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Based on interview and document review it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically an incomplete log documenting all patients seeking medical treatment and the failure to perform timely triage and medical screening exam for 1 (#1) of 20 patients seeking treatment in the Emergency Department. Findings include:



See tags:

A-2405- Failure to maintain a complete log documenting all patients seeking medical treatment, and

A-2406 Failure to provide timely triage and medical screening exam.

Based on interview and document review, the facility failed to maintain a central log for all persons seeking treatment in the Labor and Emergency Department for 1 (#1) of 14 sampled patients who presented to Labor and Delivery out of a total sample of 20, resulting in the potential for failure to track care provided to all individuals seeking emergency services. Findings include:

On 4/1/2020 at 1244 an interview with confidential informant BB revealed that patient #1 called a family member on 3/6/2020 and reported she was having nausea and diarrhea for approximately 2.5 hours. Patient #1 called her obstetrician for direction and was told if she had a fever and chills to go to the hospital. It was determined patient #1 had a fever of 100 degrees Fahrenheit. Patient #1 was transported to the hospital by family and reported to the Labor and Delivery Department (L&D) at 1630. At the L&D desk patient #1 was asked her symptoms and reported she was 37 weeks pregnant with vomiting, diarrhea, fever and bleeding. The employee made a call and informed patient #1 she would be seen in the Emergency Department (ED). The patient told the employee that during the L&D tour she was told to report to L&D for any concerns after 20 weeks and not to go to the ED. The informant stated they inquired about fetal monitoring and were told that it would be done in the ED. The informant stated no one from L&D saw or monitored patient #1. When they reported to the ED desk, they were told to wait in the waiting room. About 20-30 minutes later patient #1 was taken back for evaluation. The informant stated no one monitored the baby in the ED.

On 4/7/2020 at 1530, the electronic list for the 14 patients that were registered as seen in the Labor and Delivery Department (L&D) on 3/6/2020 was provided for review. The list was in order of times that the patients were registered. Patient #1 was listed only one time at 1841. The list did not document patient #1's first presentation at approximately 1630.

On 4/2/2020 at 1345 an interview occurred with Staff P, the Labor and Delivery (L&D) reception clerk who was on duty on 3/6/2020 when patient #1 arrived at the L&D desk. She stated we register the patients when they arrive and inform the triage nurse. Patients who are 20 weeks gestation or greater are seen in L&D.

Staff P stated she did recall patient #1. She stated, the patient had arrived at L&D with her mom and sister. The patient's, mother, and sister stated she was 37 weeks and having nausea, vomiting and diarrhea. "I called back to the triage nurse (identified as Registered Nurse (RN) Staff S) and reported patient #1's arrival and symptoms". Staff P stated, "RN Staff S did not come to see patient #1 but asked me to ask the patient if the baby was moving". Staff P stated patient #1 said "yes". Staff P stated, Staff S informed her if patients arrive for non-pregnancy related concerns they are to be sent to the Emergency Department (ED). Staff P stated, she had never been told this information prior to that day, but said they had been seeing a lot of flu patients. She stated she wrote down patient # 1's medical record number and informed her she would be seen in the ED instead. Staff P stated the patient's mother and sister spoke up and stated that during the L&D tour they were told to come to L&D and were asking if fetal heart monitoring would be done in the ED. Staff P stated she walked patient #1 and her family to the ED. She stated patient #1 looked uncomfortable, was sweating and reported "it was coming out both ends, she wanted to lay down, felt weak because she couldn't keep anything down". Staff P stated, "an hour or so later emergency department staff brought the patient (#1) back up in a hospital bed. They took her straight back into labor and delivery. I already had her medical record number from earlier. I got the consent. She (patient #1) was in a lot of pain. She was not answering any questions her Mom and sister were talking for her."

Staff P was asked, did you document/register the patient the first time she came to the L&D department? She replied, "No, I just got her medical record number and then took her to the ED after talking to the nurse."

On 4/2/2020 at 1511 an interview occurred at the facility with the L&D triage RN (staff S). Staff S stated, "after a patient is registered the reception staff call the triage nurse and tell us why the patient is here and how far along they are. We go get the patient and take them to triage with-in 10 minutes. We check their vital signs and fetal heart rate in the same room then move them to regular triage room, have them change, put on fetal heart monitor and contraction monitor and notify the nurse midwife. We do not do a vaginal exam unless birth appears to be imminent. The nurse midwife sees all the patients and does the vaginal exam and if they want the patient admitted then they are moved to a L&D room."

