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Based on documentation review of twenty emergency department/obstetrical emergency records, including patient #1's 02/05/13 record, a review of the hospital's bylaws, and a review of the policies and procedures for patients who present to the emergency department, it was determined that in one patient (patient #1) of twenty patients who presented to the hospital requesting emergency services, hospital #1 failed to ensure compliance with 489.24.
Findings include: Refer to A2409

Based on documentation and interviews, hospital #1 failed to ensure that each patient who presented to the emergency department or was triaged to the obstetrical unit with an emergency medical condition, received an appropriate transfer/discharge, including prior stabilization, in one of twenty patients reviewed (patient #1). Patient #1 first called the hospital's OB department and spoke with a nurse, then presented to the hospital in labor. The hospital identified that the patient had an emergency medical condition. The hospital then instructed the patient to go to another hospital via her private care. Patient #1 did not request the transfer, a certification form that summarized the risks and benefits of the transfer was not completed and discussed with patient #1 and necessary medical records were not sent with patient #1 at the time of transfer.
Findings include:

Patient #1 was thirty-seven weeks pregnant and presented to hospital #1 for evaluation of labor and ruptured membranes on 2/5/13. The patient was triaged to the obstetric unit where she was evaluated by nurse (F). The assessment revealed that the patient's membranes had ruptured and that the patient was 4.0 cm dilated. Nurse (F) contacted on-call physician (I), and the physician provided a telephone order to discharge patient #1 by car to hospital #3 ( hospital #3 is located fifty-two miles from hospital #1) for delivery by her primary obstetrician. Physician (I) did not come to the hospital to evaluate patient #1's condition. During the drive to hospital #3, patient #1's contractions increased in frequency and severity, and it was necessary for patient #1 to go to hospital #2 (twenty-nine miles from hospital #1) for care. Patient #1 was having contractions every 2-3 minutes and was dilated to 6-7 cm when she arrived at hospital #2. The patient arrived at hospital #2 without any treatment records from hospital #1 and delivered her infant thirty minutes after her arrival at hospital #2.

Patient #1's obstetrical unit (OB) record from hospital #1 was reviewed. The Notes Log, completed by nurse (F), revealed that patient #1 arrived on the OB unit on 2/5/13 at 5:19 p.m. with ruptured membranes and in labor with contractions every three to four minutes that lasted one minute. Patient #1's due date was 02/26/13. Patient #1 was identified as a high risk pregnancy history related to having eighteen pregnancies and fourteen miscarriages. Patient #1 received a screening examination from nurse (F), and the vaginal examination revealed that patient #1 was dilated to 4 cm. and had a 60% effacement. During the examination, fetal heart tones and vital signs were checked. Nurse (F) called physician (I), who was on call for the OB unit, and provided physician (I) with information about patient #1's condition. A note written by nurse (F), at 5:26 p.m., indicated physician (I) responded with an order to discharge patient #1 to patient #1's primary hospital, hospital #3 and that patient #1's primary physician could deliver the baby. Nurse (F) told patient #1 and her significant other that physician (I) wanted patient #1 discharged to hospital #3 for delivery of the baby and told the couple to go directly to hospital #3. After patient #1 left the OB unit, nurse (F) called hospital #3 and advised the hospital that the patient was on her way. The notes did not indicate that patient #1 requested to be sent to hospital #3 for delivery. The notes did not indicate that physician (I) came to hospital #1 to examine patient #1 or that physician (I) had a telephone conversation with patient #1. Patient #1's medical record did not contain documentation in regard to the risks and benefits of a transfer.

A 2/5/13, at 5:24 p.m., physician's telephone order given by physician (I) to nurse (F) was reviewed. The telephone order indicated that patient was to be discharged to hospital #3 for delivery with patient #1's own obstetrician. The telephone order was signed by physician (I) at 8:00 a.m. on 2/7/13.

Patient #1's ED/OB record from hospital #2 was reviewed. The record indicated patient #1 arrived at hospital # 2 on 2/5/13 at 6:15 p.m. and stated she had been at hospital #1 with severe labor pains and was discharged and told to drive to hospital #3 for delivery by her primary obstetrician. Patient #1 was 6 cm. dilated and having contractions every two to three minutes when she arrived at hospital #2. The record indicated patient #1 had a precipitous labor and delivered the baby thirty minutes after patient #1's arrival at hospital #2. Patient #1 was discharged from hospital #2 on 2/7/13.

