Based on review of medical records, ambulance trip reports, and Policy and procedures and interviews the facility failed to ensure that an individual who presented to the dedicated emergency department with presenting signs and symptoms of vaginal bleeding and abdominal pain was provided an appropriate medical screening examination that was within the capability and capacity of hospital to determine whether or not an emergency medical condition existed for 1 (#14) of 25 sampled patients. Refer to findings in Tag A-2406.

Based on review of medical records, ambulance trip reports, and Policy and procedures and interviews the facility failed to ensure that an individual who presented to the dedicated emergency department with presenting signs and symptoms of vaginal bleeding and abdominal pain was provided an appropriate medical screening examination that was within the capability and capacity of hospital to determine whether or not an emergency medical condition existed for 1 (#14) of 25 sampled patients. Findings: Closed clinical record review on 3/14/2017 for Patient revealed that Patient #14 presented by ambulance to Hospital A's DED on 02/17/2017 at 1323 (Visit #2). Review of the ambulance run report revealed Patient #14 complained of abdominal pain, vaginal bleeding, and nausea, with vital signs of BP 106/58; P 85; R 18; and SpO2 100. Patient #14 received a Saline Lock IV, and 4 mg (milligrams) Zofran IV, which helped relieved her nausea symptoms while enroute to Carolina East Medical Center (Hospital A). Patient #14's vital signs at 1325 were: BP 102/72; P 99; R 18; T 37.0 ° C; and SpO2 98 % RA. Review of a triage note, written by Registered Nurse (RN) #1 on 02/17/2017 at 1324, revealed, "Chief Complaint: 6 wks (weeks) preg (pregnant) vag (vaginal) bleeding abd (abdominal) pain. Seen here last night for same and had Vag US 'empty sac' and HCG had dropped. Told was poss (possibly) aborting. Told to come back for bleeding. Is having some cramping. Using 1 pad/hr (hour)..." Review of an ED Irregular Discharge note, written by RN #1 on 02/17/2017 at 2046 (6 hours and 23 minutes after presentation to the DED), revealed, "...Left Without Treatment... ED Irregular Discharge Comment: Called x (times) 2 no answer." There was no documentation in the medical record to indicate that patient #14 was re-evaluated by a qualified medical person for her presenting signs and symptoms complaint of abdominal pain and vaginal bleeding when she (MDS) dated [DATE]. Telephone interview with MD #1 on 03/15/2017 at 1345, revealed, Patient #14's MSE was standard for her complaint, she was stable for discharge, and received appropriate discharge instructions. Interview on 03/15/2017 at 1020 with RN #1 revealed he recalled Patient #14. Interview revealed her vital signs were stable to send her to triage. RN #1 recalled 02/17/2017 to be an extremely busy day for Hospital A's DED. Patient #14 reported her vaginal bleeding was saturating less than 1 sanitary pad per hour. RN #1 advised Patient #14 to inform him if her rate of vaginal bleeding increased to saturating 2 sanitary pads per hour, or if there were any other changes in her condition. Interview revealed Patient #14's mother verbalized concern with the wait time, and questioned why Patient #14 was not being assessed by a L&D physician, to which RN #1 informed her that patients with a gestational age less than 20 weeks were initially evaluated by ED physicians, who would consult an L&D physician if necessary; and that Patient #14 would be placed in a treatment room as soon as possible. RN #1 did not recall ever seeing an IV access in Patient #14. Interview revealed during Patient #14's wait, there was constantly new patients waiting for triage, but a visual assessment of patients waiting in the lobby was conducted between each new patient. RN #1 recalled seeing Patient #14 step outside once, after which she returned to the lobby to continue to wait. When a room became available and Patient #14 was called, there was no response and she was unable to be located in the lobby. Interview revealed RN #1 had conferred with the DED Charge Nurse, who was aware of the extended wait times for DED treatment rooms. Policy and Procedure The facilities Policy and Procedure titled "EMTALA Treatment of Patients with Emergency Medical Conditions: Policy number: 100.54; Effective Date: 11/19/14. The policy revealed in part, "POLICY: it is the policy of Carolina East Medical Center ("Carolina East") that all of the following individuals presenting to a