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.

MCLAREN PORT HURON 1221 PINE GROVE AVE PORT HURON, MI 48060 Sept. 25, 2014
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview the facility failed to document the risks and benefits of transferring a patient to another medical facility for 1 out of 3 transfer patients (#14) reviewed. Findings include:

On 9/25/14 at approximately 1230 document review of patient #14 revealed that the patient was admitted on [DATE] with a diagnosis of "fall" and "possible fracture". In patient #14's medical record on the document titled, "Emergency Department Note" dated 7/1/14 revealed under "Medical Decision Making" that the decision to transfer the patient had been made and the physician indicated, "I discussed with the patient and he does have these fractures present and will need to be transferred to the the hospital of his choice XXXX." The document titled, "Patient Transfer Form" dated 7/1/14 was reviewed. Under the section titled, "Certification: I have examined the patient and explained the risks of not consenting to the transfer are_____:" was left blank and the physician signed it. Staff Z was asked if there was any place else in the medical record where the risks and benefits of the transfer were explained to the patient and documented to which staff Z replied, "No."
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on document review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to ensure a medical screening exam (MSE) was performed by a qualified medical professional as appointed in the Bylaws and failed to document MSE's in the labor and delivery (L&D) patients' medical records, see A 2406; failure to stabilize a patient that presented to the emergency department (ED) see A 2407 and failure to document risks and benefits of transfer see A 2409.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on document review and interview, it was determined that the facility failed to specify in the Hospital Bylaws who was qualified to perform a medical screening exam (MSE) and failed to document MSE's in the labor and delivery (L&D) patients' medical records for 1 of 2 L&D patients reviewed (#16). Findings include:

On 9/25/14 at approximately 1535 during review of the Hospital Bylaws, no evidence could be found of which providers were considered qualified to conduct a MSE.

On 9/25/14 at approximately 1555, during an interview with staff A it was confirmed that the hospital bylaws did not indicate which providers were qualified to conduct a MSE.




On 9/25/14 at approximately 1250 during review of medical record #16 it was revealed that a MSE was not documented in the patient's medical record, neither in the emergency department record nor in labor in delivery record.

On 9/25/14 at approximately 1255 during an interview with staff Z it was confirmed that the MSE was not documented in the medical record for patient #16.

On 9/25/14 at approximately 1500, during an interview with staff D, the Obstetrical unit manager, who was asked whether pregnant women, who come in through the Emergency Department are given a medical screening exam after being directly transferred up to the Obstetrical Unit for evaluation to which she replied, "I don't think so."
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on document review and interview the facility failed to stabilize 1 of 20 patients (#8) that presented to the emergency department (ED) resulting in the potential to harm the patient or the patient's child. Findings include:

On 9/25/14 at approximately 1430 during review of the medical record for patient #8 it was revealed that the patient came into the facility at 1121 with complaints of "female GU (genitourinary)" and the triage comment documented was "Pt (patient) states she was sent to the emergency room by Dr. X. She states she is having suicidal thoughts and thoughts of harming her child." The triage nurse then triaged the patient and sent her back out to the waiting room at approximately 1156. The next interaction documented with the patient was at 1405 when it was documented that the patient left without being seen. The staff did not attempt to stop the patient from leaving the hospital, the patient was left unattended in the waiting room after she reported that she had thoughts of self harm and harming her child.

On 9/25/14 at approximately 1438 during an interview with staff L this surveyor asked, "What do staff normally do when a patient reports feelings of self harm or expresses that they have thoughts of harming others?" Staff L stated, "We normally would put them with a sitter and have them evaluated by the doctor to see if they need to be held for treatment." This surveyor asked staff L if she felt the patient should have been allowed to leave the hospital. Staff L replied, "Based on what I am reading [in the medical record], I don't think so."