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.

UPMC ALTOONA 620 HOWARD AVENUE ALTOONA, PA 16601 Aug. 16, 2011
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on review of facility documents, and staff interviews (EMP), it was determined the facility failed to maintain a central log on each individual who comes to the dedicated emergency department seeking assistance and whether or not he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged .

Findings include:

A review of "Altoona Regional Health System Standard Practice Date: December 31, 2010, Section: All Departments Effective Date: December 31, 2010 ... Subject: EMTALA (EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT)" revealed " Purpose: To ensure compliance with the requirements of Emergency Medical Treatment and Active Labor Act (EMTALA) 42 CFR 489.24 et seq. Policy: EMTALA is a Federal law that applies to hospitals having a dedicated emergency department (DED). The original intent of the law was to prevent hospitals from refusing to treat or transferring patients because they were unable to pay or lacked insurance coverage. EMTALA requires the Hospital to provide to any individual (including infants who are born alive at any stage of development) who "comes to" the dedicated emergency department (DED) an appropriate medical screening examination (MSE) within the capability of the Hospital. If a medical emergency is diagnosed , the Hospital must provide care until the condition ceases to be an emergency or until the individual is properly transferred to another facility. EMTALA does not apply to Hospital inpatients. An individual has "come to" the dedicated emergency department (DED) if the individual presents to the Hospital seeking care for a potential medical emergency or is known to be on the Hospital campus and appears to need emergent care. Staff is obligated to ensure that all such patients are appropriately taken or transported to the emergency department. The law defines "dedicated emergency department" (DED) more broadly than what we know as a traditional emergency department (see definition below). A DED is a licensed emergency department or it may be a department of a hospital, other than a traditional emergency department, that provides at least one-third of all outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment. It has been determined that at Altoona Regional Health system (ARHS) the LDRP unit is a dedicated emergency department (DED) and is subject to EMTALA requirements. The traditional emergency departments located on the Hospital campus are also DED's. The requirements of the EMTALA law extend beyond the confines of the DED's and apply to the Hospital "campus," which the law defines as the area immediately adjacent to the main buildings of the Hospital's two campuses and within a 250 yard radius around the main buildings. This area includes parking lots, sidewalks and other public spaces ... Dedicated Emergency Department (DED) - Any department or facility of the Hospital, regardless of whether it is located on or off the main campus, that meets at least one of the following requirements: (1) Is licensed by the State as an emergency department; (2) Is held out to the public as a place that provides care for emergency medical conditions on an urgent basis without requiring a scheduled appointment; (3) Based on a representative sample of patient visits, it provides at least one-third of all outpatients visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment .... Requirements: The EMTALA law imposes a number of requirements on the Hospital with regard to care of outpatients who present to a DED seeking care for potential EMC's. The following sets forth the general requirements of the law ... B. Central Log. The purpose of the log is to track the care provided to each individual who comes to the Hospital seeking care for a potential emergent medical condition (EMC). The DED must maintain a log of individuals who come to the DED seeking treatment and the log must indicate whether these individuals: refused treatment, were denied treatment, were treated, admitted , stabilized, transferred or discharged . The log must be retained for a minimum of five years ... ."
Review of "Altoona Regional Health System Standard Practice Date: March 21, 2011", revealed "Section: Emergency Department ... Subject: Emergency Department Documentation System / Medical Record Purpose: To provide and define an organized and efficient system of the documentation of patient care in the Emergency Department. Policy: the PICS IBEX system will be used by the physicians and nurses in the Emergency Department (ED) to document patient care. ... Patient Log This system allows electronic record keeping and electronic log of all patients presenting to the ED and disposition from ED. Upon admission to the hospital a paper chart of the ED visit is to be transferred with th patient to the inpatient unit. Paper discharge instructions are also printed and provided to the patient upon discharge."

