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Based on review of the medical records, policies/procedures and physician and staff interviews, it was determined that the facility failed to comply with 489.24 as required in the EMTALA (Emergency Medical Treatment and Active Labor Act) provider agreement.

Based on staff and physician interviews and review of medical records, policies and procedures and other facility documents, the facility failed to meet the requirements for an appropriate and safe transfer of two of 20 sample patients (sample patients #1 and #20). The sample records were of 20 patients admitted to the Emergency Department. The sample included patients that were transferred to another facility for a higher level of care or specialized care. Since the hospital had recognized the failure to arrange an appropriate and safe transfer of the patient in most recently occurring instance (sample patient #1), and taken steps prior to the survey to prevent future similar incidents, past deficient practice was cited.

The findings were:

1. Review on 12/14/10 of the medical record for sample patient #20 revealed that the patient a 3-year-old child was brought by parent to the ER (Emergency Room) of the facility on 7/4/10 approximately 2 p.m. with a deep tongue laceration after falling face forward while running. The patient was triaged at 2:35 p.m., taken to a room at 2:40 p.m. and examined by the physician at 2:45 p.m. The patient was discharged to parents at 3:15 p.m. with discharge instructions "Go directly to (another hospital approximately 1 hour away) for laceration repair of tongue." The physician ER note stated the following, in pertinent parts:

Physical Exam: "#9 tooth a little loose but not evidently fractured; minor abrasion underside of tongue; deep, flap-type mid-tongue laceration into muscle, slow but active bleeding despite ice and pressure; no other facial trauma."
"Discussed with (name of a doctor at the other),"
"Disposition: Transferred by POV (privately owned vehicle) to MRMC."
"Condition: Stable."
"Disposition Orders: Transfer to (another hospital approximately 1 hour away)."

The nursing record stated the following, in pertinent parts:
"Disposition." "Discharged home."
"Admitted/Transferred: (doctor at another hospital approximately 1 hour away)."
"Condition: Other - Referral (doctor at another hospital approximately 1 hour away)."
"Depart Time: 1515 (3:15 p.m.), carried."

The record contained no evidence of a transfer form, no documentation of appropriate mode of transportation, provision of medical records/coordination of care with the receiving facility and notification of parents (since the patient was a minor child) of the risks/benefits of transfer.

2. Review on 12/13/10 of the medical record of sample patient #1 (patient of complaint #CO12419) revealed that the patient arrived at the transferring facility on 11/13/10 at approximately 11:25 p.m., in apparent labor and initially triaged and assessed by nursing then. The patient was a young patient in final weeks of second pregnancy. First pregnancy ended in spontaneous abortion ("miscarriage") three years prior. Patient's "due date" was 11/24/10. Only significant medical history was history of seizures. During nursing assessment, patient stated she had been having "small pains" that started a day ago. The patient stated that 30 minutes prior to coming to the hospital, she began having "hard" contractions. Fetal heart tones at 182 per minute. Review of the physician notes indicted that the medical screening exam was initiated at 11:30 p.m. The physician's findings included the following, in pertinent parts:
"...chief complaint: uterine contractions...onset: today...timing: still present...context: contractions...strong...regular...mild 'bloody show,' leakage of fluid with contractions...Pelvic exam: contractions: strong...station: -1 to 0...dilation: 4 cm...effacement: 70-80%...presentation: vertex...Fetal heart tones 180. Progress note: 'Primipara, high station, not fully effaced, only mildly dilated. Patient should have sign. time before delivery and was sent to (receiving facility approximately 51 miles away) for delivery and obstetrical care.' Clinical Impression: Active term labor. Disposition: transferred...sent to (receiving facility approximately 51 miles away) by POV (privately operated vehicle).
Time spent: 10 minutes..."
Review of "Additional Notes" from nursing assessment stated: "Dr. ...ordered patient discharged as soon as possible and sent to (receiving facility approximately 51 miles away) in POV."
"Disposition: discharged...verbal/written instructions given to patient...verbalized understanding...accompanied by driver (brother-in-law) and sister...departure time: 11:50 p.m."
Review of "Instructions for Post Hospital Care: Diagnosis: Active Labor...Go directly to (receiving facility approximately 51 miles away) ER."
Review of the medical record revealed that it contained no documented evidence of that the sending physician had
-discussed the risks and benefits of transfer with the patient,
-contacted the receiving hospital to ensure that the receiving facility was able to accept the patient/coordinate care,
-ensured that medical records were provided to the receiving facility, and
-consideration was given to the appropriate level of care needed for safe transport of the patient to the receiving facility, as required by EMTALA regulations.

The record contained no evidence that the transfer was initiated at the request of the patient.

Review on 12/14/10 of the record for the facility's ambulance "trip sheet" revealed that at approximately 12:18 a.m., the ambulance was dispatched to respond to sample patient #1, who was giving birth in the private vehicle at the roadside approximately 17 miles from the sending hospital. Per the records, a sheriff, a fire/emergency vehicle and on of the hospital ambulances responded to the 911 call and help with the patient's newly delivered female infant. Per the records, the child and mother's conditions were stable and they were transported to the receiving hospital after the placenta was delivered. The infant was born at approximately 12:35 a.m., about four minutes before the ambulance arrived. There were no adverse outcomes for the patient or infant. The patient and infant were transported to the receiving hospital and arrived at the ER at approximately 1:54 a.m.

Review on 12/13/10 of the medical record for sample patient #1 and written statements from the nurses that cared for the patient in the ER also confirmed that the patient was sent to the other hospital in "active labor" before all usual assessments were completed and no transfer forms were completed. No medical records or transfer forms were sent with the patient or transmitted electronically to the receiving facility. The receiving facility was not contacted to make sure that the patient could be accepted and to coordinate care prior to the patient being sent to the other hospital. The record revealed that there was no documentation of consideration or notification of the patient of the risks/benefits of transfer, and transportation by private vehicle rather than by ambulance with a trained crew.

Interview with the sending physician who evaluated sample patient #1 confirmed that the above steps were not completed, because the physician wanted to get the patient sent off to the other hospital. The physician stated that she believed that the patient had hours before s/he was likely to deliver based on medical screening exam, onset of labor history and the fact that the patient had not delivered a full term baby before. The physician stated that the lack of coordination of the transfer was not his/her usual practice or of other practitioners of the facility. S/he attributed the lapse to the fact that other acute patients were in the facility, and that judgements were made about the most urgent use of the ambulances available.

Review on 12/14/10 of meeting minutes, training records and staff/physician interviews revealed that facility staff immediately reported the lapse. The facility then initiated corrective actions in policies/procedures, staff training and provision of additional obstetrical management equipment to correct the deficient practice. The correction were in place prior to the beginning of the complaint investigation survey. The only remaining actions at the time of the survey were additional obstetrical trainings that would be completed by 2/2011.

Review on 12/14/10 of documentation of facility training in EMTALA regulations for staff revealed that there was documentation of training for nursing staff at orientation and annually, but the facility had no documentation of EMTALA training provided to the medical staff. The director of nursing confirmed on 12/14/10 that the facility had no evidence of EMTALA training for physicians prior to the 11/13/10 incident regarding the discharge/transfer of sample patient #1 while in active labor.