The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST JOHN'S EPISCOPAL HOSPITAL AT SOUTH SHORE 327 BEACH 19TH STREET FAR ROCKAWAY, NY 11691 Feb. 27, 2013
VIOLATION: DELAY IN EXAMINATION OR TREATMENT Tag No: A2408
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

1. Based on review of procedures, and staff interviews, it was determined that the hospital did not coordinate effective emergency procedures to ensure timely triage or emergency medical screening of patients presenting to the facility for emergency treatment, including those with labor or pregnancy-related concerns.
Findings include:
The hospital did not implement an effective system to provide timely triage and medical screening of pregnant patients who present to the facility.

Specifically, the hospital's policy and process for the management of women who present with maternity conditions was incomplete. Review of the hospital's procedure on 2/25/13 titled, "Obstetrical Triage" finds that it did not fully describe a clear screening process or actions to be taken for all possible contingencies involving pregnant patients who present for emergency needs at any location within the facility.
Procedures do not explain actions to be taken for the following possible contingencies or scenarios that require alternative management of the obstetrical patient:
Patients greater than 20 weeks gestation with trauma who are taken directly to Labor and Delivery (L&D) by ambulance staff where the main emergency room (ER) staff are bypassed.

Patients less than 20 weeks gestation who report or are taken directly to Labor and Delivery (L&D) by ambulance personnel without ED approval.
Patients who arrive in the lobby with pregnancy related or other medical concerns.
Patients screened in Labor and Delivery (L&D) who must be redirected to the main ER.
Patients subsequently cleared by ED staff for transfer to Labor and Delivery (L&D).
Lack of designated responsible staff required to evaluate and sign off ambulance call reports at any location where the patient has an encounter.

The emergency obstetrical policy is incomplete as follows:
The hospital's procedure and practice currently requires in the labor and delivery suite area (L&D), medical screening of women in labor who are at 20 weeks of gestation or greater where there is no trauma or imminent delivery. This dedicated area is located on the second floor of the hospital. Pregnant trauma cases are managed in the main ER until stabilized. This obstetrical triage policy did not describe how patients are safely transported to L&D from the main ER and did not describe what type of triage and assessment, including documentation of this assessment, is provided by staff in the main emergency department. This procedure did not provide detail regarding how this information is communicated between emergency, ambulance, and L&D staff at the point of transfer to labor and delivery.

The policy also notes that patients with gestation of less than 20 weeks are seen initially in the main emergency department (ED), assessed by an emergency physician, and receive subsequent consultation by an on-call obstetrician or gynecologist. It further notes trauma, cardiac/respiratory emergencies, unstable maternal status, and threatened miscarriage at less than 20 weeks gestation shall remain in the main ED before transfer to Labor and delivery.

The policies for emergency screening did not address how the facility addresses emergencies, and all possible contingencies of pregnant women at any gestational age taking into account alternative modes of arrival or presentation at other locations in the facility. The policy did not ensure how triage assessment, hand-off, or safe transport of patients is ensured for patients who arrive directly to the labor and delivery suite who are at less than 20 weeks gestation.

Existing procedures for obstetrical triage do not explain what actions are taken in instances when women present directly to the L & D suite at less than 20 weeks gestation without being seen first in the main emergency department, or in cases where the patient ambulates or is transported by ambulance personnel directly to L&D suite. Procedures do not explain how the patient is assessed, what records are documented, and how communication processes are implemented.