Review of the Department of Emergency Medicine policy entitled "Refusal of Care; Against Medical Advice; Leaving without Being Seen & Elopements from the ED", dated May 9, 2011, was completed. The policy stated "Purpose: To define Refusal of Care and Against Medical Advice and to outline the process for documentation when a patient refuses care or decides to leave Against Medical Advice (AMA). To define leaving without being seen (LWBS) and to outline the process for documentation when a patient leaves without being seen. Policy: ... Refusal of Medical Screen. Emergency Department patients have the right to leave the hospital prior to the initiation or completion of the assessment or medical treatment. All patients who initially check in to the Emergency Department (ED) will have a chart generated on them, even if they have not yet been triaged. 1. When a patient expresses the desire to leave the ED without being seen the ED nurse is to be notified immediately. 2. The ED nurse will work to resolve the patient's concerns and encourage them to stay for treatment. If the patient still wishes to leave the nurse will document the encounter in the patient's ED medical record. 3. When it is discovered that the patient has eloped, this information will be entered into the patient's Emergency Department medical record ... ."
1) Documents related to PT1 revealed that the patient had presented to the 7th Avenue Campus Emergency Department, and was told to drive to Altoona Campus Labor and Delivery Department. Documentation also stated the patient had been seen by patient access, and was not seen in the Emergency Department.

An interview was conducted with EMP26 by telephone on August 3, 2011 at 9:00 AM. EMP26 stated that [they] did not know why [they] sent the patient to Altoona Campus. EMP26 stated that the patient should have been registered and taken back to the emergency room at the 7th Ave Campus.
A tour of the Emergency Department at the 7th Avenue campus of Altoona Regional Health System was conducted on August 4, 2011 at approximately 1:00 PM. During the tour, the Emergency log was reviewed. The patient (PT1) who had been sent to the A [Altoona] campus for care in the L&D (Labor and Delivery) unit was not located on the log. EMP15 stated that there was no record and nothing on the log because they did not know the patient was even there.
2) Review of facility documents revealed that the facility received a complaint from the parent of PT2 on August 9, 2011. Further review of the complaint revealed that PT2's [parent] had arrived at the Emergency Department with children, and requested care for one of the children. Stated that [the parent's child] had a 30 pound weight drop on [the child's] foot and it was swollen, and wanted [the child] checked. Stated that the registration person had told [the parent] that the ED would not even see [the] child since other children were present, and that the registration person stated [the parent] should have someone with [them] to watch the other children. The [parent] stated that [they] were alone and that the registration person suggested [they] should go home until [they] find a babysitter and then [they] could bring [the child] back in to be seen.
Review of the 7th Avenue Campus ED Log dated August 7, 2011, timed 14:01 to 19:48, revealed that PT2 was not listed on the log.
A telephone interview was conducted with EMP27, on August 10, 2011, at approximately 3:45 PM. EMP27 stated " I work at Patient Access at the 7th Avenue campus, I was on the Greet screen ...[the parent] had a newborn in a carrier and a six and seven year old, plus the eight year old who needed to be seen. I asked [the parent] if [they] had someone to help ... with the other children while [they were] in the treatment area with [the child] because it is our policy not to allow children in the back ... I should have never allowed [the parent] to walk out the door ... I was being too helpful. I should have put [PT2] in the system and let [them] elope."

3) A review of the Obstetrics (OB) Log dated January 1, 2011 to August 3, 2011, was completed, on August 4, 2011. During review of the Log, it was noted that the log contained approximately 2, 263 patient encounters. It was noted that the log did not indicate whether the patients were scheduled or unscheduled. It was also noted that approximately 72% of the encounters did not document a disposition.
An interview was conducted with EMP3 on August 4, 2011, at 10:15 AM. EMP3 was queried in regard to the OB Log and patients presenting to the OB unit scheduled or unscheduled. EMP3 stated, "You may or may not know by looking at the log if the patient is scheduled or unscheduled. If it was a NST [non stress test], the assumption would be that the patient was scheduled. If the patient came from the physician's office then they would be considered unscheduled. OB triage would determine if the patient was scheduled or unscheduled. We get a variety of patients. Some patients do just show up, some come from the ED, and some from the doctor's office. We do not have a policy on how to keep the log book."
An interview with EMP4, on August 5, 2011, at 9:15 AM, revealed "The log is changed effective today."
