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Based on interview and record review, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) as evidenced by:

1. The facility failed to provide an adequate medical screening exam (MSE) for Patient 1. (Refer to C 2406)

2. The facility failed to provide stabilizing treatment for Patient 1. (Refer to C 2407)

3. The facility failed to ensure that the patient acknowledgement form was signed by Patient 6, prior to transfer to another facility. (Refer to C 2409)

Based on interview and record review, the facility failed to ensure that Patient 1, a pregnant female and her unborn child, received an appropriate Medical Screening Examination (MSE) to determine if an emergency condition existed, upon presentation to the Emergency Department (ED). The hospital failed to ensure that the ED staff provided an uniform standard quality of patient care, treatment and efficiency consistent with generally accepted standards as evidenced by:

1. The facility failed to recognize and identify the signs and symptoms of Preeclampsia (high blood pressure greater than 140/90 for pregnant patients 20 weeks gestation or greater and proteinuria (protein in the urine);

2. The facility failed to obtain an Obstetrical (OB, physician specializing in the treatment of pregnant patients) consult;

3. The facility failed to closely monitor Patient 1;

4. The facility failed to obtain a necessary but routine urine test to check for protein in the urine (proteinuria); and

5. The facility failed to have emergency room policies in place to address the care and transfer of high risk pregnant patients.

These failures resulted in the delayed diagnosis and treatment of Preeclampsia and caused the condition to progress to Eclampsia (seizures or convulsions in a pregnant patient) which led to the death of both Patient 1 and her unborn child.

Due to the identification of the deficient practices related to the MSE and lack of stabilizing treatment for Patient 1, the lack of written policies and procedures to provide guidance to staff regarding the care of obstetrical (pregnant) patients who present to the ED, as well as the lack of a plan of action to prevent similar incidents from happening again, an Immediate Jeopardy was declared on 10/10/13 at 12:30 pm with the Chief Executive Officer and the Chief Nursing Officer (CNO).

The Hospital implemented a plan of action that included the following: all pregnant patients 20 weeks gestation or greater would be screened for symptoms of headache, visual disturbances, decreased fetal movement, elevated blood pressure (BP) equal to or greater than 140/90, right upper quadrant/epigastric pain, and edema (swelling). The following would be performed: urine dip test (a test strip that is dipped into a cup of the patient's urine to check for protein), deep tendon reflexes documented, BP every 15 minutes and if BP consistently elevated - equal or greater than 140/90 - an OB (Obstetrician, physician specializing in the treatment of pregnant patients) consult would be obtained, fetal heart tones, assessment for edema, if OB consultation resulted in the recommendation to transfer or MSE indicated the need to transfer, transfer arrangements would be made immediately.

The Immediate Jeopardy was abated on 10/10/13 at 5:30 pm after the hospital implemented a corrective plan of action to ensure patients' safety. The survey team evaluated the plan of action as well as the methods to disseminate the information to nursing and medical staff, prior to starting their next shifts in the ED.

Findings:

A review of Patient 1's record disclosed that she presented to the ED on 9/29/13 at 9:12 pm, with the chief complaint of upper stomach pain. Patient 1 was noted to be 38 weeks pregnant, with an estimated due date of 10/10/13. Patient 1's initial BP was 172/110 (normal for 3rd trimester pregnancy is less than 140/90-very high maternal blood pressure stops the fetus from getting enough blood and oxygen and could cause the mother to have a stroke or rupture of a blood vessel in the brain which could lead to brain damage and death). The ED physician (MD) A examined Patient 1 and noted that she had a mild headache, Fetal Heart Tones (baby's heart rate) were 132, and patient denied any complication related to her pregnancy. Maalox (over the counter medication for the treatment of heartburn) with Viscous Lidocaine (medication that provides a numbing effect), Protonix (an anti-ulcer medication also used to treat heartburn and Gastroesophageal Reflux Disease (GERD), and Tylenol were given to Patient 1 for her complaint of epigastric (upper abdominal) pain. Patient 1's repeat BP was 160/94. Patient 1 was discharged at 10:40 pm (remained in the ED for 1 1/2 hours) and told to return to the hospital in the morning for an ultrasound (machine that uses sound waves to create pictures of internal organs or a baby). Diagnoses included epigastric pain of uncertain etiology (unknown cause), probable GERD, possible biliary colic (pain related to the gallbladder), and term pregnancy (late 3rd trimester). No urine test or labs (blood tests) were done and Patient 1's elevated BP was not treated, and it as well as the headache, were not included in the physician's problem list/discharge diagnoses.

