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Based on interview and record review, Facility A failed to implement it's Emergency Medical Treatment and Active Labor Act (EMTALA), policy and procedure (P&P), by not ensuring a complete medical screening examination, necessary stabilizing treatment, placement in the facility's Emergency Department (ED) and/or Obstetric logs, and ensuring an appropriate transfer was implemented for one of 29 sampled patients, (Patient 1). Patient 1 presented to the facility with diagnoses of twin pregnancy (30 weeks gestation), pain, and a history of vaginal bleeding. These failures could impact the provision of medical care of the patient and her twin fetuses.

Findings:

An investigation, interviews and record reviews, were conducted on August 17, 2015, at 8:45 a.m., as a result of a complaint which alleged, on July 14, 2015, at approximately 9 p.m., Patient 1 presented to Facility A with a history of twin pregnancy (30 week gestation), pain, and a history of vaginal bleeding.

There was no patient information pertaining to Patient 1's presentation to the facility's ED lobby, such as an entry in the ED or OB logs, a medical screening, a medical history and associated diagnoses, or assessments documented by Labor and Delivery Registered Nurse (LDRN) 1, who met with Patient 1 when she arrived at Facility A. There was no documentation to indicate if Patient 1 was stabilized.

An interview with the Patient Access Representative (PAR) was conducted on August 17, 2015, at 9:20 a.m. She stated Patient 1 presented to the facility's ED lobby on July 14, 2015, at approximately 9 p.m., with a history of twin pregnancy, pain, and a history of vaginal bleeding. The PAR stated she asked Patient 1 if she was over 20 weeks gestation and the patient stated she was past 20 weeks gestation.

The PAR stated she went to the OB department to tell LDRN 1 she had a patient in the facility's ED lobby because LDRN 1 did not answer the phone. She stated LDRN 1 came to the facility's ED lobby, spoke to Patient 1 and "eyeballed" her. The PAR further stated LDRN 1 told her to call 911 and told Patient 1's companion to take the patient to another facility as, "They were unable to care for her here." The PAR stated this seemed "odd" to her and she subsequently called the Facility's RN Supervisor to inform her of the situation.

A review of the patient census for July 14, 2015, indicated there were no patients in the labor and delivery area at the time Patient 1 arrived at Facility A. LDRN 1 was not available for interview.

The PAR further stated Facility A's Administrator was notified that Patient 1 was going to be sent to another facility via 911 and the Administrator stated, "I am aware." The PAR acknowledged she should have registered the patient on Facility A's ED log as per hospital's policy, but she did not register Patient 1 on the log.

A review of the facility policy, "Medical Screening, Examination, Transfer and/or Referral to Outside Facility (Effective Date 1/2000)," was conducted. The document indicated, "It is policy of the Hospital to provide a medical screening examination by a qualified person to any individual who comes to the ED seeking an examination or medical treatment...Qualified medical persons means...Registered Nurse assigned to the Labor and Delivery Department pursuant to Standard of Care."

Per a Fire Department Emergency Medical Services Report dated July 14, 2015, at 9:30 p.m., Patient 1 was described as "pregnant" with a history of pain and bleeding was transported via 911 ambulance from Facility A's ED lobby to Facility B's ED. There was no evidence that transfer documentation from Facility A for Patient 1 was initiated and sent with Patient 1 to Facility B.

A review of Facility A's P&P titled "Emergency Department Patient Log" dated January, 2000, indicated, "A central log shall be maintained in the emergency department to track the care provided to each individual who comes to the hospital seeking care for and emergency medical condition, in compliance with federal regulation 489.24, Title 22, 704 B and interpretive COBRA (Consolidated Omnibus Budget Reconciliation Act) guideline A 405."

A review of Facility A's P&P titled "Medical Screening Examination, transfer and/or Referral to outside facility" dated January 2000, indicated "It is the policy of this hospital to provide a medical screening examination by a qualified person to any individual who comes to the Emergency Department (ED) seeking an examination or medical treatment (whether or not eligible for insurance benefits and regardless of ability to pay) and determine if the individual has an emergency medical condition; and, if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the medical condition, within the capabilities of the hospital or to arrange for transfer of the individual to another medical facility."