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of facility documents, closed medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow adopted policies by failing to ensure that the Medical Staff Bylaws or Rules and Regulations, designated Obstetrical registered nurses as qualified medical personnel for the performance of medical screening examinations; failed to provide an appropriate medical screening examination for two of 24 patients (PT1 and PT2) who presented to the Emergency Department; and failed to provide an appropriate medical screening examination to patients for five of 15 Obstetrics (OB) medical records reviewed. (MR31, MR32, MR33, MR34, MR35)

Findings include:

Review of "Altoona Regional Health System Standard Practice Date: December 31, 2010, Section: All Departments Effective Date: December 31, 2010 ... Subject: EMTALA (EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT)" revealed " Purpose: To ensure compliance with the requirements of Emergency Medical Treatment and Active Labor Act (EMTALA) 42 CFR 489.24 et seq. Policy: EMTALA is a Federal law that applies to hospitals having a dedicated emergency department (DED). The original intent of the law was to prevent hospitals from refusing to treat or transferring patients because they were unable to pay or lacked insurance coverage. EMTALA requires the Hospital to provide to any individual (including infants who are born alive at any stage of development) who "comes to" the dedicated emergency department (DED) an appropriate medical screening examination (MSE) within the capability of the Hospital ... An individual has "come to" the dedicated emergency department (DED) if the individual presents to the Hospital seeking care for a potential medical emergency or is known to be on the Hospital campus and appears to need emergent care. Staff is obligated to ensure that all such patients are appropriately taken or transported to the emergency department. The law defines "dedicated emergency department" (DED) more broadly than what we know as a traditional emergency department (see definition below). A DED is a licensed emergency department or it may be a department of a hospital, other than a traditional emergency department, that provides at least one-third of all outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment. It has been determined that at Altoona Regional Health system (ARHS) the LDRP [Labor, Delivery, Recovery, Post Partum] unit is a dedicated emergency department (DED) and is subject to EMTALA requirements. The traditional emergency departments located on the Hospital campus are also DED's. The requirements of the EMTALA law extend beyond the confines of the DED's and apply to the Hospital "campus," which the law defines as the area immediately adjacent to the main buildings of the Hospital's two campuses and within a 250 yard radius around the main buildings. This area includes parking lots, sidewalks and other public spaces ... Medical Screening Examination (MSE) - The process required to reach with reasonable clinical confidence the point at which it can be determined whether or not an EMC exists. Such a screening must be done within the Hospital's capability and available personnel, including on-call physicians. Screening is to be conducted to the extent necessary to determine whether an EMC exists. With respect to an individual with psychiatric symptoms, an EMC consists of both a medical and psychiatric screening ... Qualified Medical Personnel (QMP) - An individual, in addition to a licensed physician, who is licensed or certified and who has demonstrated competence in the performance of MSE's and has been approved by the Hospital's governing board as qualified to perform one or more types of initial MSE's ... The EMTALA law imposes a number of requirements on the Hospital with regard to care of outpatients who present to a DED seeking care for potential EMC's. The following sets forth the general requirements of the law. DED's within the Hospital may have policies to more specifically address procedures to comply with the following requirements ... Medical Screening Examination (MSE): EMTALA requires the Hospital to provide a MSE to any individual who comes to the dedicated emergency department (DED) and request treatment. The purpose of the MSE is to determine whether or not an EMC Exists. A MSE must be suitable for the symptoms presented by the patient and shall be conducted in a consistent fashion for all patients presenting with similar complaints. Hospitals may not refuse to provide a MSE or treat a patient having an EMC. The MSE shall not be delayed in order to inquire about the patient's payment status. The MSE must be performed by a qualified medical person (QMP). If the QMP determined to be qualified to perform the MSE is other than a physician, the non-physician practitioners to perform the MSE must be designated by the governing body of the Hospital and set forth in the Hospital Bylaws or Rules and Regulations of the Medical Staff. In situations where a patient or someone acting on behalf of the patient refuses the MSE and/or treatment for the MSE, the medical record should contain documentation of an informed refusal of the examination and/or treatment ... ."
Review of Medical Staff Bylaws of ARHS (Altoona Regional Health System) Rules and Regulations, dated May 15, 2008, revealed "... Section V. Emergency Department Requirements. 5.1 Patients coming to the Emergency Department may be evaluated and treated by an Emergency Department physician or the patient's private physician ... ."