When queried regarding patient #1 Staff S stated she recalled the patient. Staff S stated it was a very busy shift which she started at 1500. She stated the receptionist (staff P) called about patient #1 while she was admitting another patient. The receptionist reported the patient had nausea, vomiting and diarrhea. She asked the receptionist to ask patient #1 if the baby was moving and heard her reply "yes." Staff S stated she had been told that if patients reported flu symptoms they should go to the ED prior to be admitted to L&D. Staff S stated, "the patient had no other pregnancy complaints so she directed Staff P to send her to the ED. A short time later the OB [obstetric] doctor (Staff X) received a call from the ED doctor (Staff Z) and asked if I had sent a patient to ED. I told her yes for flu symptoms. OB doctor (Staff X) told me to go down and get a non-stress test on the patient with the portable monitor. I called the ED and was told the ED doctor reported leaking fluid so I told them to bring her right to L&D. Patient #1 was brought up on a stretcher with a mask on, an IV (intravenous catheter) and the ED staff reported a temperature of 100.4."

Staff S was asked if she saw patient #1 for triage the first time the patient presented to L&D? she stated, "No." When asked why? Staff S stated "I was very busy and the patient did not report any pregnancy concerns" Staff S was asked if she called to notify the ED of patient #1 being sent for evaluation, staff S stated, "not right away because I was busy with another patient. I did talk with the charge nurse after a bit of time."

Review of the facility policy 6596005 titled "Tier 1: Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance" dated effective 4/20/2017 documented the following:

"2. Policy: A. All patients who present to (name of facility) for examination and treatment of a potential emergency medical condition or who are in active labor will receive a medical screening examination and necessary stabilizing treatment for the emergency medical condition without regard to the patient's ability to pay or method of payment. Patients unstable for discharge will be admitted to (name of facility) or transferred to another hospital if (name of facility) does not have the capabilities (services) and/or capacity(resources) to provide the necessary care.
B .EMTALA regulations apply to any department, facility, or hospital property associated with (name of facility) that: 1. Is licensed by the state as an Emergency Department; or 2. Is held out to the public as providing treatment for emergency medical conditions; or 3. In 1/3 of the visits to the department in the preceding calendar year actually provided treatment for emergency medical conditions on an urgent basis. This may include labor and delivery units and urgent care centers, but does not apply to walk-in ambulatory clinics. . .
Q. A central Emergency Medical Care Log will be maintained for all patients who come to the hospital seeking care for a potential emergency medical condition at an emergency department or other areas subject to EMTALA (as defined above). The log will be maintained for a minimum of five (5) years will contain the following information:
1 .Patient identification and medical record number
2. Presentation, Triage, Medical screening and Discharge times
3. Disposition categorized as: a. Treated and released b. Admitted established and transferred d. Discharged e. Denied treatment or
f. Refusal of treatment . . ."

Based on interview and document review the facility failed to initiate the triage process in a timely manner and failed to perform a timely medical screening examination to determine whether an emergency medical condition existed for 1 (patient #1) of 14 patients presenting to the labor and delivery reception desk, from a total sample of 20, resulting in an emergent cesarean section and neonatal death. Findings include:

On 4/1/2020 at 1244 an interview with confidential informant BB revealed that patient #1 called a family member on 3/6/2020 and reported she was having nausea and diarrhea for approximately 2.5 hours. Patient #1 called her obstetrician for direction and was told if she had a fever and chills to go to the hospital. It was determined patient #1 had a fever of 100 degrees Fahrenheit. Patient #1 was transported to the hospital by family and reported to the Labor and Delivery Department (L&D) at 1630. At the L&D desk patient #1 was asked her symptoms and reported she was 37 weeks pregnant with vomiting, diarrhea, fever and bleeding. The employee made a call and informed patient #1 she would be seen in the Emergency Department (ED). The patient told the employee that during the L&D tour she was told to report to L&D for any concerns after 20 weeks and not to go to the ED. The informant stated they inquired about fetal monitoring and were told that it would be done in the ED. The informant stated no one from L&D saw or monitored patient #1. When they reported to the ED desk, they were told to wait in the waiting room. About 20-30 minutes later patient #1 was taken back for evaluation. The informant stated no one monitored the baby in the ED.

