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Based on record review and policy review, the hospital failed to follow their policies and provide an appropriate medical screening exam (MSE) for two (#1 and #30) of five obstetric (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) patients' records reviewed. These failed practices had the potential to cause harm to all pregnant patients who presented to the hospital seeking care for an emergency medical condition (EMC). An average of 100 women per month were triaged through the hospital's OB unit over the past six months.

Findings included:

1. Review of the hospital's policy titled, "EMTALA Requirements Policy," dated 08/24/21, showed:
- Qualified Medical Personnel (QMP) identified in the hospital's medical staff bylaws would provide a MSE to determine the presence of an EMC to any person who comes to the ED or OB unit.
- A MSE is a process required in determining with reasonable clinical confidence whether or not an EMC exist.
- An EMC means any condition that is a danger to the health and safety of the patient (or, with respect to a pregnant woman, the health of the woman, her unborn child) or may result in the risk of impairment or dysfunction of a bodily organ if not treated in the foreseeable future. The EMC also included undiagnosed, acute pain which impaired normal functioning.

2. Review of the hospital's policy titled, "Washington Labor (WASH LB) Admission Policies," dated 05/07/2022, showed the criteria for patients treated or admitted to the OB unit included pregnancies over 20 weeks gestation (a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days) for treatment and ante partum (before delivery of child) with any complication of pregnancy which required specialized care.

3. Review of the hospital's policy titled, "WASH LB Assessment Guidelines," dated 04/01/2022, showed when a woman presented to the Labor and Delivery (LD) Unit for a non-obstetric complaint, the nurse should do a general review of systems focusing on the chief complaint.

4. Although requested, the hospital did not provide a policy regarding the triage of pregnant patients who presented to the ED.

5. Review of the document titled, "Mercy Hospital Washington Medical Staff Bylaws, Part V: Rules and Regulations," approved 02/08/2020, showed:
- Individuals authorized to conduct the initial medical screening for an EMC when a patient presented to the hospital included Physicians, Advance Practice Nurses, Physician Assistants, ED RNs and LD Triage RNs.
- A MSE was an ongoing process that begins, but does not typically end, with triage and the hospital provided an appropriate MSE to determine whether an EMC existed.
- An EMC was a medical condition with acute symptoms of sufficient severity (including pain) that the absence of immediate medical attention could result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or serious impairment of bodily functions or dysfunction of a bodily organ.

6. Review of Patient #30's medical record showed she was a 33-year-old pregnant female at 28 weeks gestation who presented to Mercy Hospital Washington on 05/22/22 at 2:51 PM complaining of pain, headache and swelling and reported that she had talked with her OB provider three days prior about a kidney stone. The patient's problem list included high-risk pregnancy in third trimester with a history of mild preeclampsia (a disorder of pregnancy characterized by the onset of high blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80] and often a significant amount of protein in the urine which increases the risk of the mother and the baby) with her previous pregnancy. Vital signs were assessed with heart rates (the number of heart beats per minute, normal range for adults is 60 to 100 bpm) recorded as elevated at 124 and 117. A urinalysis was ordered and resulted with multiple abnormal values indicative of possible infection. A clinical note by Staff L, RN, at 3:41 PM showed that Staff N, OB Physician, was updated regarding Patient #30's status and he gave orders for discharge, to follow-up with her primary OB, to drink fluids and take pain medication as prescribed. Discharge instructions listed in the medical record showed that no prescriptions were given and the patient was instructed to notify her physician or return to OB if she experienced contractions, had vaginal bleeding, her water broke, she noticed decreased movement of her baby, or had a headache, blurred vision, severe heartburn, abdominal pain or increased swelling. She was encouraged to "push fluids." Patient #30 was discharged home on 05/22/22 at 4:07 PM with a final diagnosis of calculus of the kidney. There was no documentation in the after visit summary provided to the patient upon discharge of symptoms to watch for related to kidney infection or sepsis such as fever, chills or flank pain. Staff failed to document respiratory rate (RR, the number of breaths per minute), oxygenation saturation (measure of how much oxygen is in the blood), physical assessment of heart or lung sounds, extremity swelling or pain assessment documented in Patient #30's medical record.

