West Jersey Hospital

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 51986 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that patients were turned and repositioned at least every two hours and as needed in two of six medical records reviewed (Patient (P)2 and P4). Findings include: Policy titled, “Skin and Wound Care: Risk for or Impaired Skin Integrity-Assessment, Pressure Injury Staging, Prevention & Treatment Recommendations” last Reviewed, 4/24/2024, stated, “... Nursing Documentation 1. Document preventative measures taken ... Recommended Pressure Injury Prevention Strategies Based on Risk Factors (unless contraindicated) ... Mobility ... Reposition and turn at least every 2 hours or based on individualized schedule as appropriate per the assessed needs/condition of the patient. .... Attachment C: Skin Bundle Checklist Recommendations ... B ... Document Q2hr [every two hours] repositioning.” Policy titled, “Skin and Wound Care: Risk for or Impaired Skin Integrity-Assessment, Pressure Injury Staging, Prevention & Treatment Recommendations” last Reviewed, 4/24/2024, stated, “... Nursing Interventions: 1. Initiate Interdisciplinary Plan of Care upon admission. Review daily and revise as needed ... Nursing Documentation 1. Document preventative measures taken and any changes made to the interdisciplinary care plan base on the ongoing assessments of the patient’s needs and risk factors... Attachment C: Skin Bundle Checklist Recommendations... Braden </= [less than or equal] 18 or based on additional risk factors activate/update care plan (pressure injury/risk of with appropriate interventions every shift).” On 08/05/25 at 10:25 AM, an interview was conducted with Staff (S)8. When asked how often a patient is turned and repositioned, S8 stated, he/she uses her judgement and if the Braden Score (Pressure Injury Risk Assessment, Not at Risk 19 or above, At Risk 15-18, Moderate Risk 13-14, High Risk 10-12, Very High Risk 9 or below) is less than 18 or if a patient cannot turn themselves, he/she would turn the patient every two hours and document every two hour turns in EPIC (electronic medical record system). When asked what communication is in place to make staff members aware of the patient’s need to be repositioned every two hours, S8 stated, he/she would look at the patient and see what position they are in then turn them the other way. S8 further stated, he/she can look in the chart to see the patient’s last position. S8 stated, “everyone is pretty good at charting turns.” S8 stated, he/she gets report from the previous nurse and the patient’s position will be discussed then. In addition, S8 stated that patients have the leaf system [a sensor placed on the patient’s chest that constantly monitors the patients position and activity] and there is a reminder on the monitor that turns red when it is time to turn the patient. At 10:46 AM, an interview was conducted with S10. When asked how often a patient is turned and/or repositioned, S10 stated, “every two hours and as needed, if the patient turns self and has a Braden score of 19 or more then every two-hour turns are not required.” When asked how staff communicates with each other to ensure the patient is being turned every two hours, S10 explained, Nursing and PCTs (patient care technicians) get report at the beginning of the shift and that is when they will discuss the patients positioning.” At 11:01 AM, an interview was conducted with S11. When asked how often patients are turned and/or repositioned, S11 stated, “every two hours. There is the leaf system on a lot of floors and a chart outside of the room that staff signs off that the patient was turned, and the turns are documented in EPIC [electronic medical record system].” On 8/6/2025 a review of P2’s medical record was conducted in the presence of S17 and S45 and revealed the following: P2 was admitted on 8/5/2025 with a UTI (urinary tract infection). P2 had a stage 2 pressure injury to the coccyx/sacrum area on admission. P2 Braden Score was 17. On 8/5/2025 at 2:52 PM, a wound care consultation note, documented by S46 stated, “... Other recommendations as appropriate for the patient: Offload/Reposition in bed Q [every]1-2 hours.” On 8/5/2025 at 2:47 AM, documentation in the flowsheets titled, “Mobility” stated, “... Early Mobility Protocol Level Initiated/Maintained: Bed rest advance as tolerated. Activity: Bedrest Level of Assistance: Maximum assist, patient does 25-49% Patient Position: Supine Pillow Support, positioning frequency: every 2 hours.” On 8/5/2025 at 11:25 AM, documentation in the flowsheets titled, “Mobility” stated, “... Early Mobility Protocol Level Initiated/Maintained: Ambulation with assistance. Activity: Chair Level of Assistance: Moderate assist, patient does 50-74%, Mobility Assistive Device: Walker, Ambulation Response: Tolerated