The facility could not provide documentation of patient #1's initial presentation to the labor and delivery (L&D) reception desk on 3/6/2020. The patient was recorded presenting a second time on 3/6/2020 at 1817 to the L&D department where she was then admitted. The log did not document the patient's chief complaint.

Review of the Emergency Department (ED) log for 3/6/2020 documented patient #1 as a 35-year-old female who arrived on 3/6/2020 at 1641 with complaints of fever and abdominal cramping affecting pregnancy. Patient #1 was assigned an ESI (emergency severity index) of 2 (high risk). Disposition was documented as send to L&D.

Review of patient #1's medical record revealed the following:

ED Time-line:
Arrival 3/6/2020 at 16:41-acuity 2-emergent, walk in with family member to ED.
Arrival Complaint - nausea, emesis, body aches, 37 weeks pregnant, came from L&D.
Admission 3/6/2020 at 1707.
Patient class: Emergency Service: Emergency Medicine.
Discharge 3/6/2020 at 1815.
Final Diagnoses: *Abnormality in fetal heart rate and rhythm complicating labor and delivery. *Chorioamnionitis (intraamniotic infection-inflammation of fetal membranes), third trimester. *37 weeks gestation of pregnancy.
03/06/20 at 1815 Patient transported to L&D.

A note dated 3/6/2020 at 1701 by ED triage Registered Nurse (RN) (Staff Q) documented triage started and an assessment that included vital signs as temperature (T) 100.4, pulse (P) 136, blood pressure (B/P) 118/79, oxygen saturation (O2 sat) 96% on room air (RA). At 1737 Staff Q documented vital signs as T 101.5, P 138, B/P 127/87, O2 sat 97% RA. Pain assessment noted pain in abdomen at 5 on numerical scale of 0 no pain to 10 worst pain. Additional assessments were documented per protocol. There was no documentation of fetal heart rate.

ED physician (Staff Z) ordered blood labs, urinalysis, EKG at 1729.

An EKG was performed by ED technician (Staff W) at 1722.

ED physician (Staff Z) ordered an OB consult at 1740 and fetal heart tones at 1749.

Blood cultures were collected at 1745 (final no growth).

A note dated 3/6/2020 at 1735 by the ED physician (Staff Z) documented the following: "(name of Patient #1) is a 34 year old female with a PMHx (past medical history) as listed below who is presenting to the ED from OB triage for evaluation of fever and N/V/D (nausea/vomiting/diarrhea) onset today. Patient is a . . .female at 37 weeks gestation. She notes she began having diarrhea yesterday after she was seen by OB (obstetrician) for routine PNC (prenatal care). Patient notes she otherwise felt fine yesterday up until today around noon (approximately 5 hours ago) when she developed a fever with N/V. Patient notes associated abdominal pain and states she is unsure if it is cramping or she is having contractions. She states she is having vaginal bleeding and states a "ton of liquid coming out." She denies any cough, sore throat, congestion, rhinorrhea (runny nose), SOB (shortness of breath), CP (chest pain), dysuria (difficult/painful/urination). Denies taking any medication for her symptoms. Denies any known sick contacts. No other symptoms or complaints mentioned at this time." Patient history and ED triage nurse notes reviewed. Systems review documented patient was positive for "fever. . .Diarrhea nausea and vomiting. . .vaginal discharge." Physical exam documented "she is not in acute distress. . .tachycardia (rapid heartbeat) is present." No documentation was found for a vaginal exam or fetal heart tones."
Physician (Staff Z) documented : "Timeline:
1731 Discussed patient with obstetrical doctor (Staff X), regarding patient's ED arrival.
1738 Discussed patient with (Staff X) again. She was informed of the patient's findings and her complaints and will send down a nurse to put patient on monitor for fetal heart tones.
1744 Patient lungs are clear with no upper respiratory infection symptoms of any kind. As there is concern for membrane rupture, patient is being sent back upstairs at this time to L&D.
Final diagnosis: Fever, unspecified fever cause, Abdominal cramping affecting pregnancy."

