HospitalInspections.org

Based on interviews, medical record reviews and review of Hospital and EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures, Emergency Room Policy and procedures, Bylaws/Rules and Regulations, Hospital # 1 failed to:

A. Ensure an appropriate Medical Screening Examination (MSE) was provided to Patient Identifier (PI #1), a preterm pregnant female who presented to the Emergency Room with cramping and bleeding on 6/12/2017, to determine if an Emergency Medical Condition existed. Refer to findings at A 2406.

B. Failed to provide stabilizing treatment for PI # 1 on 6/12/2017, when Hospital # 1 had the capacity and capability to provide treatment.
Refer to findings at A 2407.

C. Prevent the inappropriate transfer of PI # 1, a patient who required further evaluation and treatment to stabilize her EMC (Emergency Medical Condition), to Hospital # 2. Because the hospital failed to triage and screen PI # 1, an appropriate transfer was not arranged. Refer to findings at A 2409.

This deficient practice effected PI #1, one of 32 ED (Emergency Department) sampled patients and had the potential to negatively affect other patients who present to Hospital #1's Emergency Department with similar obstetrical symptoms.

Based on medical record reviews, interviews, review of EMTALA (Emergency Medical Treatment and Labor) Policies and Procedures, Emergency Room Policies and Procedures, Wiregrass Medical Center, Hospital # 1, failed to provide a medical screening examination for Patient Identifier (PI) # 1, a patient who presented to the ED (emergency department) with complaints of "Cramping, Bleeding, Pregnant," on 6/12/17. Furthermore, the ER RN (Emergency Room Registered Nurse) told the patient (PI # 1) no obstetrical services were available at Hospital # 1 before offering a thorough triage assessment to PI # 1. The RN also advised PI # 1 to go to Enterprise(the name of the city where Hospital # 2) is located. These comments / "suggestions" by the RN contributed to the decision of PI # 1 to leave the ER at Hospital # 1 without being thoroughly triaged or receiving a medical screening examination to determine whether or not an emergency medical condition existed.

This deficient practice effected PI #1, one of 32 ED sampled patients and had the potential to negatively impact other patients who present to Hospital #1's Emergency Department with similar obstetrical symptoms.

Finding include:

I. Hospital # 1's ER Log dated 6/12/17 documented:

Patient Identifier (PI) # 1's Name.
Age: 28 years.
Sex: F.
Attending Physician: name of EI (Employee Identifier) # 4 / ED Physician.
Stay Type: ER.
Admit date/time: 6/12/2017 04:39.
Admit Code: Emergency.
Discharge Date/Time: 6/12/2017 04:40.
Mode of arrival: Ambulatory.
Triage Level: Patient left.
Disposition: AMA (Against Medical Advise).
Discharge Condition: Unknown.
Chief Complaint: Cramping, Bleeding, Pregnant.

II. ER Triage / Physician Order Form:
No vital signs were documented. The RN's (Registered Nurse) Employee Identifier (EI # 1's ) name was documented on the form.
PI # 1's disposition was documented as LWBS (Left Without Being Seen).
Date: 6/12/17
Time: 04:40

04:40: "Patient (PI # 1) left without being seen. She decided to go on to Enterprise(name of town where Hospital # 2 is located) and see her OB-GYN" (obstetrical and gynecological (physician). Documented by EI # 1.

There was no documentation of a Medical Screening Examination in PI # 1's ER medical record.

III. Interviews

Interview with EI # 1, RN (Registered Nurse) ED (Emergency Department) at Hospital # 1 on 6/26/17 from 17:33 to 17:58:

During an interview on 6/26/17 from 17:33 to 17:58, Employee Identifier (EI) # 1, RN (Registered Nurse) / ED (Emergency Department) at Hospital # 1, verified she was on duty on 6/12/17 from 18:00-06:00. EI # 1 confirmed she was responsible for the triage/interview with PI # 1 in the ED lobby.

EI # 1 reported events of the ED activities related to Patient Identifier (PI # 1) which included registration with an Admission Clerk. The clerk took PI # 1's chart to the ED nurse's station. EI # 1, staff ED RN was told by the Admission Clerk a 27 week pregnant lady was in the ED lobby, with complaints of cramping and bleeding (vaginal). When the staff RN opened the ED lobby door, FI # 1, (Family Identifier), the grandmother who accompanied the patient, was screaming this into a cell phone, "I'm just gonna take her to Enterprise." EI # 1 confirmed no other patients were present in the ED lobby.

During the ED lobby encounter with PI # 1, the staff RN (EI # 1) reported asking the patient (PI # 1), "How bad are you bleeding?" PI # 1 response, "pretty bad."

EI # 1 then reported to the surveyors, "I told PI # 1 like I tell all patients. We'll be glad to see you, have the doctor assess you and listen to the heart beat of the baby, but Wiregrass (Hospital # 1) does not have OB/GYN services." EI # 1 reported asking PI # 1 where her OB physician was located? PI # 1 reported Enterprise (name of the city where her obstetrician practices).

EI # 1 reported PI # 1 was crying. A family member was on the phone screaming, "I'm just going to take her to Enterprise."

EI # 1 reported telling the patient "to sit still, I'm going to get the other nurse to help." EI # 1 reported the patient's response as she "shook her head (in affirmation)."
EI # 1 reported then exiting the lobby to the nurses' desk where another Staff ED RN, EI # 2 was working.

EI # 2 reported to EI # 1, "I guess they were going to leave," as EI # 2 observed the patient and another female via a computer monitor in the ED exit the ED lobby.

EI # 1 (Staff RN, ED, responsible for triage of PI # 1) confirmed EI # 2 did not hear the conversation in the lobby with PI # 1. EI # 2 only observed the patient and family exit the ED lobby to a private vehicle in the parking lot.

EI # 1 reported the process when a patient comes to the ER. The patient "registers, then the ward clerk tells the RN the patient presented with chest pain or shortness of breath, one of us (RN's) physically goes out to the lobby gets the patient, brings them to a bed and triage is completed in an exam room..."

EI # 1 reported she had planned to put PI # 1 in a wheelchair after she retrieved the chair and transfer the patient to an exam room bed where PI # 1 would be triaged and bypass the traditional triage room.

EI # 1 verbalized there was no interaction between the patient and family member and / or the nurse and family member during the initial lobby encounter. The family member, on the phone continued to scream, "I'm just going to Enterprise." EI # 1 reported PI # 1 was tearing and crying like she was hurting.

EI # 1 reported she did not visualize any blood. EI # 1 denied patient reports of problems other than cramping and vaginal bleeding which required 1 pad change every hour.

EI # 1 acknowledged the potential for the patient's water to break (membrane rupture).

EI # 1 reported she documented in the medical record that PI # 1 left without being seen.

EI # 1 notified EI # 4, ED Physician at Hospital # 1, who was present in the ED when PI # 1 arrived on 6/12/17. According to the ED Staff RN, EI # 4 responded, "We would be more than glad to see them."

EI # 1 reported she had no knowledge who PI # 1's physician was, only that the physician was in Enterprise. EI # 1 verbalized if PI # 1 had come to the back (triage), if something was wrong, she would have called the clinic, looked up PI # 1's medical history, got a release signed, faxed the paper work and could have reviewed PI # 1's obstetrical history.

EI # 1 confirmed the triage and medical screening was not completed for PI # 1. There was no documentation an AMA (against medical advice) was obtained. There was no documentation of a conversation regarding completion of an AMA form with PI # 1 and the family member.

EI # 1 reported a written statement of the events of 6/12/17 of PI # 1's ER visit was completed on 6/19/17 at the request of the Director Of Nurses, EI # 7. EI # 1 confirmed the following events were documented on the written statement:

On June 12, 2017 around 5 AM, this nurse went to check on a patient in the lobby that had registered to be seen. The patient told the ward clerk that she was 27 weeks pregnant, cramping and bleeding. I (the nurse) went to check on the patient, and bring her back to be seen by our doctor. As I opened the door, her grandmother was on her cell phone screaming " I'm just going to take her to Enterprise". I (the nurse) looked at the patient who was crying, and "ask her who her OB GYN was?" The patient stated "he is in Enterprise." This whole time the grandmother was still on her cell phone screaming "I'm just going to take her to Enterprise," the grandmother never once took the cell phone down from her ear. I (the nurse) told the patient we would be glad to have her see our doctor, examine her, and we could listen to the babies heart beat." I (the nurse) told the patient "not to get up, that the nurse was going to get the other RN and a wheelchair." I (the nurse) went back to the ER, and as I (the nurse) approached the desk, the other RN (named staff) saw them get up and leave on the video camera. He stated to the nurse (myself) "the patient had just walked out of the hospital."


