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Based on review of medical record, staff interviews, observations, and review of facility documents, it was determined the facility governing body failed to ensure contracted staff follow facility procedure for transfer of patients and consultation procedures (A-0083).

Cross Reference:
482.12(e) Governing Body: Contracted Services

Based on medical record review, document reviews and staff interviews, it was determiend the facility failed to provide oversight to contracted services by not following their policies and procedures in one (1) out of twenty (20) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A policy was reviewed titled "Maternal Transport", revised 9/9/21. The policy has a section titled "Purpose" which states, "To provide guidelines for designation of nursing staff and preparation of the maternal patient for transport to other medical facilities for higher level of care." The policy has a section titled "Procedure Arranging Maternal Transport" which states, in part, "1. The obstetrics (OB) provider will make the decision to transport the patient, method of transport, urgency, and if an OB RN needs to travel with the patient. 2. The OB provider will discuss the treatment plan and intention to transfer with the patient and family. 3. The OB provider will contact the facility chosen and obtain consent from the receiving provider and nursing unit to accept the patient. 6. Obtain OB Transport packet. The OB provider is responsible for completing or obtaining the following: a. Patient Transfer Consent (if printing from Form Fast it will produce two (2) forms, the transfer consent, and the Interhospital Transfer / Transport Record Nursing form.) b. Physician Orders for OB transport - orders specific to care performed by nursing staff during ground transport. c. Justification of ambulance transportation - Physician statement."

A document was reviewed titled "City Hospital Medical Staff Rules and Regulations" with a last approved date of 04/02/24. This document contains a section titled "Section A Admission and Discharge", which states, in part, "Transfer: Patients with conditions whose definitive care is beyond the capabilities of this hospital shall be referred to the appropriate facility, when in the judgment of the attending practitioner the patient's condition permits such a transfer. The hospital's procedures for patient transfer to other facilities shall be followed.

Consultations: should be done in a timely manner and show evidence of a review of the patient's record by the consult, pertinent findings on examination of the patient, and the consult's opinion and recommendations. This report shall be made a part of the patients' record. When operative procedures are involved, the consultation note shall, except in emergency situations so verified on the record, be recorded prior to the operation. Informed Consent: practitioners shall be responsible for obtaining the patients' informed consent. When consent is not obtainable, the reason shall be entered in the patient's medical record. The medical record shall contain evidence of informed consent for procedures and treatments for which it is required by Hospital policy. Both the patient and the practitioner shall sign the consent form affirming that the practitioner has personally informed the patient. Space shall be provided on the form for the practitioner to document what was explained to the patient and the patient understood and agreed to the proposed treatment."

A review of the American College of Obstetrics and Gynecology (ACOG), the active phase of labor is the period of rapid cervical dilation that occurs until the cervix is fully dilated. This phase is characterized by regular contractions and can begin spontaneously at around 6 centimeters of cervical dilation, though for some women it may not start until 5-6 centimeters.

