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CATAWBA VALLEY MEDICAL CENTER 810 FAIRGROVE CHURCH RD HICKORY, NC 28602 March 13, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy and procedure reviews, Emergency Medical Services documentation review, medical records reviews, hospital documentation reviews, staff and physician interviews, the Dedicated Emergency Department (DED) physician failed to ensure a Medical Screening Exam was completed within the capabilities of the hospital that provided for the stabilization of a patient presenting to the DED with an Emergency Medical Condition.

The findings include:

1. ~ cross refer to 489.24(r) 489.24(c) Medical Screening Exam, Tag A2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure reviews, review of Medical Staff rules and regulations, Emergency Medical Services (EMS) documentation review, hospital documentation review, closed medical record review, staff and physician interviews, the Dedicated Emergency Department (DED) physician failed to ensure a Medical Screening Exam (MSE) was completed within the capabilities of the hospital that provided for the stabilization of a patient in 1 of 3 patients presenting to the DED with an Emergency Medical Condition (EMC), treated and discharged (#27).

The findings include:

Review of current hospital policy"PE - 7 approved 09/30/2013 for Emergency Medical Screening revealed the policy ensures the staff in the hospital will provide "emergency medical screening examination to any individual for whom an exam or treatment is requested in compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA: COBRA)" (Emergency Medical Treatment and Labor Act EMTALA)...All emergency medical screenings must be conducted in a manner that is reasonably calculated to exclude the presence of an emergency medical condition. This may include the utilization of necessary tests, ancillary services, and/or on-call specialist when necessary".

1. Medical record review of patient # 27 revealed a [AGE] year old female presenting to the Labor and Delivery Department on 01/09/2014 at 2346 with a chief complaint of 40 weeks gestation, estimated delivery date 01/09/2014 and having regular contractions since 2000 (approximately 3 hours 45 minutes prior to presentation). Record review revealed the patient was a Gravida 2 and Para 1 (second pregnancy and one living child). Record review revealed the MSE was started by the RN at 0000 on 01/10/2014. Review of the MSE revealed the patient complained of pain at a level of 6 out of 10 on a scale of 1 to 10 and 10 being the worst pain. Record review revealed documentation by nursing at 0000 that uterine activity "Contractions noted", the membranes were "Intact" and the fetus was "Active". Further review of the MSE revealed at 0028 the cervix was dilated at 2 centimeters (cm), the cervix was effaced (thinned) at 80 % , station -2 and uterine contractions were between 1 to 5 minutes moderate and irregular lasting 30 to 110 seconds. Record review revealed at 0030 the Certified Nurse Midwife was notified and orders were received. Review of the orders received revealed "Recheck cervix in 2 hours" and "Activity, Bedrest with bathroom privileges". Record review revealed at 0045 an order was documented for the disposition to be "Home". Record review revealed at 0057 contractions were "every 2 - 6 minutes", Contraction duration was "50 - 80 seconds", Contraction intensity "Moderate Irregular" and the contraction resting tones were "palpate soft". Record review revealed the patient was discharged home on 01/10/2014 at 0104. Record review failed to reveal any documentation of a second check of the cervix as ordered by the Certified Nurse Midwife for continued dilation or documentation of a discharge diagnosis/false labor.

Interview with administrative OB staff #1 on 03/13/2014 at 1415 revealed it was unknown why the RN did not recheck the cervix 2 hours as ordered after the initial vaginal exam. The interview revealed the reason for the recheck of the cervix in 2 hours was a standard of practice in defining if the patient is in labor. The interview revealed dilation and effacement changes in the cervix indicated the patient is in labor. The interview revealed since there was no documentation of a recheck of the cervix it was unknown if the patient was in labor or just having contractions. The interview revealed there was no available documentation of a diagnosis prior to the disposition.