The hospital also has no clear system in place to ensure triage, assessment and safe transport of patients who arrive directly in the labor and delivery suite with hemorrhage, regardless of gestational age and specificially who are at less than 20 weeks


The obstetrical triage procedure did not include a classification system by type of presenting problem for patients who directly present to L&D, other than the requirement for pregnant patients with trauma, cardiac or respiratory issues, or impending miscarriage to be managed in the main emergency room until stabilized. Patients reporting first to L& D with these conditions, regardless of gestational age, are not discussed in the policy. The procedure lacks details regarding staff accountable for triage in the L&D suite, especially in instances when ambulance staff are referred from the main emergency room or when the main emergency department is bypassed. Moreover, the obstetrical triage procedures did not indicate which hospital staff is accountable for signing the ambulance call report (ACR) at each location and encounter following patient arrival in the hospital. Procedures must detail accountability such that any encounter with ambulance staff and the patient must ensure the ACR is signed for, regardless of location.

Obstetrical triage procedures were not integrated with main emergency triage procedures.

The emergency policy titled, "Triage- Emergency Department" discusses management of patients who present to the emergency department and provides five levels of classification of diagnoses. Hemorrhage is classified as a classification 1 priority and rule out abortion or active labor is classified as level 2 priority. These general ED triage procedures do not cross-reference or correspond to the obstetrical triage procedures. There is no description of the specific triage and transfer of obstetrical patients to L&D. The procedure notes that the charge nurse in the main ED shall accept a report from ambulance personnel after doing a visual assessment and checking vital signs. However, there is no corresponding process described for patients who go directly to labor and delivery. There is no corresponding description of staff accountable for signing off on the ambulance call report for labor and delivery patients.


Furthermore, ED triage procedures in the main emergency room do not conform to actual practice, in that the process described notes a sign-in sheet is provided where the patient will record the name and reason for coming to the emergency room . At interview with the ED Director on 2/26/13, it was stated there is no longer a sign-in sheet in effect.

At interview with the Obstetrics resident (OB) resident on 2/15/13 at approximately 3 PM, it was stated that patients at 20 weeks gestation or less are treated in the main ER, yet if they presented directly to L&D suite, they would be transported back down to the main ER by either hospital staff or ambulance staff. The nurse would check the patient's vital signs before transfer and may document this, but not consistently. It was also stated there may be occasions when patients who are less than 20 weeks gestation are seen in L & D for imminent labor or miscarriage with bleeding. If there was an acute emergency or the patient is actively bleeding, it was stated that the patient would be held and treated in L & D on an individual case basis.

In contrast, interview with nursing staff in L&D on 2/26/13 at 12:10 PM determined that while not commonplace, there have been instances where patients are taken directly to the labor and delivery suite. Patients who arrive to L&D at less than 20 weeks gestation would be assessed by the nurse and transferred back to the medical ER . L&D staff would contact ED staff to inform them of impending transfer and would be escorted by ambulance staff back to the main emergency department. There would be no record of triage unless the patient is registered, which would take a few minutes to complete. The contributory reason is that the L& D uses a different electronic medical record system, Perigen, in which the triage record does not correspond to the triage system in "Meditech", the electronic records system used in the medical emergency room .

Consequently, there is no method to document the encounters of unregistered patients who are at less than 20 weeks who directly present to L & D where redirection must occur to the main emergency room with an escort.

2. Based on review of emergency records, reports, and staff interviews it was determined that the facility did not ensure the timely provision of triage or medical / psychiatric screening assessments for patients who arrived for emergency care. The lack of provision of timely triage or medical and/or psychiatric screening applies in 5/55 records reviewed.
MR #1: The patient referenced in MR #1 was taken to the emergency room for an obstetrical emergency by ambulance on 1/7/13 and did not receive a timely triage or medical screening examination. Review of grievance record on 2/25/13 determined that a complaint was received by the facility on 1/11/13 from a [AGE] year old female who reported that she was taken by ambulance to the hospital's emergency room on [DATE] due to complaints of bleeding and water breaking at 12 weeks of pregnancy.

She claims that she was told by the triage nurse that she had to wait because there were two people ahead of her. It was reported that the triage nurse was asked by the ambulance staff if she should be taken directly to the L& D unit. She was then transported by the ambulance staff to L& D where she was told by staff that she had to return to the emergency room because there was nothing that could be done in L&D. The patient claimed she was bleeding at that time. The patient reported she spoke with a staff member who made an alleged statement about policy and hung up on her. The patient left the hospital and reportedly went to another facility without being treated.