Interview with EI # 4, ED Physician at Hospital # 1, on 6/27/17 at 14:10:

The physician confirmed he was present as the ER attending physician when PI # 1 presented to the ED on 6/12/17. EI # 4 stated the nurse notified him about PI # 1. The physician said he would have been glad to examine PI # 1, but the patient left without being seen and he was unable to do a medical screening examination.


Interview with Family Identifier (FI # 1) on 6/28/17 at 13:40:

FI # 1 reported the patient, PI # 1 drove herself to the ER at Hospital # 1 and arrived at 04:30. She (PI # 1) called me and I met her at the hospital." According to FI# 1, the patient, PI # 1, told the "receptionist" she was bleeding and cramping and had a previous delivery at 27 weeks. PI # 1 was crying.

A nurse came out to the lobby and said there was nothing the hospital could do, but "monitor FHT's (Fetal Heart Tones). We (Hospital # 1) don't have OB." (Obstetrical services). FI # 1 asked the nurse if she would monitor FHT's? According to FI # 1, the nurse replied, "If I was ya'll, I wouldn't waste anymore time." We (PI # 1 and FI # 1) decided to go to Hospital # 2.


Interview with Patient Identifier (PI # 1) on 6/28/17 at 13:50:

According to PI # 1, she arrived at Hospital # 1's ER on 6/12/17 at 04:30. "I told the receptionist I was bleeding, cramping and had a previous pregnancy at 27 weeks. I am a high risk pregnancy. I need to get to the back and see somebody."

"I was scared. I was trying to get to the back (ED treatment area)." A nurse (EI # 1) came out to the lobby and said the only thing she could do was check Fetal Heart Tones. She said there was no OB/GYN (Obstetrical/Gynecological Physician) at the hospital (Hospital # 1). She said it was best for me to go to Enterprise." (name of city where Hospital # 2 is located). PI # 1 described the ED nurses' attitude as "nonchalant."


IV. ED (Emergency Department) Medical Record Review for PI # 1 at Hospital # 2:

Date: 6/12/17
Time: 05:10
Bed: Waiting
Diagnosis: 27 weeks gestation of pregnancy
05:18: ER care complete; transfer ordered by MD. Patient left the ED.


V. ED-OB (Emergency Department - Obstetrical) Handoff Form for PI # 1 at Hospital # 2:

Triage Date: 6/12/17
Time: 05:12
Arrival Mode: Car
Gestational Age: 27 weeks
Chief Complaint: Bleeding, lower abdominal pain
Expected Date of Delivery: 9/6/17
Gravida: 2 (Number of pregnancies); Para: 1 (Number of deliveries after 20 weeks)
Obstetrical Complaint: Abdominal pain, vaginal bleeding
To Labor and Delivery
Time in: 05:23
Blood Pressure: 134/87, Temperature: 100 F (Fahrenheit), Respirations: 20
Fetal Heart Rate: 145
05:47: Cervix dilated 1 centimeter per RN
06:37: Cervix dilated 3-4 centimeters per Obstetrician


PI # 1's Operative Report at Hospital # 2:

Date of Service: 6/12/17

Preoperative diagnoses:
1. Intrauterine pregnancy at 27 weeks...in active labor.
2. Preterm labor.
3. Previous cesarean section (surgical procedure used to deliver a baby through incisions in the mother's abdomen and uterus, mayoclinic.org/tests-procedures).
4. History of previous preterm delivery.
5. Malpresentation / transverse (abnormal position of the fetus in the birth canal, Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier).


Procedure: Classical cesarean section.

Postoperative Diagnoses:
1. Intrauterine pregnancy at 27 weeks and 4/7th weeks, delivered.
2. Preterm labor.
3. Previous cesarean section.
4. Previous preterm delivery.
5. Breech Presentation.

A. Indications: The patient (PI # 1) presented with bleeding and abdominal pain. She is in active labor with the cervix dilated 4 cm (centimeter) by ultrasound and hourglass membranes into the vagina. She has a history of preterm delivery at 27 weeks. She had a previous cesarean section with her first delivery.

B. The patient delivered a viable infant at 07:00...Weight: 1 pound 15 ounces. The infant was in a transverse presentation, but converted to breech presentation for delivery. Estimated blood loss: 800 cc's (cubic centimeter).


VII. History and Physical for Baby (PI # 33 ) at Hospital # 2:

Admission Date: 6/12/17

Admission and Transfer Summary:

Chief Complaint: Extreme prematurity at 27 weeks.

History of Present Illness: "I was called to a C- Section this morning...for a 27 week estimated gestational age delivery. Mom (PI # 1) had a previous C-Section (cecesarian section) - came in dilated with a bulging bag. Baby was delivered by C-Section breech presentation. Amniotic fluid was clear. Rupture of membranes at delivery. The baby was limp and not breathing, had a heart rate of less than 100, but above 60. PPV (Positive pressure ventilation: The provision of air under pressure by a mechanical respirator, a machine designed to improve the exchange of air between the lungs and the atmosphere, medicinenet.com) was initiated for three minutes in the C-section room with 100% oxygen. APGARS (appearance, pulse, grimace, activity, and respiration) were one at one minute, 2 APGARS at 2 minutes and 7 APGARS at 5 minutes (APGAR: a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score determines how well the baby tolerated the birthing process. The 5-minute score reveals how well the baby is doing outside the mother's womb, medlineplus.gov)."

"Baby was brought to the nursery...and weighed 870 grams. The initial oxygen saturation was 85% on room air. Blow-by was initiated and oxygen saturations improved to 95 - 100%....(blow-by: an imprecise method of oxygen delivery in which an oxygen source discharges oxygen in front of the nostrils or mouth of the patient. Used primarily to supply supplemental oxygen to neonates, who may not tolerate wearing other oxygen delivery systems, Medical Dictionary, © 2009 Farlex and Partners)."

"Due to the baby's prematurity we elected to intubate the baby...Oxygen saturations rose to 100%...The baby was then placed on the ventilator at the pressure of 20/4 with a rate of 40 on 30% (oxygen). Oxygen saturations had been 95% to 100%. (ventilator: a machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently,wikipedia.org)."

"Blood sugar ...was 50 (normal level when babies are 1 hour to 2 hours old is just under 2 mmol/L millimoles per liter; the presence of high levels of glucose (sugar) in blood occurs due to the lack of sufficient levels of insulin in the body, dovemed.com)."

"...Heart rates in the 150's. Respiratory rates in the 40's to 60's. We will obtain a CBC (Complete Blood Count) and a blood culture. Arterial blood gases (ABG's) showed a pH of 7.61 with a PCO2 (partial pressure of carbon dioxide) of 20. PaO2 (partial pressure of oxygen in arterial blood) at that time was 51. Bicarb was 20. We decreased the rate to 30. (ABG's measure the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery. This test is used to check how well the lungs are able to move oxygen into the blood and remove carbon dioxide from the blood, webmd.com)."

"Chest x-ray showed mild interstitial lung disease, but the Endotracheal Tube placement was good. (interstitial lung disease is characterized by progressive scarring of the lung tissue between and supporting the air sacs. Associated scarring may cause progressive lung stiffness, eventually affecting the ability to breathe and get enough oxygen into the bloodstream, mayoclinic.org)."

"Transport has been arranged with Hospital # 3 and they are en route. We (Hospital # 2's staff) are going to obtain an IV (intravenous access), start D10W ( Dextrose 10 % In Water Intravenous Solution, webmd.com)...We will also give a Normal Saline bolus... (administration of a discrete amount of medication in order to raise its concentration in the blood to an effective level, wikipedia.org) and then will start Ampicillin and Gentamycin (antibiotics) after blood cultures are drawn...We will repeat ABG's in about thirty minutes. It is now 8 o'clock. I will discuss this with the patient (Patient Identifier # 1) who is currently recovering from the operation and consent will be obtained for transport."


VIII. History and Physical for Baby (PI # 33 ) at Hospital # 3, Neonatal Intensive Care (NICU):

"Date of Admission: 6/12/17
Time of Birth: 07:00

Referring Facility: Hospital # 2

Admission Diagnoses:

1. Preterm newborn with an estimated date of confinement of 9/7/17, placing baby at 27 weeks and 4 days gestation with a birth weight of 870 grams or 1 pound 15 ounces.
2. Stat (immediate or instant) C-section secondary to preterm labor and bleeding.
3. Respiratory distress syndrome.
4. Rule out sepsis.
5. Fluid, electrolytes, nutrition.
6. Maternal drug use."