After Patient 1 returned home, an ambulance was called at 11:11 pm and arrived at her home at 11:20 pm. Patient 1 was taken to another facility (Hospital E). Upon arrival, Patient 1 began having seizures and her baby was found to be without a heartbeat and was delivered stillborn. Patient 1 expired the following day, on 10/1/13.

The following was noted in an article published in 3/2009 by the American College of Emergency Physicians (ACEP), titled, "Focus On: Preeclampsia." "Preeclampsia is defined as hypertension and proteinuria (protein in the urine) that occur after 20 weeks gestation. Management should focus on blood pressure control, seizure prophylaxis (prevention) and treatment, and delivery when necessary. Although obstetric consultation is warranted in every case of Preeclampsia, emergency physicians should be comfortable with the initial management."

"Diagnostic criteria for Preeclampsia include a systolic BP (the first or top number in a BP reading) greater than 140 or a diastolic BP (the last or bottom number in a BP reading) greater than 90 in a woman who was normotensive (normal BP) prior to 20 weeks gestation. Severe Preeclampsia is diagnosed by a systolic BP greater than 160 or diastolic BP greater than 110, excess proteinuria, severe oliguria (lack of urine), cerebral or visual disturbances, pulmonary edema (excess fluid in the lungs), impaired liver function, epigastric or right upper quadrant pain, thrombocytopenia (abnormally low amount of platelets (part of the blood that help it to clot), or fetal growth retardation."

"Delivery is the definitive treatment for Preeclampsia and should be considered after 34 weeks gestation in the case of severe Preeclampsia and 37 weeks gestation in mild Preeclampsia...Any patient with severe Preeclampsia should be started on magnesium, because it has been proven to prevent progression to Eclampsia (new onset grand-mal seizures in a woman with Preeclampsia)."

The American College of Obstetricians and Gynecologists (ACOG) published an article in 12/2011, titled, "Emergent Therapy for Acute-Onset, Severe Hypertension with Preeclampsia or Eclampsia" that read, "Acute-onset persistent (lasting 15 minutes or more), severe systolic (greater than or equal to 160) or severe diastolic hypertension (greater than or equal to 110) or both in pregnant or postpartum (immediately after giving birth and extending for six weeks) women with Preeclampsia or Eclampsia constitutes a hypertensive emergency. Severe systolic hypertension may be the most important predictor of cerebral hemorrhage (bleeding in the brain) and infarction (tissue death caused by lack of oxygen) in these patients and if not treated expeditiously (quickly)can result in maternal death...Close maternal and fetal monitoring by the physician and nursing staff are advised."

During a record review and interview on 10/9/13 at 2:25 pm, ED Physician (MD) A confirmed she was the physician who cared for Patient 1 when she came to the ED, on 9/29/13. MD A stated she examined Patient 1 who complained of burning in the epigastric area. Patient 1 told her that she had eaten hot peppers with a meat sandwich then started having epigastric pain a couple of hours later. Patient 1 denied being in labor and reported no problems with this pregnancy. Patient 1 was non-English speaking and a family member interpreted.

The problem list/discharge diagnoses were reviewed and included epigastric pain of uncertain etiology probably GERD, possible biliary colic, and term pregnancy. MD A said she would not add anything to that list such as high blood pressure because Patient 1's BP had decreased by the time of discharge. MD A confirmed Patient 1's initial BP was 172/110 and last BP, prior to discharge, was 160/94. MD A stated that she would not add headache to the problem list because it was her sense that Patient 1's headache was mild and not unusual.

