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Based on findings at A2405 and A2406, the facility failed to ensure compliance with CFR 489.24.

Based on document review and interview, the facility failed to ensure a log was maintained for all patients who presented to the Emergency Room for treatment including the disposition of each patient for 1 of 33 patients (Patient #33).

Findings include:

Patient #33

Patient #33 was a 30 year old female who presented to the Emergency Room (ER) on 4/27/11 at approximately 3:00 AM with complaints of abdominal pain and bleeding. Patient #33 indicated she was 25 weeks pregnant.

Review of the Emergency Room log for 4/27/11, revealed there was no documentation of Patient #33 entered into the ER log or computer system.

An interview with the Triage Nurse (Employee #4) confirmed Patient #33 presented to the ER on the date and time indicated. However, since the patient was over 20 weeks pregnant, she was brought to the Labor and Delivery (L&D) area to be screened. The employee added the L&D area maintained a separate log of patients who were screened in that area.

Review of the L&D outpatient Log for 4/27/11, revealed there was no documentation of Patient #33 entered on the L&D log.

Since Patient #33 was not screened by a nurse or a doctor in the L&D area or the ER, there was no documented evidence of Patient #33's encounter at this facility.

Complaint #NV28280

Based on observation, record review, document review, and interview, the facility failed to ensure a medical screening exam was conducted for 2 of 33 patients (Patients #25, #33).

Findings include:

Patient #33

Patient #33 was a 30 year old female who presented to the Emergency Room (ER) on 4/27/11 at approximately 3:00 AM with complaints of abdominal pain and bleeding. Patient #33 indicated she was 25 weeks pregnant.

There was no medical record created by the facility for Patient #33's ER encounter. The information was obtained from interviews with the patient's husband and several staff members.

On 5/24/11 at 11:30 AM, Patient #33's husband was interviewed to obtain details of the patient's ER encounter on 4/27/11.

Patient #33's husband stated he and his wife presented to the ER on 4/27/11 at approximately 3:00 AM. He informed the person at the front desk that his wife was 25 weeks pregnant and was having abdominal pain every 3-5 minutes. She was also having green discharge. The husband indicated he completed a form with his wife's name and gave that to the person at the desk. He waited approximately 10 minutes. His wife was not seen by a nurse or physician.

A staff member then called the Women's Center and indicated his wife would be seen there. Patient #33 and her husband proceeded to walk to the Women's Center, escorted by a staff member. While they were walking to the Women's Center, Patient #33 started to have a "bad" contraction and slumped over in pain. At that time, the patient's husband asked for a wheelchair for his wife, as he saw a couple of wheelchairs in the hallway. The staff member attempted to take one of the wheelchairs, however, the wheelchairs were chained together and could not be used. Patient #33 proceeded to walk the remainder of the way to the Women's Center.

Arriving at the Women's Center, the staff member from the ER informed the staff in the Labor & Delivery (L&D) area that Patient #33 was there. The ER staff informed the patient to sit in the L&D waiting area and someone would be with them soon. The ER staff escort then left Patient #33 and her husband in the L&D waiting area alone.

Patient #33 and her husband sat in the waiting area for around 10 minutes. They observed a couple of staff members entering the unit but no one addressed them. After 10 minutes, the husband started banging on the locked door to the OB unit. An OB staff member informed him that they had 2 C-Sections and they would have to "wait a bit." A man opened the door and informed him that they didn't have room for his wife. All beds were full.

After waiting several minutes longer without being seen, Patient #33 and her husband walked back to the ER. At this point he was very mad and started to yell at the staff in the ER. He asked if there were a nurse or doctor available to see his wife. When the husband and the Patient #33 returned to the waiting room, he observed only one person was waiting there.

Patient #33's husband asked where the closest hospital was. The staff member who had escorted them stated - she couldn't believe they had not seen Patient #33 in the L&D area. She then indicated she would contact the house supervisor. At this point, the patient's husband just wanted to leave the hospital and go to a different hospital. The ER staff then gave him directions to a nearby hospital.

The couple left the facility and were able to find the nearby facility. Patient #33 was seen immediately, admitted, and the baby was born within 45 minutes, and required a ventilator.

Patient #33 was not screened by a qualified medical professional in the ER or in the Labor and Delivery Department.

Interviews with staff members

On 5/25/11 at 7:30 AM, Employee #4, the ER Triage Nurse, was interviewed. Employee #4 verbalized on the day of the incident at approximately 3:00 AM, the employee was in the ER Department in the back. She was beeped and informed there was a maternity case. She came out to the registration desk. Employee #4 asked the patient questions including the patient's due date; how many weeks pregnant - "25 weeks"; if she was having abdominal pain - "yes"; the name of her doctor - "(Dr. Name), Ca."; indicated this was the first pregnancy; any bleeding - "No."