Review of the Department of Emergency Medicine policy entitled "Medical Screening Exam in the ED", dated May 9, 2011, revealed "Purpose: To ensure that all patients coming to the hospital requesting emergency services receive an appropriate medical screening examination as required by the Emergency Medical Treatment and Active Labor Act. Policy: 1. Every patient who comes to the Emergency Department requesting emergency services will receive a medical screening examination, performed by individuals qualified to perform such examinations, to determine whether an emergency medical condition exists ... 5. Medical screening examinations must be performed by individuals who are: a. Determined qualified by hospital medical staff by-laws, rules and regulations. b. Functioning within the scope of their license and in compliance with State law and applicable medical practice acts. 6. The medical screening examination may be initiated at triage. If a patient is determined to be stable by the triage process, the patient may be placed in the waiting room prior to completion of his/her medical screening examination. 7. The standard, customary registration process is completed for the stable waiting room patient, because the registration process is not delaying the medical screening examination."
Review of the Department of Emergency Medicine policy entitled "Refusal of Care; Against Medical Advice; Leaving without Being Seen & Elopements from the ED", dated May 9, 2011, was completed. The policy stated "Purpose: To define Refusal of Care and Against Medical Advice and to outline the process for documentation when a patient refuses care or decides to leave Against Medical Advice (AMA). To define leaving without being seen (LWBS) and to outline the process for documentation when a patient leaves without being seen. Policy: ... Refusal of Medical Screen. Emergency Department patients have the right to leave the hospital prior to the initiation or completion of the assessment or medical treatment. All patients who initially check in to the Emergency Department (ED) will have a chart generated on them, even if they have not yet been triaged. 1. When a patient expresses the desire to leave the ED without being seen the ED nurse is to be notified immediately. 2. The ED nurse will work to resolve the patient's concerns and encourage them to stay for treatment. If the patient still wishes to leave the nurse will document the encounter in the patient's ED medical record. 3. When it is discovered that the patient has eloped, this information will be entered into the patient's Emergency Department medical record ... ."
Review of Emergency Department policy entitled "Obstetrical Patients", dated March 21, 2011, revealed "Purpose: To define the process for the evaluation and treatment of obstetrical patients presenting to the Emergency Department (ED) and to ensure obstetrical patients receive the safety possible care. Policy: 1. Obstetrical patients who are 16 weeks or greater in gestation will be evaluated and treated in the L&D [Labor and Delivery] unit, with the exception of pregnant trauma patients or the patient presents with symptoms not related to pregnancy (ie. Shortness of breath, chest pain, migraine, etc.) ... 5. Patients 16 weeks or greater in gestation a. All medical complaints should be referred to L&D for evaluation, with the exception of trauma (i.e. MVA, assault). b. All trauma patients should first be evaluated in the ED and may be referred to L&D after completion of their ED evaluation and treatment ... 6. Laboring patients a. When a laboring patient presents to the ED, the ED triage or charge nurse will be immediately notified. b. The patient will be immediately evaluated by the ED nurse to determine if the patient can be safely transported to the L&D unit. i. If delivery is imminent the patient should be delivered in the ED and L&D notified as soon as possible. ii. In the event the ED nurse determines the patient can be safely transported to the L&D unit the patient will be accompanied by the ED nurse and the L&D unit will be notified."
Review of the facility's policy entitled "Initial Medical Screening Examination of Obstetrical Patients for Labor", dated September 2009, revealed "All patients presenting to the Obstetrical Department for evaluation of labor will have an initial medical screening for labor performed upon arrival in the Obstetrical Unit. This screening can be done by an obstetrician, family practitioner with OB privileges, family practice resident, or an obstetrical Registered Nurse ... The information obtained during the initial screening will be reported to the attending physician by means of phone consultation ... The patient's condition will be reassessed hourly or more often if her condition warrants. Changes in the patient's physical status must be called to the attending physician. A verbal or written order is needed from the attending to either admit or discharge the patient ... ."