MD A stated she had been concerned with Patient 1's initial BP of 172/110, but explained that pain could cause an elevated BP. MD A stated that Patient 1's BP, prior to discharge was 160/94. She confirmed that this BP was not ok for a pregnant patient, but the patient seemed to want to go home and take the same medications she had been given while in the ED, so Patient 1 was discharged. MD A confirmed if she had a problem with a patient, she could call Hospital E (a trauma center with high risk OB services) but did not do so in this case. MD A said, in retrospect, she should have made Patient 1 stay in the ED until her BP became normal or transfer Patient 1 to Hospital E.

MD A was asked about the symptoms of Preeclampsia and Eclampsia. She stated elevated BP and edema were symptoms of Preeclampsia and seizures for Eclampsia. MD A was unable to quote any specific BP numbers that would signify severe or moderate Preeclampsia.

During an interview on 10/10/13 at 11:35 am, ED MD B confirmed he was the Medical Director of the ED and Chief of Staff. MD B stated they see about 450-550 patients per month in the ED and about 5% of those patients were pregnant, including all stages of pregnancy. MD B was asked what the hallmark signs and symptoms of Preeclampsia were and replied, hypertension (HTN), proteinuria, and edema. He stated that he always looks for these three things.

MD B confirmed that he had reviewed Patient 1's record. MD B stated that the care given to Patient 1 was "inexcusable." Patient 1's BP upon discharge was 160/94. MD B stated that he would be worried with a BP that was lower than that. He stated that Patient 1 had been discharged with an unacceptably high BP. MD B stated he would have documented the absence or presence of edema, would have done a urinalysis (urine test) for proteinuria, and would have called the Obstetrician.

During a record review and interview on 10/9/13 at 1 pm, Registered Nurse (RN) C confirmed that he gave Patient 1 the following medications as ordered by MD A: Maalox with Viscous Lidocaine, Protonix, and Tylenol. RN C stated that he re-assessed Patient 1 about 10 to 15 minutes after he gave the medications and again about 25 minutes later. RN C stated that Patient 1's pain level had decreased but at the last assessment Patient 1 still rated her epigastric pain as a 4 on a scale of 1 to 10 (one was minimal and 10 very severe). RN C stated that Patient 1's BP was rechecked once during the time she remained in the ED and it was 160/94. He was unsure of the exact time, but stated that it was within one hour of discharge and this was reported to MD A. RN C stated that Patient 1 had complained of a headache. After reviewing the record RN C stated he believed Patient 1 was discharged at 10:40 pm.

RN C stated that if a patient needed treatment that could not be provided at their facility (Hospital I), they would call Hospital E and transfer the patient there. He also stated that they could call the ED at Hospital E for advice, if needed.

During a record review and interview on 10/9/13 at 2:25 pm, MD A was asked if a urine test to check for protein had been done. MD A explained that there was no lab staff present at the time Patient 1 was in the ED. She stated that there would have been a lab person on call but she would have taken 30 minutes to get to the hospital. MD A confirmed she did not order a urine test although she stated that if a urine dipstick (a test strip that is dipped into a cup of the patient's urine to check for protein) had been available in the ED, she would have used it.

During an interview on 10/10/13 at 10:10 am, the Lab Manager (LM D) confirmed she had been on call on 9/29/13. LM D stated that the required response time per their protocol was 20 minutes. She confirmed that 90% of the time she has arrived within 20 minutes of being called. LM D stated that urine dipsticks were available in their lab and confirmed that protein was one of the things that could be checked. LM D stated it would take five minutes to do the test and if positive, further testing would be done under the microscope.

During a record review and interview on 10/10/13 at 11:35 am, MD B confirmed that the MSE for Patient 1 was done at 9:42 pm on 9/29/13 and Patient 1 was discharged at 10:40 pm, so there would have been time for the lab tech to have been called in and have the urinalysis done to check for proteinuria, had it been ordered, before Patient 1 was discharged home.

A review of Hospital I's ED policy and procedure manual disclosed there were no policies that dealt with the care and treatment of Obstetrical patients who presented to the ED. During an interview on 10/9/13 at 11:30 am, the Chief Nursing Officer confirmed that they had no such policies and procedures.

