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Based on a review of facility documents, closed medical records (MR) and staff interviews (EMP), it was determined that the facility failed to identify in their Bylaws and Rules and Regulations that the Obstetrical staff are qualified to perform a medical screening exam, and failed to provide an appropriate medical screening examination for one of 20 applicable patients who presented to the Emergency Department (MR1), and failed to provide an appropriate medical screening examination to Obstetrical patients for two of 11 medical records reviewed. (MR13, MR18)

A review of the facility's policy entitled "EMTALA-Emergency Medical Treatment and Active Labor Act", dated November 2012, revealed "Purpose: To ensure that all patients presenting to DuBois Regional Medical Center (DRMC) requesting emergency services receive an appropriate Medical Screening Examination as required ... Policy: Any patient presenting to DRMC's main campus requesting emergency medical services, regardless of diagnosis or financial status, is entitled to and received a Medical Screening Examination (MSE) performed by a physician or Non-Physician Practitioner to determine if an emergency condition exists. When an individual presents to the DRMC's Emergency Department (ED) requesting evaluation for a perceived emergency medical condition, the individual is provided a MSE, within the capability of the hospital's ED, to determine whether an emergency condition exists ... Patients are directed to other hospital owned facilities which are contiguous to or part of the hospital' (sic) west campus only if the area is able to provide a MSE. That facility is able to provide timely and adequate care. DRMC has identified 2 locations on the main campus that have the capability to provide emergency medical services. Patients are directed to these locations based on the presenting medical conditions, irrelevant of their ability to pay. These locations are: DRMC's Hospital's Emergency Department. The Maternity Department on third floor in the hospital, and Obstetrical Patients over 20 weeks gestation who contact their physicians prior to reporting to the OB department are considered scheduled outpatients and not considered patients seeking emergency services. These patients have been referred to DRMC by the attending physician. Verbal orders for diagnostic or therapeutic services are provided to the OB staff. Individuals presenting to the ED are provided a MSE beyond initial triage. Triage is not equivalent to a MSE. Triage merely determines the "order" in which patients will be seen, not the presence or absence of any emergency medical condition. The Medical Screening Examination are the same MSE that the hospital would perform on any individual coming to the hospital's ED with the same signs and symptoms, regardless of the individual's ability to pay for medical care. It the MSE does not reveal an emergency medical condition, the hospital has no further obligation under EMTALA or this policy. Medical Screening Examinations are performed by Physicians (MD or DO), and Certified Registered Nurse Practitioners, (CRNP), Clinical Nurse Specialists (CNS) and Physician Assistants (PA-C), collectively Non-Physician Practitioners (NPP) who are: Determined qualified by DRMC's medical staff bylaws, rules and regulations which are approved by the Board of Trustees. Functioning within the scope of their license and in compliance with State Law and applicable State Nursing and Medical Practice Acts. Procedure: A. Medical Screening Examination of the Emergency Department Patient: 1. Patient is directed to the ED triage area for assessment and acuity assignment by a nurse. 2. At an appropriate time, the patient is registered as an ED patient following the established policy and practice. 3. DRMC ED is obligated to provide a MSE to determine if an emergency medical condition exists. This examination is provided by an ED physician or mid level provider. Ancillary services such as Laboratory and/or Radiology are utilized at the discretion of the practitioner. As with any patient service, documentation of the examination is recorded in the Medical Record. 4. Appropriate discharge instructions and follow up care arrangements are provided to the patient. B. Medical Screening of the Obstetrical Patient. Women, with symptoms of labor who are over 20 weeks gestation, present either to the Emergency Department or directly to the Maternity Unit. 1. A pregnant woman over 20 weeks gestation, having no other symptoms or other emergency complaints, is assessed in the Maternity Unit, for initial assessment and monitoring to determined if the patient is in active labor. 1. Patients are registered in the Maternity outpatient log. b. A permanent medical record is created for each patient. 2. The obstetrics RN evaluates the patient in accordance with the Obstetric EMTALA Protocol approved by the OB medical staff. The RN contacts the patient's physician by phone or in person and reports the findings of her assessment. If the patient is not established with a staff physician, the on call Obstetrician is contacted by the RN. 3. The physician rules out active labor or makes the diagnosis of active labor, provides orders as needed, and directs the patient's disposition. C. Medical Screening in Occupational Medicine. 1. Industries in the area may refer work related injuries directly to DRMC's Occupational Medicine Department (Occ. Med.) during the department's routine business hours. 2. The ED using emergency medicine standards of care and triage may determine that practitioners in Occ. Med provide the MSE ... ."