Poorly, Patient Position: Supine, Positioning frequency: every 2 hours.” The medical record lacks evidence of P2 being turned every two hours. On 8/6/2025 at 11:58 AM, when asked if every two-hour turning should be documented in the flowsheets, S45 stated, “yes, there shouldn’t be gaps in the documentation.” On 8/6/2025 a review of P4’s medical record was conducted in the presence of S45 and revealed the following: P4 was admitted on 8/4/2025 with abnormal labs. P4 had a Stage 3 pressure injury to the buttocks and DTI (deep tissue injury) to right heel and bilateral toe tips on admission. P4’s Braden Score was 14. On 8/5/2025 at 2:52 PM, a consultation note, documented by S46 stated, “... Other recommendations as appropriate for the patient: Offload/Reposition in bed Q [every]1-2 hours.” On 8/4/2025 at 10:52 PM, documentation in the flowsheets titled, “Mobility” stated, “...Patient Position: Lying right side; Semi Fowler’s Pillow Support.” On 8/5/2025 at 9:29 AM, documentation in the flowsheets titled, “Mobility” stated, “Early Mobility Protocol Level Initiated/Maintained: Bed rest advance as tolerated. Activity: Bedrest.” The medical record lacked documented evidence that P4 was turned every two hours. On 8/6/25 at 12:57 PM, S45 confirmed that P4 should have been repositioned per the consultation recommendations and the facility’s policy.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 51986 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that 1) Nursing staff initiated a skin integrity care plan in five of six medical records reviewed (Patient (P)2, MP3, P4, P5, and P6); and 2) patients were turned and repositioned at least every two hours in two of six medical records reviewed (P2 and P4). Findings include: 1. Facility Policy titled, “Plan of Care, Interdisciplinary” last reviewed on 3/27/2024, stated, “... III. Policy A. All admitted patients will have a plan of care initiated that is individualized for their specific care needs and limitations.... The Plan of Care will be initiated by Nursing ... The plan of care will reflect the patient’s health problems, specific goals of therapy, and will detail strategies to achieve goals.” Facility Policy titled, “Skin and Wound Care: Risk for or Impaired Skin Integrity-Assessment, Pressure Injury Staging, Prevention & Treatment Recommendations” last Reviewed, 4/24/2024, stated, “... Nursing Interventions: 1. Initiate Interdisciplinary Plan of Care upon admission. Review daily and revise as needed... Nursing Documentation 1. Document preventative measures taken and any changes made to the interdisciplinary care plan base on the ongoing assessments of the patient’s needs and risk factors... Attachment C: Skin Bundle Checklist Recommendations... Braden </= 18 or based on additional risk factors activate/update care plan (pressure injury/risk of with appropriate interventions every shift).” On 8/6/2025, a review of P2’s medical record was conducted in the presence of Staff (S)17 and S45 and revealed the following: P2 was admitted on 8/5/2025 with a UTI (urinary tract infection). P2 had a Stage 2 pressure injury to the coccyx/sacrum area on admission. P2’s Braden Score was 17. On 8/5/2025, at 2:52 PM, P2 was seen by wound care. The medical record of P2 lacked documented evidence of a Skin Integrity Care Plan. On 8/6/2025 at 11:58 AM, when asked if the patient’s medical record should contain a Skin Integrity care plan, S45 stated, “yes, there should be a skin care plan.” On 8/6/202, a review of P3’s medical record was conducted in the presence of S45 and revealed the following: P3 was admitted on 8/3/2025 with weakness. P3 had a Stage 2 pressure injury to left buttock, a Stage 1 pressure injury to the left heel on admission. P3’s Brade Score was 15. On 8/4/2025 at 2:00 PM, P3 was seen by wound care. P3’s medical record lacked evidence of a Skin Integrity Care Plan. On 8/6/2025, a review of P4’s medical record was conducted in the presence of S45 and revealed the following: P4 was admitted on 8/4/2025 with abnormal labs. P4 had a Stage 3 pressure injury to the buttocks and DTI (deep tissue injury) to right heel and bilateral toe tips on admission. P4’s Braden Score was 14. On 8/5/2025 at 2:52 PM, P4 was seen by wound care. P4’s medical record lacked evidence of a Skin Integrity Care Plan. The above findings were confirmed with S45 on 8/6/2025 at 12:07 PM. On 8/6/2025 a review of P5’s medical record was conducted in the presence of S45 and revealed the following: On 8/4/2025, P5 was admitted with left shoulder injury. P5 had a Stage 2 pressure injury to right buttocks and possible DTI to left heel on admission. P5’s Braden Score was 16. On 8/4/2025 at 2:00 PM, P5 was seen by wound care. P5’s medical record lacked evidence of a Skin Integrity Care Plan. On 8/6/2025 a review of P6’s medical record was conducted in the presence of S45 and revealed the following: On 7/31/2025, P6 was admitted with altered mental status. P6 had a Stage 2 pressure injury to coccyx/natal cleft area on admission. P6’s Braden score was 14. On 8/1/2025 at 1:31 PM, P6 was seen by wound care. P6’s medical record lacked documented evidence of a Skin Integrity Care Plan. The above findings confirmed with S45 on 8/6/2025 at 12:57 PM.