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Based on observation, interview, and record review, the facility failed to comply with CFR 489.24 by failing to ensure:

1. The Obstetrical Central Log was maintained to include the patients disposition. This resulted in the inability to determine if the patients were transferred, admitted and treated, stabilized and transferred, or discharged (A2405);

2. Pregnant patients with an obstetrical related concern were provided with a thorough medical screening examination (MSE) to determine whether an emergency medical condition (EMC) existed for two sampled patients (Patients 14 and 18). This resulted in pregnant patients being discharged from the facility with incomplete medical screening examinations (A2406);

Immediate Jeopardy was called related to this issue on April 23, 2014, at 9:30 a.m., and lifted with an acceptable plan of correction on April 23, 2013, at 5:10 p.m.

3. Allied Health Practitioners maintained the required certifications for three sampled credential files reviewed (PA 1, NP 1, and PA 2). This resulted in Allied Health Practitioners providing services in the Emergency Department (ED) without documentation of the required certifications (A2406);

4. A medical screening examination for pregnant patients seen in the Emergency Department (ED) included obtaining fetal heart tones for five sampled patients (Patients 8, 10, 11, 13 and 17). This resulted in an incomplete medical medical screening examination and had the potential for an obstetrical emergency medical condition to go undetected (A2406);

5. The physician's orders for care and treatment were followed prior to the patients being transferred to another facility or discharged home for two sampled patients (Patients 2 and 4). This had the potential to result in an infant being delivered prematurely and/or an infant's death (A2407);

6. There was not a delay in assessment, care and treatment to the obstetrical patient for six sampled patients (Patients 8, 10, 11, 13, 17, and 18). This had the potential to result in an obstetrical patient delivering her infant prematurely and/or the death of an infant (A2408); and

Based on interview and record review, the facility failed to ensure the Obstetrical Central Log was maintained to include the patients disposition. This resulted in the inability to determine if the patients were transferred, admitted and treated, stabilized and transferred, or discharged.

Findings:

On April 21, 2014, at 3:30 p.m., the Obstetrical Central Log was reviewed with the Director of Maternal Child (DMC) and the Manager Obstetrics (MO).

The Obstetrical Central Log indicated the following:
a. On December 18, 2013, 13 patients were evaluated for labor and/or seen in Labor & Delivery (L&D) and the disposition, with date and time, was blank for four (4) of the 13 patients.
b. On January 1, 2014, nine (9) patients were evaluated for labor and/or seen in L&D and the disposition, with date and time, was blank for three (3) of the nine (9) patients.
c. On January 12, 2014, 15 patients were evaluated for labor and/or seen in L&D and the disposition, with date and time, was blank for two (2) of the 15 patients.
d. On January 17, 2014, 14 patients were evaluated for labor and/or seen in L&D and the disposition, with date and time, was blank for three (3) of the 14 patients.
e. On February 20, 2014, 20 patients were evaluated for labor and/or seen in L&D and the disposition, with date and time, was blank for three (3) of the 20 patients.
f. On March 15, 2014, eight (8) patients were evaluated for labor and/or seen in L&D and the disposition, with date and time, was blank for two (2) of the eight (8) patients.
g. On March 20, 2014, nine (9) patients were evaluated for labor and/or seen in L&D and the disposition, with date and time, was blank for three (3) of the nine (9) patients.
h. On April 3, 2014, 17 patients were evaluated for labor and/or seen in L&D and the disposition, with date and time, was blank for two (2) of the 17 patients.

During a concurrent interview with the DMC and the MO, they reviewed the Obstetrical Central Log and were unable to find documentation of the patients' disposition for numerous patients on many different days. They stated the Obstetrical Central Log was incomplete, and the disposition, with date and time, should be included on the log for each patient evaluated in L&D.

The facility policy and procedure titled "Obstetrical Triage, Care of Patient" reviewed/revised March 6, 2009, revealed "... Enter patient's name and time of arrival on the Census Sheet and activity log. ... Document discharge/transfer time and unit. ..."

The facility policy and procedure titled "EMTALA Policy" dated January 22, 2014, revealed "... The hospital must maintain a central log of individuals who "come to the emergency department," and include in such a log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or medical screening examination. The Hospital has the discretion to maintain the central log in a form that best meets the needs of the Hospital. Accordingly, the central log may include, directly or by reference, patient logs from other areas of the hospital where a patient might present for emergency services or receive a medical screening examination instead of in the "traditional" emergency department. ..."

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Based on interview and record review, the facility failed:

1. To ensure pregnant patients with an obstetrical related concern were provided with a thorough medical screening examination (MSE) to determine whether an emergency medical condition (EMC) existed for two sampled patients (Patients 14 and 18). This resulted in pregnant patients being discharged from the facility with incomplete medical screening examinations.

