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Based on review of procedures, staff interviews, and observations, it was determined that the hospital did not implement an effective system or process to ensure timely and coordinated emergency screening of patients presenting to the facility for emergency treatment of labor or
pregnancy-related concerns.


Findings include:


1. Deficient practices were identified on 8/14/12 during tour and from staff interviews in that the facility has an incomplete process for medical screening of pregnant women or those are in labor who present to the main emergency room for treatment. The facility did not adequately coordinate medical screening services to ensure timely triage screening for those patients who arrive to the ground floor main emergency room for assessment of pregnancy and who require transport to the labor and delivery suite for screening and triage. This labor and delivery unit is located on the fourth floor in the main hospital building where a separate emergency arrival log is maintained from the main hospital ER logs.

Patients meeting criteria for more than 12 week gestation who walk in to the main emergency room are screened by unqualified Patient Access staff in the main emergency room and re-directed to the labor and delivery suite (L & D) at a different location. These patients are given directions to travel to L &D with no hospital escort. No written record is maintained of this encounter upon arrival. Arrival and triage are record by the L & D staff on the fourth floor.

2. It was confirmed by staff during interviews that the hospital has a process that allows patients who arrive in the main emergency room (ER) and who are pregnant more than 12 weeks, to not be consistently triaged by qualified staff.

During tours of the ED on 8/14/12 at approximately 3 PM, nursing and patient access staff confirmed that the facility has a practice in place which allows registration clerks and concierge staff to re-direct patients presenting with pregnancy at 12 weeks or greater to the labor and delivery suite unescorted. Consequently, the facility did not implement a process to coordinate immediate screening or triage by qualified personnel for patients with pregnancy or labor related treatment needs who present to the medical emergency room.
It was stated by staff that patients upon arrival, may be directed to labor and delivery by concierge, nursing, or registration staff.

While the facility's practice is to have patients first screened by a pre-triage nurse on arrival, it was stated at interview with nursing staff on 8/14/12 that this pre-triage screening nurse may not be present at all times if that nurse is in the process of directing other patients to other locations. In addition, no record is kept of the encounter by the pre-triage nurse. In these instances, patient access staff or concierge staff may be allowed to direct pregnant patients to travel to the fourth floor labor and delivery area for care. Hospital escorts are not consistently provided for safe transport nor is a formal record of the encounter generated.
Surveyors observed that patients are first seen by a concierge greeter who records names and date of arrival on a pad and excel spreadsheet. For those patients who are not directed for emergent care to the labor and delivery suite by a screening nurse, a quick registration is performed by clerical staff (Patient Access Associates) prior to full triage.

At interview with the ED Medical Director it was stated that patients who are pregnant who arrive via ambulance (EMS) are taken directly to labor and Delivery without notification of ED staff or L & D staff. It was stated that the ambulance call report (ACR) is signed by the RN in the Labor and Delivery department. The exception is when the patient is determined to have an emergent medical condition not related to pregnancy, i.e., motor vehicle accidents, trauma, or asthma for which these patients are then managed in the main ED.

It was stated at interview with ER nursing staff on 8/14/12 that the function of the pre-triage screening nurse is to provide visual triage and direction of patients to the appropriate area, whether to internal emergency area for emergent treatment or to the labor and delivery suite. Interview of nursing staff on 8/14/12 found no record is kept of this encounter if the patient presents first as a walk in to the medical emergency room. The medical record is initiated during triage aalong with a quick registration process upon arrival only in the labor and delivery suite.

3. Interviews with nursing and Patient Access registration staff on 8/14/12 corroborated that pregnant patients who walk in for emergency care to the medical emergency room are routinely redirected by Patient Access Associates to the maternity labor and delivery area without hospital escorts. The hospital's current practice is that no record of the encounter is maintained for the pregnant patient. In addition, staff who refer patients from the main Emergency Department do not contact labor and delivery staff to inform them about the referral. The process is that patients are first seen by a pre-triage screening nurse and a concierge upon walking in to the emergency room. However, if the screening nurse is busy, the concierge staff or patient access registration staff will first see the patient and redirect to labor & delivery unit.