During an interview on 10/10/13 at 11:35 am, MD B was asked about the lack of policies pertaining to treatment of Obstetrical patients in the ED. MD B stated that he sees the policies when they're updated, but he does not peruse all of them. He stated that a policy was not something that they would look up frequently. MD B confirmed that a plan of action to prevent similar incidents from happening again had not yet been formulated.

During an interview on 10/10/13 at 12:10 pm, the CNO confirmed that she had started on the investigation and root cause analysis into this incident, but had not completed it. She confirmed that she had no written plan of action to prevent similar incidents from happening again.

MD A failed to recognize the hallmark signs and symptoms (severe high blood pressure) of Preeclampsia and failed to complete an adequate MSE including a routine urine dipstick to test for proteinuria and did not obtain an OB consult. There was no close monitoring of Patient 1 for the 1 1/2 hours she remained in the ED despite presenting with severe high blood pressure (hypertension, HTN) that did not return to normal, and epigastric pain that was not fully relieved.

MD A failed to recognize that Patient 1 had an emergency medical condition due to failure to perform an adequate MSE, did not treat Patient 1's severe HTN, and discharged Patient 1 home without adequate treatment and stabilization.

Based on interview and record review, the facility failed to ensure that Patient 1, who presented to Hospital I's ED (Emergency Department) with a hypertensive (high blood pressure) emergency and term pregnancy, was given stabilizing treatment before discharge from the hospital. This failure resulted in the death of the pregnant mother (Patient 1) and her unborn fetus.

Findings:

On 10/9/13, a review of the ED records for Patient 1 was performed at Hospital I. A review of the ED Triage (assignment of degrees of urgency to ill patients to prioritize sickest first) and Assessment form, dated 9/29/2013 and timed 9:12 pm, indicated that the chief complaint (the concern that made her come to the emergency room) was listed as: Epigastric (upper middle abdomen) pain after eating a spicy meal. The form indicated that Patient 1's pain was self-rated as a pain level of 8 out of 10 (1-10, 1 being the least and 10 being the most pain).

Patient 1's blood pressure (BP) was documented as 172/110 (normal for 3rd trimester pregnancy is less than 140/90-very high maternal blood pressure stops the fetus from getting enough blood and oxygen and could cause the mother to have a stroke or rupture of a blood vessel in the brain which could lead to brain damage and death).

Review of the Emergency Room/Outpatient Record, dated 9/29/13 and timed 9:12 pm, indicated that Patient 1 was a "29-year-old female, Chief Complaint of Upper stomach/ back pain, 9 months pregnant." The initial vital signs included "blood pressure 172/110." Under the section, Review of Systems, (history of medical conditions and current complaints) the record indicated, GI (gastrointestinal): Abdominal pain, GYN (gynecologic): G3P2 (third pregnancy, two prior births), Neurological: Headache- bilateral (headache on both sides of the head) tonight." Under Social History, "Spanish/ English" was indicated.

The Physical Exam section indicated that Patient 1 was in "moderate distress." Abdominal physical exam findings were indicated as, "Tender, right, upper epigastric, FHT (fetal heart tones) 132." The Psych Affect (psychiatric or psychological emotional state) portion of the physical exam form indicated Patient 1 was "Very Anxious." The DDX (Differential Diagnosis- list of possible causes of symptoms or problems) area was left blank. The Xray and laboratory test sections were also left blank.

Review of the Physician ED Record indicated, HPI (history of present illness) PMD (primary MD- the Obstetrician) name: MD F. Chief Complaint: Epigastric Pain. Onset/Duration: 2.5 hours, gradual and worse. 29 year old, currently 38+ weeks pregnant had hot chilies and a meat sandwich about 5.5 hours ago. Then about 2.5 hours ago she developed epigastric pain radiating up (spreading up) and toward her back that she says is getting worse. She denies any uterine cramping and says this is definitely not labor (uterine contractions leading to birth). Previous similar episodes was marked "no."

