HospitalInspections.org

Based on record review of 30 sampled Emergency Department (ED) records, staff interviews, physician interview and review of facility EMTALA policies and procedures, 1 (Patient 18) of 30 sampled patients failed to receive a Medical Screening Examination (MSE) in accordance with the facility policies and procedures. The facility self -reported the incident however failed to implement corrective action prior to the unannounced survey on 4/11/17. This failure places patients presenting to the ED at risk for harm related to potential failure to identify and treat an Emergency Medical Condition (EMC). Facility provided ED records reveal the ED has seen an average of 192 patients per month since 10/1/16. Findings are:

A. Record review of facility policy titled "EMTALA PLAN" dated 02/2015 states under the section titled "Medical Screening Examination" that "For any individual who comes to the hospital seeking emergency services, an appropriate medical screening evaluation must be completed to determine whether or not an emergency medical condition exists. Record review of facility policy titled "Triage of OB [Obstetric] Patients Presenting to the Emergency Department" dated 06/2014 states "It is our policy to provide a medical screening exam and stabilizing care to all obstetric patients in need of emergency care. Care is provided in compliance with Emergency Medical Treatment and Labor Act (EMTALA ) guidelines. The policy further states "All pregnant patients greater than 20 weeks gestation, with or without a primary care provider on staff who present to the ER [Emergency Room] requesting care must have an OB and fetal evaluation, regardless of the presenting chief complaint, by a qualified provider."

B. On 4/7/17 the State Survey Agency was notified by Hospital A, Jennie M. Melham Memorial Medical Center Administration of a potential EMTALA violation related to Patient 18 who presented to their ED on 3/31/17. The report stated that the facility had been notified by (Hospital B) that Patient 18 came to their hospital with complaint of decreased fetal movement. The patient told Hospital B that Hospital A ED told Patient 18 to go to Hospital B to see her regular doctor. The patient presented to Hospital B ER without transfer papers or phone call notifying them the patient was coming.

C. Record review of the ED log revealed Patient 18 presented with her husband to the ED on 3/31/17 at 10:35 PM. The log lists the "Complaint" as "Pregnancy issues greater than 20 wks [weeks]."The record contains no evidence of a MSE as per their policy.

D. Staff Interview with Licensed Practical Nurse (LPN) C on 4/12/17 at 5:15 PM reveals that Patient 18 presented to the Registration Window of the ED on 3/31/17. LPN C registers ED patients and helps in the ED. LPN C stated Patient 18 told her she was 7 months pregnant and had been accidentally hit in the stomach. LPN C completed the registration and told the patient and her husband to come inside the ED and wait in a chair while she cleaned a room. LPN C went around the corner to the ED desk and told ED Medical Doctor (EDMD A) that "I have a woman who is 7 months pregnant and got hit in the stomach." EDMD A asked if she has a doctor locally. LPN C stated "No she doctors at [Name of OB Practice in same town as Hospital B]. EDMD A then responded stating "lets have her go down to [Name of town with Hospital B] to see her regular physician. LPN C stated this surprised her. She did not explain that the patient was in the ED. LPN C then informed the ED Charge Registered Nurse (RN B). LPN C stated she then told the patient and her husband to go visit their regular doctor. She stated they said "OK" and left. LPN C reported she read through the EMTALA policies yesterday 4/11/17 and understands anyone who presents to the ED "should be seen by a RN and MD or PA."

E. Interview with EDMD A on 4/12/17 at 1:45 PM confirmed being the EDMD on call on 3/31/17 from 5 PM until 7 AM on 4/1/17. EDMD A is also the Medical Director of the ED and provides OB services in private practice as a family medicine provider. EDMD A recalled being at the nurses desk in the ED when LPN C came up and told him about an OB patient that was hit in the stomach and had some pain. EDMD A stated "I assumed it was a patient phone call." LPN C stated the patient's OB is in [Name of town with Hospital B]. I told her it was best to to go to [Name of town with Hospital B] as our Ultrasound Technician was not available on the weekend. EDMD A stated that the patient would have had a Doppler (ultrasound) , palpation of the abdomen and Electronic Fetal Monitoring depending on gestational age as a normal part of the exam. EDMD A confirmed the patient failed to have a MSE and confirmed this failure violated the requirements of EMTALA related to MSE. The physician denied having any formal EMTALA training. ED MD A stated " I assumed she was not here and would have assumed the patient had an EMC until the exam proved otherwise." Next time "I'll make sure I ask if the patient is here or not."

F. Interview with RN B on 4/12/17 at 5:45 PM confirmed hearing LPN C tell EDMD A that she had a 30 week OB who doctors in [Name of town with Hospital B] that got hit in stomach and what should she do with the patient. RN B stated she had the impression that the "patient was here." RN B heard EDMD A tell LPN C to tell the patient to go to [Name of town with Hospital B]. RN B stated she did not see the patient in the ED. She found out a mistake was made when called by the Director of Nurses on 4/7/17. RN B stated "we failed to do a MSE."

G. Interview with the Administrator on 4/12/17 at 4 PM confirmed the facility is planning formal education for all staff and providers on EMTALA but course content or date has not been set.

