HospitalInspections.org

Based on medical record review, review of the Hospital Policies and Procedures and interviews, the Governing Body failed to ensure quality medical care to 1 patient (Patient #1) in a total sample of 10 patients who received medical care in the Emergency Department (ED).
Findings include:

1.) The Surveyor interviewed Patient #1 at 9:07 A.M. on 5/8/14. Patient #1 said that she went to the ED with vaginal bleeding on 11/30/13. Patient #1 said she was seen by the Emergency Department Physician who did not examine her or listen for a fetal heart rate (FHR). The ED Physician did not order a consultation with a trained obstetrical physician nor did she order fetal monitoring. Patient #1 said she was asked about the vaginal bleeding when she was brought to the ED examination room, but not asked again about any signs or symptoms of bleeding during the approximately three (3) hour stay in the ED.

2.) The Rapid Assessment Triage Note, dated 11/30/13 at 10:07 A.M., indicated Patient #1
presented to the Emergency Department (ED) with vaginal spotting.

3.) The ED Physician Note, dated 11/30/13 at 11:51 A.M., indicated Patient #1 was 25 weeks pregnant. The ED Physician Note did not indicate a FHR was recorded. The ED Physician Note did not contain documentation of a comprehensive review of Patient #1's bleeding symptoms i.e. amount, duration, or on-going signs of bleeding. The FHR was not recorded until an Ultrasound was performed, approximately four (4) hours after Patient #1 presented to the ED.

4.) The Surveyors interviewed the ED Physician at 3:30 P.M. on 5/8/13. The ED Physician said Patient #1 refused the internal examination and requested ultrasound testing. Patient #1's ED Physician Note did not contain documentation of an internal examination or that the internal exam was refused.

5.) The Surveyors interviewed the Medical Director for Emergency Services at 1:48 on 5/7/14. The Director said it is a standard of care to check a FHR if a FHR can be obtained.

Based on medical record review, review of the Hospital Policies and Procedures and staff interviews, the Hospital failed to establish policies and procedures to guide the Emergency Department (ED) staff in monitoring a pregnant patient according to accepted clinical practice.
Findings include:

1.) According to the Lippincott Manual of Nursing Practice, 10th Edition, 2014, the evaluation of the Fetal Heart Rate is a routine assessment of fetal well-being in cases of threatened abortion or other abnormalities.

2.) The Surveyor reviewed the ED Policy and Procedure Manual on 5/6/14. The Hospital had no policies established for monitoring pregnant patients seeking ED care.