Based on hospital policy review, medical record review, and physician interview the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings include: The hospital's Dedicated Emergency Department (DED) qualified medical professional failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 8 sampled DED patients (#7) who presented to the hospital's DED with stroke symptoms, dizziness, or visual changes. ~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A2406

Based on policy and procedure review, closed medical record review, and physician and staff interviews, the hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including further imaging and testing, to rule-out a stroke and determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 8 DED patients who presented with stroke symptoms, dizziness, or visual changes. (Patient #7) The findings include: Review of the "EMTALA" policy, number NH-PC-CC-1132, effective April 2017, revealed "...II. POLICY....It is....policy to provide care to individuals who come to the dedicated emergency department or present elsewhere with an emergency medical condition in a manner that best meets the needs of those individuals and that complies with applicable state and federal laws....A. Medical screening examination 1. Individuals (including minors) entitled to a medical screening examination a) Individuals in the dedicated emergency department (ED) seeking medical care - When an individual comes to the dedicated emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment, the hospital shall provide for an appropriate medical screening examination within the capability of the hospitals' emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists....2. Scope of the medical screening examination a) A medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. The hospital shall apply in a non-discriminatory manner....a screening process that is reasonably calculated to determine whether any emergency medical condition exists. The medical screening examination shall include both a generalized assessment and a focused assessment based on the individual's chief complaint, with the intent to determine the presence or absence of an emergency medical condition. Depending on the individuals' presenting symptoms, the medical screening examination may range from a simple process involving only a brief questioning and examination for individuals who come to the facility for non-emergency services to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures....C. Stabilization of individuals in the dedicated emergency department who have an emergency medical condition....4. Stable for discharge - An individual is considered stable for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, reasonably could be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. ..." Closed medical record review, on 05/10/2017, revealed Patient #7, a 64 year old, arrived to the DED (Dedicated Emergency Department) by ambulance on 10/08/2016 at 1727. Review of the Patient Care Timeline report revealed the patient was placed in an ED room at 1732 and triage began at 1734. The Chief Complaint was recorded as dizziness and nausea, stating "Pt. (patient) has been nauseous and dizzy since last evening. Pt. states she vomitted (sic) several times last noight (sic), today had episode where she lost vision in her right eye for approx (approximately) 45 mins (minutes)." Vital signs, at 1736, were Temperature (T) 98.9 F (Fahrenheit), Heart Rate (HR) 69, Respirations (R) 18, Blood Pressure (BP) 176/74, SpO2 (blood oxygen saturation level) 98% on room air, and pain denied at that time. At 1739, review revealed Patient # 7 was assigned an acuity level of 3 (on a scale of 1-5, with 1 being the most severe). Patient Care Timeline review revealed the Medical Screening Exam was initiated at 1753. Review of ED Provider Note, dated 10/08/2016 at 1904, revealed "...[AGE]-year-old female presents the emergency department complaining of vertigo, headache, and vision loss. The patient states that she has a history of a 'optic nerve stroke' a few years ago. She states that she had the loss of vision out of her right eye at that time. The patient states that her vision had improved in her right eye however returned to normal. Patient states that yesterday evening she began to develop some vertigo type symptoms. Her dizziness was worse with changing positions and standing upright. Her symptoms were significantly improved with rest and immobility. She states that her vertigo symptoms continued throughout the course of the day today. The patient was on her way driving to the airport when she had a fairly sudden onset of severe pain across the top of her head. The patient at that time had a significant worsening in her vertigo symptoms and developed nausea and severe vomiting. She had multiple episodes of vomiting in a short period of time. She also states that she had a loss of vision in her right eye similar to what she experienced at the time of her optic nerve stroke. She reported to urgent care who sent her to the emergency department for evaluation. She states that ....her head pain has resolved, as has her nausea, and her vision in her right eye has returned to its recent baseline. She still complains of mild vertigo symptoms. She has had no focal neurologic deficits. ....Review of Systems....Pertinent positives and negatives as per history of present illness. Remainder