"Baby was born to a 28 year old, gravida 2, para 1, mother...Pregnancy complications included a previous 27 'weeker' for which the mother received Makena injections ( medicine (progestin) used to lower the risk of preterm birth in women who are pregnant with one baby and who have delivered one baby too early in the past, makena.com) and maternal urine drug screen positive for THC on 2/9/17 and 6/12/17 (THC: the main psychoactive chemical in marijuana, responsible for most of it's intoxicating effects, is delta-9-tetrahydrocannabinol (THC), www.livescience.com).

"Delivery occurred via stat C-section under general anesthesia secondary to preterm labor and bleeding. Rupture of membranes occurred at delivery. Delivery room resuscitation consisted of drying, stimulation, suctioning and mask bagging to blow-by oxygen. Apgar scores were 1 at 1 minute, 2 at 5 minutes, and 7 at 10 minutes. (At the five minute APGAR, a score of seven to ten is normal, americanpregnancy.org). Infant was taken to the nursery on blow-by oxygen. Infant was then intubated and x-ray confirmed placement ( intubated: insertion of a breathing tube through the mouth or nose into the trachea to ensure a patent airway for the delivery of anesthetic gases and oxygen or both, Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier). Curosurf was given (medicine indicated for the rescue treatment of Respiratory Distress Syndrome in premature infants, curosurf.com). IV attempts were unsuccessful. After the transport team arrived, (last name of physician at Hospital # 2) placed the single lumen UVC (Umbilical Vessel Catheter). Infant was transported to Hospital # 3 without incident."

"On arrival, single port umbilical venous catheter was changed to a dual-lumen umbilical venous catheter. Umbilical arterial catheter was unsuccessful...Initial glucose was 132 on D10 admit fluids."

"Admission Physical Examination:

Weight: 1 pound 15 ounces...
Head Circumference: 23 centimeters.
Heart Rate: 162.
Respiratory Rate: 62.
Blood Pressure: 43/24.
Temperature: 98.3.
Oxygen Saturation: 89%.
General: ...Preterm appearing infant.
Skin: There are multiple areas of bruising.
HEENT /Head, eyes, ears, nose and throat: Anterior fontanelle soft and flat (Anterior fontanelle: one of the major bones that compose the skull of a newborn. These bony plates cover the brain and are held together by fibrous material called sutures, chw.org/medical-care/craniofacial).
Palate intact. Eyes and ears normally set.
Lungs: Coarse bilateral breath sounds with mild retractions.
Cardiac: Regular rate and rhythm. No murmur...
Abdomen: Soft non- tender...no organomegaly. There is a 3 vessel umbilical cord.
Genitalia: Normal preterm appearing genitalia.
Back: Overlying skin is intact.
Neurologic: Infant has appropriate tone and activity for gestational age.

Plan: Admit to NICU (Neonatal Intensive Care). We will continue n.p.o (nothing by mouth) with starter IV fluids..Continue Ampicillin and Gentamycin following cultures...Repeat dose of surfactant ( a naturally produced substance that acts like grease within the lungs. Without it, the air sacs open but have difficulty remaining open because they stick together. Surfactant allows the sacs to remain open (aboutkidshealth.ca) and wean support (ventilator) as able..."


IX. Interview with Employee Identifier, EI # 3, Obstetrician at Hospital # 2 on 6/29/17 at 13:25.

According to EI # 3, the patient (PI # 1) and her grandmother (FI # 1) presented to the ED at Hospital # 1. A nurse came out to the lobby and told PI # 1 "there was nothing the hospital could do." The patient and her grandmother left the ED and drove to Hospital # 2. The surveyor asked the physician to explain the risk(s) related to the patient (PI #1) not being evaluated at Hospital # 1's ER. He replied, "An unattended preterm delivery in a vehicle." EI # 3 said, "An implication from staff about not offering services or suggesting a patient go to another hospital is inappropriate based on EMTALA (Emergency Medical Treatment and Labor Act) regulations." The patient (PI # 1) and her grandmother told the story to me separately. "I tend to believe them."


X. Policies and Procedures - Hospital # 1:

Standard Policies & Procedures
Department: Emergency Department
Subject: Obstetrical Patients Presenting in the Emergency Department (ED)
Date Revised/Reviewed: 10/2000

Statement Of Purpose: To ensure proper treatment of obstetrical patients in the Emergency Department...

O. B. (obstetrical) Patients Stating They are in Labor:
The patient will be triaged and notified that Wiregrass Medical Center has no obstetrical or nursery facilities, but provides emergency services and transfers the patient(s) when stable.

The ED physician will examine the patient to determine the stage of labor and will decide if the benefits of transfer outweigh the risks of delivering in the ED. This will be discussed with the staff physician on call if times allows...and with the patient and her family.
The patient will be transferred by a private auto or rescue squad, depending on the condition...

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Standard Policies & Procedures
Department: Emergency Department
Subject: Triage
Date (s) Revised/Reviewed: 3/2016

Statement Of Purpose:
...Patients presenting to the Emergency Department...will be triaged by an Emergency Department Registered Nurse...using the Emergency Severity Index (ESI) 5 Level acuity rating system...Acuity is determined by the stability of vital functions and potential for life, limb or organ threat. Triage is used to classify patients...to identify the most efficient and judicious use of available resources.

Procedure:
The Registered Nurse assigned to triage will evaluate and categorize each patient upon arrival to the Emergency Department into either: ESI Levels I through 5

Initial evaluation shall include:
Patient's name and age...Medications...Medical History...Subjective-chief complaint, Objective-nursing observations...

Classifications:

Class I- Critical, Immediate Care, life Threatening Conditions
...Emergency childbirth, complications of pregnancy...
Class II- Emergent Life Threatening
Active Labor/Complicated childbirth...

Until the patient is triaged by the Registered Nurse and deemed to have a non-life threatening condition, the Registration Clerk is not to obtain or request any financial information or demographic information.
Standard Policies & Procedures
Department: Emergency Department
Subject: Scope of Services
Date (s) Issued: 10/2000

Statement Of Purpose:

To establish the scope of service of the Emergency Department...

The Emergency Department of this Hospital is a level Three Emergency Medical Service Department...has a 6-bed Emergency Department with 24 hours per day care.

...Scope and Complexity of Patient Care Needs:
All patients that present to Wiregrass Medical Center's premises for a non-scheduled visit and are seeking care shall receive a medical screening exam by an Emergency department physician or by an Emergency Department Registered Nurse...includes...all testing and on-call services within the capabilities...to reach a diagnosis....All necessary definitive treatment will be given to the patient within the hospital's capabilities.

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Department: Emergency Department
Subject: Purpose and Objectives
Date (s) Issued: 10/2000

Statement Of Purpose:

...to provide quality care for all patients who arrive at the Emergency Department 24 hours a day...
All patients will receive an evaluation by the Emergency Department physician.

Objectives
Emergency care shall be delivered in accordance with written policy and procedure and standard of care.
Provide quality care to all patients in accordance with Hospital policy.
Provide initial triage and treatment of all patients.
Provide adequate and appropriate licensed staff to meet the needs of the patient census 24 hours a day.
...Provide referral to speciality areas.
...Ensure all staff members within the Emergency Department receive appropriate training to maintain skills needed for this speciality department.
Provide appropriate discharge instructions and follow-up care...

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Standard Policies & (and) Procedures
Department: Emergency Department
Subject: Emergency Department Standards of Practice or Care
Date (s) Revised/Reviewed: 11/2015

Statement Of Purpose: To establish standards of practice or care for patients presenting to the Emergency Department for treatment

Standard I:

The Registered Nurse performs a comprehensive nursing assessment.... The patient and facility members are included in patient care planning and planning for discharge.

Important Aspects of Patient Care:

...Data is obtained through the following:
Interview process (patient, family, significant other), patient health history...Observation...Physical examination..Diagnostic reports...
The patient assessment is completed within 15 minutes after admission to the treatment area and includes: Chief complaint and present physical and emotional status; The presence of pain;Focused review of the affected systems and medical history, including...chief complaint; Family, social, cultural and predisposing factors...

The patient is evaluated according to Triage Categories:
Class I-Critical, Immediate Care, life Threatening Conditions
....Emergency childbirth, complications of pregnancy...

