HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 21 patients, the hospital failed to ensure compliance with 489.24 in that the hospital failed to perform a complete medical screening examination and failed to maintain an accurate emergency department (ED) log.

Findings include:

See findings cited at 489.20 (r) (3) and 489.24 (a) and (c).

Based on document review, the facility failed to document all patients presenting for treatment on the emergency department (ED) log for 1 patient presenting for treatment and not entered on the log (patient #1).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) Nursing note for a visit to clinic #1 indicates that the patient presented as a "walk-in" from the ED of facility #1 at 10:25 a.m. on 5/18/12. The note states "apparently the ED sent her here." A medical screening exam was not performed in the clinic. The documentation indicated that insurance status was discussed. Staff checked and found that the patient's insurance would not cover the visit. The patient was sent to Labor & Delivery (L&D) after the patient and significant other felt it would be a better place to be. The note indicated they were sent to L&D at 11:00 a.m. of same date.
(B) The record lacked evidence of an ED visit on 5/18/12.

2. Patient #1 was not listed on the facility ED log.

Based on document review and interview, the facility failed to provide a medical screening exam upon presentation to the facility for 1 of 21 patients (patient #1).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) Nursing note for a visit to clinic #1 indicates that the patient presented as a "walk-in" from the ED of facility #1 at 10:25 a.m. on 5/18/12. The note states "apparently the ED sent her here." A medical screening exam was not performed in the clinic. The documentation indicated that insurance status was discussed. Staff checked and found that the patient's insurance would not cover the visit. The patient was sent to Labor & Delivery (L&D) after the patient and significant other felt it would be a better place to be. The note indicated they were sent to L&D at 11:00 a.m. of same date.
(B) The record lacked evidence of an ED visit on 5/18/12.
(C) Per the history and physical (H&P), the patient was admitted on 5/18/12 because of a "big gush" of fluid that had occurred at 9:30 a.m. accompanied by cramping and contractions.
(D) Per delivery/procedure note, the patient was admitted at 11:07 a.m. on 5/18/12. The record indicated the baby was born at 12:27 p.m. on 5/18/12 at 26 2/7 week gestation.

2. The facility failed to follow policy titled "SCREENING AND TRANSFER OF EMERGENCY OR UNSTABLE PATIENTS" effective date of October 2010 with a revision due date of October 2013 by failing to provide a medical screening upon presentation to the ED for patient #1. The policy states on page 2 of 4: "1. When a patient presents at Clarian Health for emergency treatment, the medical screening examination will be done by the physician or the advance practice nurse."

3. The facility failed to follow policy titled "TRIAGE" effective date of January 2010 by failing to have a Registered Nurse (RN) triage patient #1 as required by policy. The policy states on page 1 of 2: "A. All patients presenting to the IU Emergency Department will be triaged by a registered nurse (RN)....."

4. The facility failed to follow policy titled "INDIANA UNIVERSITY OB TRIAGE" effective date of January 2010 by failing to obtain fetal heart tones, vital signs and notifying the physician within 15 minutes of arrival to triage as indicated in the policy. The policy states on pages 3 and 4 of 7 under procedures: "7. Apply external fetal monitor (EFM) when appropriate for gestational age.....11. Obtain blood pressure, pulse, respirations, and temperature. 12. Notify OB resident MD within 15 minutes for orders........"

5. Staff member #5 verified the clinic medical record documentation for patient #1 at approximately 12:30 p.m. on 4/7/16.