HospitalInspections.org

Based on a review of facility documents, and interview with staff it was determined that York Hospital failed to ensure that a medical screening examination was performed, and that a labor and delivery observation record was completed for every time a patient presented for outpatient care through the emergency room process.

Findings include:

A review of York Hospital Nursing Policy and procedure, last reviewed October, 2012, "Guidelines for Care of Outpatient in Labor and Delivery," revealed, "I. Purpose: A. To provide a guideline for nursing management for all patients evaluated in L&D [Labor and Delivery] and not immediately admitted.... II. A. Patients will have a reactive NST [non stress test for labor and delivery readiness], according to gestational age before discharge home....IV. ...7. A L&D observation record is completed and signed by the RN...."

Review of MR1 revealed the patient presented two days prior to her expected delivery date, was evaluated by L&D per policy and procedure, given prescribed treatment, and sent home at 12:30 AM, with instructions to return if her pain became more intense or more frequent.

Review of MR1B, for the same patient, revealed she was admitted with her newborn infant at 7:35 AM, the same morning, after delivering her baby at home, at 6:30 AM, three hours after she visited the labor hall to report increased pains.

Review of the L&D "Labor Hall" log revealed the same patient documented in MR1 and MR1B, logged in to be seen at 2:35 AM, and was discharged home at 3:30 AM. The facility was not able to provide documentation that a L&D observation record was completed for this visit.

Interview with EMP8, revealed the patient did speak with a physician, was not examined at that time, and no L&D observation record was completed. EMP8 further stated, "In retrospect, I should have documented."