #5's care: Patient #5 walked to the OB department from the ED, complained about abdominal pain around the umbilical area but had not felt fetal movement. Nursing Staff A took patient #5 to the OB triage room. Patient #5 indicated she had no vaginal bleeding or fluid leakage only pain and no fetal movement. Patient #5 reported their OB physician was located in another town and did not have a local physician. Nurse A called the on call OB physician who requested the nurse ask the patient if they wanted to travel to the other town (27.18 miles) to see their physician who had the patient's medical history and records. Patient #5 left this hospital with out a Medical Screening Examination or the assessment by the Score System. Nurse A indicated "they were too busy at the time patient #5 came to the OB department."

Nurse Manager Staff F and Nursing Staff G interviewed on 8/27/12 at 3:40pm confirmed, everyone who is an OB patient who comes to the ED is to have the OB Evaluation Scoring System performed and if they come to the OB Unit from ED then they are always to have fetal heart tones monitored if not seen by a Physician. It is part of the MSE for OB patients.

Family member A, who accompanied patient #5 to the hospital, interviewed on 8/29/12 at 2:45pm confirmed patient #5 was not examined at anytime while in the hospital. The patient and unborn child went in a private automobile 25.18 miles to another hospital where the baby was found to be without heart tones and was stillborn.