The Triage Nurse added Patient #33 appeared to be in obvious pain.

The Triage Nurse then called Labor and Delivery (L&D) so the patient could be evaluated there. The Triage Nurse indicated the cutoff for patients to be seen in the ER vs L&D was 20 weeks. If a patient did not know she was pregnant or the gestational age, the patient would be seen in the ER first to determine the gestational age. If the pregnancy was confirmed and the patient was greater than 20 weeks, the patient would then be sent to L&D.

The Triage Nurse indicated Patient #33's husband had not filled out a registration card in the ER. However, the Triage Nurse added when a patient completed the registration card in the ER, and then was sent to L&D, the registration card was destroyed. The information was not entered into the ER computer system.

The Triage Nurse called to have a technician (tech) escort Patient #33 to L&D, but the tech was not available. The Triage Nurse asked the patient if she could walk to the L&D area and Patient #33 stated she could.

At approximately 3:20 AM, the Triage Nurse escorted Patient #33 to the L&D area, which was all the way on the opposite side of the facility. About half way there, the patient bent over in pain. The Triage Nurse asked the patient if she wanted a wheelchair. The employee tried to obtain a wheelchair but the wheelchairs were locked. They proceeded to walk the rest of the way.

Both Patient #33 and her husband appeared to be very nervous. When they arrived at L&D, the Triage Nurse buzzed herself in and the husband and wife entered into the OB (Obstetrical Unit). They were standing in the doorway for a couple of minutes and no one was there. At that time, a staff member was observed pushing a patient, and the female staff member instructed the Triage Nurse to have Patient #33 and her husband wait in the waiting area. The Triage Nurse brought them out to the waiting area and told them to wait there. The Triage Nurse then left the couple alone in the waiting area and walked back down to the ER.

When the Triage Nurse returned to the ER, she informed the Charge Nurse of the ER about leaving Patient #33 and her husband alone in the L&D waiting area, and indicated she felt bad about leaving them.

At approximately 3:45 or 3:50 AM, the Triage Nurse was in the triage area and heard a man yelling stating - "Tell me where a real hospital is, where they can take care of my wife." She went out to the desk and saw a man but did not recognize him right away. Patient #33 was not visible.

The man continued to yell. There were patients in the lobby. The Triage Nurse followed the man outside and then saw Patient #33. The employee asked "what happened?" Patient #33's husband stated - "There was not a doctor or a nurse who would take care of my wife." The employee responded, "You can't say that, that's not true."

The Charge Nurse then walked out and asked what was going on. Patient #33's husband asked where was another hospital. The Charge Nurse asked Patient #33 to come back inside stating, "we could help you." Patient #33's husband was very upset and refused to bring his wife back inside. The Charge Nurse then gave them the name of several hospitals.

The Triage Nurse was not sure if the security guards had come out to the ER waiting area during this time. She added the whole incident was about 45 minutes from the time the couple entered the ER until the time they left.

The employee indicated that no staff member told Patient #33 to leave the hospital. She confirmed Patient #33 was not screened by a nurse or physician prior to leaving the facility.

On 5/25/11 at 9:00 AM, interviews with the staff working in the L&D area on the night of this incident, the RN Supervisor and the Surgical Technician, confirmed Patient #33 was not screened by a nurse or physician in the L&D area. The staff added there were no beds available due to a high volume of cases.

The facility policy titled Assessment of Pregnant Patients in OB/Emergency Department dated 12/2010 documented:

- "A. Patients less than 20-weeks gestation will be initially assessed in the Emergency Department. If an obstetrician is needed, the obstetrician on-call or the patient's own physician will complete the assessment in the Emergency Department.
- "B. Patients greater than 20-weeks arriving with pregnancy related problems, or symptoms (i.e., cramps, low back pain), will be assessed by the L&D staff in labor and delivery and appropriate obstetrician, as necessary..."

During the tour of the facility on 5/24/11, the distance between the ER and the L&D unit was noted to be very long, approximately 800 feet, each unit was at the opposite side of the facility. Also noted in the front of the main lobby behind the volunteer's registration desk, were 2 wheelchairs chained together. One volunteer indicated the wheelchairs were located there so they could be used by the volunteers during the day as needed. The chairs remained locked up at night so they would not be used and would be available for the next day.