dedicated emergency department including women in labor, be given an appropriate medical screening examination by a qualified medical person ("Provider") which includes all of the following: physician, advanced practice registered nurse, physician assistant or appropriately trained registered nurse, to determine whether or not an emergency medical condition exists: Individuals who request, ...examination or treatment for a medical condition ...if the Provider determines that an emergency medical condition exists, or that a woman is in labor and having contractions, the patient shall be treated ...DEFINITIONS: Capability means having qualified personnel and facilities available at the hospital to provide a medical screening exam and treatment as required to stabilize the individual's medical condition. Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment, and encompasses such things as numbers and availability of qualified staff, beds, and equipment as well as the hospital's past practices of accommodating additional patients in excess of its occupancy limits. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual ...in serious jeopardy; serious impairment to any bodily function." Interviews Interview on 03/15/2017 at 1000 with the DED Charge Nurse she did not specifically recall Patient #14. Interview revealed patients that present with unstable vital signs by ambulance do not go to triage. Interview revealed, "We try not to send patients that have an IV or have received medications from EMS (ambulance), but sometimes it is unavoidable." Interview revealed that 02/17/2017 was a "very busy" day for Hospital A's DED. Hospital B, closed medical record review on 03/15/2017 revealed Patient #14 presented to Hospital B on 02/17/2017 at 2203, with vital signs as follows: BP 120/80; P 105; R 18; SpO2 100%; and T 97.6 ° F (Fahrenheit). Review of a provider note, written by MD #2 on 02/18/2017 at 0620, revealed, "...Chief Complaint: VAGINAL BLEEDING. Still present. The symptoms are described as mild. The patient has had intermittent, crampy pelvic pain. She has had abnormal bleeding described as spotting and passing slots and tissue. The bleeding has required use of about 2 pad per day. No abdominal pain, vaginal pain, low back pain, flank pain or vaginal discharge. No vaginal itching, pain with urination, urinary frequency, urgency of urination or hematuria. Currently pregnant. In 1st trimester. Recently diagnosed . Pregnancy confirmed with home test... Recent medical care: The patient was seen recently at another facility in the emergency department. (Several times. QN (HCG Total) was 250 2 days ago, and 160 or 170 yesterday.) ... Bedside Pelvic Sonogram: Endometrial wall thickening is present. No free fluid. No intrauterine pregnancy. No visible gestational sac or yolk sac. The exam was performed by me. Transvaginal views were obtained... HCG: Urine HCG positive Serum 71... Pt with likely incomplete AB with HCG level dropping daily. No abd or pelvic ttp (tenderness to palpation) and lower susp (suspicion) of ectopic although this was disc (discussed) extensively with pt as HCG level may be unreliable - disc return precautions and need for close f/u (follow up). Not a RhoGAM candidate. Disposition: discharged . Condition: good and stable. CLINICAL IMPRESSION: Incomplete spontaneous abortion. No complications..." Review revealed other labs resulted at Hospital B to be unremarkable. The facility failed to ensure that an appropriate medical screening examination was provided that was within the capability and capacity of the hospital to determine whether or not an emergency medical condition existed for Patient #14 on 2/17/2017.

Based on hospital policy and procedure review,closed DED (Dedicated Emergency Department) medical record reviews, staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 42 CFR 489.24 by failing to ensure an appropriate transfer and providing a patient's complete and accurate medical history to the receiving hospital in 1 of 4 sampled patients presenting to the hospital's Dedicated Emergency Department (DED). (Patient #11). The findings include: 1. The hospital staff failed to ensure an appropriate transfer by failing to: provide a patient's complete and accurate medical history to the receiving hospital and failing to discuss the transfer plan with the patient's mother for 1 of 4 sampled patients presenting to the hospital's Dedicated Emergency Department (DED for (Patient #11). ~cross refer to 489.24(e)(1)-(2), Appropriate Transfer - Tag A2409.

