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Based on documentation review of twenty emergency department/obstetrical emergency records, including patient #1's 03/28/13 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 tag 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 presented to the hospital's OB unit with a complaint of a sudden onset of headaches and a history of hypertension. The hospital nursing staff identified that the patient had an emergency medical condition. The patient was transferred to another hospital, (sixty-eight miles away), via her private car, for further care.
Findings include:

Patient #1 was thirty-eight and 1/7 weeks pregnant and presented to hospital #1 for evaluation of a sudden onset of headaches and a history of hypertension on 3/28/13 at 8:40 p.m. The patient was sent to the obstetric unit by the admissions staff where she was evaluated by nurse (D). The assessment revealed that the patient was not in labor. The patient's blood pressure was 150/90, and a urinalysis revealed that the protein level in the patient's urine was 2+. Nurse (D) contacted the on-call OB/GYN physician (G) about patient #1's symptoms, and the physician provided a telephone order to discharge patient #1 by car to hospital #2 (hospital is located sixty-eight miles from hospital #1) for follow-up care with her primary obstetrician. Physician (G) did not come to the hospital to evaluate patient #1's condition. The patient arrived at hospital #2 on 3/28/13 at 11:35 p.m. without a certification form that summarized the risks and benefits of the transfer and without all of the necessary medical records from hospital #1. Upon her arrival at hospital #2, patient #2 was immediately admitted to the Obstetrics unit with diagnoses of gestational diabetes, morbid obesity, and pre-eclampsia. Patient #1 complained of a frontal headache and dizziness and her blood pressure was 173/104. Patient #1 was examined at hospital #2 by physician (E), and it was determined that she required a vaginal delivery (via Pitocin induction at 1:24 a.m. on 3/29/13) as soon as possible. However, patient #1's delivery did not progress well, and patient #1 had a Cesarean section with delivery of her infant on 3/30/13 at 10:56 a.m.

Patient #1's 3/28/13 OB record from hospital #1 was reviewed. The admission notes, completed by nurse (D), revealed that patient #1 arrived at hospital #1's OB/GYN unit on 3/28/13 at 8:40 p.m. Patient #1 was in her third trimester of pregnancy (patient #1 was not in labor) and was due on 4/12/13 with her first child. Patient #1 complained of a sudden onset of headaches and indicated she had maternal gestational diabetes. Patient #1 also stated she had a history of hypertension and had been monitoring her blood pressure at home. Due to the risk of patient #1 developing toxemia, patient #1's urine was checked for protein while at hospital #1. Patient #1's protein level was 2+ and her blood pressure was 150/90. Patient #1 was not seen by a physician while at hospital #1. Nurse (D) conducted patient #1's medical screening examination and assessment (including vital signs & fetal heart tones) and provided physician (G) with the results via phone. Physician (G) advised nurse (D) to contact hospital #2 and inform hospital #2 that patient #1 would be discharged from hospital #1 and would be coming to hospital #2 immediately (sixty-eight miles away) via private car for further evaluation by her primary physician. The record revealed that patient #1 was discharged and in route to hospital #2 before physician (E) from hospital #2 and physician (G) from hospital #1 discussed patient #1's condition and prior to the transfer being accepted by hospital #2. The record did not reveal that patient #1 requested the discharge/transfer to hospital #2. A certification form that summarized the risks and benefits of the transfer was not completed and discussed with patient #1, and all necessary medical records were not sent with patient #1 at the time of discharge/transfer. Patient #1 was discharged from hospital #1 at 10:00 p.m. on 3/28/13.

Review of patient #1's 3/28/13 OB record (11:35 p.m. admission) from hospital #2 indicated patient #1 was 38 and 1/7 weeks pregnant, not in labor and that she required an emergent admission to the hospital related to her symptoms and condition. Patient #1 complained of a frontal headache and dizziness and her blood pressure was 173/104 at the time of admission to hospital #2. Patient #1's record verified that patient #1 had maternal gestational diabetes and that she had been insulin controlled since she was twenty-eight weeks pregnant. Patient #1 also had a history of obesity, pregnancy induced hypertension and pre-eclampsia. The record indicated patient #1 went to hospital #1 earlier in the evening. Patient #1 was not seen by a physician at hospital #1, and she was asked why she came to hospital #1 instead of going to hospital #2 where patient #1's physician was based. Patient #1 was told to go to hospital #2 (via her personal car) because she had 2+ protein in her urine. An examination at hospital #2 by physician (E) of patient #1's condition revealed that patient #1 required a vaginal delivery (via Pitocin induction at 3/29/13 at 1:24 a.m.) as soon as possible. The record revealed that patient #1's labor did not progress well due to the positioning of the infant, and patient #1 had a Cesarean section with delivery of her infant on 3/30/13 at 10:56 a.m.