Review of "Care of Patient in Obstetric Triage" labor and delivery policy and procedure dated September 2013, revealed, "Policy: Obstetric patients at 20 weeks of gestation or greater is evaluated in the Obstetric Triage Unit in accordance with Emergency Medical Treatment and Labor Act (EMTALA) regulations. Patients less than 20 weeks gestation or with a non-obstetric emergency will be triaged in the medical emergency room . Procedure: Admission of Obstetric Patients to Triage (Maternal Outpatient) A. Obstetric patients at 20 weeks of gestation or more, is assessed in the Triage Unit with the following exceptions: Patients scheduled for cesarean delivery, induction of labor, cerclage, version, or dilation and curettage. Patients directly admitted to the Obstetrics or Antepartum Unit. Patients in active labor who were evaluated by their attending practitioner. Patients who give birth on their way to the hospital. Patients with imminent delivery. B. Patients will be triaged into the following levels in a private area to protect confidentiality 1. Emergent & urgent requires immediate assessment and notification to the primary practitioner 2. Stable: needs to be re-evaluated within 30 minutes by the Obstetrical RN, and seen by the practitioner if needed after the emergent and urgent cases are seen. C. Place patient on the fetal heart monitor, assess and document data on the fetal heart rate and uterine contractions D. Obtain maternal vital signs E. An Obstetrical RN completes and signs an obstetric admission and assessment forms. Prenatal records (if available) should be pulled and appropriate information documented on the obstetric admitting record 1. Medical history includes but not limited to ... Gravida/Para/EDC ... Symptoms/Complaints i.e.; vaginal bleeding, cramping, contractions, leakage of fluid, back pain, headache ... Medical and Obstetrical Conditions i.e.; Gestational Diabetes, IDDM, Chronic Hypertension, Pre-clampsia, Previous kidney Stones, UTI's ... Medications/Drugs ... Allergies 2. Medical Screening Exam for patients having contractions includes an ongoing evaluation of fetal heart tones, observation and recordation of the regularity and duration of uterine contractions, cervical dilation, fetal position, station and status of membranes F. Patients less than 37 weeks gestation; the Obstetrical RN notifies primary practitioner for orders G. Patients greater than 37 weeks gestation; the Obstetrical RN can perform the following medical screening assessments to R/O labor 1. Regular uterine contractions, urge to push exists-perform vaginal exam 2. Complaints of burning and/or frequency in urination, back pain, costovetebral angle tenderness-obtain urinalysis. 3. Suspected rupture of membranes-obtain AmniSure H. Notify primary practitioner of patients arrival, chief complaint, assessment, & findings, obtain orders for continuing care ... If patient does not have a physician at DRMC, notify the Obstetrician on call for unassigned patients I. Transfer to Antepartum or LDRP Room 1. An Obstetrical RN should accompany patients in active labor or unstable condition or when delivery is imminent. 2. Patients with non-emergency status may be transferred by a nurse, or a patient care technician J. Discharge Home 1. Primary practitioner certifies that, after a reasonable time of observation, the patient's diagnosis is false labor prior to discharge 2. Patients discharged to home may walk unaccompanied by hospital personnel. 3. If a patient needs a wheelchair, the patient is to be accompanied by hospital personnel ... Maternal Transports 1. Requests for maternal transport should be from the attending physician at the referring hospital to the Perinatologist. 2. Perinatologist should notify the Primary Obstetrician & Charge Nurse that they have accepted the transfer. 3. Referring hospital should call with a nurse-to-nurse report. The nurse receiving the referral call will complete the maternal transport data collection form, including patient information, referring physician ' s name and relevant contact numbers. The qualifications of the Obstetrical RN to perform the assessments/screening to rule out labor are: 1. Minimum of one year labor & delivery experience 2. Documented competency in Electronic Fetal Monitoring Interpretation 3. Completion of high risk obstetrical patient & labor orientation."

A review of "Medical Staff Bylaws, Policies and Rules and Regulations of Dubois Regional Medical Center Appendix D Allied Health Professional Policy Article 1 General 1.A. Definitions The following definitions apply to terms used in this policy: (1) Advanced Dependent Practitioner means an AHP who provides a medical level of care or performs surgical tasks (i.e., Advanced Practice Registered Nurse (APRN), Physician Assistant (PA), Nurse-Midwife) consistent with the clinical privileges granted, but is permitted by law or the Medical Center to only exercise those clinical privileges under the direction of, or in collaboration with, a Supervising Physician pursuant to a written supervision agreement. (2) ALLIED Health Professionals (AHPs) means a licensed or certified health care practitioner other than a physician, dentist or podiatrist who is authorized by the Medical Center to provide patient care services with the Medical Center ... (7) Dependent Practitioner means an AHP who is permitted by law or the Medical Center to function only under the direction of or in collaboration with a Supervising Physician pursuant to written supervision agreement and consistent with the scope of practice granted. (8) Licensed Independent Practitioner means an AHP who is permitted by law and by the Medical Center to provide patient care services without direct supervision, within the scope of his or her license and consistent with the clinical privileges granted ... Article 2 Scope and Overview of Policy 2A. Scope of Policy (1) This policy addresses those AHPs who are permitted to provide patient care services in the Medical Center and are listed in the Appendices to this Policy ... Appendix A Those AHPs currently practicing as Licensed Independent Practitioner at Dubois Regional Medical Center are as follows: Clinical Psychologists Chiropractors. Appendix B Those AHPs currently practicing as Advanced Dependent Practitioners at Dubois Regional Medical Center are as follows: Physician Assistants, Certified Registered Nurse Anesthetists, Certified Registered Nurse Practitioners, Nurse-Midwife. Appendix C Those AHPs currently practicing as Dependent Practitioners at Dubois Regional Medical Center are as follows: Surgical First Assistants, Radiology Practitioner Assistants."
1) Review of the Medical Staff Bylaws, and Rules and Regulations of Dubois Regional Medical Center, dated December 17, 2013, revealed that the Bylaws and Rules and Regulations failed to designate Obstetric nurses as qualified medical personnel.

2) Review of MR1 revealed the patient presented on April 5, 2014, with complaints of back pain. Continued review of MR1 revealed documentation that the patient was discharged from the Emergency Department without a documented medical screening examination.

An interview with EMP2 and EMP3 on April 29, 2014, at approximately 11:00 AM, confirmed that there is no documented medical screening examination present on MR1.

3) Review of medical record (MR18) dated March 7, 2014, revealed that the patient's Chief Complaint was abdominal cramping. Review of medical record (MR13) dated April 12, 2014, revealed that the patient's Chief Complaint was lower back pain, pressure and cramping. There was no evidence that a medical screening exam was completed in either of these two medical records (MR13 and MR18).

Interview with EMP12 on April 29, 2014, at 2:20 PM stated that there should have been medical screening examinations completed on both patients. EMP12 confirmed that labor was ruled out and that there was no MSE performed by the primary practitioner or ED physician in MR13 and MR18.