HospitalInspections.org

Based on interview and record review, the facility failed to ensure the Obstetrical Triage department (OB Triage- an obstetrical emergency department), was directed by a physician board certified in emergency medicine as required by New Jersey Law. In addition, it was determined that the hospital's emergency services (OB Triage, Pediatric Emergency and Adult Emergency departments) were not organized under the direction of a single qualified member of the medical staff.

Findings include:

1. Per New Jersey Admin. Code § 8:43G-12.3 Emergency Department Staff Qualifications "(a) There shall be a physician director of the emergency department who is board certified in emergency medicine ...."

On 7/13/23 at 9:35 AM, an interview was conducted with the VP of Clinical Operations for Women's and Children's Services (VPCWS), Assistant VP of Maternal and Child Health, the VP for Emergency Department Operations, and the VP for Clinical Operations Emergency Services (VPCOES). They stated the OB triage operated as an emergency department and the oversight of the department was the responsibility of the VPCWS. They further stated the VPCWS was not board certified in emergency medicine.

In addition, they stated the VPCOES was the director responsible for the adult emergency department, however the VPCOES was not responsible for oversight of the OB Triage or the pediatric emergency department. They further stated each emergency department within the hospital each had a separate director, and they were not organized under a single qualified member of the medical staff.

On 7/13/23 at 2:27 PM, the facility provided the document titled Emergency Services, dated 12/22 which was an organizational chart. OB Triage was not on the Emergency Services organizational chart. In addition, per the chart, the pediatrics and adult emergency departments had separate medical staff directors overseeing each.

Based on staff interviews, review of five of 12 medical records of pregnant patients presenting to the Emergency Department (ED) (#1, #22, #26, #29, #32), and review of facility policies and procedures, it was determined the facility failed to ensure that: 1) all patients presenting to the ED are triaged and assigned clinical priority, in accordance with facility policy; 2) all patients presenting to OB (Obstetrics) Triage for emergency treatment are entered in the OB log book, in accordance with facility policy.


Findings include:

1) Reference #1: Facility policy titled, "Triage Procedure Emergency Department" (dated 4/2023) states, "... Procedure 1. All patients shall initially be assigned clinical priority for treatment by licensed professional nurse or physician upon arrival in the Emergency Department. 2. All patients are seen upon arrival. The nurse assesses the patient's illness or injury, determines their Emergency Severity Index (ESI) category and places them appropriately."

Reference #2: Facility policy titled, "OB Triage at [facility name]" (dated 2/2021) states, "... Procedure ... C. Initial maternal and fetal assessment by the RN (registered nurse) or LIP (licensed independent practitioner), with decision about the priority level for evaluation, should take place within 30 minutes of arrival."

Review of the medical record of Patient #1 (P1) on 7/11/23 revealed the patient arrived to the ED on 4/6/23 at 9:40 AM with complaints of pelvic cramping. The patient was 35 weeks pregnant. P1 was triaged at 9:40 AM and transferred to the OB Triage unit at 9:49 AM. There was no evidence P1 was assigned an acuity level in the ED or once he/she was transferred to OB Triage.

Review of P1's medical record on 7/11/23 revealed the patient presented directly to OB Triage on 4/7/23 at 2:33 AM with complaints of pelvic cramping. P1 was triaged at 3:23 AM. There was no evidence the patient was assigned an acuity level during triage.

Review of P1's medical record on 7/11/23 revealed the patient presented directly to OB Triage on 4/8/23 at 10:12 AM with complaints of lower abdominal pain. P1 was triaged at 10:36 AM. There was no evidence the patient was assigned an acuity level during triage.

Review of the medical record of Patient #22 (P22) on 7/11/23 revealed the patient arrived in the ED on 2/17/23 at 5:41 PM with complaints of vaginal bleeding. P22 was transferred to OB Triage and triaged at 5:44 PM. There was no evidence the patient was assigned an acuity level during triage.

Review of the medical record of Patient #26 (P26) on 7/12/23 revealed the patient arrived in the ED on 4/2/23 at 7:22 PM with complaints of decreased fetal movement. P22 was transferred to OB Triage at 8:00 PM and triaged at 8:14 PM. There was no evidence the patient was assigned an acuity level during triage.

Review of the medical record of Patient #29 (P29) on 7/12/23 revealed the patient arrived in the ED on 4/9/23 at 2:27 PM with complaints of cramping. P29 was 19 weeks pregnant. The patient was transferred to OB Triage and triaged at 2:34 PM. There was no evidence the patient was assigned an acuity level during triage.

Review of the medical record of Patient #32 (P32) on 7/12/23 revealed the patient arrived in the ED on 3/1/23 at 8:05 PM with complaints of no fetal movement. There was no indication in the medical record of when the patient was triaged. There was no evidence the patient was assigned an acuity level during triage.

Upon interview on 7/11/23 at 11:00 AM, Staff #20 (Nurse Director, OB Triage) stated that acuity levels are not assigned during triage in OB Triage. Staff #20 stated, "The assignment of acuity levels has not been fully implemented. We trialed it and we've discussed it. But it hasn't been fully implemented."





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2) Reference #1: Facility policy titled, "Emergency Medical treatment and Active Labor Act (EMTALA) Compliance" (last reviewed 6/7/21) states, " ... Requirements: ... 5. All patients presenting for emergency medical treatment will be entered into the ED (emergency department) EMR (electronic medical record) or L&D (labor and delivery) Log Book."

Reference #2: Facility policy titled, "OB Triage at [name of facility]" (effective 2/21) states, " ... Patient is registered per hospital protocol and information entered into required logs and EMR."

During the entrance conference on 7/10/23 at 10:10 AM, Staff #1 (Assistant Vice President, Quality) stated that the facility has an OB triage walk-in entrance that is separate from the Main entrance of the ED. Staff #1 stated that OB patients can present directly to the OB triage walk-in entrance to request an emergency medical screening exam (MSE). A request was made to Staff #1 and Staff #2 (Risk Safety Manager) for the ED Central logs and the OB Triage Logs for February 2023 to July 2023.

Upon review of the medical record of Patient #1 (P1) on 7/11/23, it was revealed that the patient arrived to the OB triage walk-in entrance of the facility on 4/7/23 at 2:33 AM. The patient's chief complaint was "Bladder Pain." The patient received an MSE, was diagnosed with "Pelvic Cramping," and discharged to home on 4/7/23 at 4:49 AM.

There was no evidence of the patient's 4/7/23 emergency visit documented on the OB triage logs for April 2023. There was no evidence of the patient's 4/7/23 emergency visit documented on the ED central logs for April 2023.

At 11:05 AM, Staff #2 confirmed that the OB triage log for April 2023 does not include evidence of P1's arrival to OB triage on 4/7/23.