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.

BAYLOR EMERGENCY MEDICAL CENTER 1975 ALPHA STE 100 ROCKWALL, TX 75087 Aug. 16, 2016
VIOLATION: EMERGENCY SERVICES Tag No: A1100
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure:

A. pregnant patients received accurate and thorough assessments (Patient #12).
B. accurate information was provided to a receiving hospital in an emergency transfer involving a pregnant female in imminent delivery.
C. emergency room staff were trained in assessing and monitoring pregnant patients and fetuses.

This deficient practice was found in 1 of 1 patients (Patient #12) and had the likelihood to cause harm in all pregnant patients presenting to the emergency room .

Findings include:

Review of the emergency room nurses notes revealed Patient #12 was a [AGE] year old female who (MDS) dated [DATE] at 9:29 a.m. with presenting problems of pelvic pain and pregnant.
Review of the nurse's triage notes timed 9:30 a.m., revealed the following documentation about Patient #12:
"Pt brought via wheelchair back to restroom. Pt of normal stature with swollen abdomen, and complaints of severe left groin pain and abdominal pain overnight and more severe this AM. Pt denies pregnancy and states she took a morning after pill in October and has not had a full period since that time. Pt states she has spotted several times and mother confirms negative home pregnancy test in December."
At 9:37 a.m., underneath the physician's physical exam the following was documented:
CONSTITUTIONAL: ... "Patient appears in pain, in moderate pain distress." ...
ABDOMEN FEMALE: "Abdominal exam included findings of abdomen tender, to the left lower quadrant, moderate intensity," ... "Peritoneal signs present, guarding present, Rovsing's sign absent."
PELVIC: "Bimanual exam abnormal, Cervix dilated greater than 6 cm, No cervical motion tenderness, No adrenal mass, Uterus above umbilicus, can palpate head at cervix, Urethral exam normal. Bladder exam normal, no tenderness, Escorted by RN, ...., no mass, head at 0 station, cervix is effaced.. Not crowning."

At 9:50 a.m., nurses documented "Dr. #5 remains at bedside FHT completed at 156, he completed a visual on US and heart beat appears strong and baby appears to be in correct position. Pt cervix checked by Dr. #5 pt fully dilated, pt denies need to push c/o constant pain with periods of increased pain. Contractions are 2-3 minutes apart. Family at bedside update on POC. Pt tolerating well states took 2 hydrocodone prior to arrival, respirations easy unlabored and no distress noted."
At 10:07 a.m., nurse notes showed documentation of "MD #5 assessment, pt's cervix complete and fetal head is balottable."
At 10:08 a.m. ... "EMS was present in room to transport."
At 10:12 a.m., underneath doctor notes there was documentation of "Crowning at cervix; fully dilated. Blood at the introitus."
At 10:12 a.m.,"Dr. #5 discussed with Dr. #7 to accept pt even though she is in active labor.
At 10:15 a.m., "Pt moved to a larger room. Pt having small amount of blood discharge. Dr. #5 at bedside and completed FHT at 167 and again checked the pt with no change in labor status. Pts contractions remain at 2-3 mins apart. Pt tolerating well, respirations easy unlabored and family at side. Receiving hospital Dr. #7 has spoke to Dr. #5 and accepted pt, awaiting Admin approval and EMS."
At 10:18 a.m., "Pt left with... EMS."
At 10:18 a.m., "EMS at bedside and Admin approved transfer because pt is not delivering at this time. No crowning noted and baby still remains high up, contractions are 2 mins apart ....
At 10:19 a.m., underneath doctor notes the following was documented "pt at near term pregnancy with no PNC, not in labor. Ctxns were 4-5 mins apart but no progress in station of baby. Receiving hospital accepted and pt enroute now. Pt re-examined prior to transfer and no further movement of child, still feels to be at 0 station, fht at 148."
Review of Memorandum of Transfer revealed the physician signed the "PHYSICIAN CERTIFICATION" section, but failed to check the reason in the area for Summary of Risks and Benefits"
According to documentation there were discrepancies in the assessments on if the baby was crowning and how far Patient #12 had dilated. There was no assessment of how long the contractions were lasting and no documentation of an evaluation of the membranes being intact or not. The physician failed to complete the certification on Patient #12.