It was also stated during interview with a Patient Access Associate on 8/14/12 that if the patient is more than 12 weeks pregnant and the complaint is only related to pregnancy, the patient is referred to the department of OB/GYN on the fourth floor of the main building and given directions to that location. No quick registration is performed for patients referred to Labor and delivery and if quick registration is initiated, the encounter is voided in the electronic computer system because the quick registration and triage assessment is performed in the labor/delivery area. The patient is permitted to travel to that unit unescorted by hospital personnel. If the patient is in distress the patient access associate will query the triage nurse for advice if the prescreening nurse is not available.

4. Review of the facility's written procedures for triage found these were incomplete and did not describe a safe process for the immediate assessment of patients presenting to the main
emergency room for complaints related to pregnancy or labor.

Review of policy #600.1, titled "Triage in the Emergency Department " , on 8/15/12 finds that this policy did not define the facility's actual process for management of pregnant walk in patients who first present for treatment in the main emergency department who are 12 weeks or beyond, and who are referred for triage directly to the labor and delivery suite in the main building. The policy states that triage screening is provided by a registered nurse and then a quick registration is performed for patients with a possible ESI rating of 3,4, and 5, who will be asked to wait in the waiting room.
This procedure did not describe the actual practice observed in the emergency room for a visual nursing pre-triage screening, nor did it describe the roles of the concierge and Patient Access registration staff.
This policy does not describe documentation of the pregnant patient encounter upon arrival, notification requirements of L & D staff, nor any process to ensure that all patients are safely escorted to the L & D destination by authorized staff.

Review of the Policy and Procedure #500-L&D-000 titled "Guidelines for the Management of Patients in the Labor and Delivery Triage" finds that this policy is focused only on the triage and assessment process once the patient arrives in labor and delivery department and does not address the flow if the point of patient origin is elsewhere in the facility, i.e., the main emergency room.

The policy notes that, "all antepartum patients at 12 weeks of gestation or greater will be seen in the Labor and delivery unless conditions exist that require initial care in the Emergency Department." It also notes that antepartum patients at 12 weeks gestation or less presenting to Labor & Delivery will be escorted to the emergency department for management unless exception criteria apply.
This policy was not coordinated with the ED policy to fully address the safe accountability of pregnant patients presenting to the main ED or those presenting elsewhere in the facility with emergency conditions (i.e., clinic).

Staff was not consistently familiar with procedural requirements for disposition and management of pregnant patients or those in labor seeking treatment between the main emergency room and L & D department. Specifically it was stated at interview with the ED medical director on 8/13/12 that patients who are greater than 20 weeks gestation are referred to the Labor and delivery suite and that those less than 20 weeks pregnant are managed in the medical ER unless the primary reason for treatment requires medical or trauma care. This is not in accordance with the procedure that requires the threshold for management in L & D is 12 weeks gestation.

Review of the EMTALA policy #C-636 on 8/15/12 finds that it requires Patient Access Services to keep a log of individuals who come to the ED seeking treatment and that it must indicate outcomes related to refusal or denial of treatment, and indicate if the subject was treated, discharged, stabilized and /or transferred. The facility did not comply with this procedure in that staff interviews with Patient Access staff on 8/14/12 found the names and outcomes assigned to pregnant patients referred verbally to L & D are not recorded until following their arrival and triage in L & D. It was stated at interview with the facility VP nursing administrator on 8/15/12 that the practice of the concierge clerk recording names on a pad and excel spreadsheet in the main ED was a practice recently implemented to track the activity of the concierge worker.



Based on observation and staff interview, it was determined that the facility did not have staff in attendance at the registration desk of the labor and delivery department to receive pregnant patients seeking treatment.

Findings include:

During tour of the labor and delivery suite on 8/14/12 at 4:10 PM it was observed that no staff was present at the reception area in the 4th floor labor and delivery suite in the main hospital building where patients presenting for treatment of labor and pregnancy are triaged.

It was stated by administrative staff on 8/14/12 that staff are present in the internal treatment area and that a camera is monitored to ensure patients presenting for treatment are seen.