Review of the ED Nurses Notes, dated 9/29/13, indicated the following medications were given: Maalox (medication to decrease stomach acid and soothe stomach), viscous Lidocaine (local anesthetic in a liquid form that can be swallowed for local pain relief), Tylenol and Protonix (medication to treat GERD-Gastroesophageal reflux disease, heartburn). After the Viscous Lidocaine was given, the record indicated Patient 1's pain was improved to 6 out of 10.

Review of the Emergency Room/Outpatient Record, "Procedures: GI (gastrointestinal) cocktail (mixture of medications), Patient feeling much better." Under "ED Course/ Additional Data: Improved." A second blood pressure, taken at an unknown time, was 160/94 (normal is less than 140/90) "when patient was becoming calmer." Diagnoses included: Epigastric Pain of undetermined etiology (unknown cause), Probable GERD, Possible biliary colic (gallbladder cramping), Term pregnancy (Late 3rd trimester- fully developed fetus). There was no documented evidence of the patient's hypertension (high blood pressure), hypertensive emergency (acute, life-threatening state due to high blood pressure), Preeclampsia or headache written on the problem list in the Diagnosis area of the Emergency Room/ Outpatient Record. Further review indicated "Disposition: Home. Condition: Stable, Improved." Under Plan, the record indicated, "To call her OB MD and/or go to Hospital E if worse." It was signed by MD A.

A review of the ED Discharge Instructions, dated 9/29/13, indicated, "Other Instruction: Avoid spicy or fatty foods. Call in the morning and ask for the X-ray department in order to get a sonogram (machine that uses sound waves to create pictures of internal organs or a baby). Use 1-2 tbsp (tablespoons) of the liquid every 2 hours as needed for dyspepsia (indigestion). Also call your doctor if you are not better." These were signed by MD A on 9/30/13. Patient was discharged at 10:40 pm on 9/29/13.

During a record review and interview on 10/9/13 at 1 pm, Registered Nurse (RN) C confirmed that he gave Patient 1 the following medications as ordered by MD A: Maalox with Viscous Lidocaine, Protonix, and Tylenol. RN C stated that he re-assessed Patient 1 about 10 to 15 minutes after he gave the medications and again about 25 minutes later. RN C stated that Patient 1's pain level had decreased, but at the last assessment Patient 1 still rated her epigastric pain as a 4 on a scale of 1 to 10 (one was minimal and 10 very severe). RN C stated that Patient 1's BP was rechecked once during the time she remained in the ED and it was 160/94. He was unsure of the exact time, but stated that it was within one hour of discharge and this was reported to MD A. RN C stated that Patient 1 had complained of a headache. After reviewing the record he stated he believed Patient 1 was discharged at 10:40 pm.

RN C stated that if a patient needed treatment that could not be provided at their facility, they would call Hospital E and transfer the patient there. He also stated that they could call the ED at Hospital E for advice if needed.

During a record review and interview on 10/9/13 at 2:25 pm, MD A confirmed she was board certified in Family Practice as opposed to Emergency Medicine and stated that Family Practice was good training for rural Emergency Room (ER) medicine. MD A's documentation regarding Patient 1's physical exam was reviewed. MD A attributed Patient 1's tenderness to inflammation of the stomach, from the chili peppers. MD A was asked what she thought of Patient 1's initial BP of 172/110 and stated that "pain makes your BP go up." MD A stated that she felt that Patient 1's headache was not that unusual for her. MD A was asked if Patient 1's repeat BP of 160/94, was an OK BP for a pregnant patient. MD A said, "No, but the patient was in pain."

MD A was asked what she knew about signs of Preeclampsia and stated, high BP and edema. MD A was unable to state the blood pressure range for patients with Preeclampsia. MD stated that she did not order a urine test to check Patient 1's urine for protein. She stated that there are no urine dipsticks (a test strip that is dipped into a cup of the patient's urine to check for protein) in the ED and although lab staff was on call, it would take her 30 minutes to arrive because she lived 17 miles away.

