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Based on record review, review of the facility Emergency Treatment and Labor Act (EMTALA) policies, staff and provider interviews, review of the receiving hospital record, the hospital inappropriately discharged 1 laboring obstetrical patient (Patient 11) out of 2 sampled patients experiencing contractions, prior to providing care to the patient within the hospital's capabilities to stabilize the patient. The facility failed to ensure they followed the EMTALA policy regarding a discharge/transfer of a woman in latent or early labor having regular contractions every 2.5-3.5 minutes resulting in an un-stabilized emergency medical conditions. The discharged patient was instructed to go to Hospital B emergency department or call the obstetrician despite the hospital having the capacity and capability to provide medical services to stabilize their emergency medical condition. This failure has the potential for patients to be unnecessarily transferred delaying stabilizing treatment of their emergency medical condition. Total sampled patients 20.

Findings are:

Also see A 2409
A. Review of the facility policy titled "EMTALA Guidelines for Emergency Department Services" dated 8/17/22 defines an Emergency Medical Condition as a medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor) such that the absence of immediate medical attention could place the individual's health at risk. Labor: The process of childbirth, beginning with latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician, or other qualified medical person acting within his or her scope of practice as defined in the hospital medical staff rules and regulations and state law, certifies that, after a reasonable time of observation, the woman is in false labor.
The hospital may not transfer or discharge a patient who maybe reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patieent is at reasonable risk to deteriorate due to the natural process of their medical condition, they are leagally unstable as per EMTALA. This standard also states that a pregnant worman is not legally stable until the baby and placenta have been delivered.
The hospital may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable patient to another facility may only be for reason of medical necessity.

B. Review of the medical record for Patient 11 revealed that the patient arrived at the hospital (Hospital C) on 3/14/23 at 12:01 PM. The patient was taken to the Labor and Delivery Triage area. RN A assisted the patient to the triage area and applied the External Fetal Monitor (EFM) to the patient used to monitor the fetal heart rate of the baby and the uterine contractions of the mother. Patient 11 told RN A that "the contractions started at 4:00 AM this morning and were getting stronger, the patient left home (28 miles away) on the way to Kearney (Hospital B) (32 miles away) but didn't feel she would make it there so stopped here (Hospital C)". The EFM identified that Patient 11 was having regular contractions every 2.5-3.5 minutes with a duration of 60-70 seconds and were moderate quality. RN A did a sterile vaginal examination (SVE) showing that the cervix was dilated to 3 (0-10); 25% effaced (0-100%) fetal station -3 (-3 is when the head is above the pelvis, 0 station when the head is at the bottom of the pelvis or fully engaged and +3 is when the head is emerging from the birth canal), and the bag of water was intact. ED Nurse RN A, phoned the on call ED physician (Dr B) and updated the doctor on the patient status related to contractions every 2.5-3.5 minutes. The on call physician (Dr B) instructed the ED Nurse, (RN A) to go ahead and discharge her and send her to the doctor at (Hospital B-32 miles away) that provided her prenatal care. The patient and parent agree to that plan. Water given to drink and encouraged to call doctor office on way to see if they want her at the clinic or labor department. The medical record identified that Patient 11 left at 12:40 PM and a copy of the monitor (EFM) strip and vaginal check results written and sent with patient. The patient left in a private car.

C. Review of the receiving hospital (Hospital B) medical record for 3/14/23 showed Patient 11 was admitted at 1:49 PM. The OB flow sheet showed:
-1:55 PM the registered nurse (RN W) put on the EFM and notified the physician (MD T).
-1:56 PM, RN W did a SVE showing that the cervix was dilated to 3-4 (0-10); 50% effaced (0-100%) fetal station -3 (-3 is when the head is above the pelvis, 0 station when the head is at the bottom of the pelvis or fully engaged and +3 is when the head is emerging from the birth canal), and the bag of water was intact.
-2:17 PM, vital signs showed an elevated blood pressure 172/118-93-18, also another SVE showed that the cervix was dilated to (0-10); 50% effaced (0-100%) fetal station -3 (-3 is when the head is above the pelvis, 0 station when the head is at the bottom of the pelvis or fully engaged and +3 is when the head is emerging from the birth canal), and the bag of water was intact.
-2:45 PM Patient 1 had a spontaneous rupture of membranes.
-2:49 PM the patient delivered her baby.