Immediate Jeopardy was called related to this issue on April 23, 2014, at 9:30 a.m., and lifted with an acceptable plan of correction on April 23, 2013, at 5:10 p.m.

2. To ensure Allied Health Practitioners maintained the required certifications for three sampled credential files reviewed (PA 1, NP 1, and PA 2). This resulted in Allied Health Practitioners providing services in the Emergency Department (ED) without documentation of the required certifications.

3. To ensure a medical screening examination for pregnant patients seen in the Emergency Department (ED) included obtaining fetal heart tones for five sampled patients (Patients 8, 10, 11, 13 and 17). This resulted in an incomplete medical medical screening examination and had the potential for an obstetrical emergency medical condition to go undetected.

Findings:

1a. On April 22, 2014, the record for Patient 14 was reviewed. Patient 14 presented to the facility Emergency Department (ED) on March 10, 2014, at 3:02 p.m., complaining of "pregnant and have pain."

The initial intake documentation completed by Patient 14 asked the question "Have you been pregnant for greater then 20 weeks?" and "Yes" was marked.

On March 10, 2014, at 4:06 p.m., Patient 14 was triaged by the nurse in the ED and assigned an Emergency Severity Index (ESI - five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs) of 3. Patient 14's vital signs were obtained and she reported a pain level of 7 out of 10 (10 being the severest pain). No fetal heart tones/rate (FHTs - FHR ranges from 110 to 160 beats per minute) were obtained.

On March 10, 2014, at 5:20 p.m., Patient 14 was seen and evaluated by a Physician's Assistant (PA), and the "ED Physician" documentation indicated this was Patient 14's first pregnancy and she was 28 weeks pregnant (term pregnancy 39 to 40 weeks). In addition, the risk factors consisted of "JUST ARRIVED FROM (NAME OF COUNTRY), HAS HAD NO PRENATAL CARE."

There was no documentation to indicate the PA obtained fetal heart tones, and Patient 14 was monitored for contractions and fetal well being.

On March 10, 2014, at 7:03 p.m., an obstetrical ultra sound was obtained and the clinical indications for the obstetrical ultrasound were "complications of pregnancy." The results indicated a single intrauterine gestation with cardiac motion at "100 cc (cubic centimeters) 3 bpm (beats per minute)," a reduced amniotic fluid volume, and a pregnancy at 29 weeks and four days with an expected due date of May 22, 2014.

On March 10, 2014, at 11:46 p.m., the PA's documentation indicated Patient 14's condition had "improved, stable" and she was discharged to home.

On March 11, 2014, at 12:11 a.m., Patient 14's vital signs were obtained, and Patient 14 reported a pain level of "5." There was no indication fetal heart tones were obtained.

There was no indication vital signs, to include a pain assessment, were done between March 10, 2014, at 4:06 p.m., and March 11, 2014, at 12:11 a.m. ( 9 hours and 5 minutes).

Patient 14 was discharged home on March 11, 2014, at 12:12 a.m.

There was no documentation to indicate fetal heart tones were obtained during Patient 14's ED visit, and there was no indication Patient 14 was sent to Obstetrics for an evaluation of contractions and fetal (infant) well being.

On April 21, 2014, at 2:05 p.m., an interview was conducted with L&D Registered Nurse (RN) 1. She stated all pregnant patients, who presented to the facility, and were 20 weeks gestation or greater were seen and evaluated in L&D. RN 1 stated the nurse did the MSE and called the physician within 30 minutes of the patient's arrival to the facility.

On April 21, 2014, at 3:30 p.m., an interview was conducted with the Director of Maternal Child (DMC), the Manager Obstetrics (MO), and the Director of Emergency Services (DES). They stated non-trauma patients who were 20 weeks gestation or greater were seen and evaluated in L&D. They stated the L&D RN would do the MSE and contact the Obstetrical (OB) physician for orders and disposition. In addition, they stated patients who did not have a physician on staff would be sent to the ED for a final evaluation once cleared to be discharged by the OB physician.

During an interview with the MO, on April 23, 2014, at 3:10 p.m., she reviewed the record and was unable to find documentation of FHTs being obtained. The MO stated she did not know what "100 cc 3 bpm" meant on the ultrasound report, and maybe it was a typographical error. In addition, the MO stated Patient 14 should have been seen in L&D and evaluated for contractions and fetal well being.

b. On April 22, 2014, the record for Patient 18 was reviewed. Patient 18 arrived to the facility ED on December 26, 2013, at 9:25 p.m., with chief complaint of pain in stomach, seven months pregnant.