7. Review of Patient #30's medical record from Hospital B showed that she was admitted on 05/22/22 at 8:33 PM. She complained of back pain, fever, chills and nausea. She had a fever (a measured body temperature of 100.4° F or greater) and her heart rate was in the 120s. Patient #30's examination revealed mild tenderness over the area of the left kidney and blood in the urine. She was admitted for intravenous (IV, in the vein) antibiotics (medications that destroy or slow down the growth of bacteria) and narcotics for pain control. Patient #30 was discharged home from Hospital B on 05/25/22 with a diagnosis of sepsis (life threatening condition when the body's response to infection injures its own tissues and organs) secondary to pyelonephritis (a life-threatening bacterial infection in the kidneys and urinary tract).

8. Review of Patient #1's medical record showed she was a 36-year-old female at 34 weeks gestation who presented to Mercy Hospital Washington on 01/24/23 at 2:43 PM with a diagnosis of pregnancy induced hypertension without significant proteinuria (elevated protein in the urine), third trimester. Patient #1's previous problem lists included history of high risk pregnancy, two previous pregnancies with poor outcomes of fetal and neonatal death and a urine drug screen positive for methamphetamines (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) on 01/09/23. Patient #1's vital signs were recorded as BP of 138/86 and heart rate of 86 at 3:07 PM. Her BPs were reassessed and subsequently reported as elevated at 150/73, 153/76, 150/70 and 150/77. Laboratory tests were performed which included a urine test of the ratio of protein to creatinine and results showed a protein concentration of 75 mg/dl (with a normal reference range of 0-20 mg/dl) and a protein to creatinine ratio of 0.73 (with a normal reference range of 0-0.19). A progress note showed that the OB triage nurse spoke with the physician regarding the patient's laboratory results and received an order for admission of the patient for overnight observation and evaluation of 24-hour urine collection. Patient #1 refused to stay, signed an Against Medical Advice (AMA) form which annotated that she had received an MSE and was given a jug to collect her urine for the next 24 hours. The patient was discharged with a final diagnosis of pregnancy induced hypertension without significant proteinuria. Staff failed to document a respiratory rate, oxygenation saturation, assessment of heart or lung sounds, extremity swelling or of pain level documented in Patient #1's medical record. Staff failed to document if discharge instructions were provided to the patient.

Based on interview, record review and policy review, the hospital failed to provide an appropriate medical screening exam (MSE) for two (#1 and #30) of five obstetric (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) patients' records reviewed. These failed practices had the potential to cause harm to all pregnant patients who presented to the hospital seeking care for an emergency medical condition (EMC). An average of 100 women per month were triaged through the hospital's OB unit over the past six months.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) Requirements Policy," dated 08/24/21, showed:
- Qualified Medical Personnel (QMP) identified in the hospital's medical staff bylaws would provide a MSE to determine the presence of an EMC to any person who comes to the ED or OB unit.
- A MSE is a process required in determining with reasonable clinical confidence whether or not an EMC exist.
- An EMC means any condition that is a danger to the health and safety of the patient (or, with respect to a pregnant woman, the health of the woman, her unborn child) or may result in the risk of impairment or dysfunction of a bodily organ if not treated in the foreseeable future. The EMC also included undiagnosed, acute pain which impaired normal functioning.

Review of the hospital's policy titled, "Washington Labor (WASH LB) Admission Policies," dated 05/07/2022, showed the criteria for patients treated or admitted to the OB unit included pregnancies over 20 weeks gestation (a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days) for treatment and ante partum (before delivery of child) with any complication of pregnancy which required specialized care.

Review of the hospital's policy titled, "WASH LB Assessment Guidelines," dated 04/01/2022, showed when a woman presented to the Labor and Delivery (LD) Unit for a non-obstetric complaint, the nurse should do a general review of systems focusing on the chief complaint.

Although requested, the hospital failed to provide a policy on the triage of pregnant patients who presented to the ED.

Review of the document titled, "Mercy Hospital Washington Medical Staff Bylaws, Part V: Rules and Regulations," approved 02/08/2020, showed:
- Individuals authorized to conduct the initial medical screening for an EMC when a patient presented to the hospital included Physicians, Advance Practice Nurses, Physician Assistants, ED RNs and LD Triage RNs.
- A MSE was an ongoing process that begins, but does not typically end, with triage and the hospital provided an appropriate MSE to determine whether an EMC existed.
- An EMC was a medical condition with acute symptoms of sufficient severity (including pain) that the absence of immediate medical attention could result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or serious impairment of bodily functions or dysfunction of a bodily organ.