A medical record review was conducted for Patient #1. Patient #1 presented to the Labor and Delivery (L&D) unit on 5/28/24 at 7:57 a.m. An entry in the medical record titled "OB - GYN before childbirth (Antepartum) note" entered by CNM on 5/28/24 at 8:01a.m. which states, in part, "[Patient #1] presents for planned induction of labor (IOL) Gravida (G) 5 PARA (P) 3 Abortion (AB) 1 at 38w[weeks] and 5 days per Maternal Fetal Medicine (MFM) for chronic hypertension (cHTN) (no meds)." A section of the note titled "Fetal Data" states, in part, "Presentation: Vertex - confirmed by bedside ultrasound (US). Fetal Heart Rate (FHR) Monitoring Category: Category I, Estimated Fetal Weight: six and one half (6.5) pounds. Contractions: every (Q) six (6) to eight (8) minutes, Duration Range: sixty (60) to ninety (90) seconds, Contraction pattern: Irregular and Intensity: Mild." Vaginal exam 5 centimeters (cm), 50% effaced, -2 station. A gentle stripping of the membranes. A section of the note titled "Plan" states, in part, "1) Just prior to patient's arrival, staff notified that all main operating rooms (ORs) are all down due to flooding. As the patient is a trial of labor after cesarean (TOLAC), discussed with staff and obstetrics hospitalist group (OBHG) hospitalist #1, safest induction and delivery plan for delivery. Discussed situation with patient and partner, verbalized understanding, patient states [Patient #1] would like to deliver at [other facility], had actually inquired about delivery there at MFM last week. [CNM] called and spoke to the OBHG hospitalist at [other facility], report provided, and the hospitalist accepted the patient. Records from [outpatient facility] and most recent MFM appointment faxed to [other facility]. Patient and partner verbalized understanding of plan of care (POC) and in agreement. Discharged on 05/28/24 at 8:52 a.m. from this facility's L&D, after reactive nonstress test. Partner to drive to [other facility] for planned induction of labor (IOL) ...The patient verbalizes a reasonable understanding of [Patient #1's] diagnosis and is in agreement with the plan of care. All risks, benefits, and alternatives were reviewed with the patient. All questions were answered."

It should be noted, the medical record for Patient #1 does not contain a signed transfer form, does not contain an order for consultation with Emp #1, and does not contain a written consultation from Emp #1.

An interview was conducted with Emp # 3 on 5/28/24 at 10:45a.m. Emp #3 reported working on L&D for the last nineteen (19) years. Emp #3 was asked about their knowledge of and interaction with Patient #1. Emp #3 stated, "[Patient #1] was scheduled for a TOLAC that morning and [Patient #1] came straight to our floor and I arrived [Patient #1] on the computer. I was going to be [Patient #1's] nurse so I placed the patient in a room, provided a gown to change into and asked for a urine specimen. I went out to the nurses' station and there was a discussion about a backup plan for OR rooms. We had a scheduled section (c-section) so they were talking about doing or not doing the induction with no back up. At one point, [Emp #5] went in and talked to [Patient #1] and then talked to [Emp #1]. They decided it was not a good idea for [Patient #1] to stay here. [Emp #5] called [other facility] and they were not really happy with accepting the patient but they did. [Emp #5] checked the baby, which was head down and then asked the patient about sweeping membranes, which the patient agreed to. Afterwards, the patient got dressed, was advised not to stop along the way, and left with significant other." Emp #3 was asked why the patient was not sent via ambulance. Emp #3 stated, "I don't know why [Patient #1] was not sent by ambulance. I'm guessing since there was no active labor, they went by private car. We have a transfer/transport packet. Usually, a midwife or provider has to complete it and a checklist for us. It indicates whether the patient needs basic life support (BLS) or advanced life support (ALS) transportation." Emp #3 was asked if they transfer many patients via private vehicle. Emp #5 stated, "This is the first situation I've been involved with that the patient was discharged by car to another facility.

An interview was conducted Emp # 4 on 5/28/24 at 12:03 p.m. Emp # 4 was asked about who provides oversight to the mid-level providers in the OB area. Emp #4 stated, "Oversight to the mid-levels is provided by Obstetrics Hospitalists Group (OBHG), they are a contracted hospitalist group for inpatient (IP) OB care. They supervise certified nurse midwives (CNM), OB fellows and residents. There have been a few days of no coverage and we have covered that. They have a new director, but I don't think that person is on site currently." Emp #4 was asked about the transporting of transferred patients. Emp #4 stated, "In general, we have transport issues. In this case, we crossed the line of safety because we had stripped membranes. If necessary, we could have flown the patient. We normally offer and should have offered transport. Of course, the patient always has the right to sign out against medical advice (AMA)."