Hospital #1 reviewed the incident and interviewed both the nurse and the physician.
A review of hospital documentation indicated that Nurse (F) was interviewed by hospital staff on 2/11/13, and provided the following information: Patient #1 called the OB unit at approximately 5:00 p.m. on 2/5/13 and told nurse (F) that she thought her membrane had ruptured. After patient #1 arrived at the OB unit, nurse (F) examined patient #1. The patient was dilated to 4 cm. and was 60% effaced, full term, having moderate contractions every four minutes and her membrane had ruptured prior to her arrival at hospital #1. Nurse (F) called physician (I) and provided her with the information about patient #1's condition. The conversation with physician (I) was very brief, and physician (I) told nurse (F) to send patient #1 to hospital #3 to be delivered by her own physician. Physician (I) did not ask for any additional information. Nurse (F) followed physician (I's) order and discharged patient #1 and told her to go directly to hospital #3. After the patient left, nurse (F) called hospital #3 and reported that patient #1 was on her way. Ten minutes after patient #1 left, physician (I) called back and asked "is the patient on her way?" Then physician #1 stated, had the patient been 100% effaced, she would not have discharged patient #1 but felt comfortable about the discharge because the patient was only 60% effaced.

Hospital documentation also indicated that physician (I) was interviewed by hospital staff on 2/12/13, and provided the following information: Physician (I) stated nurse (F) told physician (I) that patient #1 preferred to see her own physician at hospital #3. Physician (I) stated there was not a medical reason for transferring patient #1 to hospital #3, and the sole reason for the transfer was because it was the patient's preference. Physician (I) stated she later called hospital #1's OB unit and was told that patient #1 was discharged and on her way to hospital #3. Physician (I) continued to state that the reason for her decision to transfer patient #1 to hospital #3 was based on the patient's desire to see her own physician.

When interviewed by the SA investigator by phone on 2/20/13, at approximately 9:00 a.m., patient #1 told the investigator that her water broke prior to arriving at hospital #1 on 2/5/13. Patient #1 stated she was seeking care when she came to hospital #1, and she had planned to deliver at hospital #1 following her arrival. She stated she was in labor and dilated to 4 cm. and her contractions were three minutes apart and strong when she arrived at hospital #1. Nurse (F) checked patient #1 and called physician (I) and told the physician that patient #1 was dilated to 4 cm. Patient #1 did not request to be sent to hospital #3 for delivery and further care. Physician (I) gave the nurse an order to discharge patient #1 to the hospital #3 delivery of the baby. Patient #1's husband asked nurse (F) if patient #1 could be transported by ambulance to hospital #3, and the nurse said the patient could not be transported by ambulance because it was not cost effective. Patient #1 stated she felt very pressured to leave hospital #1. After leaving hospital #1, patient #1 and her husband called hospital #3 and reported that her labor was rapidly progressing and that they would not be able to make it to hospital #3, but instead they would have to go to hospital #2 for care. Hospital #3 advised them to call an ambulance. Patient #1 stated she was screaming and very uncomfortable during the drive to hospital #2. She stated she was dilated to 6 cm when she arrived at hospital #2. There was no time for patient #1 to receive any pain medication prior to the delivery at hospital #2. Patient #1 stated it was a very "harsh" situation.

When interviewed by the SA investigator in person on 2/19/13 at 2:15 p.m. and by phone on 2/20/13 at 8:30 a.m., nurse (F) told the investigator that patient #1 did not request to be sent to hospital #3 for delivery of her baby, and she was seeking care when she arrived at hospital #1. Physician (I) gave nurse (F) a telephone order to discharge patient #1 and send her to hospital #3 for delivery of her baby. Physician (I) did not come in to check patient #1 and did not state that she was coming to see patient #1 at any point. No discharge/transfer paperwork, including labor precautions, was given to patient #1 when she left hospital #1.

When interviewed by phone on 2/21/13 at 11:00 a.m., physician (I) told the investigator that she is an obstetrician/gynecologist and that she began her full time employment at hospital #1 on 12/14/11. Physician (I) stated she did not review patient #1's 2/5/13 OB hospital record prior to this interview. She stated she did not tell nurse (F) that she was coming to the hospital to see patient #1. However, she stated she was on her way to the hospital. She further stated she did not give nurse (F) a telephone order to discharge patient #1 to hospital #3. Nurse (F) told physician (I) about patient #1's pregnancy history and that her membrane was ruptured. Patient #1 went to the hospital on 2/5/13 to pick up some papers and to check on the status of her labor. Nurse (F) "implied" that patient #1 wanted to go to hospital #3. Physician (I) stated she "usually" comes to the hospital when a patient is dilated to 4 cm. and "usually" would not transfer a patient who is dilated to 4 cm. Physician (I) stated patient #1 was not transported by ambulance because an "unnecessary ambulance ride" would not be paid by health insurance. Physician (I) acknowledged that the hospital placed her on an administrative leave until 4/1/13 following the incident involving patient #1. She stated she submitted her written resignation to the hospital on 2/18/13 and explained that she will not be working full time at the hospital after 4/1/13.