Fetal heart tone tracing in L&D dated 3/6/2020 at 1806 documented fetal heart tones as 120-130's beats per minute at 1809, then decelerating down to 70's beat per minute.

A note dated 3/6/2020 at 1830 by obstetrical doctor (Staff X) documented "pre-op diagnosis intrauterine pregnancy 37 weeks 1-day, fetal Brady (heart rate less than 50 beats per minute), maternal fever, vomiting and diarrhea. Emergent primary cesarean section (c-section-surgical delivery of baby). . .questionable blood."

Description of events-"Timeline: (documented by physician (Staff X):
1738 received call from ED physician (Staff Z) in-regards to pregnant patient in the ED with fever, diarrhea, nausea and vomiting. He reported some concern with possible sepsis and ruptured membranes. L&D nurse advised to send the patient to L&D immediately for evaluation.
1812 called by nurse that patient had arrived in triage.
1813 arrived in L&D to assess patient. Patient found to be 2 cm (centimeters) dilated, grossly ruptured, subjectively very hot. Fetal scalp electrode placed immediately. Fetal heart tones noted to be 50-60 beats per minute. STAT (immediate) c-section expedited transfer to operating room (OR) for delivery.
1826 Patient in OR .
1833 Incision time.
1835 Delivery time. . .
Findings: A female infant in vertex (head slightly to right and to rear) presentation who appeared flaccid with poor color and infant immediately handed to awaiting pediatrician."

A note dated 3/6/2020 at 1830 by the medical doctor who assisted with the c-section documented pre-operative diagnosis as: 1. Pregnancy @ 37 weeks 1-day gestation. 2. Suspected chorioamnionitis (intraamniotic infection-inflammation of fetal membranes).
3. Fetal bradycardia.

A note dated 3/6/2020 at 2028 by labor and delivery triage registered nurse (RN) (Staff S) documented the following: "Patient (#1) presented to the L&D (labor and delivery) desk (no time documented) with complaints of nausea, vomiting, and fever. Reported feeling baby move. No mention of pregnancy complaints by patient. Per standard unit practice, patient sent to ER (emergency department -ED) to be evaluated first for fever since there were no pregnancy complaints. At 1802 patient arrived to (L&D) triage via stretcher from ER (ED) with a surgical mask on, an IV (intravenous catheter). . . Report received from ER nurse that patient has a fever of 102 Fahrenheit, nausea and vomiting. Also, while in ER (ED) she reported leaking (ruptured membranes) to ER (ED) doctor. Patient and her sister state 'Patient has had vomiting and diarrhea since this morning, while sitting on the toilet a lot was coming out and patient thought it was diarrhea." When patient was asked about contractions, Patient's sister reports "She lives alone and this is her first time being pregnant she is unsure of what a ctx (contractions) could be and the patient said she does not know." Fetal heart monitor, contraction monitor and oxygen saturation monitor "applied at 1802. Maternal heart rate 136. Fetal heart rate appears to be in 120s at 1810. At 1812 fetal heart tones appear to be in the 70's. . .Additional staff at bedside and (name of physician) obstetrician (Staff X) came to bedside to evaluate. (Staff X) arrived immediately and performed sterile vaginal examine and speculum exam to confirm spontaneous rupture of membranes. (Staff X) inserted ISL (intracranial scalp lead). Patient moved to operating room for emergency c-section at 1825."

OB physician (staff X) ordered:
3/7/2020 at 0333 biopsy/culture-placenta (final no growth).
3/7/2020 at 0457 genital culture (final no growth).

The medical record documented patient #1 received the following antibiotic medications:
Zithromax on 3/6/2020 at 1841
Gentamicin and Clindamycin on 3/6/2020 at 2058
Ampicillin, Gentamicin, and Clindamycin on 3/7/2020 at 1005

Discharge summary: Admit date 3/6/2020, Discharge date 3/9/2020. Primary diagnosis-labor and delivery, indication for care. Secondary diagnosis-neonatal demise, chorioamnionitis. Date of delivery 3/6/2020 at 1835. Hospital course-admitted at 37 weeks gestation. Prenatal care was complicated by chorioamnionitis at the of time of presentation to L&D. Labor progressed. Delivery type - C-section (cesarean section). Delivery was complicated by Chorioamnionitis. Postpartum was uncomplicated. Baby-liveborn female. Weight 107.94 grams (6.7 pounds). Medications reviewed. Baby - fetal demise. Discharged home self-care.