Surveyors determined from staff interviews on 2/25/13 that there was no medical record generated for this alleged encounter on 1/7/13 for the patient referenced as MR #1. Review of ED logs and L&D delivery logs for 1/7/13 did not include this patient's encounter. Subsequent interview of ED staff determined that no L&D department triage record is generated where patients are not registered.

The patient was never triaged or registered in either the main emergency room or in the labor and delivery suite. The hospital had no ambulance call report on file. The patient has a prior medical record in the facility and obtained prenatal care from a private MD affiliated with the hospital and who rents office space from the facility. The hospital staff was able to obtain the Ambulance Call Report (ACR) which was received by surveyors for review on 2/26/13.

Review of the ACR on 2/26/13 confirmed that this [AGE] year old female was taken by FDNY ambulance to the hospital on [DATE] arriving at 1434 hours (2:34 PM). The patient, who was approximately 3 months pregnant, reported that her water broke, no pain, but reported pressure on lower abdomen. Patient also noted with history of miscarriage 2 years prior and currently this is patient's 9th pregnancy. Patient was taken to the hospital and given oxygen en route, 15 LPM via NC. The patient left before being triaged. The ambulance call report (ACR) was not signed by any receiving hospital staff. On 2/28/13, follow up documents received from New York State EMS included a computer assisted dispatch (CAD) report, which confirmed that the patient arrived via ambulance at the hospital on [DATE] at 1434 (2:34 PM) and ambulance staff closed the event at 1506 (3:06 PM), 32 minutes following the time of arrival.

Interview was conducted on 2/25/13 with the resident on staff in labor and delivery during 1/7/13. This resident could not recall any interaction with MR#1. It was stated that patients at less than 20 weeks who arrive to L&D from the ER with ambulance personnel would be returned to the ER if stable enough. While the patient is assessed in labor and delivery, the documentation of this may or may not be completed. If the patient is actively bleeding, the patient would remain in labor and delivery but this decision is made on a case by case basis.

Interview was conducted on 2/25/13 at 11:30 AM with the triage nurse who was on duty in the main emergency room on [DATE]. The nurse did not recall interaction with MR#1 or ambulance staff. Policy was reiterated in that patients go to L&D at 20 weeks or greater and are kept in the main ER for gestations under 20 weeks. It was confirmed that EMS ambulance may sometimes go directly to labor and delivery with patients at greater than 20 weeks and in these cases the ACR would not be signed off by the nurse in the main emergency room . It was also reported that if the patient returns to the main emergency room , the staff in L& D would notify medical ER staff and provide an escort.

Interview with the Patient Advocate on 2/25/13 found that follow up with staff who worked with the patient's obstetrician reported there was no rude interaction as reported and that while the patient was reportedly told to go to L&D directly, she had to go to the main emergency room as per hospital policy. Follow up e-mail response from the ER Director on 1/23/13 noted policy in effect that patients less than 20 weeks must be seen first in the main emergency room whereas patients who are greater than 20 weeks may go directly to L&D without stopping in the main ER. No response has been provided to the patient referenced in MR #1 regarding the results of the hospital's investigation of this complaint as of 2/25/13.

Facts collected confirm that the patient was transported by ambulance to the hospital and left without being triaged. Thirty two minutes following arrival, EMS ambulance personnel noted that the patient left without triage and closed out the record, yet no hospital receiving agent signed the ambulance call report.