MD A was asked if there was a written ED protocol or standard practice for pregnant patients who present to the ED. MD A stated "not particularly; do a FHT and an exam." MD A was asked if she was aware of any national standards and stated, "No," if concerned, she would call Hospital E (trauma center that has high risk OB). MD A stated that she could speak to the charge nurse at Hospital E and they would usually recommend transfer.

During an interview on 10/10/13 at 11:35 am, the Chief of Staff/ED Medical Director (MD B) stated that an average of 450-550 patients come to the ED each year and 5% are pregnant. MD B was asked about the lack of policies for care of the pregnant patient while in the ED. MD B stated, the policies were well intended, but not something we use.

MD B was asked about the hallmark signs of Preeclampsia and stated, Hypertension (HTN, high blood pressure), proteinuria (protein in the urine), and edema. MD B confirmed he had reviewed the case and stated that he would have checked Patient 1's urine (for protein), documented the absence or presence of edema, and called the OB (obstetrician, physician in care of pregnant patient). MD B confirmed that there would have been time, according to the record, to do a urine test for protein while Patient 1 was in the ED.

Review of the Patient Care Record/Pre-hospital Care Report- Ambulance Report for Patient 1, dated 9/29/13, indicated that an ambulance was sent to the patient's home due to a report of a female experiencing breathing problems. The report read: "Patient was reportedly sent home agitated and arduous (requiring strenuous effort, difficulty and tiring). Shortly after arriving home, patient experienced what appeared to be a possible seizure (a symptom of a brain problem because of abnormal electrical brain activity which causes unconsciousness and muscle contractions) which prompted the patient's family to summon Emergency Medical Service (the ambulance) for assistance...Interpreter (family member) shared that patient was currently complaining of generalized abdominal discomfort and requested transport to the hospital...Enroute (on the way to Hospital E) the patient remained hysterical and agitated ....Upon arrival at (Hospital E) patient experienced seizure activity while waiting for the elevator to the OB department." The report showed Patient 1 was transported on 9/29/13 at 11:30 pm and the notation "worse" was entered next to the time of 1:08 am.

Review of the History of Present Illness, dated 9/30/13, from Hospital E indicated "The patient is a 29-year-old gravida 3 (third pregnancy), para 2 (two prior births) female with an EDC (estimated date she will deliver the baby) of 10/10/13, which puts her at 38 weeks and 1 day gestation who was brought in by ambulance after a seizure episode. The history, reported from ED documents from another facility (Hosptial E), the ambulance driver and the patient's family, is that the patient started having epigastric pain in the evening of the 29th...started having significant epigastric pain and went to the (Hospital I) for evaluation. Per the patient's report, she was told it was heartburn and was given viscous Lidocaine and Maalox and discharged home. ED records have been reviewed. Patient did have blood pressures of 172/110 and 160/94 with epigastric pain and a headache while she was at that facility. She was given Maalox and Lidocaine with marginal improvement in upper epigastric pain and was discharged home to follow up with her regular provider...Once the patient returned home, the husband reported that she had at least three episodes of what he believed to be a seizure, loss of consciousness, general body convulsing and shaking and foaming at the mouth. Emergency Medical Service workers reported they got a call just after 11 pm to the patient's home ...per the Emergency Medical Service worker it was more a "wrestling match" on the way to the hospital...Upon arrival to Hospital E at about 12:30 am patient began again to have seizure activity."