Review of the facility's policy entitled "Observation of an Obstetrical Patient", dated September 2009, revealed "... 4. a. The Obstetrical Outpatient Record will be kept with the medical record copy of the outpatient service form-vital signs; vaginal exam; and any other pertinent information, including documentation of any physician's orders including medication or treatment given ... b. The Obstetrical nurse will make the following initial assessment of the patient prior to notifying the attending physician ... 5. Upon receiving the patient, the nurse will: ... c. Assess the current patient status/response to treatment and document on the outpatient obstetrical record at least every hour. The extent of the care and documentation will depend on the patient's medical problem. d. Contact the attending physician with initial observation and as needed for additional orders. Orders are to be transcribed on the physician order sheet ... 6. Communicate any unexpected change in patient's status to the attending physician. 7. Schedule all ordered diagnostic tests ... 10. If the patient is to be admitted to the Hospital, notify patient access to have her converted to an inpatient ... ."
1) Review of Altoona Regional Health System's Medical Staff Bylaws, dated June 27, 2011, and Rules and Regulations, dated May 15, 2008, and the Department of Obstetrics and Gynecology Rules and Regulations, dated May 15, 2008, revealed that the Bylaws and Rules and Regulations failed to designate Obstetric nurses as qualified medical personnel.
Interview with EMP4 on August 5, 2011, confirmed that the Rules and Regulations and Bylaws do not address the designation of Obstetrical registered nurses as qualified medical personnel.
2) Review of documents related to PT1 revealed that the patient had presented to the 7th Avenue Campus Emergency Department, and was told to drive to Altoona Campus Labor and Delivery Department. Documentation also stated the patient had been seen by patient access, and not seen in the Emergency Department.
Interview with EMP26, via telephone on August 3, 2011, at 9:00 AM, revealed that [they] did not know why [they] sent the patient to Altoona Campus. EMP26 stated that the patient should have been registered and taken back to the emergency room at the 7th Ave Campus.

Interview with EMP15 on August 4, 2011, at 1:45 PM, revealed "... I was working at the time of the event. I never knew the patient had come into the ED until the supervisor contacted me about what happened ... ."
Interview with EMP19, via telephone, on August 5, 2011, at 9:35 AM, revealed "Sunday night around 10:30 PM, I was in a patient room. [EMP2] and I were busy. [EMP2] answered the phone. EMP25 asked if [EMP2] had any idea about a pregnant woman that came into the ER ... Registration sent [the patient] to the A [Altoona] campus."
Interview with EMP2 on August 5, 2011, at 12:40 PM, revealed "... I had no idea that the patient presented to the ED."
Interview with EMP1 on August 5, 2011, at 3:30 PM, revealed "I answered a telephone call, I don't remember if the person [from Bon Secours] was a nurse, but [they] said that [they] had a patient six and a half months pregnant there and was asking if the patient needed to be seen in our ER [Altoona ED] or in our department [OB]. I told [them] that [the patient] would come to the unit [OB]. [The person's] statement was that the patient would be on [the] way over. About twenty minutes later, [the patient] showed up. We told the evening shift manager. We all knew that [the patient] should have been transported by ambulance. I should have asked [the person] if [the patient] was triaged and seen, but I just answered the question. I thought [the person] was just calling to clarify where the patient should be seen next or where [the patient] should be placed."
3) Review of facility documents revealed that the facility received a complaint from the parent of PT2 on August 9, 2011. Further review of the complaint revealed that PT2's [parent] had arrived at the Emergency Department with children, and requested care for one of the children. Stated that [the parent's child] had a 30 pound weight drop on [the child's] foot and it had swelled, and wanted [the child] checked. Stated that the registration person had told [the parent] that the ED would not even see [the] child since other children were present, and that the registration person stated [the parent] should have someone with [them] to watch the other children. The [parent] stated that [they] were alone and that the registration person suggested [they] should go home until [they] find a babysitter and then [they] could bring [the child] back in to be seen.
Interview with EMP27 on August 10, 2011, approximately 3:45 PM, revealed " I work at Patient Access at the 7th Avenue campus, I was on the Greet screen ...[the parent] had a newborn in a carrier and a six and seven year old, plus the eight year old who needed to be seen. I asked [the parent] if [they] had someone to help ... with the other children while [they were] in the treatment area with [the child] because it is our policy not to allow children in the back ... I should have never allowed [the parent] to walk out the door ... I was being too helpful. I should have put [PT2] in the system and let [them] elope."