Class II-Emergent Life Threatening
...Uncontrolled bleeding or hemorrhage
...Active Labor/Complicated childbirth

...Assessments and supportive data are thoroughly documented...

Assessments reflect changes in patient's condition...charted and communicated...members of the multidisciplinary team...

Related Standards of Patient Care:

All patients are to be triaged per policy...
The patient will receive appropriate nursing care and emergency interventions to meet his/her assessed needs including treatment protocols and standards of care for the presenting problem(s)

Standard III.

...Nursing interventions are provided by personnel ...to implement specific to emergency nursing practice;

Standard IV.
Important Aspects of Patient Care:
...Safety concerns are addressed with the patient and family members...

Standard V.
The nurse serves as a patient advocate...

The nurse informs the patient or family of their rights and responsibilities in cases where they leave (AMA) from the Emergency Department before an assessment is made or treatment is complete...

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Standard Policies & Procedures
Department: Emergency Department
Subject: Standard of Care- Emergency Delivery
Date (s) Issued: 10/2000

Statement of Purpose:
Establish criteria for the emergency delivery of the pregnant woman in active labor on arrival in the Emergency Department.

Wiregrass Medical Center does not offer obstetrical Services to patients. However, the Emergency Department will treated obstetrical emergencies as follows:
Any patient who is in active labor on arrival to the Emergency Department, and time does not allow safe transportation to the Maternity Department of the patient's obstetrician, will be evaluated by the Emergency Department physician...
If birth is imminent, prepare for delivery.
Contact the Maternity Department of the patient's obstetrician of imminent delivery in the Emergency Department at this facility.
Infant warmer will be set up...
Contact the patient's obstetrician...obstetrician on-call at the hospital of patient's choice...

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Standard Policies & Procedures .
Department: Emergency Department
Subject: Standard of Care- COBRA (Consolidated Omnibus Reconciliation Act)Guidelines
Date (s) Issued: 8-4-2000

Statement of Purpose:
To establish guidelines for treating Emergency Department patients while staying within COBRA guidelines

Text:
All patients presenting to Wiregrass Medical Center for a non-scheduled visit and seeking care must be accepted and evaluated regardless of the patient's ability to pay.

All patients shall receive a medical screening exam that include all necessary testing an on-call services within then capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment...be given to the patient...
The triage of a patient for managed care contracts without a medical screening exam is not acceptable under COBRA law...
The Critical Care Committee at Wiregrass Medical Center has authorized Emergency Department staff RN's (Registered Nurse) to provide initial medical screening exams on all patients prior to any inquiries about insurance information. Based on this initial medical screening, the patient will be placed in the Emergency Department for immediate treatment by an Emergency Department physician if their condition is deemed urgent or emergent...
Wiregrass Medical Center may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during, or after said transfer or discharge...
Wiregrass Medical Center may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care...
If a patient is to be transferred for medical necessity the following guidelines must be followed:
A physician certification that the risks...are outweighed...by the potential benefits...
The receiving hospital must give acceptance in advance. The acceptance must be documented in the medical record....

The patient must be transferred by an appropriate medical transfer vehicle...must not be transferred in a private passenger vehicle unless the patient refused to be transported by ambulance...the refusal must be in writing....

Medical Screening Exams:

Medical Screening Exams should include at minimum the following:
Emergency Department log entry including disposition of patient;
Patient's triage record;
Vital signs;
History;
Physical exam of the affected systems and potentially affected systems;
...Necessary testing...
Notification and use of on-call physicians to diagnoses and/or stabilize the patient...
Vital signs upon discharge or transfer;
Complete documentation of the medical screening exam.

Emergency Medical Conditions:
Emergency Medical Conditions under COBRA law constitute any condition that is a danger to the patient or unborn fetus or or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future.

Emergency medical conditions include:
Undiagnosed, acute pain which is sufficient to impair normal functioning
Pregnancy with contractions (defined as unstable)...

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Standard Policies & Procedures
Department: Emergency Department
Subject: EMTALA (Emergency Medical Treatment and Active Labor Act) [Patient Transfers]
Date (s) Revised: 06/09/2008

ER Admissions/Patient Transfers
I. Introduction
...Wiregrass Medical Center is committed to full compliance with all state and federal laws regarding transfers of patients from one medical facility to another. Transfers of patients from...and to...may implicate the provisions of the Emergency Medical Treatment and Active Labor Act...the "anti-dumping law".

EMTALA generally requires that all hospitals with an emergency department:
Provides all patients who come to the emergency department seeking evaluation or treatment for a medical condition with an appropriate medical screening examination to determine where or not an emergency medical condition exists and, if such condition exists either (a) stabilize the patient or (b) appropriately transfer the patient to another hospital.

An "emergency medical condition" is one with symptoms severe enough such that the absence of immediate medical treatment could reasonable be expected to result in:
placing the health of the individ

Based on medical record reviews, interviews, review of EMTALA (Emergency Medical Treatment and Labor) Policies and Procedures, Emergency Department Policies and Procedures,Wiregrass Medical Center, Hospital # 1 had sufficient staff and resources, but the hospital failed to provide stabilizing treatment for Patient Identifier (PI # 1), a 27 week high risk pregnant female who presented to the ED (emergency department) on 6/12/17 with cramping, bleeding and a previous preterm delivery at 27 weeks, before the patient left the ED in a private vehicle to go to Hospital # 2. This resulted in a delay in treatment of PI # 1. This deficient practice affected PI # 1, one of 32 sampled patients and has the potential to negatively impact all pregnant females who present to Hospital # 1's Emergency Department with similar obstetrical complaints.

Finding include:

I. Hospital # 1's ER Log dated 6/12/17 documented:

Patient Identifier (PI) # 1's Name.
Age: 28 years.
Sex: F.
Attending Physician: name of EI # 4 / ED Physician.
Stay Type: ER.
Admit date/time: 6/12/2017 04:39.
Admit Code: Emergency.
Discharge Date/Time: 6/12/2017 04:40.
Discharge Code: AMA.
Mode of arrival: Ambulatory.
Triage Level: Patient left.
Disposition: AMA.
Discharge Condition: Unknown.
Chief Complaint: Cramping, Bleeding, Pregnant.


II. ER Triage / Physician Order Form:
No vital signs were documented. The RN's (Registered Nurse) Employee Identifier (EI # 1's ) name was documented on the form.
PI # 1's disposition was documented as LWBS (Left Without Being Seen).
Date: 6/12/17
Time: 04:40

04:40: "Patient (PI # 1) left without being seen. She decided to go on to (name of town where Hospital # 2 is located) and see her OB-GYN" (physician). Documented by EI # 1.

There was no documentation in PI # 1's medical record regarding any treatment provided by Hospital # 1.


III. Interviews

Interview with EI # 1, RN (Registered Nurse/ ED (Emergency Department) at Hospital # 1 on 6/26/17 from 17:33 to 17:58:

During an interview on 6/26/17 from 17:33 to 17:58, Employee Identifier (EI) # 1, RN (Registered Nurse / ED (Emergency Department) at Hospital # 1, verified she was on duty on 6/12/17 from 06:00 - 18:00. EI # 1 confirmed she was responsible for the triage / interview with PI # 1 in the ED lobby.

EI # 1 reported events of the ED activities related to Patient Identifier (PI # 1) included registration with the Admission Clerk. The clerk took PI # 1's chart to the ED nurse's station. The staff ED RN was told by the Admission Clerk a 27 week pregnant lady was in the ED lobby, with complaints of cramping and bleeding (vaginal). When the staff RN opened the ED lobby door, FI # 1, (family identifier) mother who accompanied the patient, was screaming this into a cell phone, "I'm just gonna take her to Enterprise." EI # 1 confirmed no other patients were present in the ED lobby.

During the ED lobby encounter with PI # 1, the staff RN (EI # 1) reported asking the patient (PI # 1), "How bad are you bleeding?" PI # 1 response, "pretty bad."

EI # 1 then reported to the surveyors, "I told PI # 1 like I tell all patients. We'll be glad to see you, have the doctor assess you and listen to the heart beat of the baby, but Hospital # 1 does not have OB/GYN services." EI # 1 reported asking PI # 1 where her OB physician was located? PI # 1 reported Enterprise (name of the city where her obstetrician practices).

EI # 1 reported PI # 1 was crying. The family member was on the phone screaming, "I'm just going to take her to Enterprise.

According to EI # 1, she told the patient "to sit still, I'm going to get the other nurse to help." EI # 1 reported the patient's response, she "shook her head (in affirmation)."
EI # 1 then exited the lobby to the nurses' desk where another ED RN, EI # 2 was working.