Review of baby medical record:
Admitted 3/6/2020 at 1835. Discharge disposition: Expired.
Time of birth 1835, no cord pulsation, infant hot to touch, infant placed on warmer, suctioned, stimulated, infant pale, white, no tone, no respiratory effort, positive pressure ventilation (PPV), poor chest rise, copious secretions, suctioned, mask repositioned, PPV continued, no cord pulsation, no oxygen saturation detected, heart rate difficult to hear, possible heart rate 50s. Infant intubated at 1838. . .code called at 1858.

During a tour of the L&D department on 4/2/2020 at 1720, RN (Staff U) a L&D triage nurse was queried regarding patient triage for patients presenting to the department. Staff U stated all patients are brought to triage, have vital signs, and fetal heart tones checked. They are asked about baby's movement and any contractions, and the nurse midwife sees the patient. If admitted, they call the provider. Only patients who are screened and have no pregnancy concerns would be sent to ED.

During a tour of the L&D department on 4/2/2020 at 1730 the receptionist (Staff V) was queried about patients presenting to L&D. Staff U stated, "We asked why they are there, how far along they are, if they are having contractions, if their water has broken. We get consent, and patient identification then call triage." When asked if a patient presented with flu symptoms what is the procedure? Staff V stated, "The same procedure would apply but we would give the patient a mask and then the nurse would see them."

On 4/2/2020 at 1345 an interview occurred with (Staff P), the L&D reception clerk who was on duty on 3/6/2020 when patient #1 arrived at the facility. She stated we register the patients when they arrive and inform the triage nurse. Patients who are 20 weeks gestation or greater are seen in L&D.

Staff P stated she did recall patient #1. She stated, the patient had arrived at L&D with her mom and sister. The patient's, mother, and sister stated she was 37 weeks and having nausea, vomiting and diarrhea. "I called back to the triage nurse identified as (Registered Nurse (RN) Staff S) and reported patient #1's arrival and symptoms". Staff P stated, "RN Staff S did not come to see patient #1 but asked me to ask the patient if the baby was moving". Staff P stated patient #1 said "yes". Staff P stated, Staff S informed her if patients arrive for non-pregnancy related concerns they are to be sent to the ED. Staff P stated, she had never been told this information prior to that day, but said they had been seeing a lot of flu patients. Adding, normally patients under 20 weeks pregnant go to ED if complaints are not pregnancy related. Usually when they are that far along (patient #1 was 37 weeks gestation) the nurses do see them, but not all do. When asked if patient #1 reported contractions, Staff P stated, "I am not medical and did not ask." She stated she wrote down patient # 1's medical record number and informed her she would be seen in the ED instead. Staff P stated the patient's mother and sister spoke up and stated that during the L&D tour they were told to come to L&D and they were asking if fetal heart monitoring would be done in the ED. Staff P stated she walked patient #1 and her family to the ED. She stated patient #1 looked uncomfortable, was sweating and reported "it was coming out both ends she wanted to lay down, felt weak because she couldn't keep anything down. . .An hour or so later emergency department staff brought the patient (#1) back up in a hospital bed. They took her straight back into labor and delivery. I already had her medical record number from earlier. I got the consent. She (patient #1) was in a lot of pain. She was not answering any questions her Mom and sister were talking for her."

When Staff P was queried if patients 20 weeks or more are seen by the triage nurse before being sent to the ED Staff P stated some of the nurses do come out and see them, she (Staff S) usually does not. She did not come out to see patient #1.

On 4/2/2020 at 1455 an interview occurred with the ED receptionist (Staff O) who was on duty on 3/6/2020 at the time patient #1 would have present to the ED. Staff O was queried if she could recall patient #1 and she had no recollection of the patient.