The policy further specified "The triage nurse will assess and process maternity patients who come to the hospital requesting examination and treatment as follows: all women who are pregnant with a gestational age of twenty (20) weeks and beyond, who present to the ED (emergency department) with signs or symptoms which appear to be related to the pregnancy, will be transported to the labor and delivery (L&D) department and will receive a medical screening examination by an LDRN."

The policy further specified, "The medical screening examination performed in the L&D department will be documented on the Observation Record and include at a minimum: date, time, chief complaint, age, sex, duration of onset of chief complaint, vital signs, level of distress, allergies, current medications, tetanus status, localized examination, onset of contractions, blood type, RH status, Last Menstrual Period, estimated date of confinement, gravida/para (pregnancies/births), conditions of membrane and a minimum of 20 minute External Fetal Monitoring strip."

A review of Facility A's, "Emergency Services Rules and Regulations (Approved 12/18/14)" specified, "Transfer of a patient to another facility, because this facility is not able to manage the patient's specific medical problem or does not have the capacity to accept the patient, will be arranged only after adequate appraisal and initial emergency treatment has been rendered. No patients will be arbitrarily transferred to another facility, if the means of providing adequate care are available."

A review of Facility A's policy titled, "Maternal Transfer," dated June 2012, indicated: For pregnant patients transferred because of medical problems beyond the capability of the OB unit the following must occur: the patient must be examined by the physician, the benefits and risks must be explained to patient and family, the transfer form must be signed by patient or family, patient evaluation including vital signs, fetal heart rhythm, frequency of uterine contractions must be recorded, obtain written order for transfer from physician, complete COBRA forms and QA (quality) tool, make transfer arrangements with receiving hospital and notify house supervisor. Put the patient on continuous fetal monitoring until the time of leaving, give emotional support, call the ambulance service, send copies of x-ray or ultrasound reports and a copy of patient's records.

A review of Facility A's policy titled, "Medical screening examination, transfer and/or referral to outside facility (review date 1/2000)," was conducted on August 18, 2015, at 12:45 p.m. The policy indicated, "The Emergency Department (ED) physician/labor and delivery RN shall ensure that a completed transfer summary form signed by the patient or legally responsible person and the physician accompanies the individual."

An interview with the Physician (MD) 1 was conducted on August 18, 2015, at 9:30 a.m. MD 1 stated he was the OB physician on call July 14, 2015, and was called on July 14, 2015, at about 9:30 p.m., by LDRN 1 to inform him Patient 1 presented to the facility with a history of greater than 20 weeks gestation with a twin pregnancy.

MD 1 further stated LDRN 1 told him the patient was going to be transferred to a higher level of care via 911. He stated he thought it was strange that LDRN 1 was calling him since he assumed the patient had already been assessed and examined by the ED physician and that the proper transfer paperwork had been completed by the ED physician. He acknowledged that he did not clarify with LDRN 1 whether Patient 1 was examined prior to transfer. He said he told LDRN 1 he agreed Patient 1 should be transferred to a higher level of care and ended the phone call.

An interview with MD 2 was conducted on August 18, 2015, at 10:20 a.m. MD 2 stated he was the ED physician at the facility the night Patient 1 presented to the facility. He stated he was the only physician on site during the evening hours and he was treating a patient on the medical surgical unit when he was paged and informed by the RN Supervisor that Patient 1 had presented to the hospital with a history of twin pregnancy and vaginal bleeding and was being transferred to another hospital.

MD 2 stated by the time he arrived to the ED area the patient had already had been taken to Facility B via 911 ambulance. MD 2 stated he believed all patients should be seen in the ED department first and then referred as appropriate.

An interview was conducted with LDRN 2 on August 17, 2015, at 10 a.m. LDRN 2 stated when a pregnant patient greater than 20 weeks gestation comes to the facility the labor and delivery nurses are trained to triage the patient and do a medical screening exam.

There was no documented evidence that the hospital staff registered Patient 1 in the ED or OB logs, or provided a medical screening exam to determine if an emergency medical condition existed or that the patient was stabilized. If that information was obtained and not documented, there was no indication that the information was used in decisions concerning the care and treatment of the patient, particularly as it pertained to providing stabilizing treatment and her transfer to a higher level of care.
A review of LDRN 1's personnel file in addition to eight of eight of the facility's labor and delivery RN's personnel files were reviewed with the Human Resources Director on August 18, 2015, at 1 p.m. The Human Resources Director stated all nine of the labor and delivery RNs did not have EMTALA training documented in their personnel files and the training should have been implemented as it had been for the ED nurses.

