A 2-month-old girl born prematurely and drug-exposed vomits while at Clark County's emergency shelter for abused and neglected children.

One Child Haven nurse places her on the sick call list only to have another staff nurse take her off before she receives medical care.

A teenage girl brought to Child Haven tells a staff member she hasn't had a period in two months.

The staff member believes she might need a pregnancy test and places the teenager on the sick call list. A staff nurse subsequently removes her name from the list.

Those two situations happened during the past two weeks at the county's emergency shelter, according to Child Haven staff concerned that those who need medical attention aren't always receiving it.

They aren't the only incidents, one worker said, just the most troubling.

"Frankly, I was really stunned in the case of the 2-month-old," said a Child Haven staff member who asked not to be identified. "If the county takes custody of these children, then they take full responsibility for everything, including health care."

Questions about access to medical care at Child Haven arise at a time when child welfare in the county is under fire for system failures highlighted by civil lawsuits and federal and state government reports.

Child Haven has come under scrutiny for the death of a child in care. In August, paramedics were called to the emergency shelter because 17-month-old Joshua Sharp had stopped breathing.

Attempts at resuscitation failed, and Sharp was pronounced dead when taken to North Vista Hospital.

"Under both state and federal law, their number one priority is to keep the child safe," said Stephanie Charter, who heads the Children's Attorney Project, an arm of Clark County Legal Services, which seeks to expedite the placement of Child Haven residents into foster homes. "If a child's medical needs aren't being met, then they aren't safe."

Child Haven Manager Lou Palma said the triage system that troubled staff members was phased out entirely on Monday. Child Haven has six nurses on staff and a physician's assistant on site three days a week.

A physician acts as supervisor, Palma said, and ultimately a pediatrician will be on staff full time.

"This is a transition from a time when we used to triage because there weren't enough upper-level medical staff to see everyone," Palma said.

At this time, any Child Haven staff member or parent can place a child on the sick list and that child will be seen by a medical professional, Palma said.

That decision was made Wednesday at a meeting of child welfare officials, medical staff and representatives of the Nevada Health Center, the contract care provider for Child Haven, he said.

Palma also addressed the two examples of children diverted from care that troubled shelter staff.

In the case of the infant, Palma said, the problem was a miscommunication between medical providers.

A nurse thought that the baby girl had been seen by the physician's assistant earlier in the day. The teenage girl did ultimately receive the pregnancy test that was requested by staff.

Tom Criste, manager of specialized services for Child Haven, said every child who arrives at the shelter receives a comprehensive physical.

Criste also said the changes taking place come amid a months-long process of retooling the delivery of medical care to children in county custody.

One new measure being phased in is the creation of a medical passport that will follow the children after they leave Child Haven. It will record any services received by the individual, including immunizations, dental work or medical test results.

The medical passports are in use now with medically fragile children in custody. By the end of the year, Criste said, all children who go through Child Haven will have one.

"We think we've made incredible gains in a lot of areas," Criste said.

Gary Peck, executive director of the American Civil Liberties Union of Nevada, gave the county credit for responding quickly to the problem, but he said the situation underlines the inherent problems of congregate care for children.

The ACLU has been lobbying the county since June to replace Child Haven with more family-oriented placements for minors in county care.

"What these situations highlight is that no system of congregate care, especially for young children, is going to be one that inspires as much confidence as appropriate foster care," Peck said. "This is exactly what we're stressing in our approach: the need to move away from congregate care."