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 51986 Based on medical record review, staff interviews, and facility document review, it has been determined that the facility failed to ensure pain management as a component of the patient’s care in one of five medical records reviewed (Patient (P)1). Findings include: Facility policy titled, “Pain Assessment and Management of the Adult”, last reviewed 01/24/2024, stated, “VI. WHO MAY PERFORM? A. Provider, RN [Registered Nurse], and all appropriate health care providers... i. Tools to conduct a comprehensive pain assessment ...1. Numeric pain scale ... iv. 8 or > severe pain ... XIV. DOCUMENTATION: ... C. Patient education i. pain management techniques ... F. Non-pharmacologic interventions, including response.” On 07/23/25 at 11:09 AM, a review of P1’s medical record was conducted with Staff (S)16 which revealed the following: On 08/16/24 at 06:17 AM, a numeric pain initial assessment [zero is no pain, ten is the most severe pain] was documented by a RN as eight, indicating “severe pain.” On 08/16/24 at 06:56 AM, a numeric pain reassessment was documented by a RN as eight, indicating “severe pain ...acute pain ...headache.” On 08/16/25 at 7:16 AM, a CT scan study was completed that ruled out a possible stroke. On 08/16/24 at 07:33 AM, a numeric pain reassessment was documented by a RN as eight, indicating “severe pain ...acute pain ...headache.” On 08/16/25 at 8:46 AM, a review of the medical record revealed an MRI scan ruled out a possible stroke. On 08/16/24 at 09:45 AM, a numeric pain reassessment was documented by a RN as eight, indicating “severe pain ...acute pain ...headache.” On 08/16/24 at 10:00 AM, a numeric pain reassessment was documented by a RN as eight, indicating “severe pain ...acute pain ...headache.” On 07/23/25 at approximately 1:00 PM, an interview was conducted with S15 in the Emergency Department (ED). S15 stated, “there are a few reasons I may hold pain medication for a patient. One of those reasons might be administering pain medication and altering their mental status which would be essential for a patient who is presenting with stroke-like symptoms.” During the medical record review, there was lack of documentation indicating that the nurse notified the provider of the patient’s pain assessments. There was no documentation that the patient was ordered or offered any pharmacological or non-pharmacological interventions for pain management. Upon interview, S16 confirmed that there were no interventions provided for P1’s pain and confirmed the above findings at the time of discovery.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48414 Based on observation, staff interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure policies and procedures for patients that elope are implemented for two (2) out of three (3) medical records reviewed (Patient (P) 8 and P21). Findings include: Facility policy titled, “Discharge Without Order (Against Medical Advice, Elopement),” effective 11/8/24, stated, “ ...IX. Definitions: ...3. Elopement A patient that leaves the hospital without knowledge of staff or an Emergency Department patient who leaves without knowledge after receiving medical screening. ...XI. Procedure: ...B. Elopement i. Notify Nurse Leader or Administrative Supervisor that the patient has eloped. ii. Attempt to locate the patient. Depending upon each elopement, different mechanisms may be employed to attempt to locate patient, which may include notification of security and police. iii. Notify attending LP [licensed provider] of elopement. iv. Document in the medical record the individuals called and the activity undertaken to locate the patient including final disposition, e.g., police found patient at home. v. Complete an Occurrence Report. ...” Patient (P) 8, a 16-year-old presented to the Emergency Department (ED) on 1/6/25 at 1:51 PM, by ambulance unaccompanied by a guardian with a chief complaint of assault victim and vomiting. At 2:18 PM, the ED Triage Note stated, “Patient had altercation with [father/mother] Patient started feeling sick and vomiting yesterday while at a friends last night ...