D. Review of the 3/27/23 Hospital Database (a form that identifies the hospital's capability to provide care in specific fields, ie obstetrics, pediatrics) identifies that the hospital has the capability to provide obstetrical care.

E. An interview with the Director of Inpatient Nursing (RN L) on 3/27/23 at 11:45 AM reported that the hospital delivers around 75-100 babies per year.

Based on record review, staff and provider interviews, review of the receiving hospital record, review of the facility Emergency Treatment and Labor Act (EMTALA) policies, the facility failed to ensure they followed the EMTALA policy regarding a transfer of a woman in latent or early labor having regular contractions every 2.5-3.5 minutes resulting in an un-stabilized emergency medical conditions. Review of 20 sampled patients identified 1 patient (Patient's 11) that discharged and instructed to go to Hospital B emergency department or call the obstetrician despite the hospital having the capacity and capability to provide medical services to stabilize their emergency medical condition. The total sample of 20 records, was taken from the central logs of patients presenting to the Emergency Department from 9/2022-3/2023. This failure has the potential for patients to be unnecessarily transferred delaying stabilizing treatment of their emergency medical condition.

Findings are:

A. Review of the medical record for Patient 11 revealed that the patient arrived at the hospital (Hospital C) on 3/14/23 at 12:01 PM. The patient was taken to the Labor and Delivery Triage area. RN A assisted the patient to the triage area and applied the External Fetal Monitor (EFM) to the patient used to monitor the fetal heart rate of the baby and the uterine contractions of the mother. Patient 11 told RN A that "the contractions started at 4:00 AM this morning and were getting stronger, the patient left home (28 miles away) on the way to Kearney (Hospital B) (32 miles away) but didn't feel she would make it there so stopped here (Hospital C)". Patient 11 is a gravida 2, para 1 (this is Patient 11's second pregnancy with 1 living child and expecting her 2nd child. The EFM identified that Patient 11 was having regular contractions every 2.5-3.5 minutes with a duration of 60-70 seconds and were moderate quality. The Fetal Heart Rate (FHR) baseline of 135 with good variability with no decelerations (showing that the baby was tolerating the contractions). RN A did a sterile vaginal examination (SVE) showing that the cervix was dilated to 3 (0-10); 25% effaced (0-100%) fetal station -3 (-3 is when the head is above the pelvis, 0 station when the head is at the bottom of the pelvis or fully engaged and +3 is when the head is emerging from the birth canal), and the bag of water was intact. ED Nurse RN A, phoned the on call ED physician (Dr B) and updated the doctor on the patient status related to contractions every 2.5-3.5 minutes. The on call physician (Dr B) instructed the ED Nurse, (RN A) to go ahead and discharge the (Patient 11) and send her to the doctor at (Hospital B-32 miles away) that provided her prenatal care. The patient and parent agree to that plan. Water given to drink and encouraged to call doctor office on way to see if they want her at the clinic or labor department. The medical record identified that Patient 11 left at 12:40 PM and a copy of the monitor (EFM) strip and vaginal check results written and sent with patient. The patient left in a private car.

B. An interview on 3/27/23 at 1:30 PM with RN A revealed that this nurse was on duty on 3/14/23 when Patient 11 presented to the ED with the complaint of being in labor and unsure if could make it the rest of the way to (Hospital B). RN A stated that Patient 11 said "She stopped here because her contractions were getting stronger and didn't know if she would make it to (Hospital B)." "The patient was due April 1st so 37-38 weeks, I hooked the patient to the EFM and did a SVE. The contractions continued every 2.5-3.5 minutes for 60-70 seconds and were moderate strength to uterine palpation (touching abdomen when having a contraction)." RN A stated, "A call was placed to Dr B and reported what the monitor strip and SVE showed. Dr B said go ahead and send her on to (Hospital B) where she had received her prenatal care." RN A then went into Patient 11's room where the patient and her parent was, and informed them that "I and Dr B felt they could go onto (Hospital B) where her primary doctor was and they agreed." "I sent a copy of her (EFM) strip and the vaginal assessment on it with them and instructed them to call the provider on the way and ask where they want her to come, to their clinic or to (Hospital B)." When asked RN A if the patient was having contractions when dismissing, RN A said, "Yes, when I walked her out to her car, she had 2 contractions, she had to stop during the 2nd contraction." Asked RN A to check the medical record for vital signs. RN A verified that no vital signs were documented in the medical record.