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Based on review of records and interviews, it was determined that the facility failed to provide a medical screening examination of a pregnant patient who presented for treatment to the emergency room. This finding was evident in 1/11 applicable records reviewed.

Findings include:

The facility did not ensure the provision of a medical screening examination for a pregnant
patient, who reportedly presented for care at the facility's main emergency room on July 20, 2012 between the approximate hours of 2:30 PM and 3 PM.

It was determined during interview of the patient referenced in MR#1 on 8/15/12 that this patient was never assessed upon arrival in the emergency department nor in the labor and delivery area by qualified staff.

Interview of administrative staff on 8/14/12 determined there was no written record that existed of the patient's encounter in the facility on 7/20/12 nor on 7/18/12 (another date provided). Review of ED logs and arrival records kept by the concierge clerk for 7/20/12 found no record of the patient's arrival. Interview of the screening nurse, concierge clerk, and Patient Access clerk on 8/14/12 all determined that these staff had neither recollection nor record of the patient's encounter on the dates or times involved for 7/18/12 or 7/20/12.
However, there was corroborating evidence that the patient was seen and assessed on 7/20/12 in another nearby facility for pregnancy and leaking fluid at a time shortly following the patient's report of requesting treatment at the hospital subject to this investigation.

The patient reported presenting at the main hospital emergency room for assessment of leaking mucous plug at 23 weeks gestation on 7/20/12 or 7/18/12 at the hours between 2:30 and 3 PM. Upon reporting her name and reason for visit, a female wrote her name on the pad and a registration clerk saw the patient. This patient claimed she received verbal directions from the registration clerk instructing her to go instead to the 4th floor labor and delivery suite located in the main hospital building. No escort or paperwork was provided. While en route through the main hospital lobby, the patient was advised by the patient access clerk in the main hospital lobby to go to a different location on the second floor. The patient reportedly advised the staff of the reason for the visit (23 weeks pregnant and fluid leaking) but was re-directed away from the fourth floor labor and delivery unit.
It was subsequently determined through surveyor tour and patient interview on 8/14/12 that the patient was directed to use an elevator to go to a second floor, which leads instead to an outpatient Women's Health Clinic (a ramp leads to the 3rd floor of a building linked by an interconnecting wing).

It was determined from patient interview and by the directions received that the patient went to an area in the location of the outpatient Women's health clinic instead, where she claimed she advised the clerk behind the registration desk of the complaint of leaking mucous plug fluid. This employee reportedly advised the patient she would need to register and that the hospital did not accept the patient's out of state commercial insurance plan. The patient instead left the facility and sought treatment at another hospital. The patient was seen on 7/20/12 at this nearby area hospital at 4 PM where it was confirmed that she was evaluated and discharged for leaking mucous plug at 24 weeks gestation. (reference MR #2 at second hospital).

The facility received a complaint regarding the alleged denial of care of the patient referenced in MR #1 but maintained no record of this grievance, based on review of ED complaint logs on 8/15/12. At interview with the Director of Nursing for Maternal Child Health on 8/13/12, a call was received from the mother of a 5 month pregnant women from out of state who reportedly came to the main emergency room and was told that the hospital could not treat her. She told the parent to please call the woman back to meet her in triage but the patient could not be found. The clerk and triage staff reported there was no record of the patient or any description of the patient or situation recalled by staff. The position of the facility is that the refusal to treat is never true. No record of this investigation was maintained by the hospital which was confirmed at interview with administrative staff on 8/15/12.

Surveyors' interview of nursing and Patient Access staff in the ED, Lobby, and clinic who were on duty on 7/18 or 7/20/12 found no one recalled a patient encounter on those dates for the patient referenced as MR #1. (This patient had been present in the ED on 3/26/12 and 6/16/12).

Interview of the Patient Access Associates in the Ambulatory care clinic on 8/14/12 determined that the facility does not accept the particular insurance plan the patient reported having from out of state. Observation in the Women's Health Clinic on 8/14/12 finds a poster listing only the insurances accepted by the center. In contrast, the registration desk in the clinic posts a notice for EMTALA requirements that communicates that a medical screening exam and stabilization must be provided for those patients seeking care for emergency medical conditions.


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