Based on hospital policy review, medical record review, staff and physician interviews, the hospital staff failed to ensure an appropriate transfer by failing to: provide a patient's complete and accurate medical history to the receiving hospital and failing to discuss the transfer plan with the patient's mother for 1 of 4 sampled patients presenting to the hospital's Dedicated Emergency Department (DED for (Patient #11). The findings include: Review of the hospital's policy, "EMTALA: Treatment of Patients with Emergency Medical Conditions", revised 11/19/2014, revealed, "...C. Discharge or Transfer When Emergency Condition Exists: 1. If the Provider determines that at emergency medical condition does exist, the patient may be discharged or transferred from (Hospital A) when the patient has been stabilized...b. Stabilized for transfer means, within reasonable medical probability, that no material deterioration of the condition is likely to result from or during the transfer of the patient to another facility, and that the receiving facility has the capability to manage the patient's condition and any reasonably foreseeable complications of that condition...3. The transfer must be effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...5. (Hospital A) must send to the receiving medical facility a copy of all medical records available at the time of transfer related to the emergency medical condition for which the patient has presented, including records related to the patient's medical history, the emergency medical condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests or diagnostic studies...". Closed DED record review of Patient #11 revealed an [AGE] year-old female who presented to Hospital A's DED via private vehicle on 01/23/2015 at 1717 with suicidal ideation. Record review revealed Patient #11 was triaged by RN (Registered Nurse) #2 at 1721. Review revealed documentation by RN #2 at 1729, "patient here for evaluation of statements made to school counselor that she had tried to hang herself in November and December from her bunk bed". Review revealed documentation of home medications as Focalin (treats attention deficit hyperactive disorder), Zyrtec (treats allergies) and Albuterol inhaler (treats asthma). Further review revealed vital signs were obtained and documented at triage as within normal range. Record review revealed no documentation of medical history obtained at triage. Review of Patient #11's laboratory results revealed a whole blood glucose obtained at 1726 as 281 (high) and a urinalysis collected at 1840 with glucose 500 mg/dL (abnormal). Record review revealed a MSE was started by Physician #2 at 1941. Review of Physician #2's dictated MSE revealed, "...History of Present Illness This [AGE] year-old female brought in for evaluation of suicidal ideation...Problem List/Past Medical History Chronic No Chronic Problems Historical No historical problems. Medications Focalin..., ProAir...Zyrtec...Lab Results ...Glucose Lvl (level): 256...Medical Decision Making ...Based on patient's history and physical I do believe patient benefit from inpatient psychiatric evaluation treatment. ...I did review patient's laboratory work no significant abnormalities are noted at this time...". Further review of Patient #11's laboratory results revealed a whole blood glucose obtained at 1927 as 196 (high). Further record review revealed an order by Physician #1 at 2227, "Family to provide home insulin dose and Lantus as scheduled for this juvenile with insulin-dependent diabetes". Review of Patient #11's medication administration record revealed no documentation that the patient received insulin while in the DED. Further record review revealed an "Authorization for Transfer Form" dated 01/24/2015 at 1023. Review of the transfer form revealed, "...MEDICAL CONDITION Diagnosis Suicidal (handwritten)..REASON FOR TRANSFER Medically Indicated (box checked)...Patient Stable (box checked) The patient has been examined and any medical condition stabilized such that, within reasonable clinical confidence, no material deterioration of this patient's condition...II. RISK AND BENEFIT FOR TRANSFER Medical Benefits Adolescent Psych (handwritten) Obtain level of care/service NA at this facility Inpatient adolescent (handwritten) Benefits outweigh risks of transfer (box checked)...Medical Risks MVA (handwritten) Deterioration of condition en route (box checked) Worsening of condition or death if you stay here (box checked)...III Mode/Support/Treatment During Transfer as Determined by Physician - Mode of transportation Agency CCSD (County Sheriff Department handwritten) Support/Treatment during transfer None (box checked)...ACCOMPANYING DOCUMENTATION -sent via Transporting Agency (box checked)...". Review of the transfer form revealed no check mark in the boxes marked copy of pertinent medical record, lab/x-ray/EKG. Further review of the transfer form revealed report was given to (First Name of Person at Hospital B) by RN #3 at 1130. There was a lack of evidence that the transfer plan and risks and benefits were discussed with the patient's mom and the transferring hospital should have made it clear that the patient had diabetus that she was being treated for and on medication for and that she had an elevated glucose level. Record review revealed no documentation of what information other than vital signs were reported to the receiving hospital. Further record review