C. An interview of 3/28/23 at 8:05 AM with Dr B (a primary care physician), Dr B recalled the case of Patient 11 from 3/14/23. "The nurse (RN A) called me at the clinic where I was seeing patients. She said this was her 2nd baby, with the 1st being 5 years ago. (RN A) told me she was 3 cm dilated, bag of water intact, high and not engaged. Not in active labor by the ACOG guidelines of because she was only dilated to 3 and high, not engaged, so did not meet the "active labor" guidelines. I felt it would be safe to have her continue on to her own physician."

D. Review of the receiving hospital (Hospital B) medical record for 3/14/23 showed Patient 11 was admitted at 1:49 PM. The OB flow sheet showed:
-1:55 PM the registered nurse (RN W) put on the EFM and notified the physician (MD T).
-1:56 PM, RN W did a SVE showing that the cervix was dilated to 3-4 (0-10); 50% effaced (0-100%) fetal station -3 (-3 is when the head is above the pelvis, 0 station when the head is at the bottom of the pelvis or fully engaged and +3 is when the head is emerging from the birth canal), and the bag of water was intact.
-2:17 PM, vital signs showed an elevated blood pressure 172/118-93-18, also another SVE showed that the cervix was dilated to (0-10); 50% effaced (0-100%) fetal station -3 (-3 is when the head is above the pelvis, 0 station when the head is at the bottom of the pelvis or fully engaged and +3 is when the head is emerging from the birth canal), and the bag of water was intact.
-2:45 PM Patient 1 had a spontaneous rupture of membranes.
-2:49 PM the patient delivered her baby.

Review of the History and Physical dated 3/14/23 at 2:58 PM by Dr T, revealed, ASSESSMENT AND PLAN: 1)Admit to L & D (labor and delivery); 2) GBS (group b strep) negative; 3) Inadequate prenatal care; 4) Severe range Blood Pressure: History of methamphetamine abuse with concerns for recent use. Repeat BP in 20 minutes and treat as needed. Will also check labs for preeclampsia.

HISTORY OF PRESENT ILLNESS: A 24 year old presents at 37 weeks 3 days for complaints of uterine contractions starting earlier today. She rapidly went from 3 to 7 to 9 cm (centimeters). her pregnancy has been complicated by above (Assessment & Plan). She has had three positive urine drug screens for methamphetamines. Presentation to care was at (Hospital C) at around 32 weeks.

Review of the Discharge Summary dated 3/15/23 at 2:29 PM revealed, Pregnancy complicated by entry to care at 32 weeks and multiple positive urine drug screen for amphetamines. She delivered a viable male infant. Blood pressures severe prior to delivery but suspected due to recent substance use. Blood pressures responded to an acute treatment of labetalol (medication to lower elevated blood pressure) and then did not require further treatment. She denies headache/vision changes. Case management involved due to substance abuse history.

E. Review of the facility policy titled "EMTALA Guidelines for Emergency Department Services" dated 8/17/22 defines an Emergency Medical Condition as a medical condition with sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, pregnancy/active labor) such that the absence of immediate medical attention could place the individual's health at risk. Labor: The process of childbirth, beginning with latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician, or other qualified medical person acting within his or her scope of practice as defined in the hospital medical staff rules and regulations and state law, certifies that, after a reasonable time of observation, the woman is in false labor.
The hospital may not transfer or discharge a patient who maybe reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of their medical condition, they are legally unstable as per EMTALA. This standard also states that a pregnant woman is not legally stable until the baby and placenta have been delivered.
The hospital may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable patient to another facility may only be for reason of medical necessity.

F. Review of the 3/27/23 Hospital Database (a form that identifies the hospital's capability to provide care in specific fields, ie obstetrics, pediatrics) identifies that the hospital has the capability to provide obstetrical care.

G. An interview with the Director of Inpatient Nursing (RN L) on 3/27/23 at 11:45 AM reported that the hospital delivers around 75-100 babies per year.