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A. Based on one (1) out of two (2) patients identified on the OBED (Obstetric Emergency Department) Perinatal Patient Triage Log with multiple visits within 24 hours (Patient #1), medical record review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to implement the policy and procedure for the maintenance of a complete and accurate log of patients in the OBED.

Findings include:

Reference: Facility policy and procedure titled, Care of the OB Patient in OBED, states, "... PATIENT LOG: It is a federal regulation that the OBED maintain a log documenting the arrival time, time of treatment, final diagnosis and disposition time. This log must be accurate, complete, and legible. ..."

1. The "Perinatal Patient Triage Log" dated from 5/23/21 to 6/2/21 was not accurate for Patient #1 as follows:

a. A review of the "Perinatal Patient Triage Log" dated from 5/23/21 to 6/2/21, revealed that Patient #1 was admitted to the OBED twice on 5/29/21. Both visits were documented on the log as having the same arrival date, arrival time, and chief complaint as noted below. The first visit entry on the log is lacking evidence of a discharge/transfer time and a length of stay.

(i) Both entries on the triage log indicate that the "Arrival Date/Time" was "05/29/21" at "05:25" and the chief complaint was documented as "recived [sic] pt [patient] via whell [sic] chair, pt presented to l/d [labor and delivery] via wheel chair by main er [emergency room] tech with the c/o [complaint of] having abomninal [sic] pain since 0200 associated with lower back pain, pt stated when i went to the bathroom to void noted vaginal bleeding and my cramping stated to become very uncomfortable ..."

b. Review of Medical Record #1 revealed that Patient #1 was admitted to the OBED unit on 5/28/21 at 15:00 and was discharged home on 5/28/21 at 17:30 and not on 5/29/21 as indicated on the "Perinatal Patient Triage Log".

c. Review of Medical Record #1 evidenced on the "OBED Provider Triage History and Physical" dated 5/28/21 that states, "... presents to OBED for 4-5/10 constant low back pain and pressure like sensation when urinating for the past 2 days that has been worsening. ... She also reports having clear yellow urine w/o [without] blood, but also states that it has started to develop an odor. ..." This was not the chief complaint documented on the "Perinatal Patient Triage Log" for Patient #1's first visit.

c. The above findings were confirmed with Staff #1 and Staff #12 on 8/18/21 at 2:30 PM.

B. Based on review of three (3) out of five (5) medical records of patient's presenting to the "OBED" (Obstetric Emergency Department) (Medical Record #1, MR #7, and MR #10), review of facility policy and procedure, and staff interview, it was determined that the facility failed to implement policy and procedure for the completion of the OBED triage assessment.

Findings include:

Reference: Facility policy and procedure titled, Care of the OB Patient in OBED, states, "... PROCEDURE: ... D. Triage assessment will be done by OBED nurse using the Triage/OBED record in Centricity Perinatal. All documentation must be complete and include an Emergency Severity Index (ESI), which [sic] ... iii. A patient history including pertinent medical/surgical, prenatal data, and presenting complaints/problems. ... v. An ongoing assessment will be performed and documented electronically at the judgment of the RN, as appropriate for the clinical condition. ..."

1. A review of Medical Record #1 revealed that the OBED Triage nursing assessment dated 5/28/21 at 15:08, lacks evidence of a presenting complaint. The nursing triage assessment also lacks evidence that an Emergency Severity Index (ESI) was assigned in accordance with facility policy.

a. The "Triage Summary" section of the OB Triage nursing assessment at 15:08 states, "Dr [name] in to see pt and discuss ob triage findings. Dr. [name] addressed pt questions and urine sent for culture. discharge instructions given to pt. pt verbalized understanding and signed paperwork. pt declined wheelchair and ambulated off unit to lobby. pt will follow up with Dr [name] at next well ob visit." Documented evidence indicates that the patient was discharged at 17:30.

b. During an interview on 8/18/21 at 2:02 PM, the above findings were confirmed with Staff #12. Staff #12 stated that the triage RN documented the entire OBED visit in the triage summary instead of documenting events as they occurred. Staff #12 confirmed that the events were not time stamped and all appeared under the entry for 15:08.

c. The above findings were confirmed on 8/18/21 at 2:30 PM with Staff #1 and Staff #12.