MD G was leaving the hospital when the patient arrived, he ordered magnesium (a medication to prevent further seizures) and Preeclampsia labs (Preeclampsia is a syndrome defined by hypertension and proteinuria that may be associated with other symptoms, such as edema-swelling, visual disturbances-blurry vision, headache, and epigastric pain), ...blood pressures and fetal heart tones to be performed (checked by the nursing staff). "They were unable to find fetal heart tones with the external monitors. An FSE (fetal scalp electrode) was placed...bedside ultrasound (machine that uses sound waves to create pictures of internal organs or a baby) which showed no (fetal) cardiac (heart) activity and confirmed a fetal demise (death) with no cardiac motion seen....At this point, the patient's blood pressures were ranging from the high 160's to 200's (systolic- the top number is the highest pressure that occurs while the heart is pumping) over 110's to 130's (diastolic-the bottom number, the lowest pressure that occurs while the heart is pumping). She had a pulse (heart rate) in the 180's (normal is usually less than 100)." The patient was given medication to lower her blood pressure and stop her seizures (Hydralazine & Ativan) and the seizures subsided (stopped). "The patient had a foley catheter (catheter placed into the bladder which is attached to a bag to collect the urine) during this time that was draining blood tinged urine (normal urine is yellow and clear). She was having some bleeding from the IV sites (abnormal sign) ....Laboratory Data included liver enzyme levels (AST & ALT): AST 4,081 (normal is <48), ALT 3,306 (normal is <55)...She had significant proteinuria. Assessment and Plan: The patient is a 29-year-old gravida 3, para 2 female at 38 weeks and 1 day gestation with Eclampsia (an acute, life-threatening complication of pregnancy characterized by seizures) and evidence of HELLP syndrome (Hemolysis-destruction of red blood cells, Elevated Liver enzymes, and Low Platelets- help the blood clot after injury, a sign of severe Preeclampsia). The patient was admitted to labor and delivery ...Bedside ultrasound confirms fetal demise. Given the length of time from the initial seizures to the arrival in labor and delivery, I suspect the demise occurred significantly prior to her arrival here. I have discussed the fetal demise with the family and the need for an induction of labor (artificial stimulation of childbirth) to treat the Eclampsia and the HELLP syndrome (the ultimate treatment for Eclampsia is delivery of the pregnancy). LFT's (liver enzyme levels) are markedly elevated...there is evidence of DIC (abnormal clotting ability which can be fatal)...she is in guarded condition and expeditiously (quickly) get her induced for a vaginal delivery (non operative delivery)."

Review of a consultation note dictated on 9/30/13 at 11:23 pm, a day after Patient 1 was discharged from the first hospital (Hospital I) ED, indicated, "Impression: The patient meets the initial criteria for brain death (irreversible end of all brain activity) as she appears to have no viable brain function...She has a devastating intracranial hemorrhage (very large brain bleed leading to brain death)...Plan: As per...formal brain death evaluation (careful medical evaluation to test for loss of brain activity)."

Review of the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 33, Clinical Management Guidelines for Obstetrician-Gynecologists, Diagnosis and Management of Preeclampsia and Eclampsia, dated January 2002,: "In pregnant women, hypertension is defined as a systolic blood pressure level of 140 mmHg (millimeter of Mercury, measurement) or higher or a diastolic blood pressure level of 90 mmHG or higher that occurs after 20 weeks of gestation in a woman with previously normal blood pressure...Preeclampsia is a syndrome defined by hypertension and proteinuria that also may be associated with myriad other signs and symptoms, such as edema, visual disturbances, headache, and epigastric pain. Laboratory abnormalities may include hemolysis (destruction of red blood cells), elevated liver enzymes, and low platelet counts (HELLP syndrome). Proteinuria may or may not be present in patients with HELLP syndrome."

According to the ACOG document titled, "Key Elements for the Management of Hypertensive Crisis In Pregnancy," dated 2013, indicated, "Severe Preeclampsia is confirmed when any of the following criteria are present: Systolic blood pressure > 160 mmHg (millimeter of Mercury, measurement), Diastolic blood pressure > 110 mmHg, Cerebral (brain) or visual functional disturbances, Epigastric or right-upper quadrant abdominal pain, impaired liver function (abnormal liver enzyme levels) on laboratory analysis (elevated AST, ALT or LDH), etc. It is highly recommended that proteinuria testing be considered as a priority area for identification and management of hypertensive disorders in pregnancy. Continuous fetal (heart) monitoring should be initiated immediately upon admission. Automated blood pressure monitoring, using the appropriate cuff size, should be performed."