MR#2: This record reflected delay in triage and lack of timely medical screening examination for a patient who left before the provision of medical examination. There was a lag time of 1 hour and 45 minutes from documented arrival time to triage. This [AGE] year old female walked in to the hospital's emergency room on [DATE] and was noted with arrival time of 20:35 (8:35 PM). The patient was triaged at 22:20 (10:20 PM) with a chief complaint of "abdomen" and chief complaint onset of low abdominal pain X 2 days with symptoms noted of low back pain. Patient reported abdominal pain but no pain scale measure was implemented. Vital signs noted: 119/63, P 80, RR 20, and temperature 99.7 F. Past medical history was significant for laparoscopy and ESI priority assigned was 3. Patient was registered at 2248 (10:40 PM) . No intervention or medical screening exam was recorded. The next intervention was noted at 0606 (6:05 AM) on 1/4/13 when it was noted that the patient left without been seen in the ED.

Review of Medical ED triage procedures, on 2/26/13, finds that patients classified as level 3 triage are required to have staff response within 90 minutes. This time frame is prolonged for level 3 priority designations for abdominal pain chief complaints. Of note the hospital did not conform to its triage policy in effect for existing time frames.

MR#2 reflected a delay between arrival time and triage provision as well as delay in medical screening exam after triage. The patient left before medical assessment, 7 hours and 45 minutes following documented triage.

Two of seven patients being concurrently treated in the psychiatric emergency room as noted during tour on 2/26/13 at noon did not receive timely initial psychiatric assessments following arrival to the emergency room . The following 2/7 patients' records reviewed on 2/26/13 reflected a delay in provision of a psychiatric screening examination following triage and medical clearance.

MR #3 Patient walked in to the ED at 1232 AM on 2/24/13 and was found to have depressive disorder and non compliance with medication. Patient also noted to have alcohol and cocaine abuse. He was triaged at 1:22 AM on 2/24/13 and assessed medically at 1: 54 AM on 2/24/13 .The resident noted medical clearance at 2:29 AM. Psychiatric assessment was not recorded until 16:26 (4:26 PM) on 2/24/13 whereby it was noted patient reported auditory hallucinations in setting of cannabis and cocaine use. The patient was held until transferred to another hospital for inpatient treatment on 2/26/13 at 1930 (7:30 PM).


MR #4 Patient walked in to the ED at 3:29 AM on 2/25/13 with auditory hallucinations. Patient has history significant for schizophrenia and current homelessness. The patient was triaged on 2/25/13 at 3:30 AM but no ESI category was assigned - noted as "PC". The patient was registered at 3:50 AM. At 5:46 AM on 2/25/13, the medical resident assessed the patient and this assessment was confirmed at 6 AM. However, the psychiatric assessment was not recorded until 1903 (7:03 PM)on 2/25/13 . The patient was held until transfer to another facility for inpatient treatment on 2/26/13 at 1742.

MR #5: [AGE] year old female walked in and arrived in the emergency room on [DATE] at 11:35 AM. Patient was not triaged until 12:41 AM where it was noted a chief complaint of bites all over. Physician assessment was provided at 1413 (2:13 PM) and patient was determined to have uninfected insect bites and discharged with bedbug instruction and prescription for hydrocortisone at 1454 (2:54 PM).
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on review of logs and staff interviews, it was determined that the facility did not maintain a complete written triage log of all encounters for maternity patients who present directly to the labor and delivery suite for emergency care.Specifically, there is no formalized system in place to log the encounters for all patients who are seen in the labor and delivery suite for patients presenting with the following types of emergencies:
Pregnancies that do not result in admission or delivery.
Maternity patients with gestation of 20 weeks or less who first present to the labor and delivery area and who require assessment or escorted transfer to the main emergency room for further management.Findings include:1. The facility did not implement a system to ensure that there is documentation of maternity encounters in a written triage log to include all types of emergency visits by obstetrical patients who present directly to the labor and delivery (L&D) suite.

During a tour of the L & D suite on 2/26/13, a delivery room register was presented upon surveyors' request for a triage and disposition log. Review of the delivery room register log book, located in the labor and delivery suite on 2/25/13 at 1 PM, found that this book exclusively recorded the arrival time and information for maternity patients who presented with pregnancy related symptoms, as well as for their newborns following birth.