Review of the undated document titled, "ED to OB Triage Process," showed a flowchart which outlined the decision process when a pregnant patient presented to the ED. The document showed that if a patient was more than 20 weeks gestation and not exhibiting symptoms of labor, the patient would be evaluated and treated in the ED. If the patient was more than 20 weeks gestation and exhibiting symptoms of labor, the "ED OB Triage" form was completed, the OB nurse was given report of the patient's condition and the patient was retrieved from the ED by OB personnel.

Review of Patient #30's medical record showed she was a 33-year-old pregnant female at 28 weeks gestation who presented to the Mercy Hospital Washington on 05/22/22 at 2:51 PM complaining of pain, headache and swelling and reported that she had talked with her OB provider three days prior about a kidney stone. The patient's problem list included high-risk pregnancy in third trimester with a history of mild preeclampsia (a disorder of pregnancy characterized by the onset of high blood pressure and often a significant amount of protein in the urine which increases the risk of the mother and the baby) with her previous pregnancy. Vital signs were assessed with heart rates (the number of heart beats per minute, normal range for adults is 60 to 100 bpm) recorded as elevated at 124 and 117. A urinalysis resulted with multiple abnormal values indicative of possible infection. A clinical note by Staff L, RN, at 3:41 PM showed that Staff N, OB physician, was updated regarding Patient #30's status and orders received for discharge, to follow-up with her primary OB, to drink fluids and take pain medication as prescribed. Discharge instructions listed in the medical record showed that no prescriptions were given and the patient was instructed to notify her physician or return to OB if she experienced contractions; had vaginal bleeding; her water broke; she noticed decreased movement of her baby; or had a headache, blurred vision, severe heartburn, abdominal pain or increased swelling. She was encouraged to "push fluids." Patient #30 was discharged home on 05/22/22 at 4:07 PM with a final diagnosis of calculus of the kidney. There was no documentation in the after visit summary provided to the patient upon discharge of symptoms to watch for related to kidney infection or sepsis such as fever, chills or flank pain. Staff did not document respiratory rate (RR, the number of breaths per minute); oxygenation saturation (measure of how much oxygen is in the blood); physical assessment of heart or lung sounds, extremity swelling or pain assessment documented in Patient #30's medical record.

Review of Patient #30's medical record from Hospital B showed that she was admitted on 05/22/22 at 8:33 PM with complaints of back pain, fever, chills and nausea. She had a fever (a measured body temperature of 100.4° F or greater) and her heart rate was in the 120s. Patient #30's examination revealed mild tenderness over the area of the left kidney and blood in her urine. She was admitted for intravenous (IV, in the vein) antibiotics (medications that destroy or slow down the growth of bacteria) and narcotics for pain control. Patient #30 was discharged home from Hospital B on 05/25/22 with a diagnosis of sepsis (life threatening condition when the body's response to infection injures its own tissues and organs) secondary to pyelonephritis (a life-threatening bacterial infection in the kidneys and urinary tract).

Review of Patient #1's medical record showed she was a 36-year-old pregnant female at 34 weeks gestation who presented to Mercy Hospital Washington on 01/24/23 at 2:43 PM with a diagnosis of pregnancy induced hypertension without significant proteinuria (protein in the urine), third trimester. Patient #1's previous problem lists included history of high risk pregnancy, two previous pregnancies with poor outcomes of fetal and neonatal death and a urine drug screen positive for methamphetamines on 01/09/23. Patient #1's vital signs were recorded as blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) 138/86 and heart rate of 86 at 3:07 PM. Her BPs were reassessed and reported as elevated at 150/73, 153/76, 150/70 and 150/77. Laboratory tests were performed which included a urine test of the ratio of protein to creatinine and results showed a protein concentration of 75 mg/dl (with a normal reference range of 0-20 mg/dl) and a protein to creatinine ratio of 0.73 (with a normal reference range of 0-0.19). A progress note showed that the OB triage nurse spoke with the physician regarding the patient's laboratory results and received an order for admission of the patient for overnight observation and evaluation of 24-hour urine collection. Patient #1 refused to stay, signed an Against Medical Advice (AMA) form which annotated that she had received an MSE and was given a jug to collect her urine for the next 24 hours. The patient was discharged with a final diagnosis of pregnancy induced hypertension without significant proteinuria. Staff failed to document RR, oxygenation saturation; assessment of heart or lung sounds, extremity swelling or of pain level documented in Patient #1's medical record. There was no documentation of discharge instructions provided to the patient.