2. A review of Medical Record #7 and Medical Record #10 lacked evidence that an ESI priority was assigned during a visit to the OBED on 5/23/21 in accordance with facility policy.

a. The above findings were confirmed on 8/18/21 at 2:53 PM with Staff #1 and Staff #12.

C. Based on review of three (3) out of five (5) medical records of patient's presenting to the "OBED" (Obstetric Emergency Department) (Medical Record #1, MR #7, and MR #10), review of facility policy and procedure, and staff interview, it was determined that the facility failed to implement policy and procedure for the evaluation and treatment of pain.

Findings include:

Reference #1: Facility policy and procedure titled, Care of the OB Patient in OBED, states, "... PROCEDURE: ... D. Triage assessment will be done by OBED nurse using the Triage/OBED record in Centricity Perinatal. All documentation must be complete and include an Emergency Severity Index (ESI), which [sic] i. Assessment of vital signs including temperature, pulse, respirations, blood pressure, and pain. ..."

Reference #2: Facility policy and procedure titled, General Nursing-Pain Management, states, "... Procedure: Paint Management-Adult Patients ... 1. Initial Assessment ... b. On admission, patients will be assessed for pain, to include the patients description of pain, location, duration, intensity, radiation, precipitating factors and alleviating factors, keeping in mind that cultural beliefs and personal values can affect the patients response to pain. ... d. Objective pain scales will be used to determine the presence and intensity of pain. e. A patient's pain level of 5 or above, or a patient's verbalization of pain must be acted upon. Acceptable pain relief must be provided within 2 hours from the start of treatment. If treatment is ineffective, the nurse will notify the physician of inadequate pain relief, and obtain additional orders. ..."

1. A review of Medical Record #1 revealed an OB Triage nursing assessment dated 5/28/21, which indicated that Patient #1 arrived in the OBED at 15:00. The triage assessment lacks evidence of a nursing assessment of Patient #1's pain in accordance with the above referenced facility policy and procedure.

a. The "OBED Provider Triage History and Physical" states, "... presents to OBED for 4-5/10 constant low back pain and pressure like sensation when urinating for the past 2 days that has been worsening. ... She also reports having clear yellow urine w/o [without] blood, but also states that it has started to develop an odor. ... @1645 UA [urinalysis] done was unremarkable. Patient stable and agreeable for discharge home. All questions answered. ..."

(i) The medical record lacks evidence that Patient #1 received or was offered intervention for her complaints of pain prior to discharge.

b. The above findings were confirmed on 8/18/21 at 2:30 PM with Staff #1 and Staff #12.

2. A review of Medical Record #7 revealed an OB Triage nursing assessment dated 5/23/21, which indicated that the patient arrived in the OBED at 10:55 AM with a complaint of "Patient states she went to the ER 2 days ago at [name of different hospital] and was diagnosed with a UTI [urinary tract infection]. Patient is experiencing dysuria, oliguria, and pelvic pressure. ..." The triage assessment lacks evidence of a nursing assessment of Patient #7's pain in accordance with facility policy.

3. A review of Medical Record #10 revealed an OB Triage nursing assessment dated 5/23/21, which indicated that the patient arrived in the OBED at 13:35 with a complaint of "lower abdominal pain that started last night. Patient reports no pain when sitting or laying in bed, but pain when up and walking." The triage assessment lacks evidence of a nursing assessment of Patient 10's pain in accordance with facility policy.

4. The above findings were confirmed on 8/18/21 at 2:53 PM with Staff #1 and Staff #12.