On December 26, 2013, at 9:41 p.m., Patient 18 was triaged by the nurse in the ED and assigned an ESI level of 3. The nursing assessment documentation indicated, at 9:59 p.m., "attempted to listen to FHT's, unable to hear, MD notified and aware." At 10 p.m., Patient 18's vital signs were obtained and patient reported abdominal pain of 10 out of 10 (10 being the severest pain). The Nursing assessment documentation indicated this was a pregnancy related complaint.

Pain was reassessed at a level 10 at 11:29 p.m., and a level 7 the following morning, December 27, 2013, at 5:20 and 6:40 a.m. There was no evidence of monitoring for contractions or obtaining fetal heart tones.

The documentation is unclear as to when the physician first assessed Patient 18. The documentation indicated Patient 18 was seen and evaluated by a Physician on December 27, 2013, at 7:23 a.m., however, there were physician orders written by the physician as early as December 26, 2013, at 9:57 p.m. The "ED Physician" documentation indicated the patient presented to the ED with flank pain. The onset was two weeks ago, and symptoms were constant.

There was no indication the physician obtained fetal heart tones, or was monitoring Patient 18 for contractions and fetal well being.

The Physician documentation indicated a diagnosis of, "Flank pain, pregnancy." A physician order was written on December 27, 2013, at 6:18 a.m., to discharge the patient home.

The ED nurses notes, dated December 27, 2013, at 6:45 a.m., indicated the patient refused to go to L&D to be monitored, and the physician was notified. There was no documentation, signed by the patient, to indicate she refused the monitoring, or if she left the hospital against medical advice.

Patient 18 was discharged home on December 27, 2013, at 7:32 a.m. without any assessment and/or monitoring for a potential EMC related to the pregnancy (10 hours 7 minutes after the patient arrived). The discharge instructions did not include anything related to the pregnancy, such as signs and symptoms of preterm labor.

On December 27, 2013, at 10:20 a.m., Patient 18 returned to the ED with complaints of vaginal bleeding (two hours 48 minutes after she was previously discharged from the ED).

Patient 18 was seen and evaluated by a Nurse Practitioner at 10:23 a.m. There was no indication that FHT's were obtained. The documentation indicated, "Medically cleared, Discharged: Time 12/27/13 10:31, to be transferred to OB immediately for further evaluation and treatment."

The nurses triage assessments was completed at 10:34 a.m. The documentation indicated the chief complaint was vaginal spotting for one and a half hours, approximately 27 weeks pregnant.

The ED Discharge Record indicated Patient 18 was transferred to L&D at 11 a.m. (40 minutes after the patient arrived to the ED).

On April 22, 2013, at 2:20 p.m., RN 2 was interviewed. RN 2 stated, when a pregnant patient arrived to the ED, one of the first things they find out is how many weeks gestation the patient was. If the patient was 20 weeks or greater, they would ask if she had an OB doctor on staff, and if so, the patient would go straight to L&D to be evaluated. If the patient did not have an OB doctor on staff, then they would be evaluated by a provider in the ED. If patient complaint was not pregnancy related, the patient would be discharged from the ED.

On April 22, 2013, at 2:40 p.m., the triage nurse (RN 3), was interviewed. RN 3 stated if a pregnant patient presented to the ED, and was 20 weeks or greater, then it would depend on what her complaint was as to whether she would go to L&D for an evaluation. She stated if the patient had a doctor on staff, she would first be "cleared" by a provider then to go to L&D. She stated, if the patient did not have a doctor on staff at the facility, then the patient would be evaluated and treated in the ED. RN 3 stated, if the patient was in obvious labor, only then would she go straight to L&D for evaluation and treatment.

During an interview with the Director of Maternal Child (DMC), the Manager Obstetrics (MO), and the Director of Emergency Services (DES), on April 22, 2014, at 3:15 p.m., they stated the ED did have a doppler (equipment needed to obtain fetal heart tones) and obtaining fetal heart tones/fetal heart rate should be part of the assessment for a pregnant patient seen in the ED. They stated obtaining fetal heart tones on the infant was like obtaining vital signs on the mother. In addition, they stated if a patient entered the facility through the "maternity entrance," a medical screening examination would be completed in L&D by the nurse and the obstetrician would be notified for orders. They stated if the patient entered the facility through the ED, sometimes the patient was evaluated in the ED, sometimes the patient would be seen in ED and then go to L&D, and sometimes the patient would go straight to L&D.