Interviews:
When interviewed by phone on 4/12/13 at 2:45 p.m., nurse (D) told the SA investigator she was working on 3/28/13 when patient #1 arrived at hospital #1 and was triaged to the OB unit. Patient #1 complained of a headache, said she was diabetic and said her primary physician had been monitoring her blood pressure and protein level in her urine since she was twenty-two weeks pregnant. Nurse (D) performed patient #1 ' s medical screening examination and called physician (G) and informed him of patient #1's visit to hospital #1. Physician (G) said he would not be coming in to see patient #1, and he wondered why patient #1 came to hospital #1 for care instead of going directly to hospital #2. Patient #1's protein level was 2+, and physician (G) told nurse (D) to discharge patient #1 to hospital #2 and her primary physician for further care. Nurse (D) called hospital #2 and spoke with nurse (F) and told nurse (F) that patient #1 was being discharged from hospital #1 and sent to hospital #2 for further care with her primary physician. Patient #1 did not request to go to hospital #2, and patient #1 was not offered an ambulance transport to hospital #2. Physician (G) did not discuss the patient's discharge/transfer with on-call physician (E) prior to the patient leaving hospital #1 and being sent to hospital #2 for further care. The only paperwork that was sent with patient #1 was the 3/28/13 laboratory results.

When interviewed by phone on 4/11/13 at 3:00 p.m., nurse (F) told the SA investigator she received the call from nurse (D) at hospital #1 and nurse (D) said patient #1 was being sent to hospital #2 for further care. Patient #1 was sent to hospital #2 without a prior discussion between physician (G) from hospital #1 and physician (E) from hospital #2 related to the patient's condition and acceptance of transfer by hospital #2. When patient #1 arrived at hospital #2, patient #1 was upset and stated she felt like hospital #1 was trying to get rid of her. When patient #1 arrived, her blood pressure was very elevated and her lower extremities were very edematous. Hospital #1 only sent patient #1's laboratory results with her and did not include any other transfer paperwork.
When interviewed by phone on 4/11/13 at 2:10 p.m., physician (E) told the SA investigator that he was on-call (OB/GYN) at hospital #2 and received a call from physician (G) who told him that patient #1 was on her way from hospital #1 to hospital #2. There was no prior discussion between physicians (G) and (E) or prior acceptance of the transfer to hospital #2. After his conversation with physician (G), physician (E) determined that patient #1's stability was questionable and that patient #1 should have been transported by ambulance. Patient #1 required immediate hospitalization related to her symptoms. Patient #1 did not request to be sent to hospital #2. Patient #1 wondered why physician (G) did not come to see her when she was at hospital #1.
When interviewed by phone on 4/16/13 at 12:50 p.m., physician (G) told the SA investigator that he was on call (OB/GYN) at hospital #1 on the evening of 3/28/13. Nurse (D) called him and told him that patient #1 had a headache and a history of chronic hypertension and that patient #1 was wondering if she should go to hospital #2 related to her symptoms. Physician (G) told nurse (D) to check patient #1's urine for protein, and the urinalysis revealed that her urine was 2+ for protein. Physician (G) directed nurse (D) to discharge patient #1 to hospital #2. Physician (G) stated he thought about coming to hospital #1 to see patient #1 but decided not to come to the hospital. Physician (G) did not speak to physician (E) about patient #1 prior to patient #1 being discharged and on her way to hospital #2. He did not give nurse (D) an order to transport patient #1 by ambulance to hospital #2 because he thought patient #1 would have to pay the bill for the ambulance. He stated he realizes something could have happened during patient #1's transport via car to hospital #2. He stated he could have admitted patient #1 to hospital #1 and delivered her baby instead of sending her to hospital #2.
When interviewed by phone on 4/12/13 at 9:15 a.m., patient #1 told the SA investigator that she lives in a town that is approximately nine miles from hospital #1. She stated her primary physician is affiliated with hospital #2 which is sixty-eight miles from hospital #1. She stated she had a headache and dizziness and had been feeling poorly prior to going to hospital #1 on 3/28/13. She stated her blood pressure had been elevated for ten days prior to going to hospital #1. She stated she knew that these were symptoms of pre-eclampsia, and she stated she was aware of the risks of pre-eclampsia. She realized her condition was serious and that she needed to be hospitalized. Prior to going to hospital #1, she thought maybe she would be admitted to hospital #1 and deliver at hospital #1. Hospital #1 did not ask her if she wanted to be admitted to hospital #1, and she did not request to be discharged and transferred to hospital #2. Transport to hospital #2 via ambulance was not mentioned as an option, and physician (G) did not come to hospital #1 to see her. She was nervous during the drive to hospital #2 and was fearful that something might go wrong during the trip, such as possibly having a stroke. Hospital #2 was set up for the delivery of her baby when she arrived.