On 5/24/11 in the morning, the Chief of Security was interviewed to determine if there was videotape of the incident available. There were two additional security guards, as well as a "trainee" present at the time of the interview. None of these security guards were present the night of the incident. The Chief of Security explained there were cameras located throughout the facility and in the ER waiting area. The ER camera captured people at the ER Registration Desk, as well as the ER Waiting area. The videotapes were taped over every 7 days, so no videotape was available for the night of the incident. A security guard added the guards did not sit at the desk monitoring the cameras at all times. They made rounds throughout the facility and responded when they heard a disturbance or were called by staff members.

On 5/24/11 in the morning, the Risk Manager indicated the facility did not pull the tape for the night of this incident, so no videotape was available.

Complaint #NV20280

Patient #25

Patient # 25 was a 27 year old female who presented to the Emergency Room on 2/24/11 at 16:04 (4:04 PM) with a chief complaint of abdominal cramping, nausea, vomiting, and vaginal bleeding, which started 3 hours prior to admission.

Additional documentation on the Emergency Nursing Record by the triage nurse indicated Patient #25's LMP (Last Menstrual Period) was on December 4, and the patient was pregnant. The patient's current pain level at the time of triage (4:06 PM), was documented as 10/10.

The triage nurse listed the patient's acuity level as a III.

The triage nurse's additional notes indicated "1615 (4:15 PM) No exam room available. Charge nurse aware. Will protocol. 16:20 (4:20 PM) Unable to start IV (Intravenous) or draw blood. Called lab." "1800 (6:00 PM) Patient no longer in lobby."

The Emergency Department Standing Orders form included in Patient #25's medical record circled the section for vaginal bleeding orders which included:
- "CBC, (Complete Blood Count), BMP (Basic Metabolic Panel), Serum Preg (Pregnancy), Quant HCG (Quantatative human chorionic gonadotropin), (if pregnant), Cath (Catheterized) UA (urinalysis), RH (Blood type test)
- Collect all vaginal products for examination in a sterile container and label
- Obtain physician order for Pelvic Ultrasound: R/O (Rule out) Ectopic Pregnancy (if pregnant)" (This order for the Pelvic Ultrasound was crossed out which indicated this was not a valid order for this patient)

An additional notation in this section included "In lobby" which indicated the Patient #25 was waiting in the ER lobby.

There was no documented evidence any blood work was drawn on Patient #25.

The facility's policy titled Triage - Emergency Department, dated 8/04 documented:
"A. Triage: Defined as the means by which persons seeking emergency medical care are prioritized according to urgency of illness or injury."

The urgency category indicated :
- "Category II; Acuity - Urgent; Examples - Open fracture, severe pain, minor burn, acute abdomen, sickle cell crisis. Patients in this category have a potential threat to life or limb or are suffering extreme pain. Generally they will deteriorate if not being treated quickly..."
- "Category III; Acuity - Nonurgent; Examples - Closed fracture, laceration/contusions, sprains, noncardiac chest pain. Patients in this category must be seen within 1 hour, if possible, because their pain, severe symptoms, or risk profiles indicate the probability of deterioration without intervention..."

On 5/24/11 at 11:00 AM, the R.N. (Registered Nurse) Triage Nurse (Employee #2) was interviewed. She did not remember Patient #25 but provided general information regarding all patients triaged in the ER. The R.N. indicated when she triaged a patient in the ER, she performed a visual assessment and then made the determination regarding acuity. Even though a patient indicated the pain level was 10/10, if the R.N.'s visual examine did not confirm that pain level, the patient could wait in the ER Lobby. The R.N. indicated she checked on the patients waiting in the lobby at least every 2 hours, usually hourly. However, she did not routinely document the hourly checks. The R.N. also revealed when a patient had to wait in the lobby prior to being seen, the patient was instructed to notify the staff if he/she felt there was a change in their condition.

The R.N. explained when there was not a bed available for a patient in the ER, the protocol was to obtain the standing orders and initiate them, such as blood work. Then, when a bed became available, the lab results would be available to the physician, which would prevent any further delays in teatment.

On 2/24/11 at 2122 (9:22 PM), Patient #25 returned to the ER with the chief complaint of abdominal pain, and was assigned an acuity level III. Documentation by the triage nurse indicated the patient had left AMA (Against Medical Advice) earlier that day. There was no documented evidence in the ER record from the earlier ER encounter that the patient left AMA. The documentation on the ER log indicated the patient left after triage.

Patient #25 was seen by the physician at 2215 (10:15PM). Blood work was drawn and an abdominal ultrasound performed which showed a suspected ruptured ectopic pregnancy.

Patient #25 was taken to the Operating Room on 2/25/11 at 4:15 AM for an exploratory laparotomy for a ruptured ectopic pregnancy.