During an interview on 05/02/23 at 12:40 PM, Staff M, LD Supervisor, stated that the RN performed the MSE for patients in OB triage, charted the assessment in the medical record and forwarded the information to the patient's primary obstetrician. If the patient did not have an obstetrician associated with the hospital, the RN notified the obstetrician on-call.

During a telephone interview on 05/02/23 at 2:15 PM, Staff L, RN, stated that an MSE included a head to toe assessment of vital signs (body temperature, blood pressure, heart rate, and breathing rate); heart, lungs and abdomen sounds; assessment of reflexes and swelling. If the patient was stable and did not require immediate intervention by the physician, the appropriate tests from the order set and assessments were completed prior to notifying the physician of the MSE findings. Staff L stated that symptoms of headache, pain and swelling could be attributed to preeclampsia and increased heart rate could indicate dehydration. Some physicians would wait for culture results before treating an abnormal urinalysis because of concerns that the urine sample was contaminated. Patients with urinary symptoms received instructions to follow-up with their regular OB provider and to watch for specific urinary symptoms of painful or difficult urination.

During a telephone interview on 05/02/23 at 4:40 PM Staff N, OB physician, stated he expected that the RN performed a focused assessment based on the patient's presenting complaint and reported abnormal findings within the assessment. The focused assessment included fetal monitoring, vital signs, labs from the order set and a physical assessment which might include assessment of abdominal tenderness, reflexes and heart and lung sounds. Staff N stated that he did not remember if he was informed of Patient #30's elevated heart rate. He stated he did not prescribe antibiotic treatment for Patient #30 because the urine sample was possibly contaminated. He waited to see if the culture and sensitivity (a test to identify bacteria that may cause an infection and see what kind of medication will work best to treat the infection) test showed which antibiotic would best treat the potential infection. He stated that Patient #30's complaints were headache and swelling and not urinary in nature. He would have expected Patient #30 to be given discharge instructions that included to follow-up with her primary obstetrician within the next week or sooner if her symptoms worsened.

During an interview on 05/03/23 at 9:00 AM, Staff D, ED Manager, stated that once a ED patient was identified as pregnant, a specific Situation-Background-Assessment-Recommendation (SBAR, a communication technique used between members of a healthcare team about a patient's condition) form was completed which included the patient's chief complaint and vital signs. If the patient was more than 20 weeks gestation and complaints were potentially labor-related, the patient was sent to the OB unit for further evaluation. The SBAR form was not retained or included in the patient's medical record. There was no documentation from the ED within the medical record of a pregnant patient who initially presented to the ED and was transferred to the OB unit. Staff D stated that potential labor patients were the only pregnant patients sent to OB through the ED.

During an interview on 05/03/23 at 11:05 AM, Staff T, RN, stated that the physical assessment of patients who presented to the OB unit for triage was dependent upon their chief complaint or the reason for their referral to the unit. Patients who presented for a scheduled, non-stress test would not receive a complete physical assessment. A patient with a concern for pregnancy induced hypertension would have an assessment which included lung sounds and reflexes. Patients were not always seen face-to-face by a physician. The nurse received additional orders after informing the physician of the complaint of the patient, focused assessment and examination of the patient and the results of any tests completed from the order set.

During an interview on 05/03/23 at 11:45 AM and follow-up at 1:10 PM, Staff K, OB Director of Nursing, stated that patients with a medical condition could go through the ED where they were triaged and evaluated to determine if the complaint was pregnancy-related. The MSE was completed in the ED if the condition was not obstetric-related. She expected that a patient who presented to the OB unit received an assessment by the RN focused on the patient's complaint. A patient who presented with complaints of headache and swelling or with a previous history of preeclampsia would raise questions of pregnancy induced hypertension and would include a physical assessment of the presence of abdominal tenderness, reflexes and listening to heart and lung sounds. Staff K stated that the OB physicians assumed that a nurse was completing a full exam and reporting abnormal findings. Nurses in the OB unit received no training specific to the assessment of patients in triage. Staff K stated that OB nurses would likely say that "they are doing a nursing assessment, but not a medical screening."

During a telephone interview on 05/03/23 at 12:30 PM, Staff U, OB Medical Director, stated that the RNs performed the MSE for patients who presented to OB for triage. Patients received an assessment focused on their complaint. The assessment would typically include an evaluation for swelling, abdominal pain and listening to heart and lung sounds. Any abnormal findings were forwarded during communication with the physician. Staff U stated that any pregnant patient beyond 20 weeks gestation who presented to the hospital was sent to the OB unit and that if their complaint was determined non-OB, the patient may be referred back to the ED.