of 10 systems reviewed and are unremarkable....Gastrointestinal: Positive for Nausea and vomiting. Negative for blood in stool and diarrhea. Neurological: Positive for dizziness and headaches.... Physical Exam Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. HENT: Head: Normocephalic and atraumatic. Eyes: EOM (extraocular muscles/movement) are normal. Pupils are equal, round, and reactive to light. No [DIAGNOSES REDACTED] (rapid, uncontrollable eye movement) Neck: Normal range of motion. Neck supple. Cardiovascular: Normal rate and regular rhythm....Musculoskeletal: Normal range of motion. She exhibits no edema or tenderness. Neurological: She is alert and oriented to person, place, and time. She has normal strength. No cranial nerve deficit or sensory deficit. ..." Review of ED Provider Notes, at 1950, revealed "... Patient states that she had improvement of her vertigo symptoms with the Antivert. CT scan here was normal, laboratory studies showed no significant abnormalities. The patient has a history of similar vision loss in her right eye past. Her symptoms are primarily vertigo associated with an episode of severe head pain earlier today. These symptoms have all completely resolved and she has only mild residual vertigo at this time. The patient lives in the (City Name) area, has eye doctors and primary care physician there. She would prefer to be discharged tonight to follow-up with her physicians at home for any of her symptoms continue. I've instructed her to return to the emergency department if she has any further problems while staying in the area.... Patient progress: stable.... New Prescriptions DIAZEPAM (VALIUM) 5 MG [milligram] TABLET Take one tablet (5 mg total) by mouth every 8 (eight) hours as needed (vertigo).... MECLIZINE HCL (ANTIVERT) 25 MG TABLET Take one tablet (25 mg total) by mouth every 6 (six) hours as needed for Dizziness.... Final diagnoses: Vertigo Decreased vision....Disposition Discharge....Condition at discharge: Stable.... Please follow up.... Follow-up with your eye doctor and primary physician as soon as you get home for reevaluation. Return to the emergency department with any worsening of her symptoms or other concerning problems. ..." Patient Care Timeline review revealed Patient #7 was discharged at 2008. Review revealed "...Departure Condition: Improved; Discharge Instructions Reviewed with: Patient; Method of Teaching: Verbal; Written discharge instructions; Patient Teaching: Discharge instructions reviewed; Follow-up care reviewed; Prescription given to patient/support person. ..." Telephone interview, on 05/10/2017 at 1500, with the physician who cared for Patient #7 in the ED (MD #1), revealed that in a situation like this patient's presentation, the sudden onset of symptoms was concerning. By the time the patient was examined in the ED, with the exception of the vertigo, everything returned to baseline. The headache was completely gone, he stated, vision had returned to baseline, and there were no neurological symptoms. Primary concerns, he stated, would be TIA or hemorrhage, that peripheral vertigo would be way down the list. Per MD #1, labs were ordered as was a head/brain CT. Interview revealed that, as he recalled, the labs were "ok" and the brain CT was normal. Interview revealed the newer generation of CT scanners, although not 100%, are very reliable. MD #1 stated that in looking at the documentation, the patient's symptoms were much improved, the Antivert had helped the vertigo, test results thus far had been normal, there was not an acute problem right then. More evaluation was needed to rule out other issues, with clinical options including spinal tap or MRI or admission. MD #1 stated Patient #7's doctors were in a different city/state and based on his documentation "it looks like she said she would prefer her doctors." Interview revealed MD #1 discharged the patient. She had concerning symptoms, he stated, but most had completely resolved, she was alert and oriented, was neurologically intact, and she "had a right to participate in her health care decisions". MD # 1 stated he felt the patient was stable for discharge with the understanding of the concerns and good reliable resources for follow-up care. Interview revealed that while he did not recall the conversation, based on documentation to follow-up "as soon as" she returned home, he would have reviewed his concerns and the importance of follow-up with Patient #7. Interview revealed MD #1 considered the exam to be thorough, stating he considered all the patient's symptoms, as well as the concerns going forward, and involved the patient in the decision. In summary, Patient #7 did not receive an appropriate medical screening examination, as further imaging and testing was required to rule-out a stroke and assess for stroke risk factors. In addition, there was no evidence in the medical record of discussion of the risks and benefits of discharge prior to further testing. NC 227

Based on hospital policy review, medical record review, physicians and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings include: The hospital's Dedicated Emergency Department (DED) qualified medical professional failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 10 sampled DED patients (#12) who presented to the hospital's labor and delivery department for evaluation and treatment. ~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A2406.