The facility policy and procedure titled "Obstetrical Triage, Care of Patient" reviewed/revised March 6, 2009, revealed "... Pregnant women who are 20 weeks gestation and above are evaluated in the OB Triage area. ... All patients 28 weeks or greater must have a Reactive NST (non stress test). ... Assessment by the RN (Registered Nurse) is done within 15 minutes of arrival, and includes ... fetal heart rate, variability, pattern ... uterine activity: contraction frequency and duration; intensity (by palpation) ..."

The Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Emergency Services(DES) and additional administrative staff were notified that Immediate Jeopardy was declared on April 23, 2014, at 9:30 a.m. The Immediate Jeopardy was identified due to the facility's failure to ensure pregnant patients, greater than 20 weeks gestation, with an obstetrical related concern, were provided with a thorough medical screening examination (MSE) to determine whether an emergency medical condition existed for two sampled patients (Patients 14 and 18). This resulted in pregnant patients being discharged from the facility with an incomplete MSE.

On April 23, 2013, at 4:20 p.m., an acceptable plan of correction was received from the facility, which indicated the following:

a. All non-traumatic pregnant patients presenting to the ED that are 20 weeks gestation or greater, regardless if they have an OB doctor on staff or not, will first be evaluated in the OB triage area;

b. All ED and L&D staff (including staff that floats to ED) will receive education on the triage care of OB patients. The training to start immediately and continue until 100% completed; and

c. An email and/or blast fax will be sent to all ED and OB physician (including AHP's) by 5 p.m.

On April 23, 2013, at 4:50 p.m., tours of the ED and OB areas were conducted. Observations were made of impromptu 1:1 inservice training, for the staff currently on duty, by the Nurse Educator and the DES. Interviews were conducted with staff to evaluate understanding of the process.

Copies of the email/fax sent to the physicians was reviewed.

On April 23, 2014, at 5:10 p.m., the CEO, CNO, Director of Quality, and Corporate Quality Manager were notified that the Immediate Jeopardy was abated.

2. On April 23, 2014, at 9:45 a.m., the Allied Health Practitioners credential files were reviewed with the Director Medical Staff (DMS) and the Medical Staff Coordinator (MSC).

a. The credential file for Physician Assistant (PA) 1 indicated the certifications for BCLS (Basic Cardiac Life Support), ACLS (Advanced Cardiac Life Support), and PALS (Pediatric Advanced Life Support) were expired.

b. The credential file for Nurse Practitioner (NP) 1 indicated the certifications for BCLS, ACLS, and PALS were expired.

c. The credential file for PA 2 indicated the certifications for BCLS, ACLS, and PALS were expired. In addition, there was no indication PA 2 possessed a current NCCPA (National Commission on Certification of Physician Assistants) Certification.

During a concurrent interview with the DMS and the MSC, they reviewed the credential files and were unable to find current certifications. They stated the facility did not currently have a functioning Interdisciplinary Practice Committee. The DMS stated she was sure the PAs and NP had and met all of the qualifications of the positions but the required documentation of the certifications was not in their credential files and the current certifications should have been in the credential files.

The "Scope and Protocols for Emergency Department Physician Assistants (California) (name of facility)" dated 2012, revealed " ... The Physician Assistant must be in possession of a valid California Physician Assistant license, must maintain NCCPA Certification, must maintain a valid DEA License, and must maintain current Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support (PALS) certificates. The authorized services of the PA includes ... medical screening examinations (MSE) to determine whether or not an emergency medical condition exists. ..."

3a. On April 22, 2014, the record for Patient 8 was reviewed. Patient 8 presented to the facility on March 11, 2014, at 9:48 a.m., with the chief complaint of pregnancy at 36 weeks gestation (term pregnancy 39 to 40 weeks) with low back pain following a low speed motor vehicle accident.

Patient 8 was triaged by the Emergency Department (ED) Registered Nurse (RN) at 9:49 a.m., and vital signs were taken and documented.

Patient 8 was seen and examined by the ED Physician's Assistant.

There was no indication in the record fetal heart tones (FHTs)/fetal heart rate was obtained while the patient was being evaluated in the ED.

On March 11, 2014, at 10:32 a.m., Patient 8 was transported from the ED to Labor & Delivery (L&D) via wheelchair and arrived in L&D at 10:35 a.m. (46 minutes after the patient's arrival at the facility).

b. On April 22, 2014, the record for Patient 10 was reviewed. Patient 10 presented to the facility on April 19, 2014, at 11:18 p.m., with the chief complaint of pregnancy at 22 weeks gestation with light vaginal bleeding.

Patient 10 was triaged by the ED RN at 11:36 p.m., and vital signs were taken and documented.

Patient 10 was seen and examined by the ED Physician's Assistant.

There was no indication in the record fetal heart tones (FHTs)/fetal heart rate was obtained while the patient was being evaluated in the ED.