4) A review of MR31 dated June 29-30, 2011, revealed nursing documentation which stated "OB Triage ... 06/29/11 ...17:30 ... Complaint patient n [sic] here for c/o right sided pain that started with sudden onset and N/V. Denies any blood in urine. Patient has a history of kidney stones and states feels exact same way. ... Vital Signs ... Temperature 99.0 ... Objective Assessment Pain Type Other ... right sided and back ... 17:38 Medications ... morphine 4 mg im for pain ... 18:15 ... patient to ultrasound via wheelchair ... Provider Notification ... Report Given To ... 19:38 ... OTH1 informed of patient status (covering for OTH2) and ultrasound results. Will keep the patient overnight to hydrate and treat pain. ... 6/30/11 05:00 ... Interventions ... patient's hat emptied for 600 mls dark amber urine, stone collected and placed in specimen [sic] container. ... 07:43 Interventions RN Procedures ... Pt. made aware of plan of care: to feed and await OTH3 to make rounds and [the patient] verbalizes an understanding. ... 10:00 OTH3 here and orders are received and noted. ... 10:15 ... Pt. made aware of plan for discharge. ... Disposition ... discharged Home. ... . "
Further review of MR31 " Telephone Orders and Orders Written By Physician Assistants and Nurse Practitioners" dated June 29, 2011, revealed a telephone order from OTH2 that revealed, "Outpatient status c/o kidney pain/back pain ultrasound-kidneys check fetal heart tones Morphine 4mg IM x1 18 weeks gestation."
Continued review of MR31 revealed, " Physician's Order Sheet" dated June 30, 2011, at 10:45 AM, that stated, "1) d/c IV 2) d/c to home after monitor strip."
A review of MR32 dated July 19, 2011, revealed nursing documentation which stated, "OB Triage ... 7/19/11 ... 16:58 ... Complaint ... pt was walking around ... and a lady on a scooter hit her directly on her right side SUBJ ASSESS. (ACCIDENT) ... direct hit to abd [abdomen] right side ... 17:27 ... spoke with OTH4 made ... aware of strip. Pt discharged to home with discharge instructions. Pt states understanding and comfort going home. ... Disposition ... discharged Home. ... ."
Continued review of MR32 revealed " Telephone Orders and Orders Written By Physician Assistants and Nurse Practitioners" dated July 17, 2011, at 5:00 PM which revealed a telephone order from OTH4 that stated, "Assess pt. as outpatient at 29.3 weeks gestation. EDC 9-30-11 efm-NST for a direct hit to the Abd. R side. 1830 may be discharged to home F/U at next office visit. May take Tylenol and use moist heat."
A review of MR33 dated July 3, 2011, revealed nursing documentation which stated, "OB Triage ... 01:30 ... Complaint ... Pt states that [they were] at a wedding reception all evening, and got nauseated at 0030 and had a large emesis at home, came in to hospital c/o nausea, stuffy nose, diarrhea x 7 days. Denies any abd. Cramping or contractions. ... SUBJ ASSESS. (R/O PREECLAMPSIA) ... Hx of Nausea/Vomiting ... INTERVENTIONS ... 01:30 ... pt given two glasses of water to drink over the next twenty minutes ... 02:10 ... PROVIDER NOTIFICATION ... OTH5 notified of pt's nausea and one episode of vomiting. Informed of fht [fetal heart tones] pattern and no contractions palpated or showing on monitor. Pt tolerated two glasses of water without any emesis. Discharge instructions given to pt. Informed pt to keep well hydrated in the hot humid weather, eat small frequent meals to avoid over distention of stomach and decrease nausea, eat dry toast or crackers as needed. Keep appt. for 7/7/2011 at OTH5 office, pt verbalizes an understanding. ... DISPOSITION Patient Left Unit Ambulatory ... ."
Further review of MR33 revealed a "Physician's Order Sheet" dated July 3, 2011, at 1:30 AM that stated, "observe out pt status check for evidence of labor at 34.2 wks External monitor Routine orders OTH5/[nurse signature]."
Continued review of MR33 revealed "Telephone Orders and Orders Written By Physician Assistants and Nurse Practitioners" dated July 3, 2011, at 2:10 AM, which revealed, "Pt may be discharged home Keep Appointment for 7/7/11."
