HospitalInspections.org

Based on review of the medical record of patient #26, interview with staff, and other available documentation, the hospital failed to comply with CFR 489.24 for the transfer of patient #26, who had not been stabilized, to a nearby local hospital.

Findings were:

Pt #26 presented to the Women's Center Labor and Delivery on 11-13-09 complaining of contractions. The 28 year old was assessed by a QMP (qualified medical person) and determined to be 33-34 weeks gestation, dilated 2-3 centimeters, with contractions 2-4 minutes apart. At 9:50 AM staff contacted physician #3 who is on staff at the hospital and who had also seen the patient in the office of his private practice. The physician gave an order to admit the patient and start IV fluid and antibiotics. At 9:55 AM, staff again called the physician who gave an order to transfer the patient to a near by hospital by ambulance. The MOT stated that the transferring physician was also the receiving physician who planned to meet the patient there.

The patient was transferred to the receiving hospital by EMS accompanied by an unnamed physician from the sending hospital. Patient #26 arrived at the receiving hospital at 11:08 AM, the receiving RN accepted care at 11:10 AM, a male infant was delivered at 11:11 AM.

Mother and baby were discharged the next day, 11-14-09, in stable condition.

Based on review of the medical record of patient #26, interview with staff, and other available documentation, the hospital failed to ensure that patient #26 was treated and stablized before being transferred to another hospital.


Findings were:

Pt #26 presented to the Women's Center Labor and Delivery on 11-13-09 complaining of contractions. The 28 year old was assessed by a QMP (qualified medical person) and determined to be 33-34 weeks gestation, dilated 2-3 centimeters, with contractions 2-4 minutes apart. At 9:50 AM staff contacted physician #3 who is on staff at the hospital and who had also seen the patient in the office of his private practice. The physician gave an order to admit the patient and start IV fluid and antibiotics. At 9:55 AM, staff again called the physician who gave an order to transfer the patient to a near by hospital by ambulance. The MOT stated that the transferring physician was also the receiving physician who planned to meet the patient there.

The patient was transferred to the receiving hospital by EMS accompanied by an unnamed physician from the sending hospital. Patient #26 arrived at the receiving hospital at 11:08 AM, the receiving RN accepted care at 11:10 AM, a male infant was delivered at 11:11 AM.

Mother and baby were discharged the next day, 11-14-09, in stable condition.

Based on review of the medical record of patient #26, interview with staff, and other available documentation, the hospital failed to comply with CFR489.24 requirements of an appropriate transfer.

Findings were:

Patient #26 was transferred to a local hospital on 11-12-09 following a telephone order from the transferring physician. The QMP (qualified medical person) wrote the order but failed to sign a certification containing the risks and benefits of the transfer. The order to transfer the patient had not been authenticated at the time of the investigation (1-06-10), and a summary of the circumstances, including risks and benefits, was not included in the patient's chart until 1-06-10.