On August 17, 2015, the facility's policy entitled, "EMTALA and Transfer of patients to another facility (dated August 2012)," was reviewed. Per the policy, "A medical screening examination must be offered to any individual presenting for examination or treatment of a medical condition...A medical screening examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist."

Based on interview and record review, the facility failed to ensure one of 28 sampled patients, (Patient 1) who presented to Facility A on July 14, 2015, at approximately 9 p.m., with a history of twin pregnancy (30 week gestation), pain, and a history of vaginal bleeding was registered on the facility's Emergency Department's (ED) or Obstetric Department's (OB) logs as required by Facility A's policy. This failure could potentially lead to confusion regarding whether Patient 1 was refused treatment, was stabilized, and was discharged or transferred.

Findings:

An investigation, including interviews and record reviews, was conducted on August 17, 2015, at 8:45 a.m., as a result of a complaint which alleged, on July 14, 2015, at approximately 9 p.m., Patient 1 presented to Facility A with a history of twin pregnancy, pain, and a history of vaginal bleeding.

There was no documented evidence that Patient 1 was registered on Facility A's ED or OB logs, nor was there documentation that Patient 1 received a medical screening examination to determine if an emergency medical condition existed or if the patient was medically stabilized prior to her transfer on a 911 emergency status.

There was no relevant patient information, pertaining to Patient 1's medical history and associated diagnoses, or assessments documented by Labor and Delivery Registered Nurse (LDRN) 1, who met with Patient 1.

An interview with the Patient Access Representative (PAR) was conducted on August 17, 2015, at 9:20 a.m. She stated Patient 1 presented to the facility's ED lobby on July 14, 2015, with a history of twin pregnancy, pain, and a history of vaginal bleeding. The PAR stated she asked Patient 1 if she was over 20 weeks gestation and she was told yes. The PAR stated she called LDRN 1, who was responsible for triaging pregnant emergency room patients that were over 20 weeks of gestation.

The PAR stated she went to the OB department and told LDRN 1 she had a patient in the facility's ED lobby because LDRN 1 did not answer the phone. She stated LDRN 1 came to the hospital lobby and spoke to Patient 1 and "eyeballed" the patient. The PAR further stated LDRN 1 told her to call 911 and then LDRN 1 asked Patient 1's companion if he could take her to another facility as "They were unable to care for her here." The PAR stated this seemed "odd" to her and she subsequently called the facility's RN Supervisor to inform her of the situation.

A review of the patient census for July 14, 2015, indicated there were no patients in the labor and delivery area at the time Patient 1 arrived at Facility A. LDRN 1 was not available for interview.

The PAR further stated Facility A's Administrator was notified that Patient 1 was going to be sent via to another facility via 911 and that the Administrator stated "I am aware." The PAR acknowledged she should have registered the patient on Facility A's ER log as per hospital's policy, but she did not register Patient 1 on the log.

Per a Fire Department Emergency Medical Services Report dated July 14, 2015, at 9:30 p.m., Patient 1 was described as "pregnant" with a history of pain and bleeding was transported via 911 ambulance from Facility A's lobby to Facility B's emergency department. There was no evidence that transfer documentation for Patient 1 was initiated or sent from Facility A with the 911 staff to give to the receiving facility (Facility B).

A review of Facility A's policy and procedure (P&P) titled, "Emergency Department Patient Log," dated January, 2000, indicated, "A central log shall be maintained in the emergency department to track the care provided to each individual who comes to the hospital seeking care for and emergency medical condition, in compliance with federal regulation 489.24, Title 22, 704 B and interpretive COBRA (Consolidated Omnibus Budget Reconciliation Act) guideline A 405."

During an interview was conducted with LDRN 2 on August 17, 2015, at 10 a.m., she stated all women who come to the ED for treatment and are over 20 weeks pregnant should be documented in the obstetric log, be triaged, and receive a medical screening exam.

There was no documented evidence that the hospital staff registered Patient 1 on the emergency room or the OB logs, or provided a medical screening exam to determine if an emergency medical condition existed. If that information was obtained and not documented, there was no indication that the information was used in decisions concerning the care and treatment of the patient, particularly as it pertained to providing stabilizing treatment and her transfer to a higher level of care.