A review of MR34 dated May 27-28, 2011, revealed nursing documentation which stated "OB Triage ... May 28, 2011, at 0010 that stated 26 weeks gestation assess as outpatient for [decreased] FM back pain and cramping following MVC [motor vehicle collision] this am vaginal exam urinalysis" and "Telephone Orders and Orders Written By Physician Assistants and Nurse Practitioners" dated May 28, 2011, at 0100 that stated, "Discharge home Follow up as scheduled in office."
A review of MR35 dated July 19, 2011, revealed nursing documentation which stated, "OB Triage ... 7/19/11 ... 03:06 ... ARRIVAL INFORMATION ... came up from ED Complaint fell down some steps fell on her side abd cramping started after she fell ... 03:30 PROVIDER NOTIFICATION ... OTH6 notified of pt status [OTH6] stated to discharge pt at this time for her to report back if she had any bleeding or cramping gets worse and to keep all appt ... DISPOSITION ... discharged Home ... instructions given to pt she stated that she understood them and had no questions. ... ."
Further review of MR35 revealed, "Telephone Orders and Orders Written By Physician Assistants and Nurse Practitioners" dated July 19, 2011, that stated, "OP check 20 weeks G EDC 12/2/11 pt fell down steps, get FHT evaluate pain. Discharge to home."
Interview with EMP3 on August 4, 2011, at 10:15 AM, revealed "... The MSE is generally done by the nurse, resident or if no particular provider, it would be the next in line of specialty service. The nurses would determine gestation, do fetal monitoring, vital signs, discuss what the physician wants done as far as testing and vaginal exam. The nurses would be performing OB triage. They do not do the screening exam. A patient with chest pain or respiratory distress would be sent back down to the emergency department. The OB screen would determine if the patient was in labor, abdominal pain, preterm labor, or migraine related to pregnancy. The physician would not necessarily see the patient. They may just manage them over the phone provided that fetal heart tones and vital signs are stable."
Interview with EMP7 on August 5, 2011, at approximately 1:30 PM, revealed "Patients are received in the OB department several ways. Patients are sent to the department by the Obstetrician from their office, patients walk in, or patients are sent to the department by the ED. Any patient who is 16 weeks or more pregnant who comes into the ED with a medical complaint are sent to the OB department. The nurses on the department determine if the medical problem is labor. If it is determined the woman is not in labor then the physician or resident is called. We have on occasion sent a pregnant patient back to the ED for treatment but if we do that someone from OB goes with them. Problems are generally taken care of on the department. The Obstetrician does not always come in to see the patient. The OB may order tests and we call the results ... ."
Interview with EMP20 on August 5, 2011, at 1:45, revealed "EMTALA meant that all patients who come to the OB department must be screened and treated for their problem because their department is a dedicated ED." EMP20 stated it is a dedicated ED because pregnant patients come to OB from the ED. Staff on the OB department determine if the patient is in labor and then the patient is treated. We usually call the resident. We always call the Obstetrician for orders. The Obstetrician sometimes just discharges the patient after test results are received."
Interview with EMP 21 on August 5, 2011, at 2:00 PM, revealed "EMTALA meant that any patient who presented to their department with a medical problem would be seen. All pregnant women who come to the OB department are evaluated for labor. If the patient is not in labor the physician is called and makes a decision about the treatment. Sometimes a urine or blood test is done and depending on those results the patient is discharged or admitted . We sometimes do a non-stress test. The Obstetrician does not always come in. We use the resident who is here to see the patient ... ."
Interview with EMP22 on August 5, 2011, at 2:10 PM, revealed "All the nurse determines is if the pregnant woman is in labor. If the patient is not in labor the physician is called and all medical decisions come from the doctor. The doctor may tell us to call the resident on duty and to have testing done for the resident to look at ... I do not remember patients going back to the ED from the OB department."
Interview with EMP3 on August 5, 2011, at 2:20 PM, revealed "... OB triage would be done for injury, labor, or complaints. We would do OB triage. Any additional pain, we would report to the physician and [they] would make the determination to see the patient or not." EMP3 confirmed that a physician may not wish to see those things outside the parameters related to pregnancy so the patient would be taken back down to the ED for evaluation. EMP3 further confirmed that MR31, MR33, MR34, and MR35 did not contain documentation of a medical screening evaluation.