Based on interview, record review and policy review, the hospital failed to provide stabilizing treatment for one (#30) of five obstetric (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) patients' records reviewed. These failed practices had the potential to cause harm to all pregnant patients who presented to the hospital seeking care for an emergency medical condition (EMC). An average of 100 women per month were triaged (process of determining the priority of a patient's treatment based on the severity of their condition) through the hospital's OB unit over the past six months.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) Requirements Policy," dated 08/24/21, showed:
- An EMC means any condition that is a danger to the health and safety of the patient (or, with respect to a pregnant woman, the health of the woman, her unborn child) or may result in the risk of impairment or dysfunction of a bodily organ if not treated in the foreseeable future. The EMC also included undiagnosed, acute pain which impaired normal functioning.
- Stabilizing treatment was the treatment necessary to stabilize the patient's EMC.
- Patients were considered stabilized when diagnostic work-up and treatment had reached a point where continued care could be performed as an outpatient and patients were given appropriate follow-up care and discharge instructions.

Review of the hospital's policy titled, "Washington Labor (WASH LB) Admission Policies," dated 05/07/22, showed the criteria for patients treated or admitted to the OB unit included pregnancies over 20 weeks gestation (a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days) for treatment and ante partum (before delivery of child) with any complication of pregnancy which required specialized care.

Review of the hospital's policy titled, "WASH LB Assessment Guidelines," dated 04/01/22, showed when a woman presented to the Labor and Delivery (LD) Unit for a non-obstetric complaint, the nurse should do a general review of systems focusing on the chief complaint.

Although requested, the hospital failed to provide a policy on the triage of pregnant patients who presented to the ED.

Review of the document titled, "Mercy Hospital Washington Medical Staff Bylaws, Part V: Rules and Regulations," approved 02/08/20, showed:
- Individuals authorized to conduct the initial medical screening for an EMC when a patient presented to the hospital included Physicians, Advance Practice Nurses, Physician Assistants, ED RNs and LD Triage RNs.
- An EMC was a medical condition with acute symptoms of sufficient severity (including pain) that the absence of immediate medical attention could result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or serious impairment of bodily functions or dysfunction of a bodily organ.
- When admission of a patient was not deemed necessary, appropriate care and treatment was implemented and the patient was provided with applicable follow-up care.

Review of the undated document titled, "ED to OB Triage Process," showed a flowchart which outlined the decision process when a pregnant patient presented to the ED. The document showed that if a patient was more than 20 weeks gestation and not exhibiting symptoms of labor, the patient would be evaluated and treated in the ED.

Review of Patient #30's medical record showed she was a 33-year-old pregnant female at 28 weeks gestation who presented to Mercy Hospital Washington on 05/22/22 at 2:51 PM complaining of pain, headache and swelling. She reported that she had talked with her primary OB provider three days prior about a kidney stone. The patient's problem list included high-risk pregnancy in third trimester with a history of mild preeclampsia (a disorder of pregnancy characterized by the onset of high blood pressure and often a significant amount of protein in the urine which increases the risk of the mother and the baby) in her previous pregnancy and history of renal stone. Vital signs were assessed with heart rates (the number of heart beats per minute, normal range for adults is 60 to 100 bpm) recorded as elevated at 124 and 117. A urinalysis resulted with multiple abnormal values indicative of possible infection. A clinical note by Staff L, RN, at 3:41 PM showed that Staff N, OB physician, was updated regarding Patient #30's status and orders received for discharge, to follow-up with her primary OB, to drink fluids and take pain medication as prescribed. Discharge instructions listed in the medical record showed that no prescriptions were given and the patient was instructed to notify her physician or return to OB if she experienced contractions; had vaginal bleeding; her water broke; she noticed decreased movement of her baby; or had a headache, blurred vision, severe heartburn, abdominal pain or increased swelling. She was encouraged to "push fluids." Patient #30 was discharged home on 05/22/22 at 4:07 PM with a final diagnosis of calculus of the kidney. There was no documentation in her assessment of a review of systems, the patient's prenatal care, history of kidney stones, imaging studies or assessment of pain. No additional orders were entered for straining of her urine or 24-hour urine collection for presence of protein. There was no documentation of administration of medications for the patient's pain or for treatment of her abnormal urinalysis. The physical examination did not include the patient's respiratory rate (RR, the number of breaths per minute); oxygenation saturation (measure of how much oxygen is in the blood); assessment of heart sounds, lung sounds or extremity swelling. The after visit summary provided to the patient upon discharge did not include instructions regarding her reported kidney stone, such as to watch for symptoms related to kidney infection or sepsis (life threatening condition when the body's response to infection injures its own tissues and organs).

