HospitalInspections.org

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Based on observation, interview, and record review, in one (1) of fifteen (15) medical records (MR) reviewed, the hospital failed to implement the Emergency Department policy for the initial evaluation of obstetrical patients presenting to the ED (Patient #15).

Findings:

A review of the Emergency Department (ED) Policy titled "Initial evaluation of obstetric patients presenting to the ED and L&D (Labor & Delivery)," effective 10/21, stated, "all stable pregnant patients greater than 16 weeks gestational age who are experiencing a non-life-threatening complaint will be evaluated in Labor and Delivery. If the patient arrives to the ED via ambulance or walk in, she will be assessed by the ED staff. Documentation will be placed in the EMR. A handoff report will be provided by the nurse (in ED) to the nurse (on L&D). Once the patient is evaluated by the provider and stabilized, she will be transferred to L&D.
All pregnant patients presenting with a communicable disease will be referred directly to the (Main) ED. The labor and delivery staff will be notified and will be responsible for evaluating the patient in the emergency department. If the patient is in active labor, she will be transferred to a labor room but kept in isolation, and all necessary precautions will be taken. A physician (Resident or Attending) or mid-level provider will examine the patient and determine the disposition of the patient. If it is determined that the patient is in the wrong location (e.g., the patient is in the ED, and it is determined that they should be in L&D, or the patient is in L&D and it is determined that they should be in the ED) the Attending in the present location must call the Attending in the receiving location to discuss the patient and make arrangements for the transfer. After the involved Attendings agrees to the transfer, the nurse in the present location must call the nurse in the receiving location to discuss the patient and make arrangements for the transfer; after all, parties have been notified and agreed, an order is written by the Attending in the present location to transfer the patient. Patient transport is called, and the patient is transferred to the new location."

A review of the Emergency Medical Services (EMS) Pre-Hospital Care (PHC) report dated 8/17/24 at 12:56 AM indicated that Patient #15 requested to be taken to the hospital for respiratory distress. The patient had been positive for COVID-19 for four days and had a history of asthma; the patient was 19 weeks pregnant and denied any associated obstetric complaints.

Review of the MR for Patient #15 revealed that the patient presented to the Emergency Department (ED) on 08/17/2024 at 1:09 AM. The Triage Nurse documented at 1:18 AM, "Patient #15 arrived at the ED with a chief complaint of shortness of breath." The ED Nurse documented that a Physician (ED Attending) examined the patient, including listening to breath sounds, and determined that the patient's disposition was to L&D.

There was no documented evidence that a provider conducted a medical examination, including auscultation of the lungs, and there was no documented evidence in the MR of a written order by the attending physician to transfer the patient to L&D.


During the interview on 1/08/25 at 11:40 AM, Staff J (Medical Chair ED) explained that all patients, regardless of gestation, will undergo a medical evaluation because only the physician can give the orders to move a patient to the L&D.

In an interview on 1/09/25 at 10:00 AM, Staff E (Attending Main ED) stated, "I did not see this patient or evaluate them because my usual practice is to open the computer and drop the template, and then I go to see the patient and start the H&P (history and physical exam) of the patient ...and because I don't have anything written that is how I know I didn't see or evaluate the patient. I don't know why the nurse wrote that I did see and evaluate the patient when I did not."

The Emergency Department policy titled, "Triage Adult and Pediatric," effective 5/23/2023, stated that "EMS triage procedures are that the ambulance triage nurse will take a report from 1 crew member while the other crew member presents patient demographic information to the designated registrar at the information desk. Pregnant patients presenting to the ED are evaluated for obstetrical emergencies, and medical evaluation and clearance will be conducted prior to transferring to Labor and Delivery."

The ED Nurse did not implement ED procedures for the immediate isolation and evaluation of a COVID-positive, asthmatic patient presenting with complaints of respiratory distress.
Patient #1 MR had an incomplete Triage, and there was no documented evidence on 8/17/24 that the ED Staff screened for recent illness, foreign travel, or sick contacts.

As per the interview on 1/9/25 at 10:10 AM, Staff D (Triage Nurse-Main ED) stated, "I remember the patient was here with asthma...and her respiratory complaints were because of her asthma...she didn't have Covid ...and no one told me she had Covid ...I took her vital signs and I called the doctor over, (Staff H), so he came over and listened to her lungs and he said "she doesn't have any wheezing send her to L&D." ...but the patient decided she didn't want to go to L&D and she left the ED before I could complete triage ...the EMS crew had already left ...I don't have the authority to tell someone to go to L&D and that is why I needed the doctor to tell me..." Staff D acknowledged that the patient's triage was incomplete: "I wasn't told the patient was Covid positive ... the risk assessments and screening questions including recent travel history and contact with others with communicable disease were not asked and addressed and the immediate isolation of the patient wasn't implemented ..."

There is no documented evidence that the Triage Nurse assigned to the Ambulance Bay area of the Main ED called the nurse in the receiving location (L&D) to discuss the patient and make arrangements for their transfer.

During an interview on 1/10/25 at 11:00 AM, Staff L (L&D Triage Nurse) stated, "The patient arrived at L&D Unit at about 2:00 AM in a wheelchair with EMS and had a diagnosis of Covid and complaints of difficulty breathing ...I didn't expect her and no one had called me to tell me she was coming over to us ...so I said she needs to be in the main ED because she doesn't have any problems or issues with her pregnancy ...the patient got very upset when she heard that and said "no, she wasn't going back and forth from the ED to L&D and back again to the ED and then she got up and left." EMS seemed shocked and just stood there after the patient got out of the wheelchair and left..."

Interviews with Staff D and Staff L were inconsistent. While Staff D reported that "the patient decided she didn't want to go to L&D, and she left the ED before I could complete triage, and the EMS crew had already left," Staff L reported that the patient left L&D in the presence of EMS when they were told to return to the ED for evaluation.

On 1/10/25 at 3:15 PM, facility Administration and Leadership (Staff A, [Nursing], B [Quality], and C [Risk], acknowledged these findings.