Based on interview and record review, Facility A failed to implement it's Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedure (P&P), by not ensuring an appropriate medical screening examination and necessary stabilizing treatment was performed on one of 28 sampled patients, (Patient 1). Patient 1 presented to the facility with an emergency medical condition, twin pregnancy, pain, and a history of vaginal bleeding. This failure had the potential to severely impact the health and welfare of Patient 1 and her twin fetuses.

Findings:

An investigation, interviews, and record reviews were conducted on August 17, 2015, at 8:45 a.m., as a result of a complaint which alleged that, on July 14, 2015, at approximately 9 p.m., Patient 1 presented to Facility A (which had a labor and delivery department), with diagnoses of twin pregnancy (30 week gestation), pain, and a history of vaginal bleeding.

There was no patient information pertaining to Patient 1's medical history and associated diagnoses, or assessments documented by Labor and Delivery Registered Nurse (LDRN) 1 who met with Patient 1.

There was no documented evidence to indicate Patient 1 was registered on Facility A's Emergency Department (ED) or obstetric (OB) logs, nor was there documentation indicating Patient 1 received a medical screening examination to rule out if an emergency medical condition existed or that the patient was medically stabilized.

An interview with the Patient Access Representative (PAR) was conducted on August 17, 2015, at 9:20 a.m. She stated Patient 1 presented to the hospital lobby on July 14, 2015, with a history of twin pregnancy, pain, and a history of vaginal bleeding. The PAR stated she asked Patient 1 if she was over 20 weeks gestation and she was told yes. The PAR stated she called LDRN 1 who was responsible for triaging pregnant emergency room (ER) patients that were over 20 weeks of gestation.

The PAR stated she went to the OB department and told LDRN 1 she had a patient in the facility's ED lobby because LDRN 1 did not answer the phone. She stated LDRN 1 came to the hospital lobby and spoke to Patient 1 and "eyeballed" the patient. The PAR further stated LDRN 1 told her to call 911. LDRN 1 asked Patient 1's companion if he could take the patient to another facility as, "They were unable to care for her at the facility (which had a labor and delivery department)." The PAR stated this seemed "odd" to her and she subsequently called the Facility's RN Supervisor to inform her of the situation.

A review of the patient census for July 14, 2015, indicated there were no patients in the labor and delivery area at the time Patient 1 arrived at Facility A. LDRN 1 was not available for interview.

The PAR further stated Facility A's Administrator was notified that Patient 1 was going to be sent via to Hospital B via 911 and that the Administrator stated, "I am aware." The PAR acknowledged she should have registered the patient on Facility A's ED log as per the facility's policy, but she did not register Patient 1 on the log.

On a Fire Department Emergency Medical Services Report, dated July 14, 2015, Patient 1 was described as "pregnant" with a history of pain and bleeding who was transported via 911 ambulance from Facility A's lobby to Facility B's ED. There was no evidence that transfer documentation for Patient 1 was sent with the emergency personal when the patient was transferred from Hospital A to the receiving facility (Facility B).

A review of Facility A's P&P titled, "Medical Screening Examination, transfer and/or Referral to outside facility," dated January 2000, indicated, "It is the policy of this hospital to provide a medical screening examination by a qualified person to any individual who comes to the Emergency Department (ED) seeking an examination or medical treatment (whether or not eligible for insurance benefits and regardless of ability to pay) and determine if the individual has an emergency medical condition; and, if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the medical condition, within the capabilities of the hospital or to arrange for transfer of the individual to another medical facility."

The policy further specified, "The triage (obstetric/labor and delivery) nurse will assess and process maternity patients who come to the hospital requesting examination and treatment as follows: all women who are pregnant with a gestational age of twenty (20) weeks and beyond, who present to the ED (emergency department) with signs or symptoms which appear to be related to the pregnancy, will be transported to the labor and delivery (L&D) department and will receive a medical screening examination by and LDRN."

The policy further specified, "The medical screening examination performed in the L&D department will be documented on the Observation Record and include at a minimum: date, time, chief complaint, age, sex, duration of onset of chief complaint, vital signs, level of distress, allergies, current medications, tetanus status, localized examination, onset of contractions, blood type, RH status, Last Menstrual Period, estimated date of confinement, gravida/para (pregnancy/births), conditions of membrane and a minimum of 20 minute External Fetal Monitoring strip."