EI # 2 reported to EI # 1, "I guess they were going to leave," as EI # 2 observed PI # 1 and another female (FI# 1) via a computer screen monitor in the ED exit ED lobby.

According to EI # 1 (Staff RN - responsible for triage of PI # 1), EI # 2 did not hear the conversation in the lobby. EI # 2 observed the patient and family member exit the ED lobby to a private vehicle in the parking lot.

EI # 1 reported the process when a patient comes to the ER. The patient "registers, then the ward clerk tells the RN the patient presented with chest pain or shortness of breath, one of us (RN's) physically goes out to the lobby gets the patient, brings them to a bed and triage is completed in an exam room..."

EI # 1 reported she had planned to put PI # 1 in a wheelchair after she retrieved the chair and transfer the patient to an exam room bed where PI # 1 would be triaged and bypass the traditional triage room.

EI # 1 verbalized there was no interaction between the patient and family member and / or the nurse and family member during the initial lobby encounter. The family member, on the phone continued to "Scream, I'm just going to Enterprise." EI # 1 reported PI # 1 was tearing and crying like she was hurting.

EI # 1 reported she did not visualize any blood. EI # 1 denied patient reports of problems other than cramping and vaginal bleeding which required 1 pad change every hour.

EI # 1 acknowledged the potential for the patient's water to break (membrane rupture).

EI # 1 reported documenting in the medical record PI # 1 left without being seen.

EI # 1 notified EI # 4, ED Physician, who was present when PI # 1 arrived on 6/12/17. EI # 4 was entering an exam room when the RN (EI # 1) notified him of the departure of PI # 1. EI # 4 responded, "We would be more than glad to see them."

EI # 1 reported she had no knowledge who PI # 1's physician was, only that the physician was in Enterprise. EI # 1 verbalized if PI # 1 had come to the back (triage). If something was wrong, I would have called the clinic, looked up PI # 1's medical history, got a release signed, faxed the paper work and reviewed PI # 1's obstetrical history.

EI # 1 confirmed the triage and medical screening was not completed for PI # 1. There was no documentation an AMA form was obtained. There was no documentation of a conversation regarding completion of an AMA form with PI # 1 and her family member.


Interview with EI # 4, ED Physician at Hospital # 1, on 6/27/17 at 12:00 and 14:10:

The RN (EI # 1) told me about the patient when she came to the back to get a wheelchair. The patient (PI # 1) left the ED. The physician said he did not see (provide a medical screening examination) the patient. The RN reported it was "massive chaos" (referring to family member yelling on a cell phone) "and they left."
When asked if he made a courtesy call to Hospital # 2 about the patient's impending arrival the physician said, "I did not know where the patient was going and there was no guarantee the patient would actually go to the hospital, but I would have."
(There was no documentation in PI # 1's medical record to indicate a call was made to Hospital # 2 by any staff member).


Interview with EI # 5, ED (Emergency Department) Staff RN (06:00 AM - 18:00) on 6/27/17 at 14:00:

The RN was asked about a room that could accommodate an obstetrical patient, equipment and process for assessing an obstetrical patient. EI # 4 showed the surveyor the "OB" room and demonstrated how the table breaks down and has stirrups. Several boxes of disposable speculums (including speculums with lights) were located in the room. Two sterile OB packs with items needed for delivery were located in supply room. Other equipment included an external doppler with gel and an incubator.


Interview with Family Identifier (FI # 1) on 6/28/17 at 13:40:

FI # 1 reported PI # 1 drove herself to the ER at Hospital # 1 and arrived at 04:30. She (PI # 1) called me and I met her at the hospital." The patient, PI # 1, told the "receptionist" she was bleeding and cramping and had a previous delivery at 27 weeks. PI # 1 was crying.

A nurse came out to the lobby and said there was nothing the hospital could do, but "monitor FHT's (Fetal Heart Tones). We (Hospital # 1) don't have OB." (Obstetrical services). FI # 1 asked the nurse if she would monitor FHT's. According to FI # 1 the nurse replied, "If I was ya'll I wouldn't waste anymore time. We (PI # 1 and FI # 1) decided to go to Hospital # 2."


Interview with Patient Identifier (PI # 1) on 6/28/17 at 13:50:

PI # 1 stated she arrived at Hospital # 1's ER on 6/12/17 at 04:30. "I told the receptionist I was bleeding, cramping and had a previous pregnancy at 27 weeks. I am a high risk pregnancy. I need to get to the back and see somebody."

"I was scared. I was trying to get to the back (ED treatment area)." A nurse came out to the lobby and said the only thing she could do was check Fetal Heart Tones. She said there was no OB/GYN (Obstetrical/Gynecological Physician) at the hospital (Hospital # 1). She said it was best for me to go to Enterprise." ( name of city where Hospital # 2 is located. PI # 1 described the ED nurses' attitude as "nonchalant."


IV. ED (Emergency Department) Medical Record Review for PI # 1 at Hospital # 2:

Date: 6/12/17
Time: 05:10
Bed: Waiting
Diagnosis: 27 weeks gestation of pregnancy
05:18: ER care complete; transfer ordered by MD. Patient left the ED.


V. ED-OB (Emergency Department - Obstetrical) Handoff Form for PI # 1 at Hospital # 2:

Triage Date: 6/12/17
Time: 05:12
Arrival Mode: Car
Gestational Age: 27 weeks
Chief Complaint: Bleeding, lower abdominal pain
Expected Date of Delivery: 9/6/17
Gravida: 2 Para: 1
Obstetrical Complaint: Abdominal pain, vaginal bleeding
To Labor and Delivery
Time in: 05:23
Blood Pressure: 134/87, Temperature: 100 F (Fahrenheit), Respirations: 20
Fetal Heart Rate: 145
05:47: Cervix dilated 1 centimeter per RN
06:37: Cervix dilated 3-4 centimeters per Obstetrician


VI. PI # 1's Operative Report at Hospital # 2:

Date of Service: 6/12/17

Preoperative diagnoses:
1. Intrauterine pregnancy at 27 weeks and 4/7th weeks, in active labor.
2. Preterm labor.
3. Previous cesarean section (surgical procedure used to deliver a baby through incisions in the mother's abdomen and uterus, mayoclinic.org/tests-procedures).
4. History of previous preterm delivery.
5. Malpresentation / transverse (abnormal position of the fetus in the birth canal, Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier).


Procedure: Classical cesarean section.

Postoperative Diagnoses:
1. Intrauterine pregnancy at 27 weeks and 4/7th weeks, delivered.
2. Preterm labor.
3. Previous cesarean section.
4. Previous preterm delivery.
5. Breech Presentation.

A. Indications: The patient (P # 1) presented with bleeding and abdominal pain. She is in active labor with the cervix dilated 4 cm (centimeter) by ultrasound and hourglass membranes into the vagina. She has a history of preterm delivery at 27 weeks. She had a previous cesarean section with her first delivery.

B. The patient delivered a viable infant at 07:00...Weight: 1 pound 15 ounces. The infant was in a transverse presentation, but converted to breech presentation for delivery. Estimated blood loss: 800 cc's (cubic centimeter).


VII. History and Physical for Baby (PI # 3 ) at Hospital # 2:

Admission Date: 6/12/17

Admission and Transfer Summary:

Chief Complaint: Extreme prematurity at 27 weeks.

History of Present Illness: "I was called to a C- Section this morning...for a 27 week estimated gestational age delivery. Mom (PI # 1) had a previous C-Section - came in dilated with a bulging bag. Baby was delivered by C-Section breech presentation. Amniotic fluid was clear. Rupture of membranes at delivery. The baby was limp and not breathing, had a heart rate of less than 100, but not above 60. PPV (Positive pressure ventilation: The provision of air under pressure by a mechanical respirator, a machine designed to improve the exchange of air between the lungs and the atmosphere, medicinenet.com) was initiated for three minutes in the C-section room with 100% oxygen. Apgars (a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score determines how well the baby tolerated the birthing process. The 5-minute score reveals how well the baby is doing outside the mother's womb, medlineplus.gov)."

"Baby was brought to the nursery...and weighed 870 grams. The initial oxygen saturation was 85% on room air. Blow-by was initiated and oxygen saturations improved to 95 - 100%....(blow-by: an imprecise method of oxygen delivery in which an oxygen source discharges oxygen in front of the nostrils or mouth of the patient. Used primarily to supply supplemental oxygen to neonates, who may not tolerate wearing other oxygen delivery systems, Medical Dictionary, © 2009 Farlex and Partners)."