An interview was conducted with Emp # 1 on 05/31/23 at 9:02 a.m. Emp # 1 was asked about their role on the OB unit on 5/28/24. Emp #1 explained that they were the provider covering labor and delivery that day. Emp #1 explained that the charge nurse had informed them that the operating room (OR) had flooded during the previous day and that the obstetrics operating room (OBOR) was the only operating room currently available. Emp #1 was asked about their interaction with Patient #1. Emp #1 said they had spoken with [Emp #5] about [Patient #1] and was informed that a nonstress test had been completed and that the baby was in the vertex (head down) position. Emp #1 said that staff was concerned about not having a second OR room available in the event of an emergency and that [Patient #6] was an elective cesarean section (c-section) scheduled that morning as well as [Patient #1] who was a scheduled trial of labor after c-section (TOLAC). Emp #1 was asked what information was available concerning a second room becoming available. Emp #1 stated, "We decided to move the 8 a.m. case to noon or later, once a second OR room became available." Emp #1 was asked about the decision to transfer Patient #1 to another facility. Emp #1 stated, "[Patient #1] was at a higher risk for a c-section since [Patient #1] had a previous c-section." Emp #1 was asked about transporting Patient #1 via ambulance since a membrane sweeping had been completed. Emp #1 stated, "Sweeping a patient's membranes can be done to start contractions and some providers will even do it in the office. Membrane sweeping is regularly done in the outpatient (OP) setting. Emp #1 was asked about following the American College of Obstetricians and Gynecologists (ACOG) guidelines in the delivery of care on the unit. Emp #1 stated, "We follow ACOG guidelines as best as we can."

An interview was conducted with Emp # 2 on 5/31/24 at 10:02a.m. Emp # 2 was asked about their involvement in the care of Patient #1 on 5/28/24. Emp #2 stated, "I was late getting here that morning. I didn't arrive until around 11a.m. [Patient #1] wasn't here very long and was gone before I got here that morning." Emp #2 was asked about documentation of Patient #1's stay and Emp #2 expressed that they felt that 'the documentation was poor" and that it "did not tell a story." Emp #2 was asked about their understanding of the events that occurred on the morning of 5/28/24 prior to their arrival at the facility. Emp #2 stated, "Anesthesia and the command center decided to not do (surgical) cases that morning due to not having an available second room in the event of an emergent case and the possibility of a postpartum patient needing an additional procedure due to bleeding." Emp #2 was asked about transferring Patient #1 to another facility after sweeping the membranes. Emp #2 stated, "There's not a protocol for sweeping membranes and then sending a patient out. I would agree that the big question is why the patient was not sent by ambulance. We only do a handful of transfers per year and they usually go to [tertiary facility]." Emp #2 was asked about the provider that assessed Patient #1. Emp #2 stated, "[Emp #5] is not employed by the facility but does have privileges to admit and deliver at [the facility]." Emp #2 was asked about following ACOG guidelines. Emp #2 stated that they follow both ACOG guidelines as well as the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) guidelines.

A telephone interview was conducted with Emp # 5 on 5/31/24 at 12:22p. Emp #5 was asked about work experience. Emp #5 stated, "I've been a CNM for the last five (5) years. I work here two (2) days per week and the rest of the time I work at [local clinic]. I am privileged here." Emp #5 was asked about their interaction with Patient #1 on the morning of 5/28/24. Emp #5 stated, "[Patient #1] was scheduled for an induction that morning. I saw [Patient #1] throughout the entire pregnancy. That morning the OR had flooded, and anesthesia came to the floor and said that the OB OR was the only functional room at that time and they were not sure about doing a procedure with no back up room. The patient had previously asked about delivering at [other facility] so I contacted [other facility]. We did not feel it was safe to deliver here so I called [other facility] and they were not happy about it but they accepted the patient. I checked the patient and found that [Patient #1] was dilated to five (5) centimeters (cm), not laboring, and was having contractions every six (6) to eight (8) minutes. I did sweep the membranes, but I would not call it an aggressive sweep. [Patient #1] wanted a vaginal birth and I tried to give [Patient #1] the best chance." Emp #5 was asked if Patient #1 was offered ambulance transportation to the other facility. Emp #5 stated, "[Patient #1] was not offered an ambulance, there was no reason to call an ambulance." Emp #5 was asked about completing a transfer form for the patient. Emp #5 stated, "I did not do one. No one asked for it. I did a discharge on the computer; I didn't see it as a typical discharge. It wasn't like it was an official transfer. We sent (faxed) information to [other facility] so they would have it. We also sent the MFM report as well." Emp #5 was asked who they report to while in this facility. Emp #5 stated, "I report to the OBHG hospitalist here and at [other facility]. [Emp #1] covers here and [other facility]."

