HospitalInspections.org

Based on document review and staff interview the hospital failed to provide an appropriate medical screening exam for one patient (Patient 1) during her admission to the emergency department with the resulting risk of harm to both the patient and to her infant who was delivered in transit.

Finding:

During a review of the electronic medical record on 9/8/16 at 11:50AM, a Quality Management staff (QM), acknowledged Patient 1 arrived to the Emergency Department (ED) on 8/24/16 3:51 AM. Review of the "Triage" note entered at 3:57 AM indicated "...presents to the ED with lower abdominal cramping. 24 weeks pregnant...EDD (estimated delivery date) 12/11/16. Pain intermittent since 12 midnight. 1 episode of vaginal discharge with some bleeding noted. Cramping at triage for 10 minutes."
At 4:18 AM under "Nurses Notes: Patient examined by physician...".
At 5:38 AM an ED physician (MD 1) entered "History of Present Illness...approximately 25 weeks pregnant...".
At 5:42 AM MD 1 wrote "Doctor Notes...based on the physical exam and history, concern is high for labor cramps,...patient will require fetal monitoring...Spoke with Dr...at [GACH] L and D (labor and delivery) who agrees with transfer. Patient's boyfriend will drive them by private car...".
At 4:21 AM MD 1 wrote under "Disposition Type: Discharge...[GACH] Labor and Delivery, Disposition Transport: Auto".

During an interview on 9/14/16 at 10 AM, MD 1 was asked if he had performed a pelvic exam on Patient 1. He replied that the patient required a higher level of care and that he did not want to delay that by doing a pelvic exam. In addition he stated that a pelvic exam might complicate future examinations that would be done once she arrived in Labor and Delivery so he thought it would be better to defer the exam. He was also asked if he performed a Doppler test for fetal heart tones, to which he replied no. When asked how he determined that Patient 1 was stable for transfer, he replied that since all her vital signs were stable, she looked comfortable and there was no external sign of active bleeding, she was stable. When asked if the patient was having contractions, he answered, "she was likely having contractions." MD 1 was asked if a risk/benefit analysis was done. He stated that because the patient's baby was just past the cusp of viability and that our hospital does not have labor & delivery services and no neonatal intensive care, it would be better to send the patient via her boyfriend's private car to the receiving hospital rather than wait for an ambulance.

Based on interview and record review, the facility failed to appropriately transfer one of twenty two sampled patients, Patient 1, to another hospital when:
1. Physician certification form for the transfer was not completed.
2. Patient 1, while in labor, was transferred via personal car.
This deficient practice resulted in a potential risk for harm to Patient 1 and to her infant who was delivered in transit.


Findings:


During a review of the electronic medical record on 9/8/16 at 11:50 AM, a Quality Management staff (QM), acknowledged Patient 1 arrived to the Emergency Department (ED) on 8/24/16 at 3:51 AM. Review of the "Triage" note entered at 3:57 AM indicated "...presents to the ED with lower abdominal cramping. 24 weeks pregnant...EDD (estimated delivery date) 12/11/16. Pain intermittent since 12 midnight. 1 episode of vaginal discharge with some bleeding noted. Cramping at triage for 10 minutes."
At 4:18 AM "Nurses Notes: Patient examined by physician...".
At 5:38 AM an ED physician (MD 1) entered "History of Present Illness...approximately 25 weeks pregnant...".
At 5:42 AM MD 1 wrote "Doctor Notes...based on the physical exam and history, concern is high for labor cramps,...patient will require fetal monitoring...Spoke with Dr...at [GACH 3] L and D (labor and delivery) who agrees with transfer. Patient's boyfriend will drive them by private car...".
At 4:21 AM MD 1 wrote "Disposition Type: Discharge...[GACH 3] Labor and Delivery, Disposition Transport: Auto".


During an interview on 9/8/16 at 12:15 PM, QM stated "Pregnant patients are followed at our facility. We have an agreement with GACH 3 for Labor and Delivery (L and D). When patients come to the ED and are sent to L and D, they are given a printout of the ED paperwork to take with them, and family may take patients there in their own vehicle. Patients are aware they will deliver their baby at GACH 3..."


QM printed a copy of Patient 1 ED medical record and stated "This is Patient 1's full ED record...there is not a transfer form...". Review of that printed copy did not indicate a discussion with Patient 1 or her husband about the risks and benefits of the transfer to Labor and Delivery via their own car. There was no evidence of consent to the transfer using that vehicle.


During a phone interview on 9/14/16 at 10:00 AM, MD 1 stated "Patient 1 was definitively a transfer to [GACH 3] L and D...I was concerned she could be in labor, she could possibly deliver her baby, Patient 1 pregnancy was a high risk...I did not want her delivering early nor to delay her care...I can't explain why a transfer form was not completed...,". When asked about the option of using an ambulance with qualified personnel to transport Patient 1, MD 1 stated "I was told by the clerk that it would take 45 minutes to get an ambulance...".


Record review of a 9/7/16 printed copy of Patient 1's ED electronic record from [GACH 2] indicated under "Chief Complaint: ...went into labor on the way here. Baby was out but placenta was not...". Under "ED Provider Notes", a physician entry on 8/24/16 read "...Primigravida [first pregnancy]...denies problems prenatal...patient was on way to [GACH 3]....child had delivered in car now in parking lot. Patient presents with fetus on her chest. The umbilical cord was clamped and cut. Child quickly handed off to peds/NICU [Neonatal Intensive Care Unit]...Clinical Impressions: Precipitous delivery...Sent to Labor and Delivery".


Record review of [GACH 2] 9/2/16 entity reported incident statement to State Agency indicated "...The patient delivered her child in route to [GACH 3]...Arrived on 8/24/16 at 5:15 AM and her child was not breathing. A code blue was called in the [GACH 2] ED and the patient's [Patient 1's] child expired".


Record review of a facility's blank form titled "Patient Referral Form for Transfer" indicated in section "Certification- Physician must complete" and check boxes for "Patient condition at time of transfer, It is my medical judgment that this transfer will not create a medical hazard for this patient, The reason for transfer have been explained to the patient and the patient understands and agrees,...". At the bottom of the form there was a "Patient signature..." space for "Patient consent to transfer: All transfers have inherent risks of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transport units that may limit available care in the event of a crisis."


Record review of a facility policy most recent review date of "04/04" and titled "Transfer of the Patient in Early Labor" indicated under "Policy: The patient who presents to the Emergency Department in labor will be triaged and classified as an emergent patient and immediately evaluated..., 3...the Emergency Department will complete the necessary transfer forms and arrange transportation to [GACH 3] as appropriate..."


Record review of a facility policy most recent review date of "6/11/2014" and titled "Emergency Medical Patient Transfers..." indicated under "Purpose...to provide emergency medical services, and that patients requiring transfer to another facility for any reason will be transferred safely and without delay. III. Patient transfers involve the following physician and hospital staff responsibilities:...I. All patient transfer documents including...Patient transfer Acknowledgement, Patient Transfer Form...and Physician Certification...IV...C. Transfer of Patients with Unstable Emergency Medical Condition. If the individual is in active labor...the patient may not be transferred unless the following conditions are met: 1. The individual or individual's legal representative...after being fully informed of the risks and possible benefits...signs the Patient Request/Refusal/Consent to transfer under EMTALA... 2. The emergency physician has signed a certification,..."