Due to the baby's prematurity we elected to intubate the baby...Oxygen saturations rose to 100%...The baby was then placed on the ventilator at the pressure of 20/4 with a rate of 40 on 30% (oxygen). Oxygen saturations had been 95% to 100%. (ventilator: a machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently,wikipedia.org)."

"Blood sugar ...was 50 (normal level when babies are 1 hour to 2 hours old is just under 2 mmol/L millimoles per liter; the presence of high levels of glucose (sugar) in blood occurs due to the lack of sufficient levels of insulin in the body, dovemed.com)."

"...Heart rates in the 150's. Respiratory rates in the 40's to 60's. We will obtain a CBC (Complete Blood Count) and a blood culture. Arterial blood gases (ABG's) showed a pH of 7.61 with a PCO2 (partial pressure of carbon dioxide) of 20. PaO2 (partial pressure of arterial blood) at that time was 51. Bicarb was 20. We decreased the rate to 30. (ABG's measure the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery. This test is used to check how well the lungs are able to move oxygen into the blood and remove carbon dioxide from the blood, webmd.com)."

"Chest x-ray showed mild interstitial lung disease, but the Endotracheal Tube placement was good. (interstitial lung disease is characterized by progressive scarring of the lung tissue between and supporting the air sacs. Associated scarring may cause progressive lung stiffness, eventually affecting the ability to breathe and get enough oxygen into the bloodstream, mayoclinic.org).

"Transport has been arranged with Hospital # 3 and they are en route. We (Hospital # 2's staff) are going to obtain an IV (intravenous access), start D10W ( Dextrose 10 % In Water Intravenous Solution, webmd.com)...We will also give a Normal Saline bolus... (administration of a discrete amount of medication in order to raise its concentration in the blood to an effective level, wikipedia.org) and then will start Ampicillin and Gentamycin (antibiotics) after blood cultures are drawn...We will repeat ABG's in about thirty minutes. It is now 8 o'clock. I will discuss this with the patient (Patient Identifier # 1) who is currently recovering from the operation and consent will be obtained for transport."


VIII. History and Physical for Baby (PI # 33 ) at Hospital # 3: Neonatal Intensive Care (NICU):

"Date of Admission: 6/12/17
Time of Birth: 07:00

Referring Facility: Hospital # 2

Admission Diagnoses:

1. Preterm newborn with an estimated date of confinement of 9/7/17, placing baby at 27 weeks and 4 days gestation with a birth weight of 870 grams or 1 pound 15 ounces.
2. Stat C-section secondary to preterm labor and bleeding.
3. Respiratory distress syndrome.
4. Rule out sepsis.
5. Fluid, electrolytes, nutrition.
6. Maternal drug use."

"Baby was born to a 28 year old, gravida 2, para 1, mother...Pregnancy complications included a previous 27 'weeker' for which the mother received Makena injections ( medicine (progestin) used to lower the risk of preterm birth in women who are pregnant with one baby and who have delivered one baby too early in the past, makena.com) and maternal urine drug screen positive for THC on 2/9/17 and 6/12/17 (THC: the main psychoactive chemical in marijuana, responsible for most of it's intoxicating effects, is delta-9-tetrahydrocannabinol (THC), www.livescience.com).

"Delivery occurred via stat C-section (cesarean section) under general anesthesia secondary to preterm labor and bleeding. Rupture of membranes occurred at delivery. Delivery room resuscitation consisted of drying, stimulation, suctioning and mask bagging to blow-by oxygen. Apgar scores were 1 at 1 minute, 2 at 5 minutes, and 7 at 10 minutes. (At the five minute APGAR, a score of seven to ten is normal, americanpregnancy.org). Infant was taken to the nursery on blow-by oxygen. Infant was then intubated and x-ray confirmed placement ( intubated: insertion of a breathing tube through the mouth or nose into the trachea to ensure a patent airway for the delivery of anesthetic gases and oxygen or both, Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier). Curosurf was given (medicine indicated for the rescue treatment of Respiratory Distress Syndrome in premature infants, curosurf.com). IV attempts were unsuccessful. After the transport team arrived, (Dr...; last name of pediatrician at Hospital # 2)placed the single lumen UVC (Umbilical Vessel Catheter). Infant was transported to Hospital # 3 without incident."

" On arrival, single port umbilical venous catheter was changed to a dual-lumen umbilical venous catheter. Umbilical arterial catheter was unsuccessful...Initial glucose was 132 on D10 admit fluids.

Admission Physical Examination:

Weight: 1 pound 15 ounces...
Head Circumference: 23 centimeters.
Heart Rate: 162.
Respiratory Rate: 62.
Blood Pressure: 43/24.
Temperature: 98.3.
Oxygen Saturation: 89%.
General: ...Preterm appearing infant.
Skin: There are multiple areas of bruising.
HEENT /Head, eyes, ears, nose and throat: Anterior fontanelle soft and flat (Anterior fontanelle: one of the major bones that compose the skull of a newborn. These bony plates cover the brain and are held together by fibrous material called sutures, chw.org/medical-care/craniofacial).
Palate intact. Eyes and ears normally set.
Lungs: Coarse bilateral breath sounds with mild retractions.
Cardiac: Regular rate and rhythm. No murmur...
Abdomen: Soft non- tender...no organomegaly. There is a 3 vessel umbilical cord.
Genitalia: Normal preterm appearing genitalia.
Back: Overlying skin is intact.
Neurologic: Infant has appropriate tone and activity for gestational age.

Plan: Admit to NICU. We will continue n.p.o (nothing by mouth) with starter IV fluids..Continue Ampicillin and Gentamycin following cultures...Repeat does of surfactant ( a naturally produced substance that acts like grease within the lungs. Without it, the air sacs open but have difficulty remaining open because they stick together. Surfactant allows the sacs to remain open (aboutkidshealth.ca) and wean support (ventilator) as able..."


IV. Interviews:

Interview with Employee Identifier, EI # 3, Obstetrician at Hospital # 2 on 6/29/17 at 13:25:

According to EI # 3, the patient (PI # 1) and her grandmother presented to the ED at Hospital # 1. A nurse came out to the lobby and told PI # 1 "there was nothing the hospital could do." The patient and her grandmother left the ED and drove to Hospital #2. The surveyor asked the physician to explain the risk(s) related to the patient not being evaluated at Hospital # 1's ER. He replied, "An unattended preterm delivery in a vehicle." EI # 3 said, "An implication from staff about not offering services or suggesting a patient go to another hospital is inappropriate based on EMTALA (Emergency Medical Treatment and Labor Act) regulations." The patient (PI # 1) and her grandmother told the story to me separately. "I tend to believe them."

******

Standard Policies and Procedures: Imaging Department
Number: Not documented
Date Revised: 5/2016

...imaging: includes ultrasounds... (a noninvasive diagnostic test that uses sound waves to create a visual image of the baby, placenta, and uterus, as well as other pelvic organs (www.babycenter.com).

Hours: The Department is open from 06:30 to 23:00 Monday through Friday. Weekends are covered 24 hours Saturday and Sunday by an in-house Radiology Technologist... After 23:00 weekdays...ultrasounds are covered on an on call basis only for emergencies...

The June 2017 Ultrasound Call schedule revealed a technologist was on call on 6/12/17 when PI # 12 presented to the ED at Hospital # 1.


Interview on 6/28/17 from 15:10 to 15:25 with EI # 7, Director of Nurses:

According to EI # 7, Hospital # 1 has on call ultrasound coverage after 11:00 PM Monday thru Friday. EI # 7 reported that EI # 2, ED RN, may not be aware of this as they don't walk around the hospital as they may in other facilities.

EI # 7 verbalized in that he felt their was no violation here, but there are areas for improvement. EI # 7 reported he talked with the involved RN EI # 1 about presentation of information. EI # 7 verbalized, "its not what you say, but how you say it."


X. Standard Policies & Procedures
Department: Emergency Department
Subject: EMTALA (Emergency Medical Treatment and Active Labor Act) [Patient Transfers]
Date (s) Revised: 06/09/2008

ER Admissions/Patient Transfers
I. Introduction
...Wiregrass Medical Center is committed to full compliance with all state and federal laws regarding transfers of patients from one medical facility to another. Transfers of patients from...and to...may implicate the provisions of the Emergency Medical Treatment and Active Labor Act...the "anti-dumping law".