Review of EMS report with a departure for 10:18 a.m. revealed the following documentation:
... " PT is in labor, 10 cm dilated and is having contractions at 90 seconds apart lasting for 30 seconds ....During transport PT began to have contractions every 60 seconds lasting 30 seconds with more intense pain. Report called to RN staff, Pt was taken straight to L&D .....RN nurse was also taken and rode in the back of the MICU with PT and medic 302 for assistance in case of delivery." According to documentation the EMS arrived at the receiving hospital at 10:24 a.m. (6 minutes after leaving the transferring hospital).
The EMS documentation revealed the contractions were close and Patient #12 was dilated at 10 centimeters.

Review of nurse's notes from the receiving hospital, at 10:39 a.m., Patient #12 was complete at 100 percent and baby at station +2. Patient #12 was repositioned to push.
Review of the receiving hospital's notes Patient #12 gave birth to the baby at 10:49 a.m. (25 minutes after getting to the hospital).

During an interview on 08/15/2016 after 2:30 p.m., Staff #10 confirmed she was the primary nurse taking care of Patient #12 on 07/04/2016. Staff #10 confirmed she recorded some of the information as Dr. #5 was checking Patient #12. Staff #10 confirmed she recorded that Patient #12 was fully dilated because that's what was said. Staff #10 reported that fully dilated meant at a 10 (centimeters). Staff #10 confirmed she rode in the ambulance with the EMTs because they thought Patient #12 might have the baby in the ambulance. Mid trip Patient #12 starting complaining that the contractions were getting really bad and the EMS staff called ahead to see if the receiving hospital was ready. After getting to the receiving hospital Patient #12 had the baby about 30 minutes later.
Staff #10 reported she did not have any training on assessing pregnant moms or monitoring neonates from the hospital. Staff #10 confirmed they did not have fetal monitoring equipment, they just had the Doppler to check the baby's heart rate.

During an interview on 08/15/2016 after 3:25 p.m., Staff #11 reported she was the other nurse that assisted with Patient #12. Staff #11 confirmed she recorded some information in the chart for the physician. Staff #11 recorded that the cervix appeared complete in the notes. It was taken to mean fully dilated at 10 centimeters. Staff #11 confirmed not knowing how the contractions were on Patient #12. There was no monitoring equipment to check contractions. Staff #11 reported she knew about delivering babies from working in another emergency room and from nursing school. No training had been provided at this facility.

During an interview on 08/15/2016 after 4:00 p.m., with Dr. #5 confirmed he was the physician that assessed Patient #12. Dr. #5 reported he did not feel like Patient #12 was at imminent delivery. He did not observe active contractions. Dr. #5 reported Patient #12 was in active labor, but the baby was not crowning yet. Dr. #5 reported the documentation in the chart about the baby crowning was written in error by the scribe. Dr. #5 reported Patient #12 was dilated at about 6-7 centimeters, contractions were 4-5 minutes apart and the baby's station was 0 or -1.

During an interview on 08/15/2016 after 4:00 p.m., Staff #1 and #2 confirmed the problems found with the inaccurate assessments.

During an interview on 08/16/2016 after 12:00 p.m. with Staff #9, revealed there were tapes from the transfer line conversations. The tapes confirmed that initially Staff #12 called the transfer line and reported that they needed a STAT transfer and that Patient #12 was full term and fully dilated. They were going to deliver and stabilize and then transfer. Dr. #7 approved the transfer for post-delivery. During a conversation with Dr. #5 and Dr. #7, it was reported that Patient 12 was dilated at a 5 centimeters. Dr. #7 approved the transfer based on the information provided to her from Dr. #5.
Inaccurate information was provided to the receiving facility.

Review of facility training information that was provided revealed no documentation of care of pregnant patients. Information given was concerning annual training provided in January 2016 and another training about a recent EMTALA which did not involve a pregnant patient.
A mock code dated November 2015 was provided which involved taking care of a pregnant patients in the emergency room .
During an interview on 08/16/2016 after 10:00 a.m., Staff #1 reported the mock code was performed in November 2015. No attendance list was provided to show who attended and if they were tested for proficiency over the information.


