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SAMPSON REGIONAL MEDICAL CENTER 607 BEAMAN ST CLINTON, NC 28328 March 10, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy review, closed medical record review, staff and physician interviews, transfer call center logs, audio recordings, and e-mail documentation, the hospital failed to comply with 42 CFR 489.24.

The Findings include:

~cross refer to 489.24(r)and 489.24(c) Medical Screening Exam Tag A2406
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, closed medical record review, and staff and physician interviews, the hospital staff failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 1 of 2 sampled pregnant patients that presented to the hospital's Labor and Delivery Unit with complaints of uterine contractions (Patient #26).

The findings include:

Review of the hospital's policy, "Protocol for Screening Evaluation of Obstetrical Patients by Registered Nurse", effective 11/01/2008, revealed "Purpose: Provide a process that allows obstetrical patients greater than 20 weeks gestation with specific isolated pregnancy related complaints to be medically screened by a qualified registered nurse of the obstetrical staff. Policy: ...5. After the examination, the qualified staff member will relay by telephone or in person to the attending physician a summary of the information obtained. 6. On the basis of the nurse's evaluation, the physician will determine whether to admit, admit to observation or discharge the patient. ...8. Based on the nurses' findings the physician may be telephoned any time during the evaluation to relay clinical data or request that the obstetrician personally see the patient...."

Medical record review of Patient #26 revealed a [AGE] year-old pregnant female who presented to Hospital A's Labor and Delivery unit on 02/24/2011 at 1532 with chief complaint of "contractions". Record review revealed "Physician's Orders", dated 02/24/2011 at 1635. Review of the orders revealed "Admit to outpatient status. ...3. Fetal Monitor: (checked) Continuous....4. Vital Signs: Temperature, Blood Pressure, Pulse and Respirations on admission to unit...6. Diet: Ice Chips 7. Activity (checked) BRP (bathroom privileges only)...9. Lab: (checked) U/A (urinalysis) (checked ) Urine Culture (checked) Urine Drug Screen...". Record review revealed an "Obstetrical Out Patient Record" dated 02/24/2011 at 1635. Review of the obstetrical outpatient record revealed "...EDC (estimated date of confinement / due date) 4/21/11, 32 1/7 (weeks gestation) ?LMP (last menstrual period) Nurses Admission Notes G2 P1 (gravida 2 para 1) presents to L&D (labor and delivery) c (with) c/o (complaint of) labor pain since 1600. Also c/o feeling lightheaded and weak & SOB (short of breath). To BR (bathroom) u/a (urinalysis) obtained (and) sent to lab. To bed. EFM (external fetal monitor) applied. FHR (fetal heart rate) 130. VSS (vital signs stable). SVE (sterile vaginal exam) L/T/C (long, thick, closed). 1700 (up) to BR, had small BM (bowel movement). Allergies NKA (no known allergies) Temp 98.9 Pulse 96 Resp (respirations) 22 BP (blood pressure) 134/67 FHR 130...." Record review revealed results of a urinalysis microscopic exam collected at 1716 (results not timed) which showed WBC (white blood cells) 10-15 and 1+ bacteria. Record review revealed Patient #26 was discharged home at 1755. Record review revealed no documentation a physician evaluated the patient prior to discharge. Further record review revealed Physician #1 signed the record on 02/25/2011 at 0900 (15 hours, 5 minutes after Patient #26 was discharged by the nurse). Review of the obstetrical outpatient record revealed no evidence that the registered nurse telephoned the physician to relay a summary of the information obtained for Patient #26.

Interview on 03/09/2011 at 1420 with the director of obstetrics/pediatrics revealed "the nurse should always call the physician before sending a patient home". Interview confirmed there was no documented evidence that the registered nurse telephoned the physician to relay a summary of the information obtained for Patient #26 prior to discharge.

Interview on 03/09/2011 at 1425 with Registered Nurse #1 revealed the nurse assessed Patient #26 when she presented with uterine contractions on 02/24/2011. Interview revealed the nurse's usual practice was to document in the medical record whenever she called a physician with report about a patient. Interview revealed "I'm sure I called the doctor before I let her go home. I just didn't document it". Interview confirmed there was no documented evidence that the registered nurse telephoned the physician to relay a summary of the information obtained for Patient #26 prior to discharge.

Interview on 03/09/2011 at 1430 with Physician #1 revealed he was the attending physician for Patient #26. Interview revealed, "there should be documentation in the record that I was consulted/telephoned prior to discharge from L&D". Interview revealed the physician did not remember if he was called by the registered nurse on 02/24/2011 to relay a summary of the information obtained for Patient #26 prior to discharge.