EMTALA generally requires that all hospitals with an emergency department:
Provides all patients who come to the emergency department seeking evaluation or treatment for a medical condition with an appropriate medical screening examination to determine where or not an emergency medical condition exists and,
If such condition exists either (a) stabilize the patient or (b) appropriately transfer the patient to another hospital.

An "emergency medical condition" is one with symptoms severe enough such that the absence of immediate medical treatment could reasonable be expected to result in:
placing the health of the individual (or with respect to a pregnant women, the health of the unborn child) in serious jeopardy...With respect to a pregnant women who is having contractions, an emergency medical condition is one which there is inadequate time to effect a safe transfer to another hospital before delivery, or transfer may pose a threat to the health of the woman or the unborn child.

An "appropriate medical screening examination" is one that is consistent with the medical examination which the Hospital would provide to any patient who presents with the same symptoms and clinical presentation as the patient seeking medical examination and treatment.

The term 'transfer" refers to any movement of the patient out of the Hospital at the direction of any person employed by, or otherwise affiliated with, the hospital...The term...does not include the movement of any person (1)...declared dead, or (2) leaves the Hospital without permission.

A person is not considered "stabilized" until such time as, within reasonable medical probability, no material deterioration of the medical condition is likely to result from, or to occur during, a transfer, or with respect to a pregnant woman in active labor, until delivery of he infant and the placenta. However, an unstable patient cab be transferred in accordance with the "appropriate transfer" provisions...

II. Policies and Procedure

B. Appropriate Medical Screening Examination
All patients who come to the Emergency Department seeking examination or treatment for a medical condition will be given an appropriate medical screening examination, within the capability of the Hospital's Emergency Department, by the Emergency Department physician on duty. The screening may not be delayed in order to inquire about...health insurance or...ability to pay. The Hospital may follow reasonable registration procedures, consistently applied to all patients, following triage by a registered nurse.

For the purpose of EMTALA, a patient has "come to the emergency department" if he/she is on hospital property. Hospital property refers to the entire main hospital campus, including parking lots, sidewalks, and driveways...

C. Patient Transfers
If the appropriate medical screening reveals that the patient has emergency medical condition, the patient will not be transferred or discharged until stabilized unless:
At the patient's...specific written request after being fully informed of the Hospital;s obligations under EMTALA, and of the risks and/or benefits of transfer, or A physician signs a certification...that the medical benefits reasonably expected...outweigh any increased risks...in the case of a woman in labor, or the woman her unborn child, from the transfer...

Prior to transferring any patient...the Hospital will provide medical treatment, within its capacity, that minimizes the risks to the patient's health and, in case of a woman in labor, to the health of the unborn child.
Also, prior to transfer, Wiregrass Medical Center will obtain from the receiving hospital's acknowledgement that the receiving hospital has available space and qualified personnel...and expressed agreement of the receiving hospital to accept the transfer and provide care to the patient. The name, title, and telephone number of the individual at the receiving hospital who accepts the transfer will be documented in the patient's medical record...Wiregrass Medical Center will send...all hospital medical records related to the medical condition...to there receiving hospital, at...the time of transfer...

Wiregrass Medical Center will take measures to affect the transfer through qualified personnel and with proper transportation equipment during the transfer.

Patients who are determined not to have an emergency medical condition will not be discharged or transferred o (to) other medical facilities unless a physician, in conjunction with nursing personnel:
assess the individual's vital signs and discharge status as soon as practical prior to transfer or discharge;
orally provides the individual with a post transfer or discharge plan of care;
certified the individual's non-emergency status;
assesses the individual's method of transportation from the hospital in light of the individual;s medical condition);
documents fully all of the above in a medical record for the patient; and
in the case of a patient transferred to another facility, sends...all medical records...

D. Patient Consent or Refusal
Wiregrass Medical Center will have satisfied it's obligations under EMTALA, if after being fully informed of the hospital's obligations under EMTALA, and the risks associated with refusing evaluation, treatment or transfer, the patient (or someone acting on his/her behalf);
refuses to allow the Hospital to provide an appropriate medical screening,
refuses to allow the Hospital to provide stabilizing treatment, or
refuses to allow the Hospital to transfer the patient...
The Hospital will fully disclose to the patient...its obligations under EMTALA, as well as refusing the risks for refusing examination, treatment or transfer, and will attempt to obtain any such refusal in writing.

When a patient (or someone acting on his/her behalf) requests transfer to another facility, the hospital will fully disclose to the patient...the Hospitals obligations under EMTALA, along with the risks associated with transfer, and will obtain any such in writing.

Wiregrass Medical Center has policies designed to provide reasonable assurance that a patient's refusal of treatment or his/her request for transfer is not coerced, or otherwise influenced by the Hospital...

Hospital staff will encourage any patient who believes he/she may have an medical emergency condition to remain at the Hospital for a medical screening and any necessary stabilizing treatment.

If an individual chooses to leave the Hospital prior to receiving a medical screening or stabilizing treatment, and the hospital is aware that he/she intends to leave, Hospital staff will:
Offer the individual further medical examination and treatment within the staff and facilities available at the Hospital; as may be required to identify and stabilize an emergency medical condition;
Inform the individual of the benefits of such examination and treatment and of the risks of withdrawal prior to receiving such examination; and
Take all reasonable steps to secure the individual's written informed refusal to such examination and treatment.

E. Record Keeping
The Hospital will maintain a log of all patients who come to the Emergency Department seeking examination or treatment of a medical condition. Including information regarding the patient's ultimate disposition-e.g... refused treatment, admitted, transferred, or discharged.

Based on medical record reviews, interviews and review of EMTALA (Emergency Medical Treatment and Labor) Policies and Procedures, Emergency Department policy and procedure, Hospital # 1 failed to arrange an appropriate transfer with qualified staff and equipment to Hospital # 2 for Patient Identifier (PI # 1), a high risk 27 week pregnant patient who presented to the Emergency Room with cramping and vaginal bleeding. As a result of this deficient practice, PI # 1 was transported via private vehicle to Hospital # 2 without being informed of the potential risks where delivery occurred via stat C-section under general anesthesia secondary to preterm labor and bleeding. The baby was limp and not breathing at birth and required ventilator support and transport to the Neonatal Intensive Care at Hospital # 3.


This deficient practice affected PI # 1, one of 32 sampled patients and has the potential to negatively impact all pregnant females who present to Hospital # 1 with similar obstetrical complaints.

Finding include:

I. Hospital # 1's ER (emergency) Log dated 6/1217 documented:

Patient Identifier (PI) # 1's Name.
Age: 28 years.
Sex: F.
Attending Physician: name of EI # 4 / ED Physician.
Stay Type: ER.
Admit date/time: 6/12/2017 04:39.
Admit Code: Emergency.
Discharge Date/Time: 6/12/2017 04:40.
Discharge Code: AMA.
Mode of arrival: Ambulatory.
Triage Level: Patient left.
Disposition: AMA.
Discharge Condition: Unknown.
Chief Complaint: Cramping, Bleeding, Pregnant.


II. ER Face Sheet for PI # 1 at Hospital # 1:

Date of Service: 6/12/17
Time: 04:39
Chief Complaint: Cramping, Bleeding, Pregnant


III. ER Triage / Physician Order Form:
No vital signs were documented. The RN's (Registered Nurse) Employee Identifier (EI # 1's ) name was documented on the form.
PI # 1's disposition was documented as LWBS (Left Without Being Seen).
Date: 6/12/17
Time: 04:40

There is no documentation in the ED record to indicate a transfer via ambulance was discussed with PI # 1 and/or her family.

04:40: "Patient left without being seen. She decided to go on to (name of town where Hospital # 2 is located) and see her OB-GYN" (physician). Documented by EI # 1.


Interview with Patient Identifier (PI # 1) on 6/28/17 at 13:50:

PI # 1 stated she arrived at Hospital # 1's ER on 6/12/17 at 04:30. "I told the receptionist I was bleeding, cramping and had a previous pregnancy at 27 weeks. I am a high risk pregnancy."

"I was scared. I was trying to get to the back (ED treatment area)." A nurse came out to the lobby and said the only thing she could do was check Fetal Heart Tones. She said there was no OB/GYN (Obstetrical/Gynecological Physician) at the hospital. She said it was best for me to go to (Hospital # 2)." PI # 1 described the ED nurses' attitude as "nonchalant." According to PI # 1, she and her mother left Hospital # 1's ER and drove to Hospital # 2.

Interview with Employee Identifier, EI # 3, Obstetrician at Hospital # 2, on 6/29/17 at 13:25.