Review of Patient #30's medical record from Hospital B showed that she was admitted on 05/22/22 at 8:33 PM with complaints of back pain, fever, chills and nausea. She had a fever (a measured body temperature of 100.4° F or greater) and her heart rate was in the 120s. Patient #30's examination revealed mild tenderness over the area of the left kidney and blood in her urine. She was admitted for intravenous (IV, in the vein) antibiotics (medications that destroy or slow down the growth of bacteria) and narcotics for pain control. Patient #30 was discharged home from Hospital B on 05/25/22 with a diagnosis of sepsis secondary to pyelonephritis (a life-threatening bacterial infection in the kidneys and urinary tract) and arrangements for continued IV antibiotic administration as an outpatient.

During a telephone interview on 05/02/23 at 2:15 PM, Staff L, RN, stated that a patient exam in the OB unit included a head to toe assessment; vital signs (body temperature, blood pressure, heart rate, and breathing rate); heart, lungs and abdomen sounds; assessment of reflexes and swelling. If the patient was stable and did not require immediate intervention by the physician, the appropriate tests from the order set and assessments were completed prior to notifying the physician of findings. Staff L stated that symptoms of headache, pain and swelling could be attributed to preeclampsia and increased heart rate could indicate dehydration. Some physicians would wait for culture results before treating an abnormal urinalysis because of concerns that the urine sample was contaminated. Patients with urinary symptoms received instructions to follow-up with their regular OB provider and to watch for specific urinary symptoms of painful or difficult urination.

During a telephone interview on 05/02/23 at 4:40 PM Staff N, OB physician, stated he expected that the RN performed a focused assessment based on the patient's presenting complaint and reported abnormal findings within the assessment. The focused assessment included fetal monitoring, vital signs, labs from the order set and a physical assessment which might include assessment of abdominal tenderness, reflexes and heart and lung sounds. Staff N stated that he did not remember if he was informed of Patient #30's elevated heart rate. He stated he did not prescribe antibiotic treatment for Patient #30's abnormal urinalysis because he believed the sample was possibly contaminated. He waited to see if the culture and sensitivity (a test to identify bacteria that may cause an infection and see what kind of medication will work best to treat the infection) test showed which antibiotic would best treat the potential infection. He stated that Patient #30's complaints were headache and swelling and not urinary in nature. He would have expected Patient #30 to be given discharge instructions that included to follow-up with her primary obstetrician within the next week or sooner if her symptoms worsened.

During a telephone interview on 05/03/23 at 12:30 PM, Staff U, OB Medical Director, stated that assessment of a patient in the OB unit was focused on their presenting complaint and would typically include an evaluation for swelling, pain and listening to heart and lung sounds. Any abnormal findings were forwarded during communication with the physician. Staff U stated that any pregnant patient beyond 20 weeks gestation who presented to the hospital was sent to the OB unit and that if their complaint was determined non-OB, the patient may be referred back to the ED.

During an interview on 05/03/23 at 9:00 AM, Staff D, ED Manager, stated that if a patient presented to the ED, was more than 20 weeks gestation and complaints were potentially labor-related; the patient was sent to the OB unit for further evaluation. Staff D stated that potential labor patients were the only pregnant patients sent to OB through the ED.

During an interview on 05/03/23 at 11:05 AM, Staff T, RN, stated that the physical assessment of patients who presented to the OB unit for triage was dependent upon their chief complaint or the reason for their referral to the unit. A patient with a concern for pregnancy induced hypertension would have an assessment which included lung sounds and reflexes. Patients were not always seen face-to-face by a physician. The nurse received additional orders after informing the physician of the complaint of the patient, focused assessment and examination of the patient and the results of any tests completed from the order set.

During an interview on 05/03/23 at 1:10 PM, Staff K, OB Director of Nursing, stated that patients with a medical condition could go through the ED where they were triaged and evaluated to determine if the complaint was pregnancy-related. The examination was completed in the ED if the condition was not obstetric-related.