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Based on interviews and review of the facility's Labor and Delivery Logbook, medical records, and facility policies, it was determined the facility failed to ensure stabilizing medical treatment was provided for one (1) of twenty (20) sampled patients (Patient #1) that presented to the facility's Labor and Delivery (L&D) Department for an Emergency Medical Condition.

Interviews revealed Patient #1 presented to the L&D on 09/11/16 with a complaint of active labor. Patient #1 was taken to a room and provided with a medical screening by Registered Nurse (RN) #1 and informed she was dilated to one (1) centimeter. Patient #1's family member stated RN #1 informed her that the patient's Obstetrician (OB) (Physician #1) did not deliver at Facility #1 and RN #1 would contact the OB on call (Physician #2). Physician #2 did not return RN #1's calls and Advanced Practice Registered Nurse (APRN) #1 was contacted. APRN #1 gave RN #1 an order to "discharge [Patient #1] to [Facility #2]" (23 miles away) where Physician #1 would deliver the baby. At approximately 11:15 AM, RN #3 assessed Patient #1 and found the patient to be "dilated to 3." RN #1 and RN #3 failed to contact APRN #1 with the change in Patient #1's condition. Patient #1 left Facility #1 in a privately owned vehicle and arrived at Facility #2 at 12:14 PM. Patient #1 delivered by Caesarean section at 1:38 PM due to fetal intolerance of labor.

Refer to 42 CFR 489.24 (d)(1-3) Stabilizing Treatment (A2407).

Based on interviews and review of the facility's Labor and Delivery Logbook, medical records, and facility policies, it was determined the facility failed to ensure stabilizing medical treatment was provided for one (1) of twenty (20) sampled patients (Patient #1) that presented to the facility's Labor and Delivery (L&D) Department for an Emergency Medical Condition. Interviews revealed Patient #1 presented to the L&D on 09/11/16 with a complaint of active labor. Patient #1 was taken to a room and provided with a medical screening by Registered Nurse (RN) #1 and informed she was dilated to one (1) centimeter. Patient #1's family member stated RN #1 informed her that the patient's Obstetrician (OB) (Physician #1) did not deliver at Facility #1 and RN #1 would contact the OB on call (Physician #2). Physician #2 did not return RN #1's calls and Advanced Practice Registered Nurse (APRN) #1 was contacted. APRN #1 gave RN #1 an order to discharge Patient #1 to Facility #2 (23 miles away) where Physician #1 would deliver the baby. At approximately 11:15 AM, RN #3 assessed Patient #1 and found the patient to be dilated to three (3). RN #1 and RN #3 failed to contact APRN #1 with the change in Patient #1's condition. Patient #1 left Facility #1 in a privately owned vehicle and arrived at Facility #2 at 12:14 PM. Patient #1's baby was delivered by Caesarean section at 1:38 PM due to fetal intolerance of labor.

The findings include:

Review of the facility's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," revised and effective 07/25/16, revealed the facility will provide a medical screening examination to any individual who comes seeking examination or treatment for an emergency medical condition. Further review of the policy revealed if it is determined that the patient has an emergency medical condition, the facility will provide the patient with such further medical examination and treatment required to stabilize the emergency medical condition.

Review of the facility's policy titled, "Emergency Medical Screening for Labor & Delivery," effective 08/08/16, revealed after an initial assessment is conducted by qualified medical personnel, the provider should be notified by the RN. Further review of the policy revealed Registered Nurses designated as qualified medical personnel to provide care for obstetric patients during the initial assessment and triage period of an emergency medical exam had the following competencies: completion of unit based orientation; minimum of six (6) month labor and delivery experience; completion of AWHONN (The Association of Women's Health, Obstetric and Neonatal Nurses) intermediate fetal monitoring; and completion of EMTALA (Emergency Medical Treatment and Active Labor Act) Education. Continued review of the policy revealed the provider would be notified after the initial assessment, unless earlier notification is warranted by the Registered Nurse and/or requested by the provider. The decision of the existence of an emergency medical condition is determined by the provider and a false labor diagnosis must be certified by the provider.

Review of the Labor and Delivery Logbook revealed Patient #1 presented on 09/11/16 at 9:27 AM with a chief complaint of "labor." Continued review of the Logbook revealed Patient #1 was discharged on 09/11/16 at 11:15 AM with a disposition of "discharge to go to [Facility #2]."