According to EI # 3, the patient (PI # 1) and her grandmother presented to the ED at Hospital # 1. A nurse came out to the lobby and told PI # 1 "there was nothing the hospital could do." The patient and her grandmother left the ED and drove to Hospital # 2 on 6/12/17.

The surveyor asked the physician to explain the risk(s) related to the patient not being evaluated at Hospital # 1's ER. He replied, "An unattended preterm delivery in a vehicle." EI # 3 said, "An implication from staff about not offering services or suggesting a patient go to another hospital is inappropriate based on EMTALA (Emergency Medical Treatment and Labor Act) regulations." The patient (PI # 1) and her grandmother told the story to me separately. "I tend to believe them."

*********

Standard Policies & Procedures
Department: Emergency Department
Subject: EMTALA (Emergency Medical Treatment and Active Labor Act) [Patient Transfers]
Date (s) Revised: 06/09/2008

ER Admissions/Patient Transfers
I. Introduction
...Wiregrass Medical Center is committed to full compliance with all state and federal laws regarding transfers of patients from one medical facility to another. Transfers of patients from...and to...may implicate the provisions of the Emergency Medical Treatment and Active Labor Act...the "anti-dumping law".

EMTALA generally requires that all hospitals with an emergency department:
Provides all patients who come to the emergency department seeking evaluation or treatment for a medical condition with an appropriate medical screening examination to determine where or not an emergency medical condition exists and,
If such condition exists either (a) stabilize the patient or (b) appropriately transfer the patient to another hospital.

An "emergency medical condition" is one with symptoms severe enough such that the absence of immediate medical treatment could reasonable be expected to result in:
placing the health of the individual (or with respect to a pregnant women, the health of the unborn child) in serious jeopardy...With respect to a pregnant women who is having contractions, an emergency medical condition is one which there is inadequate time to effect a safe transfer to another hospital before delivery, or transfer may pose a threat to the health of the woman or the unborn child.

An "appropriate medical screening examination" is one that is consistent with the medical examination which the Hospital would provide to any patient who presents with the same symptoms and clinical presentation as the patient seeking medical examination and treatment.

The term 'transfer" refers to any movement of the patient out of the Hospital at the direction of any person employed by, or otherwise affiliated with, the hospital...The term...does not include the movement of any person (1)...declared dead, or (2) leaves the Hospital without permission.

A person is not considered "stabilized" until such time as, within reasonable medical probability, no material deterioration of the medical condition is likely to result from, or to occur during, a transfer, or with respect to a pregnant woman in active labor, until delivery of he infant and the placenta. However, an unstable patient cab be transferred in accordance with the "appropriate transfer" provisions...

II. Policies and Procedure

B. Appropriate Medical Screening Examination
All patients who come to the Emergency Department seeking examination or treatment for a medical condition will be given an appropriate medical screening examination, within the capability of the Hospital's Emergency Department, by the Emergency Department physician on duty. The screening may not be delayed in order to inquire about...health insurance or...ability to pay. The Hospital may follow reasonable registration procedures, consistently applied to all patients, following triage by a registered nurse.

For the purpose of EMTALA, a patient has "come to the emergency department" if he/she is on hospital property. Hospital property refers to the entire main hospital campus, including parking lots, sidewalks, and driveways...

C. Patient Transfers
If the appropriate medical screening reveals that the patient has emergency medical condition, the patient will not be transferred or discharged until stabilized unless:
At the patient's...specific written request after being fully informed of the Hospital;s obligations under EMTALA, and of the risks and/or benefits of transfer, or A physician signs a certification...that the medical benefits reasonably expected...outweigh any increased risks...in the case of a woman in labor, or the woman her unborn child, from the transfer...

Prior to transferring any patient...the Hospital will provide medical treatment, within its capacity, that minimizes the risks to the patient's health and, in case of a woman in labor, to the health of the unborn child.
Also, prior to transfer, Wiregrass Medical Center will obtain from the receiving hospital's acknowledgement that the receiving hospital has available space and qualified personnel...and expressed agreement of the receiving hospital to accept the transfer and provide care to the patient. The name, title, and telephone number of the individual at the receiving hospital who accepts the transfer will be documented in the patient's medical record...Wiregrass Medical Center will send...all hospital medical records related to the medical condition...to there receiving hospital, at...the time of transfer...

Wiregrass Medical Center will take measures to affect the transfer through qualified personnel and with proper transportation equipment during the transfer.

Patients who are determined not to have an emergency medical condition will not be discharged or transferred o (to) other medical facilities unless a physician, in conjunction with nursing personnel:
assess the individual's vital signs and discharge status as soon as practical prior to transfer or discharge;
orally provides the individual with a post transfer or discharge plan of care;
certified the individual's non-emergency status;
assesses the individual's method of transportation from the hospital in light of the individual;s medical condition);
documents fully all of the above in a medical record for the patient; and
in the case of a patient transferred to another facility, sends...all medical records...

D. Patient Consent or Refusal
Wiregrass Medical Center will have satisfied it's obligations under EMTALA, if after being fully informed of the hospital's obligations under EMTALA, and the risks associated with refusing evaluation, treatment or transfer, the patient (or someone acting on his/her behalf);
refuses to allow the Hospital to provide an appropriate medical screening,
refuses to allow the Hospital to provide stabilizing treatment, or
refuses to allow the Hospital to transfer the patient...
The Hospital will fully disclose to the patient...its obligations under EMTALA, as well as refusing the risks for refusing examination, treatment or transfer, and will attempt to obtain any such refusal in writing.

When a patient (or someone acting on his/her behalf) requests transfer to another facility, the hospital will fully disclose to the patient...the Hospitals obligations under EMTALA, along with the risks associated with transfer, and will obtain any such in writing.

Wiregrass Medical Center has policies designed to provide reasonable assurance that a patient's refusal of treatment or his/her request for transfer is not coerced, or otherwise influenced by the Hospital...

Hospital staff will encourage any patient who believes he/she may have an medical emergency condition to remain at the Hospital for a medical screening and any necessary stabilizing treatment.

If an individual chooses to leave the Hospital prior to receiving a medical screening or stabilizing treatment, and the hospital is aware that he/she intends to leave, Hospital staff will:
Offer the individual further medical examination and treatment within the staff and facilities available at the Hospital; as may be required to identify and stabilize an emergency medical condition;
Inform the individual of the benefits of such examination and treatment and of the risks of withdrawal prior to receiving such examination; and
Take all reasonable steps to secure the individual's written informed refusal to such examination and treatment.

E. Record Keeping
The Hospital will maintain a log of all patients who come to the Emergency Department seeking examination or treatment of a medical condition. Including information regarding the patient's ultimate disposition-e.g......, refused treatment, admitted, transferred, or discharged.

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Standard Policies & Procedures .
Department: Emergency Department
Subject: Standard of Care- COBRA (Consolidated Omnibus Reconciliation Act)Guidelines
Date (s) Issued: 8-4-2000

Statement of Purpose:
To establish guidelines for treating Emergency Department patients while staying within COBRA guidelines

Text:
All patients presenting to Hospital # 1 Wiregrass Medical Center for a non-scheduled visit and seeking care must be accepted and evaluated regardless of the patient's ability to pay.

All patients shall receive a medical screening exam that include all necessary testing an on-call services within then capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment...be given to the patient...

The patient must be transferred by an appropriate medical transfer vehicle...must not be transferred in a private passenger vehicle unless the patient refused to be transported by ambulance...the refusal must be in writing....

Medical Screening Exams:

Medical Screening Exams should include at minimum the following:
Emergency Department log entry including disposition of patient;
Patient's triage record;
Vital signs;
History;
Physical exam of the affected systems and potentially affected systems;
...Necessary testing...
Notification and use of on-call physicians to diagnoses and/or stabilize the patient...
Vital signs upon discharge or transfer;
Complete documentation of the medical screening exam.

Emergency Medical Conditions:
Emergency Medical Conditions under COBRA law constitute any condition that is a danger to the patient or unborn fetus or or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future.

Emergency medical conditions include:
Undiagnosed, acute pain which is sufficient to impair normal functioning
Pregnancy with contractions (defined as unstable)...

Conclusion:

The ED RN (EI # 1) at Hospital # 1 failed to inform and document that PI # 1 was informed of the risks associated with private vehicle transport from Hospital # 1 to Hospital # 2, which is approximately a 30 minute drive, 24 miles one way.

There was no documentation staff at Hospital # 1 offered assistance by emergency transport to Hospital # 2 or that PI # 1 refused emergency transport.