On 4/2/2020 at 1511 an interview occurred at the facility with the L&D triage RN (Staff S). Staff S stated, "after a patient is registered the reception staff call the triage nurse and tell us why the patient is here and how far along they are. We go get the patient and take them to triage with-in 10 minutes. We check their vital signs and fetal heart rate in the same room then move them to regular triage room, have them change, put on fetal heart monitor and contraction monitor and notify the nurse midwife. We do not do a vaginal exam unless birth appears to be imminent. The nurse midwife sees all the patients and does the vaginal exam and if they want the patient admitted then they are moved to a L&D room."

When queried regarding patient #1 Staff S stated she recalled the patient. Staff S stated it was a very busy shift which she started at 1500. She stated the receptionist (Staff P) called about patient #1 while she was admitting another patient. The receptionist reported the patient had nausea, vomiting and diarrhea. She asked her to ask patient #1 if the baby was moving and heard her reply "yes." Staff S stated she had been told that if patients reported flu symptoms they should go to the ED prior to be admitted to L&D. Staff S stated, "the patient had no other pregnancy complaints so she directed Staff P to send her to the ED. A short time later the OB doctor (Staff X) received a call from the ED doctor (Staff Z) and asked if I had sent a patient to ED. I told her yes for flu symptoms. OB doctor (Staff X) told me to go down and get a non-stress test on the patient with the portable monitor. I called the ED and was told the ED doctor reported leaking fluid. So I told them to bring her right to L&D. Patient #1 was brought up on a stretcher with a mask on, IV and the ED staff reported a temperature of 100.4. The patient was not answering questions, her mother and sister answered. The mother and sister said the patient had reported diarrhea for two days and the sister thought it may have been her water broke (rupture of membrane)." Staff S stated, "the patient was not presenting with symptoms of labor. I did a paper tracing of fetal heart tones and it appeared the baby's heart rate was in the 120-130's then dropped to the 60's. We called OB doctor (Staff X) who arrived in seconds. She did a speculum and digital exam and said she was not in labor but had ruptured membranes. (Staff X) called for a c-section and notified the family."

Staff S was asked if she saw patient #1 for triage the first time the patient presented to L&D? She stated, "No." When asked why? Staff S stated "I was very busy and the patient did not report any pregnancy concerns". Staff S was asked if she called to notify the ED of patient #1 being sent for evaluation. Staff S stated, "not right away because I was busy with another patient. I did talk with the charge nurse after a bit of time."

On 4/2/2020 at 1542 an interview was conducted via phone with the ED triage RN (Staff Q) who was on duty on 3/6/2020 when patient #1 arrived. Staff Q stated he recalled the patient. He stated he brought patient #1 to the triage room and asked why she was there and was told for nausea, vomiting and diarrhea, and 37 weeks pregnant. He stated, "I told her she needed to go to L&D. I asked if she had called her OB doctor and she stated "no'." He asked if she had been triaged in L&D and she said "yes." Staff Q said he took her vital sings and noted a high heart rate of 120-130 beats per minute and a fever. Adding, she looked sick, denied abdominal pain and didn't look well. He took her to an ED room gave her a gown and told her she would need an EKG (an electrical recording of the heart), fetal heart tones and he placed a mask on her for possible flu. He then called the ED tech (Staff W) to do the EKG. He informed the ED RN (Staff R). Staff Q stated he asked her several times about her symptoms and if she had been evaluated in L&D.

On 4/3/2020 at 1101 an interview was conducted via phone with ED RN (Staff R) who was assigned to patient #1 on 3/6/2020. Staff R stated he recalled patient #1 but only saw her for a few seconds. Staff R said another nurse had worked her up and she left very quickly for L&D. Staff R said he recalled the patient had reported to the EKG technician that she was bleeding. She was seen by ED physician (Staff Z). Staff R stated he was "very surprised she was sent down to ED from L&D."

On 4/3/2020 at 1108 an interview was conducted via phone with ED technician (Staff W) who performed an EKG on patient #1 on 3/6/2020. Staff W stated she was told the patient was sent down from L&D to ED. She stated the patient was in the restroom when she arrived, and the patient's family stated she was having diarrhea and reported some bleeding. When she saw the patient, "she looked worried, but was not complaining of pain."