Based on policy and procedure review, closed medical record review, and physician and staff interviews, the hospital's Dedicated Emergency Department (DED) failed to provide a complete Medical Screening Examination (MSE) within the capability of the hospital's DED, including interpretation of ancillary testing, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 10 sampled DED obstetrical patients (Pt # 12) who presented to the hospital for evaluation and treatment. The findings include: Review of facility "EMTALA" policy, number NH-PC-CC-1132, effective July 2013, revealed "...It is....policy to provide care to individuals who come to the dedicated emergency department or present elsewhere with an emergency medical condition in a manner that best meets the needs of those individuals and that complies with applicable state and federal laws....A. Medical screening examinations 1. Individuals (including minors) entitled to a medical screening examination. a) Individuals in the dedicated emergency department (ED) seeking medical care - When an individual comes to the dedicated emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment, the hospital shall provide for an appropriate medical screening examination within the capability of the hospitals' emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists....2. Scope of the medical screening examination a) A medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. The hospital shall apply in a non-discriminatory manner....a screening process that is reasonably calculated to determine whether any emergency medical condition exists. The medical screening examination shall include both a generalized assessment and a focused assessment based on the individual's chief complaint, with the intent to determine the presence or absence of an emergency medical condition. Depending on the individuals' presenting symptoms, the medical screening examination may range from a simple process involving only a brief questioning and examination for individuals who come to the facility for non-emergency services to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures....3. Individuals who may perform the medical screening examination a) Medical screening examinations must be performed by individuals who are: i) Determined qualified by the hospital's Medical Staff Bylaws, or Rules and Regulations, which are approved by the hospital's governing body and ii) Functioning within the scope of their license and in compliance with state law and applicable Nurse and Medical Practice Acts....c) Physicians and the following categories of individuals are designated as qualified medical personnel authorized to perform a medical screening examination to determine the existence of an emergency medical condition, subject to appropriate physician supervision and established protocols"....iii) Labor and Delivery Department: labor and delivery nurses who have passed competencies and course requirements to work in labor and delivery and nurse midwives....C. Stabilization of individuals in the dedicated emergency department who have an emergency medical condition ....4. Stable for discharge - An individual is considered stable for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, reasonably could be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions....VII. DEFINITIONS Dedicated emergency department ....For....facilities, dedicated emergency department include emergency departments and labor and delivery departments. Emergency medical condition - a medical condition manifesting itself by acute symptoms of sufficient severity....such that the absence of immediate medical attention reasonably could be expected to result in: 1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy. ..." Closed DED Labor and Delivery medical record review of patient (Pt) # 12 revealed a [AGE] year old pregnant female that (MDS) dated [DATE] at 2336 at 39 weeks gestation with her first pregnancy. Record review revealed Pt # 12 had a positive GBS [Group B Streptococcus - a type of bacteria found in a pregnant woman's vagina or rectum] test on 12/27/2015. Further review revealed "...No sensitivities sent w/ [with] PCN [Penicillin] allergy. For vancomycin [antibiotic]. ..." Review of nursing flowsheets revealed an electronic fetal monitor (EFM, a device to record fetal heart rate and uterine activity) was applied at 2349 and vital signs taken at 2350 which were temperature 97.9 F, heart rate 86, respirations 20, and blood pressure 99/65. Review of nursing flowsheets at 2353 revealed Pt # 12 reported contractions began on 01/17/2016 at 2130, denied vaginal bleeding, was "unsure" if she was leaking fluid, and reported a "mucous" vaginal discharge. On 01/18/2016 at 0008, review revealed, a cervical exam was completed by RN # 3 with "...Dilation 1.5 [centimeters], Effacement (%) 50, Station -3". Review of physician's orders at 0022, revealed a verbal/telephone order for "Microbiology-Other Orders Rupture of (Fetal) Membranes [ROM]" [amnisure test - a laboratory test to be done to check for ROM]. At 0045 review of Nursing Flowsheets revealed "...Uterine Activity....Contraction Frequency (min) [minutes] 2-6....Contraction Duration (sec) [seconds] 50-90....Contraction Quality Mild.... Resting Tone Relaxed. ..." Further review revealed "...Fetal Heart Rate....Baseline Rate 135 bpm [beats per minute]....Baseline Classification No Baseline Change....Variability Moderate 6-25bpm....Accelerations Present....Decelerations None. ..." Review revealed a physician's order, entered by RN #3 as a verbal order with readback, on 01/18/2016 at 0051, to "Discharge patient". Record review did not reveal documentation of the phone call or report given by the RN to the physician. At 0055, review of a nursing note revealed "Discharge instructions given and explained. Pt verbalizes understanding. Questions and concerns addressed. Pt discharged to home accompanied by family in NAD [no apparent distress]. Pt remains undelivered." Review of results of the amnisure test for ROM revealed it was resulted on 01/18/2016 at 0057 (six minutes after the verbal order was obtained to discharge the patient home) with a "Positive" result. Review did not reveal any notation related to the positive result. Further review revealed Pt # 12 departed the facility on 01/18/2016 at 0100. Record review of results of a previous amnisure test on Pt # 12 to assess for ROM revealed a "Negative" result on 01/14/2016 at 0930. Record review revealed Pt # 12 returned to the DED L&D on 01/18/2016 at 0948 (8 hours and 48 minutes after departure). Review of History and Physical, date of service 01/18/2016 at 1153, revealed "...