A review of Facility A's, "Emergency Services Rules and Regulations (Approved 12/18/14)" specified, "Transfer of a patient to another facility, because this facility is not able to manage the patient's specific medical problem or does not have the capacity to accept the patient, will be arranged only after adequate appraisal and initial emergency treatment has been rendered. No patients will be arbitrarily transferred to another facility, if the means of providing adequate care are available."

An interview with the Physician (MD) 1 was conducted on August 18, at 9:30 a.m. MD 1 stated he was the OB physician on call July 14, 2015, and was called on July 14, 2015, at about 9:30 p.m., by LDRN 1 to inform him Patient 1 presented to the facility with a history of greater than 20 weeks gestation with a twin pregnancy.

MD 1 further stated LDRN 1 told him the patient was going to be transferred to a higher level of care via 911. He stated he thought it was strange that LDRN 1 was calling him since he assumed the patient had already been assessed and examined by the ED physician and that the proper transfer paperwork had been completed by the ED physician. MD 1 acknowledged he did not clarify with LDRN 1 whether Patient 1 was examined prior to transfer. He said he told LDRN 1 he agreed Patient 1 should be transferred to a higher level of care and ended the phone call.

An interview with MD 2 was conducted on August 18, 2015, at 10:20 a.m. MD 2 stated he was the ED physician at the facility the night Patient 1 presented to the facility. He stated he is the only physician on site during the evening hours and he was seeing a patient on the medical surgical unit when he was paged and informed by the RN Supervisor that Patient 1 had presented to the hospital with a history of twin pregnancy and bleeding and was being transferred to another facility.

MD 2 stated by the time he arrived to the ED area the patient had already had been taken to another facility via 911 ambulance. MD 2 stated he believed all patients should been seen in the ED department first and then referred as appropriate.

There was no documented evidence that the hospital staff provided a medical screening exam for Patient 1 to determine if an emergency medical condition existed. If that information was obtained and not documented, there was no indication that the information was used in decisions concerning the care and treatment of the patient, particularly as it pertained to providing stabilizing treatment and her transfer to a higher level of care.

The facility failed to implement its EMTALA (Emergency Medical Treatment and Active Labor Act) policy and procedure by not ensuring a complete medical screening examination was performed. On August 17, 2015, the facility's policy entitled, "EMTALA and Transfer of patients to another facility," dated August 2012, was reviewed. Per the policy, "A medical screening examination must be offered to any individual presenting for examination or treatment of a medical condition...A medical screening examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist."

Based on interview and record review, Facility A failed to ensure Patient 1 was medically stabilized when the patient presented to the facility's Emergency Department (ED) with diagnoses of twin pregnancy, pain, and a history of vaginal bleeding. Patient 1 was subsequently transferred via a 911 emergency call to Facility B. This failure could potentially result in harm to the patient and her twin fetuses en route to the receiving facility (Facility B).

Findings:

An investigation, interviews and record reviews were conducted on August 17, 2015, at 8:45 a.m., as a result of a complaint which alleged, on July 14, 2015, at approximately 9 p.m., Patient 1 presented to Facility A (which had a labor and delivery department) with a history of twin pregnancy, pain and history of vaginal bleeding.

There was no relevant patient information, pertaining to Patient 1's medical history, associated diagnoses, and assessments documented by Labor and Delivery Registered Nurse (LDRN) 1, who triaged Patient 1.

An interview with the Patient Access Representative (PAR) was conducted on August 17, 2015, at 9:20 a.m. She stated she was working when Patient 1 presented to the hospital lobby on July 14, 2015, at approximately 9 p.m., with a history of twin pregnancy, pain and a history of bleeding. The PAR stated she asked Patient 1 if she was over 20 weeks gestation and she was told yes. The PAR stated she called LDRN 1 who was responsible for triaging pregnant ED patients that were over 20 weeks of gestation.

The PAR stated she went to the OB department and told LDRN 1 she had a patient in the hospital lobby because LDRN 1 did not answer the phone. She stated LDRN 1 came to the hospital lobby and spoke to Patient 1 and "eyeballed" her. The PAR further stated LDRN 1 told her to call 911. The PAR stated LDRN 1 asked Patient 1's companion if he could take the patient to another facility as, "They were unable to care for her here." The PAR stated this seemed "odd" to her and she subsequently called the Facility's RN Supervisor to inform her.