Review of a facility policy named "EMTALA-MEDICAL SCREENING EXAMINATION AND STABILIZATION POLICY" revealed the following:
EXTENT OF THE MSE
5 ....
"Pregnant Women: the medical records should show evidence that the screening examination includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membrane(i.e. ruptured, leaking and intact)" .....

Review of a facility policy named "EMTALA GUIDELINES" revealed the following:
"Emergency Medical Condition: A medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor) such that the absence of immediate medical attention could place the individual's health at risk."

EMERGENCY MEDICAL CONDITIONS:
"Pregnancy with contractions (defined as unstable)"


According to the facility Medical Staff "Rules and Regulations" the following was documented:
X. EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT
"In compliance with the federal Emergency Medical Treatment and Active Labor Act ("the Act"), every patient who comes to the Emergency Department is entitled to an appropriate medical screening examination to determine whether the patient suffers from an emergency medical condition or is in active labor (i.e., pregnancy with contractions present). If either condition is present, qualified medical personnel will provide treatment as may be required to stabilize the medical condition regardless of the patient's insurance status or ability to pay. The emergency needs of the patient will be met according to acceptable standards of medical practice. A medical screening examination sufficient to detect the presence of an emergency medical condition or active labor will be performed by qualified medical personnel, which will be the attending ER physician. The attending physician is ultimately responsible for screening examinations. If, after the screening examination, in the best medical judgement of the provider, the patient is not in active labor and no emergency condition is present, the patient will be treated, referred or transferred according to the internal Emergency Department or Ambulatory Services procedures and appropriate standards of medical practice. Where the patient is transferred to another facility, appropriate documentation will be sent with the patient."...

Review of a facility policy named "PATIENT TRANSFER POLICY" revealed the following:
Special requirements related to the transfer of patients who have emergency medical conditions.
b. Our hospital may not transfer a patient with an emergency medical condition which has not been stabilized unless:
"a physician has signed a certification, which includes a summary of the risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonable expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer";
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure:
A. accurate information was provided to a receiving hospital about an emergency transfer involving a unstable pregnant female in imminent delivery.
B. ensure the physician certification contained a summary of the risks and benefits of the transfer.
This deficient practice was found in 1 of 1 patients (Patient #12) and had the likelihood to cause harm in all pregnant patients presenting to the emergency room .

Findings include:

Review of the emergency room nurses notes revealed Patient #12 was a [AGE] year old female who (MDS) dated [DATE] at 9:29 a.m. with presenting problems of pelvic pain and pregnant.
Review of the nurse's triage notes timed 9:30 a.m., revealed the following documentation about Patient #12:
"Pt brought via wheelchair back to restroom. Pt of normal stature with swollen abdomen, and complaints of severe left groin pain and abdominal pain overnight and more severe this AM. Pt denies pregnancy and states she took a morning after pill in October and has not had a full period since that time. Pt states she has spotted several times and mother confirms negative home pregnancy test in December."
At 9:37 a.m., underneath the physician's physical exam the following was documented:
CONSTITUTIONAL: ... "Patient appears in pain, in moderate pain distress." ...
ABDOMEN FEMALE: "Abdominal exam included findings of abdomen tender, to the left lower quadrant, moderate intensity," ... "Peritoneal signs present, guarding present, Rovsing's sign absent."
PELVIC: "Bimanual exam abnormal, Cervix dilated greater than 6 cm, No cervical motion tenderness, No adrenal mass, Uterus above umbilicus, can palpate head at cervix, Urethral exam normal. Bladder exam normal, no tenderness, Escorted by RN, ...., no mass, head at 0 station, cervix is effaced.. Not crowning."