On 4/3/2020 at 1058 a phone interview was conducted with ED physician (Staff Z) who treated patient #1 on 3/6/2020. Staff Z stated he recalled the patient. He stated he was given an EKG from the nurse and a technician which showed the patient was a little tachycardic (increased heart rate). He was told the patient was sent from L&D and was 37 weeks gestation, with nausea, vomiting, diarrhea and fever. He stated he called OB physician (Staff X) who reported being told the patient had a cold/flu and fever. He stated when he saw and assessed patient # 1, she had no respiratory symptoms. She was alert, sitting up, had a low-grade fever, and complaints of abdominal sensations, but was unsure if it was cramping or contractions, and was complaining of discharge of fluid.

When asked if the patient had bleeding, he did not recall any. He was asked if it was routine for patients to be sent down from L&D without being triaged. He stated, he was "unsure of L&D's policy and procedure." He said, "I think as a general rule if the patient is 20 + weeks gestation without emergent medial concerns they are triaged in L&D. If not assessed to be related to the pregnancy, then they would be sent to ED. They are generally assessed in L&D."

On 4/3/2020 at 1116 a phone interview was conducted with OB physician (Staff X) the obstetrician who treated patient #1 on 3/6/2020. She stated she was covering for a colleague at the time and did not know the patient. She had received a call from the ED physician (Staff Z) asking if she was aware a patient was sent to the ED from L&D. She stated she asked the RN (Staff S) and was told yes, she sent her down. Staff X said she told the nurse to go and bring the patient to L&D. At that time, she was told the patient was already on her way. Staff X said she "saw the patient immediately and found she was dilated 1-2 cm, membranes ruptured. She placed a fetal scalp monitor and the baby's heart rate was 55-60 beats per minute. The mother felt very hot and I called for an emergent c-section and we went to the OR. I delivered the baby very fast and the baby felt hot and was passed to the neonatal team, who reported the baby's heart rate was in the 50s beats per minute."

Staff X was asked if it was routine for a patient who reports to L&D to be sent to ED without being triaged? Staff X stated, "No we usually triage the patient in L&D". When asked if it was routine for a 37-week gestation patient to be sent to ED? Staff X stated, "No, we usually triage them in L&D".

On 4/3/2020 at 1139 a phone interview was conducted with the ED Clinical Coordinator (Staff Y) who was the charge nurse in the ED on 3/6/2020 when patient #1 presented. She stated she was made aware of patient #1 by the triage nurse who stated the patient was sent from L&D and was asking about fetal monitoring. She called the L&D charge nurse (Staff AA) who reported the patient was sent to ED for non-pregnancy related symptoms. Staff Y stated "we don't do fetal heart monitoring in the ED." She was told by the L&D charge nurse (Staff AA) L&D would send someone down to do fetal monitoring. Staff Y stated before that happened another L&D nurse called ED and stated they wanted patient #1 sent back to L&D per OB physician (Staff X) because it was reported the patient's membranes were ruptured. Staff Y stated she helped transfer the patient who was alert, and pale but did not show any respiratory symptoms. She stated, she did not assess the patient. She said she was aware ED physician (Staff Z) had spoken with OB physician (Staff X).

When queried about OB patients being sent from L&D to ED Staff Y stated, "We do get patients from L&D once they are assessed for pregnancy concerns. If none and the patient has other non-pregnancy concerns, they would be sent to us."

On 4/3/2020 at 1304 a phone interview was conducted with the L&D Charge Nurse (Staff AA) who was the charge nurse in L&D on 3/6/2020 when patient #1 presented. She stated on that day she was admitting another patient when the triage nurse (Staff S) informed her she sent a patient to ED who presented with flu symptoms and was not term. Staff AA stated it was later determined the patient was term. Staff AA stated she heard the ED physician (Staff Z) called OB physician (Staff X) and asked "why we sent a septic patient to the ED." Staff AA said "then we heard she had ruptured membranes and I told RN (Staff S) to go and get her. When she (patient #1) arrived her fetal heart, tones showed a low heart rate in the 60's. They did a c-section and they baby was limp. They coded the baby and she didn't make it."