revealed Patient #11 was transferred to Hospital B on 01/24/2015 at 1140 under IVC (involuntary commitment) via sheriff's deputy. Closed medical record review from Hospital B for Patient #11 revealed she was admitted on [DATE] at 1535 (3 hours, 55 minutes after leaving Hospital A). Record review revealed the DED record sent from Hospital A contained IVC papers, lab results and Physician #1's MSE documentation. Review revealed no documentation in the record related to diabetes from Hospital A to Hospital B. Review of the physician's discharge summary from Hospital B revealed, "...The patient was admitted and evaluated medically and psychiatrically. She had type 1 diabetes mellitus and had an extremely high blood sugar. She was originally continued on her homolog [sic], Lantus (insulin)...but her blood sugar was still high. In consultation with our internal medicine doctor, she was sent to local medical hospital for treatment and was admitted to the pediatric unit at (Hospital C), so was discharged from our care...". Review revealed Patient #11 was transferred from Hospital B to Hospital C's DED on 01/24/2015, arriving to Hospital C's DED at 1850 (3 hour,15 minutes after admission to Hospital B) after the attending psychiatrist obtained a medical consult to manage her diabetes. Closed medical record review from Hospital C for Patient #11 revealed a reported blood sugar of 426 (high) at 2023 on 01/24/2015. Review revealed Patient #11 was admitted to Hospital C's pediatric unit for hyperglycemia and management of diabetes and discharged to Hospital D's behavioral health unit on 01/27/2015. Review of the transfer summary to Hospital D dictated on 01/27/2015 revealed, " ...Labs were drawn, and she did not have ketogenic acidosis but had a blood sugar of 426 ...she received 5 units of Humalog in the emergency department for her blood sugar, and she then dropped her blood sugar to 35 ...She had blood sugars in the 280s and 300s overnight, which were not corrected, and her regular insulin doses were restarted for breakfast in the morning ... " . Interview on 02/05/2015 at 0930 with RN #1 revealed the RN was the triage nurse in Hospital A's DED on 01/23/2015 when Patient #11 presented to the DED with suicidal ideation. Interview revealed, "she (Patient #11) told me that the reason she wanted to hurt herself was because she didn't like being different. When I asked her why she was different, she said it was because she had diabetes". Interview further revealed, "I didn't document that she had diabetes. I should have". Interview further revealed, "I did do her blood sugar in triage. It was 281. That is abnormal. I don't remember telling her primary nurse that she had diabetes". Interview revealed RN #2 did not report the high blood sugar to the DED physician. Interview on 02/05/2015 at 0900 with Physician #2 revealed, "I don't really remember her. I get my past medical history on a patient by reading the nurses' notes. A blood sugar of 256 could be high. I had no reason to clarify or ask further questions". Interview further revealed, "there is no normal for an emergency department". Interview on 02/04/2015 at 1500 with Physician #1 revealed the DED physician was working in Hospital A's DED on 01/23/2015. Interview revealed, "the nurse asked if the patient's mother or father could check her (Patient #11) blood sugar and give insulin. I told her they (parents) could manage her diabetes". Interview further revealed, "Patients are not allowed to keep their home meds (medication) at the bedside in the ED. We were really busy so the parents could do a better job of managing her diabetes overnight than we could". Interview further revealed, " a blood sugar of 256 should have been noticed". Interview on 02/05/2015 at 0910 with RN #2 revealed she was Patient #11's primary nurse in Hospital A's DED on 01/23/2015 beginning at 1900, until 01/24/2015 at 0700. Interview revealed, "I found out she was diabetic from her Mom. I took her fingerstick blood sugars a couple of times and I was in her room when she administered her own insulin after she ate a peanut butter and jelly sandwich. (Physician #1) told me it was ok for her mother to manage her insulin. I was concerned about the patient administering her own insulin. I did not document this in her record". Telephone interview on 02/05/2015 at 1030 with RN #3 revealed he was the RN who discharged Patient #11 with the deputy sheriff for transfer to Hospital B on 01/24/2015. Interview revealed, "she had a bag with insulin supplies, syringes and snacks with her when she left in the deputy's car. I checked her sugar before she left. Her mother told me she gave 1.5 units to cover her for breakfast. I'm not sure what kind of insulin it was and I don't know if we even had that kind of insulin here. I should have documented in her record but I got busy and forgot". Further interview revealed, "I gave report to the intake person at (Hospital B). I told them she was diabetic. I told them we were sending her supplies with her". In summary, Patient #11 presented to Hospital A's DED with suicidal ideation. The hospital staff failed to ensure an appropriate transfer by failing to: provide a patient's complete and accurate medical history to the receiving hospital and failing to discuss the transfer plan with the patient's mother for 1 of 4 sampled patients presenting to the hospital's Dedicated Emergency Department (DED for (Patient #11). NC 823 NC 336