The PAR further stated Facility A's Administrator was notified that Patient 1 was going to be sent via to Facility B via 911 and the Administrator stated, "I am aware."

Per a Fire Department Emergency Medical Services Report (911) dated July 14, 2015, at 9:30 p.m., Patient 1 was described as "pregnant" with a history of pain and bleeding was transported via 911 ambulance from Facility A's lobby to Facility B's ED. There was no evidence transfer documentation was initiated for Patient 1 in order to give the documentation to Facility B when Patient 1 arrived at that facility.

A review of Facility A's P&P titled "Medical Screening Examination, transfer and/or Referral to outside facility (dated January 2000)" indicated, "It is the policy of this hospital to provide a medical screening examination by a qualified person to any individual who comes to the Emergency Department (ED) seeking an examination or medical treatment (whether or not eligible for insurance benefits and regardless of ability to pay) and determine if the individual has an emergency medical condition; and, if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the medical condition, within the capabilities of the hospital or to arrange for transfer of the individual to another medical facility."

A review of the facility policy, "Emergency Medical Treatment and Active Labor Act (EMTALA) and Transfer of patients To Another Facility (Effective Date 8/2012)," was conducted on August 18, 2015. The policy indicated, "Stabilization is defined as, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer. A patient is deemed stabilized if the treating physician has determined, within reasonable clinical confidence, that the emergency medical condition has been resolved."

An interview with the Physician (MD) 1 was conducted on August 18, at 9:30 a.m. MD 1 stated he was the OB physician on call July 14, 2015, and was called on July 14, 2015, at about 9:30 p.m. by LDRN 1 to inform him Patient 1 presented to the facility with a history of greater than 20 weeks gestation with a twin pregnancy.

MD 1 further stated LDRN 1 told him the patient was going to be transferred to a higher level of care via 911. He stated he thought it was strange that LDRN 1 was calling him since he assumed the patient had already been assessed and examined by the ED physician and that the proper transfer paperwork had been completed by the ED physician. He acknowledged that he did not clarify with LDRN 1 whether Patient 1 was examined prior to transfer. He said he told LDRN 1 he agreed Patient 1 should be transferred to a higher level of care and ended the phone call.

An interview with MD 2 was conducted on August 18, 2015, at 10:20 a.m. MD 2 stated he was the ED physician at the facility on the night Patient 1 presented to the facility. He stated he was the only physician on site during the evening hours and was treating a patient on the medical surgical unit when he was paged and informed by the RN Supervisor that Patient 1 had presented to the hospital with a history of twin pregnancy and vaginal bleeding and was being transferred to another hospital.

MD 2 stated by the time he arrived to the ED area Patient 1 had already been taken to the other facility via 911 ambulance and he did not treat Patient 1.

There was no documented evidence that the hospital staff provided Patient 1 with a medical screening exam to determine if an emergency medical condition existed or if the patient was stabilized.

On August 17, 2015, the facility's policy entitled, "...EMTALA and Transfer of patients to another facility (dated August 2012)," was reviewed. The facility failed to implement it's EMTALA (Emergency Medical Treatment and Active Labor Act) policy and procedure by not ensuring Patient 1 received a medical screening examination and was stabilized prior to being transferred, when a labor and delivery nurse and a ER physician were on duty when Patient 1 presented to Facility A on July 14, 2015.

Based on interview and record review, Facility A failed:

1. To ensure an appropriate transfer was implemented for Patient 1, with diagnoses of twin pregnancy and a history of vaginal bleeding, and;

2. To ensure transfer documents were completed for three of three transferred patients (Patients 12, 14, and 15).

Together, these failures had the potential to impact the ongoing provision of care for these patients who presented to Facility A's Emergency Department (ED).

Findings:

1. An investigation and document review was initiated on August 17, 2015, at 8:45 a.m., as a result of a complaint which alleged, on July 14, 2015, at approximately 9 p.m., Patient 1 presented to Facility A with a history of twin pregnancy, pain, and vaginal bleeding.

There was no relevant patient information, pertaining to Patient 1's medical history, associated diagnoses, or assessments documented by Labor and Delivery Registered Nurse (LDRN) 1, who met with Patient 1.