[Father/Mother] was arguing with patient Patient reports [father/mother] was hitting [him/her] with a broom and trying to strangle [him/her] ...Patient was fearful for this [sic] safety and picked up a knife to defend [himself/herself] ...Patient states [he/she] feels safe at home most of the time and that [stepmother/stepfather] is the issue ...” At 3:51 PM, P8’s Medical Screening Examination was completed. At 4:36 PM, the Registered Nurse (RN) ED Note stated, “[Mother/father] arrived ...” At 6:35 PM, P8’s ED Disposition was set to Elopement. At 6:45 PM, the RN ED Note stated, “Parent eloped with patient Attempted to get family back [Father/Mother] refused Psych NP [Nurse Practitioner] to file DCPP [Division Child Protection and Permanency] Dr. [name] aware ...” On 1/31/25 at 11:29 AM, S1, Risk Safety Manager, confirmed there was no occurrence report completed when P8 eloped with his/her parent. 48965 On 1/30/25 at 11:26 AM, P21’s medical record was reviewed in the presence of S33, Advance Nurse Clinician. P21, a 24-year-old patient who was 37 weeks pregnant presented to OB-triage (Obstetrics) on 9/3/24 at 12:59 PM, via a private vehicle with reported contractions every 15 minutes and membranes intact. The triage RN and Provider performed an assessment together at 2:33 PM. An order for observation was placed by the provider at 2:33 PM. At 3:55 PM, the medical record lists P21’s disposition as “Left AMA or elopement.” The medical record lacked evidence of provider notification of P21’s elopement. S33 confirmed that P21’s medical record did not include provider notification of her elopement. On 1/31/24 at 1:38 PM, S1 confirmed that there was no occurrence report submitted when P21 eloped.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 41646 Based on observation, review of surveillance video from 12/3/24, staff interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure that all patients are assigned a clinical priority for treatment upon arrival to the Emergency Department (ED). Findings include: Facility policy titled, “Triage Procedure, Pediatric Patients,” effective date 6/23, stated, “...XI Procedure: A. All patients shall be assigned a clinical priority for treatment by a professional nurse upon arrival to the Emergency Department. ...” Facility policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance,” effective date 4/23, stated, “...Definitions: ...3. Triage A process to determine the order in which patients will be seen by qualified medical personnel for a medical screening examination. ...” Facility policy titled, “Triage Procedure Emergency Department,” effective date 4/23, stated, “Procedure: 1. All patients shall initially be assigned clinical priority for treatment by a licensed professional nurse or physician upon arrival in the Emergency Department. 2. All patients are seen upon arrival. The nurse assesses the patient’s illness or injury, determines their Emergency Severity Index (ESI) category and places them appropriately. ...” On 1/29/25 at 9:58 AM, during the entrance conference with Staff (S)1 (Risk Safety Manager), S2 (Assistant Vice President), S3 (Vice President of Patient Care Services /Chief Nursing Officer), and S4 (Assistant Vice President, Risk and Patient Safety), S1 stated that the facility has three emergency departments (EDs) - an adult ED, a pediatric ED, and an obstetrics ED. At 11:04 AM, a tour of the pediatric ED was conducted. A separate seated area next to registration was identified by S6 (Nursing Director of Pediatrics), as the triage area. Upon interview, S6 stated, “the triage nurse sits here. There is always a nurse present in the triage area.” At 11:08 AM, during an interview with S18 (Registered Nurse), he/she stated, “we used to not have a triage nurse in the mornings until 12pm.” During the interview, S6 stated that having a triage nurse at all times started approximately a month ago, “Until then, we only had a triage nurse from around 12 noon until 12 AM.” At 2:40 PM, a review of P1’s medical record with S6 and S26 (Assistant Nursing Director, Pediatrics), revealed the following: On 12/3/24 at 10:36 AM, P1 arrived at the Pediatric ED via car with his/her mother. An arrival complaint of “Rash; Post-Op Bleeding; Breathing Problem” was entered by S25, (Patient Access [registration]). At 11:35 AM, 59 minutes later, P1 was roomed in P-05. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the 59 minutes P1 waited in the waiting area. At 11:38 AM, S27 (a physician), was assigned to the patient, and at 11:39 AM, a “First Provider Evaluation” of P1 by S27 was documented in the timeline, one hour and three minutes after the patient arrived. P1 was assigned an acuity level of 1, and at 3:04 PM, the patient was transferred via helicopter to a higher level of care. On 1/30/25 at 9:59 AM, a review of the video surveillance footage of the Pediatric Waiting Room on 12/3/24, was conducted with S30 (Security), in the presence of S1, S3, and S29. S30 stated that the time of the footage is approximately two minutes later than the medical record time. The video began at 10:38 AM when P1 entered the waiting area, held by his/her