Based on record review of 30 sampled Emergency Department (ED) records, staff interviews, physician interview, receiving hospital record review and review of facility EMTALA policies and procedures, 1 (Patient 18) of 30 sampled patients who presented to the ED failed to receive a Medical Screening Examination (MSE). The facility self -reported the incident however failed to implement corrective action prior to the unannounced survey on 4/11/17. This failure places patients presenting to the ED at risk for harm related to potential failure to identify and treat an Emergency Medical Condition (EMC). Facility provided ED records reveal the ED has seen an average of 192 patients per month since 10/1/16. Findings are:

A. Record review of facility policy titled "EMTALA PLAN" dated 02/2015 states under the section titled "Medical Screening Examination" that "For any individual who comes to the hospital seeking emergency services, an appropriate medical screening evaluation must be completed to determine whether or not an emergency medical condition exists. Record review of facility policy titled "Triage of OB [Obstetric] Patients Presenting to the Emergency Department" dated 06/2014 states "It is our policy to provide a medical screening exam and stabilizing care to all obstetric patients in need of emergency care. Care is provided in compliance with Emergency Medical Treatment and Labor Act (EMTALA ) guidelines. The policy further states "All pregnant patients greater than 20 weeks gestation, with or without a primary care provider on staff who present to the ER [Emergency Room] requesting care must have an OB and fetal evaluation, regardless of the presenting chief complaint, by a qualified provider."

B. On 4/7/17 the State Survey Agency was notified by Hospital A, Jennie M. Melham Memorial Medical Center Administration of a potential EMTALA violation related to Patient 18 who presented to their ED on 3/31/17. The report stated that the facility had been notified by (Hospital B) that Patient 18 came to their hospital with complaint of decreased fetal movement. The patient told Hospital B that Hospital A ED told Patient 18 to go to Hospital B to see her regular doctor. The patient presented to Hospital B ER without transfer papers or phone call notifying them the patient was coming.

C. Record review of the ED log revealed Patient 18 presented with her husband to the ED on 3/31/17 at 10:35 PM. The log lists the "Complaint" as "Pregnancy issues greater than 20 wks [weeks]."The record contains no evidence of a MSE as per their policy.

D. Staff Interview with Licensed Practical Nurse (LPN) C on 4/12/17 at 5:15 PM reveals that Patient 18 presented to the Registration Window of the ED on 3/31/17. LPN C registers ED patients and helps in the ED. LPN C stated Patient 18 told her she was 7 months pregnant and had been accidentally hit in the stomach. LPN C completed the registration and told the patient and her husband to come inside the ED and wait in a chair while she cleaned a room. LPN C went around the corner to the ED desk and told ED Medical Doctor (EDMD A) that "I have a woman who is 7 months pregnant and got hit in the stomach." EDMD A asked if she has a doctor locally. LPN C stated "No she doctors at [Name of OB Practice in same town as Hospital B]. EDMD A then responded stating "lets have her go down to [Name of town with Hospital B] to see her regular physician. LPN C stated this surprised her. She did not explain that the patient was in the ED. LPN C then informed the ED Charge Registered Nurse (RN B). LPN C stated she then told the patient and her husband to go visit their regular doctor. She stated they said "OK" and left. LPN C reported she read through the EMTALA policies yesterday 4/11/17 and understands anyone who presents to the ED "should be seen by a RN and MD or PA."

E. Interview with EDMD A on 4/12/17 at 1:45 PM confirmed being the EDMD on call on 3/31/17 from 5 PM until 7 AM on 4/1/17. EDMD A is also the Medical Director of the ED and provides OB services in private practice as a family medicine provider. EDMD A recalled being at the nurses desk in the ED when LPN C came up and told him about an OB patient that was hit in the stomach and had some pain. EDMD A stated "I assumed it was a patient phone call." LPN C stated the patient's OB is in [Name of town with Hospital B]. I told her it was best to to go to [Name of town with Hospital B] as our Ultrasound Technician was not available on the weekend. EDMD A stated that the patient would have had a Doppler (ultrasound) , palpation of the abdomen and Electronic Fetal Monitoring depending on gestational age as a normal part of the exam. EDMD A confirmed the patient failed to have a MSE and confirmed this failure violated the requirements of EMTALA related to MSE. The physician denied having any formal EMTALA training. ED MD A stated " I assumed she was not here and would have assumed the patient had an EMC until the exam proved otherwise." Next time "I'll make sure I ask if the patient is here or not."

F. Interview with RN B on 4/12/17 at 5:45 PM confirmed hearing LPN C tell EDMD A that she had a 30 week OB who doctors in [Name of town with Hospital B] that got hit in stomach and what should she do with the patient. RN B stated she had the impression that the "patient was here." RN B heard EDMD A tell LPN C to tell the patient to go to [Name of town with Hospital B]. RN B stated she did not see the patient in the ED. She found out a mistake was made when called by the Director of Nurses on 4/7/17. RN B stated "we failed to do a MSE."

G. Record review of the ED record from Hospital B revealed the patient arrived on 4/1/17 at 12:05 AM. The Physician Progress notes stated the patient presented with complaint of trauma to abdomen. The patient was evaluated until discharge at 4:45 AM with diagnosis of a "Reactive NST [Non Stress Test]. A NST measures the fetal heart rate by using an Electronic Fetal Monitor. The heart rate if reactive accelerates above the baseline 2 times or more for at least 10 seconds in a 20 minute window. A Reactive NST is a normal finding and confirmation of fetal well being.

H. Interview with the Administrator on 4/12/17 at 4 PM confirmed the facility is planning formal education for all staff and providers on EMTALA but course content or date has not been set.