At 9:50 a.m., nurses documented "Dr. #5 remains at bedside FHT completed at 156, he completed a visual on US and heart beat appears strong and baby appears to be in correct position. Pt cervix checked by Dr. #5 pt fully dilated, pt denies need to push .c/o constant pain with periods of increased pain. Contractions are 2-3 minutes apart. Family at bedside update on POC. Pt tolerating well states took 2 hydrocodone prior to arrival, respirations easy unlabored and no distress noted."
At 10:07 a.m., nurse notes showed documentation of "MD #5 assessment, pt's cervix complete and fetal head is balottable."
At 10:08 a.m. ... "EMS was present in room to transport."
At 10:12 a.m., underneath doctor notes there was documentation of "Crowning at cervix; fully dilated. Blood at the introitus."
At 10:12 a.m.,"Dr. #5 discussed with Dr. #7 to accept pt even though she is in active labor.
At 10:15 a.m., "Pt moved to a larger room. Pt having small amount of blood discharge. Dr. #5 at bedside and completed FHT at 167 and again checked the pt with no change in labor status. Pts contractions remain at 2-3 mins apart. Pt tolerating well, respirations easy unlabored and family at side. Receiving hospital Dr. #7 has spoke to Dr. #5 and accepted, pt awaiting Admin approval and EMS."
At 10:18 a.m., "Pt left with... EMS."
At 10:18 a.m., "EMS at bedside and Admin approved transfer because pt is not delivering at this time. No crowning noted and baby still remains high up, contractions are 2 mins apart ....
At 10:19 a.m., underneath doctor notes the following was documented "pt at near term pregnancy with no PNC, not in labor. Ctxns were 4-5 mins apart but no progress in station of baby. Receiving hospital accepted and pt enroute now. Pt re-examined prior to transfer and no further movement of child, still feels to be at 0 station, fht at 148."
Review of Memorandum of Transfer revealed the physician signed the "PHYSICIAN CERTIFICATION" section, but failed to check the reason in the area for Summary of Risks and Benefits".
According to documentation there were discrepancies in the assessments on if the baby was crowning and how far Patient #12 had dilated. There was no assessment of how long the contractions were lasting and no documentation of an evaluation of the membranes being intact or not. The physician failed to complete the certification on Patient #12.

Review of EMS report with a departure for 10:18 a.m. revealed the following documentation:
... " PT is in labor, 10 cm dilated and is having contractions at 90 seconds apart lasting for 30 seconds ....During transport PT began to have contractions every 60 seconds lasting 30 seconds with more intense pain. Report called to RN staff, Pt was taken straight to L&D .....RN nurse was also taken and rode in the back of the MICU with PT and medic 302 for assistance in case of delivery." According to documentation the EMS arrived at the receiving hospital at 10:24 a.m. (6 minutes after leaving the transferring hospital).
The EMS documentation revealed the contractions were close and Patient #12 was dilated at 10 centimeters.

Review of nurse's notes from the receiving hospital, at 10:39 a.m., Patient #12 was complete at 100 percent and baby at station +2. Patient #12 was repositioned to push.
Review of the receiving hospital's notes Patient #12 gave birth to the baby at 10:49 a.m. (25 minutes after getting to the hospital).

During an interview on 08/15/2016 after 2:30 p.m., Staff #10 confirmed she was the primary nurse taking care of Patient #12 on 07/04/2016. Staff #10 confirmed she recorded some of the information as Dr. #5 was checking Patient #12. Staff #10 confirmed she recorded that Patient #12 was fully dilated because that's what was said. Staff #10 reported that fully dilated meant at a 10 (centimeters). Staff #10 confirmed she rode in the ambulance with the EMTs because they thought Patient #12 might have the baby in the ambulance. Mid trip Patient #12 starting complaining that the contractions were getting really bad and the EMS staff called ahead to see if the receiving hospital was ready. After getting to the receiving hospital Patient #12 had the baby about 30 minutes later.
Staff #10 reported she did not have any training on assessing pregnant moms or monitoring neonates from the hospital. Staff #10 confirmed they did not have fetal monitoring equipment, they just had the Doppler to check the baby's heart rate.

