HospitalInspections.org

Based on review of the Obstetrics (OB) Department Patient Register and staff interview it was determined the Hospital failed to ensure the OB Patient Register identified those patients that presented to the OB department for Emergency Services and the disposition of those patients. This has the potential to affect 100% of the patients who present to the OB department to obtain a Medical Screening Examination (MSE) which currently delivers 130 to 150 babies per month and an undetermined number of OB patients who presented to the OB department for a MSE and were subsequently discharged back home.
Findings include:

1. The "OB Patients' Register" (1/1/13 thru 6/3/13) was reviewed on 6/3/13. The Register consists of all patients who present to the OB Department. The log failed to indicate who presented to the OB Department for emergency services and also failed to indicate the disposition of OB patients who presented for emergency services and were admitted to observation status, inpatient status or if the patient was discharged home. The log only indicated dispositions if the patient was transferred to another hospital or if sent to the ED.

2. A staff interview was conducted with the OB Manager (E-4) on 6/3/13 at 9:50AM with the CNO present. The OB Manager indicated the "OB Patients' Register" is a handwritten log for all patients who present to the OB Department. When the OB manager was asked if the OB Manager could determine who presented for emergency services versus those who presented for tests or admission, the OB Manager indicated the log did not indicate if the patient presented for emergency services but that one could tell by what the patient's diagnosis was. When inquired about patient disposition, the OB Manager stated that one could not tell if the patient was admitted to observation, inpatient status, or if the patient was discharged home without looking at the medical record.