When asked about the procedure for patients presenting to L&D staff AA stated, "We normally see the patients and triage them. "I believed at the time RN (Staff S) had followed our usual process and that she had spoken to and assessed the patient. Every OB patient is seen and assessed/evaluated in L&D. Our process has not changed. The usual process was not followed that day." Staff AA stated, "I often work triage and all patients are seen and we clear them obstetrically, do a fetal heart strip and they see the nurse midwife. If they are 18-20 weeks and we can't use a fetal heart monitor, we do a doppler for fetal heart tones. Then if cleared we call the ED charge nurse."

On 4/2/2020 at 1815 the Director of Clinical Operations Specialist (Staff T) was asked for a L&D triage policy. Staff T stated, "We do not have a L&D triage policy." When asked if the expectation was that any patient presenting to L&D reception desk would be seen and triaged in L&D Staff T replied, "absolutely."

On 4/3/2020 at 1400 a phone conference was held with the facility Chief Medical Officer (Staff A), the facility president (Staff B), the facility Chief Nursing Officer (Staff E), several facility and corporate Quality, Risk, Patient Safety and Accreditation staff including Quality Risk (Staff F) who was lead on the investigation of the event with patient #1 on 3/6/2020. Staff F discussed the event, the facilities investigation, findings and follow-up plan. Staff F stated involved staff were interviewed, records reviewed, and polices were reviewed. She stated it was found that the L&D triage nurse thought she was following a Tier 2 policy for L&D, but it was an ED policy. The facility President (Staff B) stated the nurse did misapply a policy, (noted to be policy 7252681 titled Tier 2-Care of the Pregnant Patient that Presents to the Emergency Department).

Staff was asked if the facility followed their Tier 2- Emergency Medical Treatment and Active Labor Act?

The facility Chief Medical Officer (Staff A) stated, "The patient should be seen and triaged when she presents to labor and delivery. It was not optimal. . ."

The facility President (Staff B) stated, "It was found there was a variation from the policy, a one off by one team member."

Review of the facility policy 6596005 titled "Tier 1: Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance" dated effective 4/20/2017 documented the following:
"All patients who present to (facility name) for examination and treatment of a potential emergency medical condition or who are in active labor will receive a medical screening examination and necessary stabilizing treatment for the emergency medical condition without regard to the patient's ability to pay or method of payment. . . EMTALA regulations apply to any department, facility, or hospital property associated with (facility name) that: Is licensed by the state as an Emergency Department; or Is held out to the public as providing treatment for emergency medical conditions; or In 1/3 of the visits to the department in the preceding calendar year actually provided treatment for emergency medical conditions on an urgent basis. This may include labor and delivery units and urgent care centers but does not apply to walk-in ambulatory clinics. Medical screening examinations at (name of facility) may be conducted by physicians or other qualified medical providers (i.e. certified nurse midwives, nurse practitioners and physician assistants) privileged by (name of facility). . .Emergency Medical Condition (EMC) - means a medical condition manifesting itself by acute symptoms of sufficient severity, (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the patient (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part. A pregnant woman having contractions has an emergency medical condition if: There is inadequate time to safely transfer to another medical facility before delivery, or
That transfer may pose a threat to the health or safety of the woman or the unborn child. An Emergency Medical Condition may also be present in any patient for whom a prudent layperson would conclude from the patient's appearance or behavior that the individual needs examination or treatment of a medical condition. . .Any patient who presents for service seeking examination or treatment for an emergency condition will be provided a medical screening exam (MSE) to determine whether an EMC exists. . ."

Review of facility policy 7252681 titled "Tier 2: Care of the Pregnant Patient that Presents to the Emergency Department" dated 2/25/2020 documented the following: "Pregnant patients often present to the emergency Department (ED) for care related to their health or pregnancy. This protocol addresses the expectations for care the pregnant patient evaluated in the Emergency Department. Patients who present to the Emergency Department (ED) who are pregnant will be assessed and triaged, seen in the ED or Labor and delivery based on the following criteria:
1. Delivery is Imminent: . . .
2. If presenting with complaints of Labor, Delivery Not Imminent: Patient will be transported to L&D immediately by clinical staff. . .
5. Suspected Contagious Infection: Patients who are not in labor with suspected contagious infection (TB, Mumps, Measles, Rubella, Influenza, etc.) will be evaluated in the Emergency Department with OB/GYN consultation. May be transferred to L&D with appropriate isolation after initial evaluation. . ."