mother, (identified by S1 and S3). From the time of P1’s arrival at 10:38 AM until 11:39 AM, when P1 was brought in to be assessed, there were no nurses observed entering the waiting area, as confirmed by S1 and S3. A review of the emergency department log from 12/3/24 revealed that seven patients (P1 - P7) arrived between 10:23 AM and 10:54 AM. On 1/30/25 at 2:00 PM, medical record review was conducted with S26 (Assistant Nursing Director, Pediatrics), who confirmed the triage start times and medical screening examination (MSE) times, as follows: P5 - Arrived at 10:23 AM- Triage began at 11:39 AM, Acuity 3, Migraine; MSE 10:51 AM. P4 - Arrived at 10:27 AM - Triage began at 11:34 AM, Acuity 4, Eye Problem; MSE 11:33 AM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the one hour and five minutes P4 waited in the waiting area. P2 - Arrived at 10:29 AM - Triage began at 11:02 AM, Acuity 4, Swallowed Foreign Body; MSE 11:02 AM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the 33 minutes P2 waited in the waiting area. P1 - Arrived at 10:36 AM - Triage began at 12:46 PM, Acuity 1, Respiratory Distress; MSE 11:39 AM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the 59 minutes P1 waited in the waiting area. P6 - Arrived at 10:38 AM - Triage began at 12:14 PM, Acuity 4, Facial Laceration; MSE 1:55 PM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the one hour and 36 minutes P6 waited in the waiting area. P7 - Arrived at 10:39 AM - Triage began at 12:20 PM, Acuity 4, Sore Throat; MSE 2:06 PM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the one hour and 41 minutes P7 waited in the waiting area. P3 - Arrived at 10:54 AM - Triage began at 11:57 AM, Acuity 3, Breathing Problem; MSE 12:07 PM. The medical record lacked documentation of any clinical assessment by a nurse to determine priority for treatment upon arrival or during the one hour and three minutes P3 waited in the waiting area. On 1/29/25 at 3:10 PM, during an interview, S6 (Nursing Director of Pediatrics), stated that at the time of P1’s ED visit, the pediatric ED did not have a dedicated triage nurse 24 hours a day. The process then was, the nurses would come out to the waiting area from the back and “triage patients as soon as possible upon arrival.” S6 further stated that in order to select which patient from the waiting area would be roomed next in the main ED, the nurse would utilize arrival time, an “eyeball assessment” [of the patient], and the arrival complaint. This deficient practice resulted in delaying assessment of each patient’s presenting signs and symptoms at the time of arrival in order to prioritize the time of the MSE. In order to remove noncompliance with EMTALA requirements, S6 stated that the following changes had been implemented prior to survey: beginning on 12/20/24, a 24/7 triage nurse was assigned in the waiting area/triage room. Documentation was provided of email commuications sent to staff on 12/20/24, 12/31/24, and 1/14/25. The email included changes to staffing/scheduling to accommodate a 24/hour RN triage system, a review of triage requirements, and a PowerPoint education. S6 stated that the PowerPoint was posted on the unit, and that staff were re-educated by him/her as they came into work and asked to sign a sheet documenting their conversation. On 1/30/25 at 10:48 AM, S6 provided copies of the sign-in sheets documenting the staff education from the ED review PowerPoint. On 1/31/25 at 10:40 AM, S6 provided documentation of triage audits, which began on 1/28/25, with a goal to improve triage time. The facility was found to be in compliance, but previously out of compliance with EMTALA requirements. The facility has no previous EMTALA violations in the last 6 (six) months. Facility Policy titled “OB [Obstetrics] Triage at Virtua Health” states, “ ...XI. Procedure: ... B. Initial maternal and fetal assessment by the RN or LP should take place within 30 minutes of arrival to OB Triage. A triage acuity index of 1-5 (see Appendix) should be assigned to the patient ...” On 1/30/25 at 11:26 AM, P21’s medical record was reviewed in the presence of S33, Advance Nurse Clinician. P21, a 24-year-old patient who was 37 weeks pregnant presented to OB-triage on 9/3/24 at 12:59 PM via a private vehicle with reported contractions every 15 minutes and membranes intact. The triage RN and Provider performed an assessment together at 2:33 PM. P21 was triaged and received an MSE 94 minutes after arrival. The medical record lacked evidence of a MFTI (Maternal Fetal Triage Index) assessment. S33 confirmed no MFTI number was assigned to the patient. On 1/30/25 at 11:37 PM, S34, Director of Clinical Practice, explained that triage time in the OB triage area is monitored and reported at the OB-ED (Emergency Department) meetings. S34 reported that the dedicated triage room opened September 10, 2025.”