HospitalInspections.org

Based on document review and interviews, the Hospital's policies and procedures (P&P) and Medical Staff Bylaws / Rules & Regulations were not accurate and complete regarding EMTALA (Emergency Medical Treatment and Labor Act) requirements. Findings include: -- The hospital P&P titled "Triage of Obstetric Patients," last revised June 2013, was reviewed on 11/04/13. It indicated that medical screening examinations (MSEs) must be performed for all patients who present for obstetrical evaluation, screening or services, and defined the qualified medical provider (QMP) who can perform MSEs as a doctor of medicine or osteopathy, or a certified nurse midwife. The P&P also contained the statement, "If appropriate the on call OB (obstetrical) MD (physician) will respond within a reasonable amount of time per the Medical Staff By Laws." The P&P lacked definition of "if appropriate" and lacked procedures to ensure completion of MSEs for all OB patients presenting with potential emergency medical conditions. -- Also, 11/04/13 review of the hospital Medical Staff By Laws, last approved 4/22/13, and the Medical Staff Rules & Regulations, last approved 2/08/11, revealed they did not define response times by on-call physicians. -- Additionally, EMTALA requirements regarding how the hospital should respond to situations in which a particular physician specialty is not available or the on-call physician cannot respond because of circumstances beyond his/her control were not addressed in any hospital documents, including the ones noted above. -- During interviews with the Quality Department RN/ Medical Staff Quality Nurse at various times on 11/04/13 and 11/05/13, he/she acknowledged the findings above.

Based on document review, medical record (MR) review, and interview, the Hospital failed to provide timely treatment to 1 of 8 patients presenting to rule out labor (Patient A). Specifically, a qualified medical provider (QMP) did not perform a timely medical screening examination (MSE) when the patient presented to the obstetrics unit. Findings include:

-- At this hospital, the QMPs who are authorized to perform MSEs are doctors of medicine or osteopathy, and certified nurse midwives. See findings in tag A2400.
-- Review of Patient A's MR reveals the following information:
This twenty-seven year old female was admitted to the obstretrical unit at 4:30 pm on 9/30/13 with chief complaint of scant amount of vaginal bleeding, pressure and labor. She was Gravida 7 Para 5 (history of 7 pregnancies and 5 births) at 36 4/7 weeks gestation. By 5:30 pm RN (registered nurse) #1 performed an admission assessment, was monitoring fetal activity (fetal heart rate baseline 130 with positive accelerations) and completed a sterile vaginal examination (SVE) which showed small amount of bloody mucus on the glove. RN #1 documented notifying the attending obstetrician (Physician #1) of the patient's admission and SVE results; physician #1 indicated he/she would be in to see the patient. Nursing staff continued to monitor the patient throughout the night. There is no documentation indicating Physician #1 evaluated Patent A. On 10/01/13 at 9:00 am Physician #2 (another attending obstetrician) evaluated Patient A, ordered a bedside ultrasound and documented that Patient A had no contractions for past 2-3 hours and was not in labor. Patient A was discharged home with written instructions. This MSE by a QMP was not performed until 16 1/2 hours after the patient presented.
-- During interview with RN #1 on 11/05/13 at 1:20 pm, he/she reviewed the MR documentation about the SVE and acknowledged that at this hospital RNs are not QMPs who can perform MSEs, i.e., determine if a patient is in labor.

Based on findings from medical record (MR) review, an obstetrical patient (Patient B) was discharged in an unstable condition following presentation and evaluation for antepartal bleeding. The patient was not monitored for a sufficient period of time following admission for observation.
Findings include:

Review of Patient B's MR reveals the following information:

This twenty-eight (28) year old female (Gravida 6 Para 3 at 35 5/7 estimated gestational age) presented to the hospital on 7/18/13 at 2330 via ambulance with chief complaints of frank vaginal bleeding - estimated to be 100 ml during transport- and arrived on the obstetrical unit at 23:00. Nursing notes by Registered Nurse (RN) #3 state "patient comes from home with towel moderately soaked with bright red blood. No active bleeding." Physician #3 (a Resident) completed the history & physical examination at 23:00 and admitted the patient for observation. Physician #3 completed medical re-evaluations of the patient at 01:00; 04:40 and 8:30. On 7/19/13 at 12:45, Physician #4 (an Attending Obstetrician) evaluated the patient and noted no active bleeding, ultrasound sonogram (US; done at 9:39) revealed the placenta was posterior, no previa or abruption, amniotic fluid within normal limits. The patient was discharged home at 13:31 with diagnosis of "antepartum bleed - resolved," with instructions about signs requiring emergency medical attention and with a follow up appointment to "see in office" on 7/23/13, 4 days later.

Physician review of this case has identified the following:

Regarding placental abruption:
The patient was contracting every 2 minutes from admission through 5:30 am on 7/19. Regular painful contractions in the setting of spontaneous bleeding are placental abruption until proven otherwise. Although the notes explain that the patient did not have any significant bleeding in the hospital, she did have significant bleeding prior to admission. EMS (Emergency Medical Services) reported that the patient noted blood running down her legs and estimated blood loss on the floor to be 50 - 75 cc (cubic centimeters): this is not a typical sign of preterm labor. The admitting RN noted that the patient had a towel "moderately soaked with bright red blood" from home.

Regarding preterm labor: Although this is not the patient ' s primary diagnosis, the following cervical examinations are recorded in the chart:

7/18 at 23:00, closed/thick/-3/posterior (recorded by RN #3, performed by Physician #3)
7/19 at 04:45, 1cm/30% effaced/-3 to -2 station/anterior/soft (recorded by RN #3, performed by Physician #3)
7/19 at 08:15, closed/30%/-3 to -2 station/anterior/soft (recorded by RN #3, performed by Physician #3)
7/19 at 13:31, discharge notes by RN #4 indicate pelvic rest and bed rest and to "keep appointment next Tuesday."

In summary, the patient had 3 exams by Physician #3. There was cervical change from 1st to the 2nd examination. When labor is starting the cervix softens (effacement went from " thick " which is 0% to 30%), and moves from posterior to anterior, begins to dilate (went from closed to 1 cm open) and also softens. All of these changes are documented but there is no plan in place regarding their findings.

It is confusing that at the 3rd exam by the same physician (Physician #3), RN #3 described the cervix as closed. The cervix does not close up again once labor begins. So, as documented, one of these examinations is erroneous.

In summary, the patient's presentation was most consistent with a placental abruption. Although preterm labor can result from abruption and must be considered, the patient should have been monitored for a much longer time to ensure that the placenta was not prematurely separating from the uterine wall. She should not have been discharged. Signs of abruption include bleeding, but also pain and contractions. The patient was discharged home just a few hours after her contractions spaced out a bit. But they did not go away, and since there was no other explanation for contractions, the most likely diagnosis was abruption. An US cannot be used to "rule out" abruption. If a section of placenta is noted to have separated from the uterus on US this can support the diagnosis, but most cases of abruption are not evident on US.

An additional finding in the US revealed the estimated fetal weight (EFW) was less than 10 percentile. This was a significant finding and should have been followed by either immediate umbilical artery dopplers or a plan for very short term follow up. There is no evidence of either in the MR.