During an interview on 08/15/2016 after 3:25 p.m., Staff #11 reported she was the other nurse that assisted with Patient #12. Staff #11 confirmed she recorded some information in the chart for the physician. Staff #11 recorded that the cervix appeared complete in the notes. It was taken to mean fully dilated at 10 centimeters. Staff #11 confirmed not knowing how the contractions were on Patient #12. There was no monitoring equipment to check contractions. Staff #11 reported she knew about delivering babies from working in another emergency room and from nursing school. No training had been provided at this facility.
During an interview on 08/15/2016 after 4:00 p.m., with Dr. #5 confirmed he was the physician that assessed Patient #12. Dr. #5 reported he did not feel like Patient #12 was at imminent delivery. He did not observe active contractions. Dr. #5 reported Patient #12 was in active labor, but the baby was not crowning yet. Dr. #5 reported the documentation in the chart about the baby crowning was written in error by the scribe. Dr. #5 reported Patient #12 was dilated at about 6-7 centimeters, contractions were 4-5 minutes apart and the baby's station was 0 or -1.

During an interview on 08/15/2016 after 4:00 p.m., Staff #1 and #2 confirmed the problems found with the inaccurate assessments.

During an interview on 08/16/2016 after 12:00 p.m. with Staff #9, revealed there were tapes from the transfer line conversations. The tapes confirmed that initially Staff #12 called the transfer line and reported that they needed a STAT transfer and that Patient #12 was full term and fully dilated. They were going to deliver and stabilize and then transfer. Dr. #7 approved the transfer for post-delivery. During a conversation with Dr. #5 and Dr. #7, it was reported that Patient #12 was dilated at a 5 centimeters. Dr. #7 approved the transfer based on the information provided to her from Dr. #5.
Inaccurate information was provided to the receiving facility.

Review of facility training information that was provided revealed no documentation of care of pregnant patients. Information given was concerning annual training provided in January 2016 and another training about a recent EMTALA which did not involve a pregnant patient.
A mock code dated November 2015 was provided which involved taking care of a pregnant patients in the emergency room .
During an interview on 08/16/2016 after 10:00 a.m., Staff #1 reported the mock code was performed in November 2015. No attendance list was provided to show who attended and if they were tested for proficiency over the information.


Review of a facility policy named "EMTALA-MEDICAL SCREENING EXAMINATION AND STABILIZATION POLICY" revealed the following:
EXTENT OF THE MSE
5 ....
"Pregnant Women: the medical records should show evidence that the screening examination includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membrane(i.e. ruptured, leaking and intact)" .....

Review of a facility policy named "EMTALA GUIDELINES" revealed the following:
"Emergency Medical Condition: A medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor) such that the absence of immediate medical attention could place the individual's health at risk."

EMERGENCY MEDICAL CONDITIONS:
"Pregnancy with contractions (defined as unstable)"


According to the facility Medical Staff "Rules and Regulations" the following was documented:
X. EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT
"In compliance with the federal Emergency Medical Treatment and Active Labor Act ("the Act"), every patient who comes to the Emergency Department is entitled to an appropriate medical screening examination to determine whether the patient suffers from an emergency medical condition or is in active labor (i.e., pregnancy with contractions present). If either condition is present, qualified medical personnel will provide treatment as may be required to stabilize the medical condition regardless of the patient's insurance status or ability to pay. The emergency needs of the patient will be met according to acceptable standards of medical practice. A medical screening examination sufficient to detect the presence of an emergency medical condition or active labor will be performed by qualified medical personnel, which will be the attending ER physician. The attending physician is ultimately responsible for screening examinations. If, after the screening examination, in the best medical judgement of the provider, the patient is not in active labor and no emergency condition is present, the patient will be treated, referred or transferred according to the internal Emergency Department or Ambulatory Services procedures and appropriate standards of medical practice. Where the patient is transferred to another facility, appropriate documentation will be sent with the patient."...

Review of a facility policy named "PATIENT TRANSFER POLICY" revealed the following:
Special requirements related to the transfer of patients who have emergency medical conditions.
b. Our hospital may not transfer a patient with an emergency medical condition which has not been stabilized unless:
"a physician has signed a certification, which includes a summary of the risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonable expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer;"