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Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to follow its own policy ensuring that the patient ESI (Emergency Severity Index - determines how soon a patient needs to be seen), was applied correctly. This delayed the medical screening examination by a Qualified Medical Practitioner (QMP). Subsequently, when Pt. #1 was evaluated, Pt. #1 was identified as having a footling breach (baby delivered feet first instead of the head). (See A-2406).

Based on document review and interview it was determined that for 1 (Pt. #1) of 9 obstetric patients, that presented to the Emergency Department (ED), the hospital failed to follow its own policy ensuring that the patient ESI (Emergency Severity Index - determines how soon a patient needs to be seen), was applied correctly. This delayed the medical screening examination by a Qualified Medical Practitioner (QMP). Subsequently, when Pt. #1 was evaluated, Pt. #1 was identified as having a footling breach (baby delivered feet first instead of the head).


Findings include:

1. The "Medical Screening Examination, Stabilization and Patients Transfer" policy (rev 9/13/23), was reviewed and included, " ...2. Medical Screening Examination (MSE) ...c. The MSE may include both generalized and focused assessment based on the patient's chief complaint(s) to determine the presence or absence of an emergency medical condition ..."

2. The "ED Management of the Pregnant Patient Procedure" (rev 3/23/23) was reviewed and included, "A. Obtain Chief Complaint, to determine if it is related to: Active labor or impending labor; pregnancy complications ...OB[obstetrics] ED Triage ...C. 1 ...Medical and OB and/or OB chief complaints in a pregnant patient less than 20 weeks gestation: Notify OB hospitalist (x8488) if 14-20 weeks of gestation and OB related chief complaint including ...cramping/contractions, pelvic or back pain ...

3. The ED Triage Protocol (rev 2/24/23) was reviewed and included, "A. Purpose 1. All patients presenting for care to the Emergency Department at (the Hospital) will be assessed and triaged by a trained health-care professional. All patients will be categorized utilizing Emergency Severity Index (ESI) criteria, a 5-category ED triage acuity scale (ESI 1/Requires immediate interventions- ESI 5/non-urgent) . Patient will be placed in the emergency department according to their acuity and nature of their complaint ...G. Triage Procedure 2. All patients will receive an initial triage screening (brief, primary survey and evaluation of chief complaint) and be assigned an estimated ESI level by the RN (Registered Nurse). This determines if the patient needs to be seen immediately or can wait safely for further assessment ...l. Special Considerations ...5. OB Pregnant Patients ...d ...The triage RN or APP (Advance Practice Practitioner), will complete an abbreviated triage assessment on all OB patients ..."

4. The Emergency Severity Index Handbook Fifth Edition (2023) was reviewed and included. " ...Chapter 4 ... Obstetrical and Gynecological Concerns ...Pregnant patients with abdominal pain should be triaged as ESI 2 (high risk situation/emergent) and rapidly assessed by ED and/or OB providers ..."

5. On 10/15/2024, the clinical record of Pt. #1 was reviewed. Pt. #1 presented to the ED on 3/8/24 at 2:02 AM, with a chief complaint - hip pain. The clinical record included the following:

-The hospital failed to follow its own policy ensuring that the patient ESI was applied correctly. This delayed the medical screening examination by a QMP. Subsequently, when Pt. #1 was evaluated, Pt. #1 was identified as having a footling breach.

- The ED notes written by E #6 dated 3/8/2024 at 2:07 AM noted, " Called Labor & Delivery and relayed Pt. #1 's symptoms. Labor and Delivery deferred care to main ER due to Pt. #1 not being over 20 weeks pregnant.

-On 10/16/2024, the Labor and Delivery OB ED log dated 3/8/2024 was reviewed. The log indicated Pt. #1 was admitted to the Labor & Delivery on 3/8/2024 at 4:28 AM with admitting comments BBOW (bulging bag of water) and PTD (preterm delivery).

- The Labor and Delivery progress notes written by E #3 dated 3/8/2024 at 4:52 AM noted included, " Pt. #1 admitted to Labor and Delivery for abdominal pain, contractions, and pelvic pressure. US (ultrasound) and toco (tocodynamometry is a noninvasive device that monitors uterine contractions during labor and delivery) applied. Vital signs taken. Multiple contractions noted on monitor. MD #2 notified of Pt. #1's status. Pt. #1's OB Admission History & Physical note written by MD #1 dated 3/8/2024 at 6:17 AM indicated, " (Pt. #1) who presents with abdominal pain since midnight and was sitting in the ER since 1:00 AM and then to Labor and Delivery at 4:28 AM still not seen by the ER doctor and hospitalist (MD #2) saw (Pt. #1) with amniotic bag (thin membrane that surrounds and protect the fetus) in vagina and sono (ultrasound used in Labor and Delivery) revealing cervix open 4 cm (centimeters) on abdominal scan with bulging bag into vagina.

-Pt. #1's OB Admission History & Physical note written by MD #1 dated 3/8/2024 at 6:17 AM indicated, " (Pt. #1) who presents with abdominal pain since midnight and was sitting in the ER since 1:00 AM and then to Labor and Delivery at 4:28 AM still not seen by the ER doctor and hospitalist (MD #2) saw (Pt. #1) with amniotic bag (thin membrane that surrounds and protect the fetus) in vagina and sono (ultrasound used in Labor and Delivery) revealing cervix open 4 cm (centimeters) on abdominal scan with bulging bag into vagina.