[Pt # 12] is a 39 y.o. female G1P0 [gravida 1, para 0] at 39w5d [39 weeks, 5 days]....The patient was seen here last night and an amnisure [to test for ROM] done at 0000 was positive. The patient was discharged to home and then presented to the office today for evaluation. AFI [amniotic fluid index - estimate of the amount of amniotic fluid] normal in the office, no evidence of ROM on SSE [sterile speculum exam]. Pt sent over to the hospital due to the above findings. ..." Further review revealed a cervical exam at 1113 with dilation 4 cm, effacement 90%, and station -1. Medication Administration Record review revealed Pt # 12 received doses of intravenous Vancomycin 1 gram in 250 ml (milliliters) NaCL 0.9% (Normal Saline) on 01/18/2016 at 1146 and 2350. Review of Obstetrics Discharge Note, dated 01/22/2016 at 0828, revealed Pt # 12 delivered by Cesarean Section on 01/19/2016 at 0132 with infant apgar scores of 8 at one minute and 9 at five minutes. Further review revealed Pt # 12 was discharged home on 01/22/2016. Staff interview on 06/01/2016 at 1215 with the Chief Nursing Officer [CNO], Nurse Manager [NM] #1, and Patient Representative [Pt Rep] #2 revealed the hospital first became aware of a grievance when Pt #12 sent an email to hospital administration and DHSR [Division of Health Service Regulation]. Interview revealed the grievance process was followed and an immediate investigation was begun. Interview revealed they learned RN #3 was on duty and the nurse who sent the amnisure test. Interview revealed RN #3 looked in the computer, saw amnisure results and thought they were the results of the test being performed that night. Interview revealed those results were negative and RN #3 called and notified MD # 4 of a negative amnisure result after which MD # 4 placed a discharge order. Interview revealed RN #3 was reviewing a test result from 01/14/2016 and at the time of the RN's review the result of the current test had not been released. The actual result of the amnisure test done the night of 01/17/2016 was positive. The next morning (01/18/2016) Pt # 12 followed up at her OB (Obstetrician) office and a physician saw the positive result from the night before. Interview revealed this MD did other checks including getting an AFI, performing both a Fern test and a nitrazine test [both test for leakage of amniotic fluid]. The AFI was normal, and both the Fern and Nitrazine tests were negative for ROM. Pt # 12 was having contractions , interview revealed, and based on this and the positive result from the night before, the MD sent the patient back to the hospital where she was subsequently admitted . If MD # 4 had known of the positive results, interview revealed, Pt #12 would not have been discharged . Further interview revealed Pt # 12 delivered on 01/19/2016 after receiving more than one dose of antibiotics. Interview revealed RN #3 was educated to watch the dates and times of test results and it was discussed with other staff in shift change huddles. Staff interview on 06/02/2016 at 0855 with RN #3, the RN who completed the MSE on Pt #12, revealed Pt # 12 came to the hospital with contractions and unsure if her water had broken. Interview revealed RN #3 did vital signs, attached an external fetal monitor, did a physical assessment and a cervical exam. Interview revealed Pt # 12 did not have obvious ROM on exam. RN #3 then called MD # 4, reported findings, and asked for an order to send an amnisure test to the Lab. The order was received, interview revealed, and the amnisure swab sent to the Lab. Pt # 12, RN # 3 stated, was kept on the monitor, but "she was not contracting a lot....so I went to see if the results of the test were back....I saw a negative result....I called the Doctor and told her there was a negative result." RN # 3 stated "...I also told her baby looked good....[Pt # 12] wasn't contracting a lot, wasn't in a lot of pain and the patient had a follow-up appointment in the morning. The doctor gave a discharge order. ..." Interview revealed RN #3 never realized that night that the amnisure result reported was not correct. Interview revealed RN # 3 learned of the positive result when she returned to work a few days later; that when the patient went to the office, they saw the positive test result. RN # 3 stated "...the patient had not said she had been there before, when I saw the negative result, I assumed it was from that night. ..." Further interview revealed that to prevent this in the future, RN # 3 "...will look at the dates, I will do that every time. ..." Physician interview with MD # 4 revealed she was the MD on call the night of 01/17-18/2016. Interview revealed MD # 4 did not see Pt # 12 that night. Interview revealed MD # 4 received a call from the nurse, who reported assessment information on the patient, including her chief complaint, and MD # 4 then gave the order for an amnisure test to be done. Interview revealed they keep patients in the hospital until getting amnisure results. Interview revealed that patients with a positive result are then kept for admission. Further interview revealed the patient would not have been sent home had the MD known of the positive result. NC 889