An interview with the Patient Access Representative (PAR) was conducted on August 17, 2015, at 9:20 a.m. She stated Patient 1 presented to the facility's ED lobby on July 14, 2015, with a history of twin pregnancy, pain and a history of vaginal bleeding. The PAR stated she asked Patient 1 if she was over 20 weeks gestation and she was told yes. The PAR stated she called LDRN 1 who was responsible for triaging pregnant ED patients that were over 20 weeks of gestation.

The PAR stated she went to the obstetric (OB) department and told LDRN 1 she had a patient in the hospital lobby because LDRN 1 did not answer the phone. She stated LDRN 1 came to the hospital lobby and spoke to Patient 1 and "eyeballed" her. The PAR further stated LDRN 1 told her to call 911. The PAR stated LDRN 1 asked Patient 1's companion if he could take her to another facility as "They were unable to care for the patient here." The PAR stated this seemed "odd" to her and she subsequently called the Facility's RN Supervisor to inform her.

The PAR further stated Facility A's Administrator was notified that Patient 1 was going to be sent via to Hospital B via 911 and that the Administrator stated "I am aware." The PAR acknowledged she should have registered the patient on Facility A's ER log as per hospital's policy, but she did not register Patient 1 on the log.

Per a Fire Department Emergency Medical Services Report dated July 14, 2015, at 9:34 p.m., Patient 1 was described as "pregnant" with a history of pain and vaginal bleeding was transported via 911 ambulance from Facility A's lobby to Facility B's emergency department. There was no evidence that transfer documentation was initiated for Patient 1 at Facility A so the emergency personal could present the information to the receiving facility.

LDRN 1 was not available for interview.

A review of Facility A's P&P titled "Medical Screening Examination, transfer and/or Referral to outside facility (dated January 2000)" indicated, "It is the policy of this hospital to provide a medical screening examination by a qualified person to any individual who comes to the Emergency Department (ED) seeking an examination or medical treatment (whether or not eligible for insurance benefits and regardless of ability to pay) and determine if the individual has an emergency medical condition; and, if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the medical condition, within the capabilities of the hospital or to arrange for transfer of the individual to another medical facility."

A review of Facility A's "Emergency Services Rules and Regulations (Dated 12/18/14)" specified, "Transfer of a patient to another facility, because this facility is not able to manage the patient's specific medical problem or does not have the capacity to accept the patient, will be arranged only after adequate appraisal and initial emergency treatment has been rendered. No patients will be arbitrarily transferred to another facility, if the means of providing adequate care are available."

A review of Facility A's policy titled "Medical screening examination, transfer and/or referral to outside facility (Effective Date 1/2000)" was conducted on August 18, 2015, at 12:45 p.m. The policy indicated, "The Emergency Department (ED) physician/labor and delivery RN shall ensure that a completed transfer summary form signed by the patient or legally responsible person and the physician accompanies the individual."

An interview with the Physician (MD) 1 was conducted on August 18, at 9:30 a.m. MD 1 stated he was the OB physician on call July 14, 2015, and was called on July 14, 2015, at about 9:30 p.m. by LDRN 1 to inform him Patient 1 presented to the facility with a history of greater than 20 weeks gestation with a twin pregnancy.

MD 1 further stated LDRN 1 told him the patient was going to be transferred to a higher level of care via 911. He stated he thought it was strange that LDRN 1 was calling him since he assumed the patient had already been assessed and examined by the ED physician and that the proper transfer paperwork had been completed by the ED physician. He acknowledged that he did not clarify with LDRN 1 whether Patient 1 had been examined prior to transfer. He said he told LDRN 1 that he agreed Patient 1 should be transferred to a higher level of care and ended the phone call. MD 1 stated he did not come in to the facility.

An interview with MD 2 was conducted on August 18, 2015, at 10:20 a.m. MD 2 stated he was the ED physician at the facility the night Patient 1 presented to the facility. He stated he is the only physician on site during the evening hours and he was seeing a patient on the medical surgical unit when he was paged and informed by the RN Supervisor Patient 1 had presented to the hospital with a history of twin pregnancy and bleeding and was being transferred to another hospital.

MD 2 stated by the time he arrived to the ED area the patient had already had been taken to Facility B via 911 ambulance. MD 2 stated he believed all patients should been seen in the ED department first and then referred as appropriate.