An interview was conducted on 06/04/24 at 9:50 a.m. with Emp #2. When asked why patients were not contacted prior to their arrival for an elective procedure due to the Operating Room (OR) proper being closed due to flooding? They stated in part, The Incident Command Center (ICC) did not close the Obstetric OR. We were allowed to perform surgeries and knew that a second OR was being opened in the cardiac catheter OR. The providers took it upon themselves to make decisions that went against what the ICC plan was and that is why they sent [Patient #1] to another hospital. Emp. #2 was asked if they should have waited to strip the patient's membranes until after they transferred to another hospital? "I believe they should have waited."

An interview was conducted on 06/04/24 at 10:05 a.m. with Emp #5. When asked why they sent a patient to another hospital in a private vehicle after stripping their membranes (a form of inducing labor) and why did they not get a consent for transfer signed? They stated in part, Well that day the OR was flooded, and we were told we couldn't do a trial of labor after a cesarean section [TOLAC] because we didn't have a back-up OR for other emergencies. I stripped their membranes because they wanted to be induced and sent them to the hospital by car because they were only contracting every four (4) to six (6) minutes. When asked who told them they could not use the OR they stated in part, Anesthesia told me to cancel elective TOLAC. So, I sent them to [hospital transferred to]. When asked if they consulted the physician prior to transfer they stated, "Yes, they were on the floor, and we discussed it." When asked why there was no order for a consult? They replied in part I don't really know.

An interview was conducted on 06/04/24 at 11:30 a.m. with Emp #4. When asked if they reviewed the medical record they stated, "They reviewed the whole medical record." When asked if they agreed with the care or the transfer of the patient. They stated in part, The provider had a few options to give safe care. They could have sent the patient home if they felt uncomfortable without a second operating room, they could have waited to start the induction until noon when the second OR was open, or they could have waited to strip the membranes until they were transferred to the other hospital. When asked if they felt the patient should have been sent to the receiving hospital via car. They stated in part, "No, if they felt the patient should have been transferred it should have been via ambulance or they should have gotten a refusal to transfer signed and they did not do that."

An interview was conducted on 06/04/24 at 11:45 a.m. with Emp #8. When asked to explain what the plan was for the OB OR after the flooding of the OR proper and did they know if anesthesia told the OB provider that they refused to do a TOLAC at approximately 8:10 a.m. on 05/28/24. They stated in part, well [anesthesiologist] could not have told the provider at that time because they were on a safety call with us and we discussed that the OB OR was open and a second OR would be opened in the cardiac cath unit by approximately noon. We discussed that an elective cesarean section was scheduled for 9:00 a.m. and they did say they would not do an elective cesarean section until the second OR was open because of potential emergencies for the other labor patients. "I feel the providers went against what the command center wanted carried out and made their own decisions for whatever reason."

A telephone interview was conducted on 06/04/24 at 3:20 p.m. with Emp #1. When asked if they remembered patient #1, and if so to explain their care? They stated in part, I consulted with the other provider on transferring the patient due to the main OR being flooded and only one operating room was open on OB. I felt it was safer to transfer the patient. When asked if they were aware that the provider stripped the patient's membranes prior to transfer they stated, "Yes". When asked if they thought that was safe? They stated, "We do it all of the time." When asked if they realized the patient was sent via private car and was not offered an ambulance transfer? They stated "I did not know they were sent by car. I thought they left by ambulance." When asked why they did not document the consult in the medical record? They stated, "I must have forgotten."