Review of the ACOG Committee Opinion 514, dated December 2011, titled, "Emergent Therapy for Acute-Onset, Severe Hypertension with Preeclampsia or Eclampsia" indicated, "Acute-onset, persistent (lasting 15 minutes or more), severe systolic (greater than or equal to 160 mm Hg) or severe diastolic hypertension (greater than or equal to 110 mm Hg) or both in pregnant or postpartum (after birth) women with Preeclampsia or Eclampsia constitutes a hypertensive emergency. Severe systolic hypertension may be the most important predictor of cerebral hemorrhage (brain bleed that can lead to brain damage) and infarction (lack of oxygen to the brain tissue causing brain damage) in these patients and if not treated expeditiously (quickly) can result in maternal death. Intravenous (medication given through a catheter in the arm) labetolol and Hydralazine (medications to rapidly decrease dangerously high blood pressure) are both considered first-line drugs for the management of acute, severe hypertension (sudden, very high blood pressure) in this clinical setting. Close maternal and fetal monitoring by the physician and nursing staff are advised. Preeclampsia if not treated can lead to Eclampsia which is a rare, life threatening obstetrical emergency...characterized by the onset of convulsions or seizure activity...in women with clinical presentation consistent with Preeclampsia...Management of Eclampsia: Control seizures and provide patient safety...control severe hypertension...if antepartum (before delivery), delivery (of baby) after maternal stabilization. Anticonvulsant Therapy (medication to stop seizures): Initiate and maintain magnesium sulfate (medication to prevent further seizures) infusion for seizure prevention when severe Preeclampsia or Eclampsia is suspected."

Further review indicated, "Emergency Department Postpartum Preeclampsia" - Effective interdepartmental collaboration and communication of healthcare delivery among care team members for complex conditions, such as hypertension in pregnancy is essential for successful management of patient care ... If the patient's blood pressure is elevated, assess for the following symptoms of Preeclampsia in the pregnant or postpartum patient and report findings to the physician. Headache, abdominal pain, right upper quadrant tenderness, visual disturbances, elevated BP, nausea, vomiting, edema, neck pain, malaise (a feeling of uneasiness or unwillingness), speech difficulties, lateralizing (only on side of the body) neurological signs. If any of the above symptoms are offered or observed, a bedside evaluation is warranted...Management of Postpartum Preeclampsia, Emergency Department Triage, Severe Preeclampsia BP > 160/100 or BP 140/90-160/100 with: Headaches, Visual disturbances, epigastric pain----OB Consult (call the obstetrician for advice). Emergency Department begins evaluation."

A review of the Hospital I's Medical Staff Bylaws, revised and adopted on 11/29/12, indicated, "1.3.1 The Medical Staff's purposes are: To assure that all patients admitted or treated in any of the hospital services receive a uniform standard of quality patient care, treatment and efficiency consistent with generally accepted standards."

A review of the Medical Staff Rules and Regulations, reviewed and updated 11/29/12, indicated under General Conduct of Care 10. "The good conduct of medical practice includes the proper and timely use of consultation. Judgment as to the serious nature of the illness and the question of doubt as to the diagnosis and treatment rests with the practitioner responsible for the care of the patient."

Based on interview and record review, the hospital failed to ensure the patient transfer acknowledgement form was signed by Patient 6, prior to being transported to another hospital. This failure had the potential to transfer individuals without their consent and knowledge of the risks and benefits of the process.

Findings:

On 2/23/13 at 10:55 am, Patient 6 presented in the emergency room with dizziness. Patient 6 was evaluated and then transferred to another hospital on 2/23/13 at 3 pm, in an advanced life support ambulance.

During a record review on 10/10/13, for Patient 6, there was no patient transfer acknowledgement form found in the record.

During a interview and record review on 10/10/13 at 5:30 pm, the Chief Nursing Officer confirmed there was no patient transfer acknowledgement form in the record.

The hospital's policy and procedure titled, "Assessment Emergency Patient" formulated 7/97 and reviewed 6/06, III. Transfer, F. Notice to patient, "1. The individual, or the individual's representative if any is present, must be notified of the transfer and the reasons for it. The individual's acknowledgement of this notification will be reflected in the Patient Transfer Acknowledgement."