A review of Facility A's policy titled "Maternal Transfer (dated June, 2012)" indicated, "For pregnant patients transferred because of medical problems beyond the capability of the OB unit the following must occur: the patient must be examined by the physician, the benefits and risks must be explained to patient and family, the transfer form must be signed by patient or family, patient evaluation including vital signs, fetal heart rhythm, frequency of uterine contractions must be recorded, obtain written order for transfer from physician, complete COBRA (Consolidated Omnibus Budget Reconciliation Act) forms and QA (quality) tool, make transfer arrangements with receiving hospital and notify house supervisor. Put the patient on continuous fetal monitoring until the time of leaving, give emotional support, call the ambulance service, send copies of x-ray or ultrasound reports and a copy of patient's records."

2 a. The record for Patient 12 was reviewed on August 18, 2015. The record indicated Patient 12's mother brought Patient 12 to the Emergency Department (ED), on May 26, 2015, at 10:43 p.m., with the chief complaint of vomiting.

The nursing document titled "ED Triage entry for 10:52 p.m., indicated "...Suicide attempt, intentional overdose... with 18 tablets of Tylenol 500 mg. (milligrams)..."

The physician document titled "Emergency Provider Record" entry for midnight, indicated Patient 12's diagnosis was suicidal, Tylenol overdose, and the patient would be transferred to another facility.

There was no documentation to indicate Patient 12's mother was informed of the risks and benefits of the transfer. There was no documentation to indicate Patient 12's mother consented to the transfer. There was no documentation to indicate the physician and/or qualified medical professional had discussed the transfer with the receiving facility.

b. The record for Patient 14 was reviewed on August 17, 2015. Patient 14 presented to the ED on July 19, 2015, at 6 p.m., with the chief complaint of foot pain.

The record indicated the Patient 14 completed multiple diagnostic tests to include laboratory and X-rays.

The physician order entry date for July 20, 2015, at 1 a.m., indicated "Transfer to ...(name of facility followed by a physician's name)."

There was no documentation to indicate Patient 14 was informed of the risks and benefits of the transfer. There was no documentation to indicate Patient 14 consented to the transfer. There was no documentation to indicate the physician and/or qualified medical professional discussed the transfer with the receiving facility. There was no documentation that indicated the time the patient was transferred, vital signs upon transfer, or if the facility requirements for transfer were met.

c. The record for Patient 15 was reviewed on August 17, 2015. Patient 15 was brought to the ED on July 30, 2015, at 11:34 a.m., by ambulance with the chief complaint of nausea, vomiting, and diarrhea for two days.

The physician document titled "Emergency Provider Record" entry for July 30, 2015, at 3:30 p.m., indicated the plan was for Patient 15 to be admitted with the diagnosis of gastroenteritis (stomach flu).

The nursing document titled "Flowsheets" entry for July 30, 2015, at 9:59 p.m., indicated "...Pt (patient) will be going to ...(name of facility) under the services of...(physician name)...Ambulance will be picking up pt..."

There was no documentation to indicate Patient 15 was informed of the risks and benefits of the transfer. There was no documentation to indicate Patient 15 consented to the transfer. There was no physician documentation to indicate the physician and/or qualified medical professional discussed the transfer with the receiving facility. There was no documentation that indicated the time the patient was transferred, vital signs upon transfer, or if the facility requirements for transfer were met.

An interview was conducted with the Chief Clinical Officer (CCO), on August 18, 2015, at 2:15 p.m. The CCO stated the transfer document was required to be completed for all transferred patients. The CCO stated the documentation contained vital information that must be shared with the receiving facility and was an important part of the patients record. The CCO stated she had reviewed the records and was unable to find the completed transfer form for Patients 12, 14, and 15.

The facility form titled "Emergency Department Request For Transfer/Consent To Transfer Certification For Transfer" was reviewed. The document contained areas to include risks and benefits of transfer, patient consent for transfer, physician or qualified medical person's certification for transfer, and requirements that must be met prior to transfer.

The facility policy and procedure titled "Medical Screening Examination, Transfer and/or Referral to outside Facility" effective date January 2000, indicated, "Transfer For Care Outside the Hospital:...Informed request: The individual or legal responsible party acting on the individuals behalf is first fully informed of the risks of the transfer and the benefits...acknowledges the request and his/hers awareness of the risks and benefits of the transfer in writing on the "Transfer Summary Form"..."

The policy further indicated "...The ED Physician...shall ensure that a completed, "Transfer Summary Form," signed by the patient, the physician, and accompanies the patient..."