On April 20, 2014, at 12:09 a.m., Patient 10 was transported from the ED to L&D via wheelchair and arrived in L&D at 12:10 a.m. (52 minutes after the patient's arrival at the facility).

c. On April 22, 2014, the record for Patient 11 was reviewed. Patient 11 presented to the facility on February 24, 2014, at 10:04 p.m., with the chief complaint of pregnancy at 21 weeks gestation with abdominal pain, epigastric pain and a headache.

Patient 11 was triaged by the ED RN at 10:25 p.m., and vital signs were taken and documented.

Patient 11 was seen and examined by the ED physician.

There was no indication in the record fetal heart tones (FHTs)/fetal heart rate was obtained while the patient was being evaluated in the ED.

On February 25, 2014, at 1:52 a.m., Patient 11 did not respond from the waiting room when "called for care" (3 hours and 48 minutes after the patient's arrival at the facility), and at 2:30 a.m., it was determined Patient 11 had "eloped" from the facility.

d. On April 22, 2014, the record for Patient 13 was reviewed. Patient 13 presented to the facility on November 7, 2013, at 6:19 p.m., with the chief complaint of pregnancy at 35 weeks gestation with intermittent contractions following a fall which included the patient hitting her abdomen.

Patient 13 was triaged by the ED RN at 6:39 p.m., and vital signs were taken and documented.

Patient 13 was seen and examined by the ED Nurse Practitioner on November 7, 2013, at 6:39 p.m.

There was no indication in the record fetal heart tones (FHTs)/fetal heart rate was obtained while the patient was being evaluated in the ED.

On November 7, 2013, at 6:52 p.m., Patient 13 was transported from the ED to L&D via wheelchair and arrived in L&D at 7 p.m. (41 minutes after the patient's arrival at the facility).

e. On April 22, 2014, the record for Patient 17 was reviewed. Patient 17 arrived to the facility ED on October 7, 2013, at 3:09 p.m., with chief complaint of 21 weeks pregnant, difficulty walking, and back pain.

On October 7, 2013, at 3:39 p.m., Patient 17 was triaged by the nurse in the ED and assigned an ESI level of 3. Patient 17's vital signs were obtained and she reported back pain level of 7 out of 10 (10 being the severest pain). The Nursing assessment documentation indicated this was a pregnancy related complaint. No FHT's were obtained at that time.

Pain was reassessed at a level 9 at 3:49 p.m. Additional vital signs were taken at 5:19 and 6:08 p.m. No fetal heart rate/tones were obtained.

On October 7, 2013, at 3:17 p.m., Patient 17 was seen and evaluated by a Physician. The "ED Physician" documentation indicated the course/duration of Patient 17's symptoms were episodic and fluctuating in intensity.

There was no indication the physician obtained fetal heart tones, and was monitoring Patient 17 for contractions and fetal well being.

The Physician documentation indicated a diagnosis of, "Back pain" and "UTI (Urinary tract infection) in pregnancy." A physician order was written at 5:03 p.m., to discharge the patient home.

The documented "Nursing Notes" for October 7, 2013, indicated the following:
- at 5:24 p.m., provided patient with discharge instructions, advised to follow up with physician, patient stated she felt a little dizzy and called her mother for a ride, and currently RN was attempting to find fetal heart tones prior to patient leaving (two hours 15 minutes after the patient arrived)

- at 5:55 p.m., two different RN's were unable to find fetal heart tones, multiple attempts failed. Pt stated she had not had anything to eat since the night before, "Patient given orange juice in hopes to wake up the baby."

- at 6:02 p.m., the Physician Assistant was unable to obtain fetal heart tones, but per patient "I feel him move."

- at 6:07 p.m., patient will be taken to Labor and Delivery (L&D) because unable to detect heart tones.

- at 7:03 p.m., patient taken to L&D (three hours 54 minutes after patient arrived to ED, and one hour 38 minutes after RN's unable to obtain fetal heart tones).

During an interview with the Director of Maternal Child (DMC), the Manager Obstetrics (MO), and the Director Emergency Services (DES), on April 22, 2014, at 3:15 p.m., they stated the ED did have a doppler (equipment needed to obtain fetal heart tones) and obtaining fetal heart tones/fetal heart rate should be part of the assessment for a pregnant patient seen in the ED. They stated obtaining fetal heart tones on the infant was like obtaining vital signs on the mother.

The facility policy and procedure titled "Emergency Department, Obstetrical Patients" reviewed/revised March 19, 2009, revealed "... If patient is over 20 weeks and has had prenatal care, direct to Labor and Delivery as per policy on page one. ... No Prenatal Care, No Private Obstetrician - Obtain obstetrical history including: ... Fetal heart tones. ..."