Review of Patient #1's medical record revealed the facility admitted Patient #1 on 09/11/16 with a diagnosis of "active labor." Continued review of the record revealed at 9:30 AM, RN #1 assessed Patient #1 to be "Station: 0; Position: vertex; Dilation: 1; Effacement: 70; Position: posterior; Consistency: soft." RN #1 documented at 9:45 AM "contraction intensity to be mild-strong; activity: breathing with contractions; position: semi-fowlers; pain: 4." Further review of the medical record revealed RN #1 documented at 10:15 AM "contractions were every 3 to 6 minutes lasting 60-80 seconds." RN #1 contacted Physician #2 at 10:15 AM and left a message for a return call. A second call for orders to Physician #2 was documented at 10:38 AM with a message left. RN #1 contacted APRN #1 at 10:52 AM and notified her of "patient arrival with SROM [Spontaneous Rupture of Membranes], VE [Vaginal Exam] 1-/70/0. Contraction pattern of 3-6 minutes reviewed, reactive NST [Non-Stress Test]." RN #1 documented an order to "discharge [Patient #1] to [Facility #2]." RN #3 documented at 10:58 AM "[Patient #1] was dilated to 3 with effacement of 70 in the posterior position." RN #1 entered into the record at 12:48 PM "patient discharged to [Facility #2]."

Interview with RN #1 on 10/10/16 at 3:35 PM revealed she was working in Labor & Delivery on 09/11/16 and recalled Patient #1. RN #1 stated Patient #1 presented with her "water broke" and in labor. RN #1 stated she informed APRN #1 that Patient #1 was dilated to one (1) centimeter and APRN #1 felt Patient #1 was ok to "discharge to [Facility #2]." RN #1 stated that she did not think this was a "transfer" so she did not fill out the EMTALA forms. RN #1 stated she did not contact APRN #1 with the change in Patient #1's condition after RN #3 had assessed the patient and found her to be dilated to three (3) because she already received the order for discharge and did not think it was necessary to notify APRN #1 again. RN #1 stated she did contact Facility #2 and give report to a Labor and Delivery nurse.

Interview with RN #3 on 10/11/16 at 10:30 AM revealed that she was working in Labor & Delivery on 09/11/16 and assisted RN #1 with Patient #1. RN #3 stated she checked Patient #1 when she first arrived and the patient was dilated to one (1) centimeter at that time. RN #3 stated she checked Patient #1 right before discharge and the patient was then dilated to three (3) centimeters; however, she did not contact APRN #1 nor did she think RN #1 did. RN #3 stated that Patient #1 was not her patient and she did not think it was her responsibility to contact APRN #1.

Interview with Patient #1's family member on 10/10/16 at 12:24 PM revealed she was with Patient #1 at Facility #1 on 09/11/16. The Family Member of Patient #1 stated she overheard nurses stating "that [Physician #2] likes to do the easy part then let us do the hard part." Patient #1's family member stated Patient #1 wanted to remain at Facility #1 but was never given the option. Further interview with the Family Member of Patient #1 revealed that Facility #1 never offered Patient #1 Emergency Transportation to Facility #2, and just discharged Patient #1 to go to Facility #2 in their personal vehicle, wearing a hospital gown. Patient #1's Family Member stated that upon arrival at Facility #2 Patient #1 was immediately taken to the floor and then it was decided the baby was in distress and the baby was taken by Caesarean section at approximately 1:38 PM.

Interview with Physician #2 on 10/11/16 at 9:40 AM revealed he was the on-call OB on 09/11/16 for Facility #1. Physician #2 stated that he contacted Facility #1 after APRN #1 had given the order to discharge Patient #1. Physician #2 stated that labor is considered active when a patient is dilated to three (3) or four (4) centimeters. Physician #2 stated he agreed with APRN #1's medical decisions based on the information she had been given by the nursing staff.

Interview with Physician #1 on 10/11/16 at 11:00 AM revealed he was Patient #1's Obstetrician. Physician #1 stated that he did not receive any call from Facility #1 to inform him that his patient was in labor and on the way to Facility #2. Physician #1 stated that if Facility #1 had contacted him, he would have accepted transfer of his patient as long as the patient was transported by Emergency Medical Services; or he would have been in agreement with the patient remaining at Facility #1 and delivering the baby. Physician #1 stated Patient #1 delivered by Caesarean section at 1:38 PM due to fetal intolerance to labor.

Review of Patient #1's medical record from Facility #2 revealed the facility admitted Patient #1 on 09/11/16 at 12:09 PM with a diagnosis of "active labor." Continued review of the medical record revealed Physician #1 documented Patient #1 "recently arrived to L&D as transfer from [Facility #1]. On auscultation fetal heart rate in 60's per nursing, recovered with reassuring pattern." Continued review of the medical record revealed Physician #1 was called and "[Patient #1] was contracting irregularly and had epidural in place." Further review of the record revealed Physician #1 was contacted by nursing staff after completing his evaluation and was informed Patient #1 had a "prolonged decel." Physician #1 called an emergent Caesarean section and Patient #1 delivered at 1:38 PM. The facility discharged Patient #1 on 09/13/16.