- The Labor and Delivery notes written by E #4 dated 3/8/2024 at 1:15 PM noted, " MD #3 at bedside. At 10:04 AM, delivery of non-viable male infant."

6. On 10/15/2024, the hospital's occurrence report dated 3/8/2024 was reviewed. The report noted, "Charge RN (E #5) received call from ER that they had received a 19-week patient who was experiencing back pain and abdominal pain. I (E #5) notified ER RN to update Labor and Delivery following patient triage in ER and recommended an OB (obstetrics) ultrasound ...(Pt. #1) remained in the ER with increasing pain ...Labor and Delivery was not notified she had not been seen and symptoms had progressed. Labor and Delivery received second call from ER ... that (Pt. #1) had yet to be seen and was now experiencing pelvic pressure and increased pain. (Pt. #1) was then transferred to Labor and Delivery. Manager's comments - (Pt. #1) was brought up to Labor and Delivery after sitting in the ED waiting area for several hours. (Pt. #1) apparently told (Pt. #1's) physician that (Pt. #1) had asked multiple time to be seen because the pain was worsening, and (Pt. #1) wanted to be put on the monitor. The second call to Labor and Delivery came after several hours. (Pt. #1) was brought directly to Labor and Delivery at that time. (Pt. #1) was found to have amniotic membranes bulging into the vagina with a 4 cm dilated cervix. (Pt. #1) was contracting every 2 minutes. (Pt. #1) delivered later that morning. "

7.On 10/15/2024 at 9:30 AM, an interview was conducted with Pt. #1 via telephone. Pt. #1 stated that Pt. #1 was 19 weeks pregnant and came to the hospital on 3/8/2024 at 2:00 AM with a complaint of back and pelvic pain. Pt. #1 stated that Pt. #1 told the ED staff member in triage that Pt. #1 was in pain. Pt. #1 stated that Pt. #1 had not been seen by a doctor and had not been monitored until approximately 4:00 AM when Pt. #1 was brought to Labor and Delivery. Pt. #1 stated that no one assessed Pt. #1's baby the entire time Pt. #1 was in the ED. Pt. #1 stated that Pt. #1 kept going to the desk in the waiting area and telling the staff member the Pt. #1's pelvic pain was getting worse. Pt. #1 stated that when Pt. #1 arrived in Labor and Delivery unit, Pt. #1 was 4 cm dilated and having multiple contractions. Pt. #1 stated that Pt. #1 lost her baby later that morning.

8.On 10/16/2024 at 9:00 AM, an interview was conducted with the E #2. E #2 stated that Pt. #1 was 19 weeks pregnant. E #2 stated that Pt. #1 's vital signs were stable. E #2 stated that Labor and Delivery was called to see if they would see Pt. #1. E #2 stated that Labor and Delivery stated that since Pt. #1 was 19 weeks pregnant, Pt. #1 was to be seen in the main ED. E #2 stated that when E #2 went on break, E #8 relieved E #2. E #2 stated that E #8 was going to call Labor and Delivery again to see if Pt. #1 could be brought up to Labor and Delivery. E #2 stated that when E #2 returned from E #2's break, Pt. #1 had already been brought up to the Labor and Delivery unit.

9.On 10/16/2024 at 9:30 AM, an interview was conducted with the MD #4. MD #4 stated that if the patient is less than 20 weeks, the patient is seen in the main ED.

10. On 10/16/2024 at 10:00 AM, an interview was conducted with the E #9. E #9 stated that Labor and Delivery deferred Pt. #1 to the main ED due to Pt. #1 being 19 weeks pregnant. E #9 stated that when Labor and Delivery was called again, Pt. #1 was transported to the Labor and Delivery unit.

11. On 10/16/2024 at 10:15 AM, an interview was conducted with the E #8. E #8 stated that E #8 relieved E #2 on 3/8/2024 when E #2 took a break. E #8 stated that E #2 reported that Labor and Delivery wanted Pt. #1 to be seen in the main ED. E #8 stated that E #8 called Labor and Delivery again and asked if Pt. #1 could be brought to Labor and Delivery. E #8 stated that Pt. #1 was transported to Labor and Delivery unit.

12. On 10/15/2024 at approximately 11:55 AM, the E #10 was interviewed. E #10 stated that an ESI score is generated based on the information provided and the patient 's reported and observed symptoms. E #10 stated that patients are taken back to a triage room for a medical screening evaluation based on patient severity and availability of provider. E #10 stated that if a patient is less than 20 weeks pregnant, the patient would be evaluated in the ED and the ED physician would be in contact with the OB Hospitalist to determine if Labor and Delivery placement is required.

13. On 10/15/2024 at 2:00 PM, an interview was conducted with MD #3 (OB/GYN). MD #3 stated that MD #3 was present for Pt. #1's delivery on 3/8/2024. MD #3 stated that the protocol for a pregnant patient if a patient is 19 weeks pregnant, the patient is evaluated in the main ED. MD #3 stated that Pt. #1 had the MSE in Labor and Delivery by MD #2.