Based on interview and record review, the facility failed to ensure the physician's orders for care and treatment were followed prior to the patients being transferred to another facility or discharged home for two sampled patients (Patients 2 and 4). This had the potential to result in an infant being delivered prematurely and/or an infant's death.

Findings:

a. On April 22, 2014, the record for Patient 2 was reviewed. Patient 2 presented to the facility on December 1, 2013, at 10:59 a.m., with the chief complaint of pregnancy at 26 weeks and 6 days gestation (term pregnancy - 39 to 40 weeks gestation) with vaginal bleeding.

On December 1, 2013, at 11:22 a.m., Patient 2 was triaged by the Emergency Department (ED) Registered Nurse (RN), and the patient's vital signs were taken.

On December 1, 2013, at 11:30 a.m., Patient 2 was seen by the ED Nurse Practitioner, and discharged to the Obstetrics (OB) Department.

Patient 2 arrived in Labor & Delivery (L&D) on December 1, 2013, at 11:50 a.m. (51 minutes after presenting to the facility with a chief complaint that was pregnancy related).

The "Physician Orders L&D Outpatient" dated December 1, 2013, at 12:15 p.m., indicated "Verify RH (Rhesus - blood grouping system - Rh incompatibility condition occurs during pregnancy if a woman has Rh-negative blood and her baby has Rh-positive blood) if negative D/C (discharge) home ..."

There was no indication in the record Patient 2's RH factor was verified/determined.

Patient 2 was discharged from the facility on December 1, 2013, at 12:55 p.m.

During an interview with the Manager Obstetrics (MO) on April 22, 2014, at 4 p.m., she reviewed the record and was unable to find documentation of Patient 2's Rh factor. The MO stated Patient 2's Rh factor should have been obtained because she might of qualified for a shot of RhoGAM (rhod immune globulin human - used to prevent an immune response to Rh positive blood in people with an Rh negative blood type).

b. On April 21, 2014, the record for Patient 4 was reviewed. Patient 4 presented to the facility on January 3, 2014, at 4:23 a.m., with the chief complaint of pregnancy at 24 weeks and 6 days gestation with cramping and vaginal discharge.

The "Physician Orders L&D Outpatient" dated January 3, 2014, at 5:10 a.m., indicated "terbutaline (medication used in the treatment of preterm labor) 0.25 mg (milligrams) SC (subcutaneous - under the skin) x 1 (times one dose)."

The "Triage Flowsheet and Test Record" dated January 3, 2014, indicated:
- At 5 a.m., Patient 4 was noted to have contractions which were three minutes apart.
- At 6 a.m., Patient 4 continued to have contractions every two to three minutes.

There was no indication in the record Patient 4 was given the terbutaline as order by the physician.

Patient 4 was transferred to Facility B (a higher level of care) via ambulance on January 3, 2014, at 9:30 a.m.

During an interview with the Manager Obstetrics (MO) on April 22, 2014, at 4 p.m., she reviewed the record and was unable to find documentation of Patient 4 receiving the terbutaline as ordered by the physician. The MO stated the patient should have received the terbutaline or the nurse should have documented why the patient did not receive the terbutaline as ordered by the physician.

The facility policy and procedure titled "EMTALA Policy" dated January 2, 2014, revealed "... The Hospital will: provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to "stabilize" the emergency medical condition, ..."

Based on interview and record review, the facility failed to ensure there was not a delay in assessment, care and treatment to the obstetrical patient for six sampled patients (Patients 8, 10, 11, 13, 17, and 18). This had the potential to result in an obstetrical patient delivering her infant prematurely and/or the death of an infant.

Findings:

a. On April 22, 2014, the record for Patient 8 was reviewed. Patient 8 presented to the facility on March 11, 2014, at 9:48 a.m., with the chief complaint of pregnancy at 36 weeks gestation (term pregnancy 39 to 40 weeks) with low back pain following a low speed motor vehicle accident.

Patient 8 was triaged by the Emergency Department (ED) Registered Nurse (RN) at 9:49 a.m., and vital signs were taken and documented.

Patient 8 was seen and examined by the ED Physician's Assistant.

There was no indication in the record fetal heart tones (FHTs)/fetal heart rate was obtained while the patient was being evaluated in the ED.

On March 11, 2014, at 10:32 a.m., Patient 8 was transported from the ED to Labor & Delivery (L&D) via wheelchair and arrived in L&D at 10:35 a.m. (46 minutes after the patient's arrival at the facility).

b. On April 22, 2014, the record for Patient 10 was reviewed. Patient 10 presented to the facility on April 19, 2014, at 11:18 p.m., with the chief complaint of pregnancy at 22 weeks gestation with light vaginal bleeding.