This written L & D delivery room register log was incomplete in that it did not include patients who presented directly to the labor and delivery suite for assessment of labor or pregnancy related symptoms or triage in instances when there was no admission or delivery of a newborn.


Maternity patients who were screened, treated, released, or redirected to the main emergency room from L&D were not recorded in this log book. This log book, titled "delivery room register" recorded data for patients seen in labor and delivery during 12/31/12 to 1/31/13, and include the following:

Delivery number
Patient name
Age
Date and time of arrival
Medical record number


Patients who were triaged, discharged , or redirected with escorts to the main emergency room were not documented in this log. The facility's labor and delivery suite is located on the second floor of the hospital.


2. During a tour of the labor and delivery (L&D) suite, and at interview with the nurse and head nurse in the labor and delivery suite on 2/26/13 at approximately 1 PM, it was confirmed that there was no readily available log for women who are triaged and assessed, screened and discharged and whose encounter does not result in delivery.

It was stated by nursing staff at interview on 2/26/13 that no record is documented for patients in the electronic medical record system for maternity patients, Perigen, unless the patient is registered within a few minutes of arrival to the L& D suite. All patients that are admitted to labor and delivery must be registered by admitting staff, which usually requires several minutes following arrival. This is required in order to generate a medical encounter record in the maternity electronic medical record, "Perigen" .


It was stated that patients may arrive directly on the second floor labor and delivery suite who are at less than 20 weeks pregnant and who may bypass the main emergency area. It was stated that the procedures mandate pregnancies less than 20 weeks gestation must be treated in the main emergency room . On occasion,however, it has happened that patients less than 20 weeks pregnant may be brought directly to the second floor labor and delivery area by emergency ambulance staff.

In these instances, the patient is briefly screened and if stable, is brought back to the emergency room by escort for treatment This quick assessment does not generate an electronic medical record or encounter unless the patient is registered. Ambulance staff, if still present, may escort the patient to the main emergency room . The nurse will also call the nurse in the main emergency area to advise of impending escort of the patient to the emergency room . However, there is no formal record kept of this encounter in L& D and the patient is not registered.

It was also confirmed at interview with nursing staff that the delivery log book does not include encounters of patients who are transported to the main emergency department for gestation of less than 20 weeks.

Staff reported that going forward, there is a plan to develop a system to monitor the arrival, encounters, and disposition of all patients who present to the labor and delivery suite in emergency. This recording log would include those patients who do not deliver, are treated and released, or where the visit results in escorted redirection to the main emergency department in instances where the pregnancy is less than 20 weeks gestation.
3. Follow up interviews with the L& D Head Nurse and administrative staff on 2/27/13 determined that information on L&D patients could be obtained from the individual case record in Perigen, the electronic medical record system used in L&D. However, it was also stated that a log of all maternity patients treated in L &D who do not deliver could be readily generated in Perigen. This electronic medical record system differs from the electronic medical record system used in the emergency department. This log was not generated at the time of the survey.


Nursing staff reported that no medical record is available in the Perigen system unless the patient is formally registered , which might require a few minutes after arrival to L&D. Consequently, the log would not include unregistered patients who might be redirected to the emergency room . Therefore, there is no current method to document any patient who arrives in labor and delivery where registration does not occur, nor for those patients who are redirected with ambulance staff or hospital escort to the main emergency room . Therefore, there was no log available of the encounters of patients who are unregistered, including maternity patients and others who are at less than 20 weeks, who directly present to L & D and where redirection occurs to the main emergency room with an escort.


Therefore, if a maternity patient is transported directly to L& D by self, family, or emergency ambulance staff and bypasses the main emergency room , there is no formal record of encounter maintained, especially if the patient is redirected to the emergency room for assessment in instances where the patient is at less than 20 weeks gestation or for trauma cases.

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