Patient 10 was triaged by the ED RN at 11:36 p.m., and vital signs were taken and documented.

Patient 10 was seen and examined by the ED Physician's Assistant.

There was no indication in the record fetal heart tones (FHTs)/fetal heart rate was obtained while the patient was being evaluated in the ED.

On April 20, 2014, at 12:09 a.m., Patient 10 was transported from the ED to L&D via wheelchair and arrived in L&D at 12:10 a.m. (52 minutes after the patient's arrival at the facility).

c. On April 22, 2014, the record for Patient 11 was reviewed. Patient 11 presented to the facility on February 24, 2014, at 10:04 p.m., with the chief complaint of pregnancy at 21 weeks gestation with abdominal pain, epigastric pain and a headache.

Patient 11 was triaged by the ED RN at 10:25 p.m., and vital signs were taken and documented.

Patient 11 was seen and examined by the ED physician.

There was no indication in the record fetal heart tones (FHTs)/fetal heart rate was obtained while the patient was being evaluated in the ED.

On February 25, 2014, at 1:52 a.m., Patient 11 did not respond from the waiting room when "called for care" (3 hours and 48 minutes after the patient's arrival at the facility), and at 2:30 a.m., it was determined Patient 11 had "eloped" from the facility.

d. On April 22, 2014, the record for Patient 13 was reviewed. Patient 13 presented to the facility on November 7, 2013, at 6:19 p.m., with the chief complaint of pregnancy at 35 weeks gestation with intermittent contractions following a fall which included the patient hitting her abdomen.

Patient 13 was triaged by the ED RN at 6:39 p.m., and vital signs were taken and documented.

Patient 13 was seen and examined by the ED Nurse Practitioner on November 7, 2013, at 6:39 p.m.

There was no indication in the record fetal heart tones (FHTs)/fetal heart rate was obtained while the patient was being evaluated in the ED.

On November 7, 2013, at 6:52 p.m., Patient 13 was transported from the ED to L&D via wheelchair and arrived in L&D at 7 p.m. (41 minutes after the patient's arrival at the facility).



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e. On April 22, 2014, the record for Patient 17 was reviewed. Patient 17 arrived to the facility ED on October 7, 2013, at 3:09 p.m., with chief complaint of 21 weeks pregnant, difficulty walking, and back pain.

On October 7, 2013, at 3:39 p.m., Patient 17 was triaged by the nurse in the ED and assigned an ESI level of 3. Patient 17's vital signs were obtained and she reported back pain level of 7 out of 10 (10 being the severest pain). The Nursing assessment documentation indicated this was a pregnancy related complaint.

Pain was reassessed at a level 9 at 3:49 p.m. Additional vital signs were taken at 5:19 and 6:08 p.m. No fetal heart rate/tones were obtained.

On October 7, 2013, at 3:17 p.m., Patient 17 was seen and evaluated by a Physician. The "ED Physician" documentation indicated the course/duration of Patient 17's symptoms were episodic and fluctuating in intensity.

There was no indication the physician obtained fetal heart tones, and was monitoring Patient 17 for contractions and fetal well being.

The Physician documentation indicated a diagnosis of, "Back pain" and "UTI (Urinary tract infection) in pregnancy." A physician order was written at 5:03 p.m., to discharge the patient home.

The documented "Nursing Notes" for October 7, 2013, indicated the following:
- at 5:24 p.m., provided patient with discharge instructions, advised to follow up with physician, patient stated she felt a little dizzy and called her mother for a ride, and currently RN was attempting to find fetal heart tones prior to patient leaving (two hours 15 minutes after the patient arrived)

- at 5:55 p.m., two different RN's were unable to find fetal heart tones, multiple attempts failed. Pt stated she had not had anything to eat since the night before, "Patient given orange juice in hopes to wake up the baby."

- at 6:02 p.m., the Physician Assistant was unable to obtain fetal heart tones, but per patient "I feel him move."

- at 6:07 p.m., patient will be taken to Labor and Delivery (L&D) because unable to detect heart tones.

- at 7:03 p.m., patient taken to L&D (three hours 54 minutes after patient arrived to ED, and one hour 38 minutes after RN's unable to obtain fetal heart tones).

f. On April 22, 2014, the record for Patient 18 was reviewed. Patient 18 arrived to the facility ED on December 26, 2013, at 9:25 p.m., with chief complaint of pain in stomach, seven months pregnant.

On December 26, 2013, at 9:41 p.m., Patient 18 was triaged by the nurse in the ED and assigned an ESI level of 3. The nursing assessment documentation indicated, at 9:59 p.m., "attempted to listen to FHT's, unable to hear, MD notified and aware." At 10 p.m., Patient 18's vital signs were obtained and patient reported abdominal pain of 10 out of 10 (10 being the severest pain). The Nursing assessment documentation indicated this was a pregnancy related complaint.

Pain was reassessed at a level 10 at 11:29 p.m., and a level 7 the following morning, December 27, 2013, at 5:20 and 6:40 a.m. There was no evidence of monitoring for contractions or obtaining fetal heart tones.

The documentation is unclear as to when the physician first assessed Patient 18. The documentation indicated Patient 18 was seen and evaluated by a Physician on December 27, 2013, at 7:23 a.m., however, there were physician orders written by the physician as early as December 26, 2013, at 9:57 p.m. The "ED Physician" documentation indicated the patient presented to the ED with flank pain. The onset was two weeks ago, and symptoms were constant.

There was no indication the physician obtained fetal heart tones, or was monitoring Patient 18 for contractions and fetal well being.

The Physician documentation indicated a diagnosis of, "Flank pain, pregnancy." A physician order was written on December 27, 2013, at 6:18 a.m., to discharge the patient home.

The ED nurses notes, dated December 27, 2013, at 6:45 a.m., indicated the patient refused to go to L&D to be monitored, and the physician was notified. There was no documentation, signed by the patient, to indicate she refused the monitoring, or if she left the hospital against medical advice.

Patient 18 was discharged home on December 27, 2013, at 7:32 a.m. without any assessment and/or monitoring for a potential EMC related to the pregnancy (10 hours 7 minutes after the patient arrived). The discharge instructions did not include anything related to the pregnancy, such as signs and symptoms of preterm labor.

On December 27, 2013, at 10:20 a.m., Patient 18 returned to the ED with complaints of vaginal bleeding (two hours 48 minutes after she was previously discharged from the ED).

Patient 18 was seen and evaluated by a Nurse Practitioner at 10:23 a.m. There was no indication that FHT's were obtained. The documentation indicated, "Medically cleared, Discharged: Time 12/27/13 10:31, to be transferred to OB immediately for further evaluation and treatment."

The nurses triage assessments was completed at 10:34 a.m. The documention indicated the chief complaint was vaginal spotting for one and a half hours, approximately 27 weeks pregnant.

The ED Discharge Record indicated Patient 18 was transferred to L&D at 11 a.m. (40 minutes after the patient arrived to the ED).

On April 22, 2013, at 2:20 p.m., RN 2 was interviewed. RN 2 stated, when a pregnant patient arrived to the ED, one of the first things they find out is how many weeks gestation the patient was. If the patient was 20 weeks or greater, they would ask if she had an OB doctor on staff, and if so, the patient would go straight to L&D to be evaluated. If the patient did not have an OB doctor on staff, then they would be evaluated by a provider in the ED. If patient complaint was not pregnancy related, the patient would be discharged from the ED.

On April 22, 2013, at 2:40 p.m., the triage nurse (RN 3), was interviewed. RN 3 stated if a pregnant patient presented to the ED, and was 20 weeks or greater, then it would depend on what her complaint was as to whether she would go to L&D for an evaluation. She stated if the patient had a doctor on staff, she would first be "cleared" by a provider then to go to L&D. She stated, if the patient did not have a doctor on staff at the facility, then the patient would be evaluated and treated in the ED. RN 3 stated, if the patient was in obvious labor, only then would she go straight to L&D for evaluation and treatment.

During an interview with the Director of Maternal Child (DMC), the Manager Obstetrics (MO), and the Director of Emergency Services (DES), on April 22, 2014, at 3:15 p.m., they stated the ED did have a doppler (equipment needed to obtain fetal heart tones) and obtaining fetal heart tones/fetal heart rate should be part of the assessment for a pregnant patient seen in the ED. They stated obtaining fetal heart tones on the infant was like obtaining vital signs on the mother. In addition, they stated if a patient entered the facility through the "maternity entrance," a medical screening examination would be completed in L&D by the nurse and the obstetrician would be notified for orders. They stated if the patient entered the facility through the ED, sometimes the patient was evaluated in the ED, sometimes the patient would be seen in ED and then go to L&D, and sometimes the patient would go straight to L&D.

The facility policy and procedure titled "Emergency Department, Obstetrical Patients" reviewed/revised March 19, 2009, revealed "... If patient is over 20 weeks and has had prenatal care, direct to Labor and Delivery as per policy on page one. ... No Prenatal Care, No Private Obstetrician - Obtain obstetrical history including: ... Fetal heart tones. ..."