HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital (Hospital A/transferring hospital) failed to appropriately stabilize the patient's emergency medical condition to ensure proper assessment, monitoring and interventions were provided. See A-2407.

2. The hospital failed to ensure that the medical record included documentation about the risks and benefits of transfer. See A-2409-A.

3. The hospital failed to ensure that the receiving facility accepted the transfer.See A-2409-B.

4. The Hospital failed to ensure that the medical records were sent to the receiving hospital. See A-2409 -C.

The immediate jeopardy (IJ) began on 2/16/2025, due to the hospital's failure to properly address Pt. #1's medical and obstetrical needs while in the OB (Obstetric) triage area. Subsequently, Pt. #1 had diabetic ketoacidosis (acid build-up in the blood) and intrauterine fetal death, and was identified on 5/07/2025. The IJ was announced on 5/07/2025 during a meeting with the Chief Executive Officer, Chief Medical Officer, and Chief Quality and Nursing Officer, and was not removed by the survey exit date of 5/13/2025.

Based on document review, and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for transferred OB (obstetrics) patients, Hospital A (transferring hospital) failed to appropriately stabilize the patient's emergency medical condition to ensure proper assessment, monitoring and interventions were provided. Subsequently, Pt. #1 was transferred to Hospital B (receiving hospital) and found to be in DKA (diabetic ketoacidosis/acid in the blood that can lead to significant maternal and fetal morbidity and mortality) and IUFD (intrauterine fetal death).

Findings include:

1. The hospital's policy, "Emergency Medical Treatment (EMTALA)" (dated 12/2023) was reviewed and indicated, "Emergency medical condition" refers to both a labor and non-labor related emergency medical condition. Labor related emergency medical condition means a pregnant woman who is having contractions: when there is inadequate time to affect a safe transfer to another hospital before delivery, or when transfer may pose a threat to the health or safety of the woman or the unborn child ...placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy ...Stabilize - with respect to a labor-related emergency medical condition, the term "stabilize" means for a woman to deliver (including the placenta) as clinically determined ...If the patient has an emergency medical condition, the patient is to be treated in the ED [emergency department] or as an inpatient until the condition is stabilized or die. Patient is to be transferred appropriately."

2. The hospital's policy, "Triage" (dated 2020) was reviewed and indicated, "Purpose - to outline the care and evaluation for obstetrical patients presenting to the OB Triage ...Fetal status is assessed and documented at least 30 minutes on the OB Triage form ..."

3. On 5/5/2025, Pt. #1's clinical record (dated 2/16/2025) was reviewed and indicated:

-At 8:20 AM, Pt. #1 arrived at the Hospital A ED .

-At 8:28 AM, E #2 (ED Triage Nurse) noted, "Chief complaint - 28 weeks pregnant, complained of nausea, vomiting and body aches. Vital signs - blood pressure 136/88 (low blood pressure is below 90/60, high blood pressure is 130/80 and above), pulse 126 (Normal 60-100), respirations 21 (normal 12-20), temperature 98.4 (normal 97-99) and oxygen saturation 97% (Normal 92%-100%). No bleeding, no leaking. ED pain assessment - pain intensity (0-10) 6, pain present now, yes, pain onset gradual and duration -intermittent. Triage services - fetal heart monitor used -yes. There was no documentation of fetal heart rate in the ED. Pt. #1 seen by MD #2 (ED Physician). MD #2 spoke with MD#1 (OB Physician) who accepted Pt. #1.

-At 8:28 AM - ED MD #2 notes indicated, "-Physical exam - no apparent distress, general physical exam -normal inspection, conscious, alert, coherent - disposition: discharge to OB/gyn[obstetrics/gynecology], clinical impression - abdominal pain affecting pregnancy."

-At 8:50 AM - Pt. #1 had ultrasound. The ultrasound results noted, "Findings - there is a single live intrauterine pregnancy ...fetal heart rate is 130 (range from 120 to 160 beats per minute).

- At 9:50 AM, E #2's (OB Triage Nurse) note indicated, "(Pt. #1) on the unit, endorses that (Pt. #1) feels weak."

-At 9:55 AM - E #2 noted "(Pt. #1) had a large emesis of bile colored fluid. (Pt. #1) noted has had multiple episodes of vomiting. (Pt. #1) has general sickly appearance and malaise (weakness). Skin is pale, and mucous membranes very dry."

- At 10:00 AM - E #2 noted, "(Pt. #1) notes that (Pt. #1) is having back pain. Pain scale - 8, contractions intermittent, pain location -back. Uterine activity - external toco (refers to a tocodynamometer, a device used to monitor uterine contractions)."

-At 10:10 AM - E #2 noted, "FHR (fetal heart rate) baseline rate - 130."

- At 10:25 AM - E #2 noted, "FHR 130. Uterine activity -external toco -frequency 3-4 per minute, duration 80 seconds."

-At 10:35 AM - E #2 noted, "Unable to accurately monitor FHT[fetal heart tone], adjusting toco."

-At 10:47 AM - E #2 noted, "Contacted ambulance for transport to Hospital B (receiving hospital). Ambulance company noted ambulance would be at Hospital A in approximately 1 hour."

-At 11:07 AM - E #2 noted, "(E #2) notified (MD #1) that (E #3/OB nurse) was having difficulty keeping the baby on the monitor and that (E #2) will attempt to obtain fetal heart tones."

-At 11:25 AM - E #2 noted, "(E #2) having difficulty sustaining fetal heart tones on the external monitor. (E #2 and E #3) at the bedside and is able to audibly hear the fetal heart tones via the monitor ranging in the 125 -130s. (Pt. #1) endorses that (Pt. #1) is feeling fetal movement." There was no documentation of fetal heart rate on Pt. #1's fetal monitoring strip for this time.

-At 11:30 AM - E #2 noted, "(MD #1) notified (E #2) that (Pt. #1's) glucose is 452 (normal range between 70 and 100) and other labs are grossly abnormal." (Pt. #1's) urine ketone was 80/normal is 0. Anion gap was 24.2/normal 10-20. (High level of ketones and anion gap may indicate DKA).

-At 11:35 AM - E #2 noted, "(Pt. #1) had diabetes in (Pt. #1's) last pregnancy. (Pt. #1) stated that since that time, (Pt. #1) has not had any diabetes issues."

-At 11:40 AM - E #2 noted, "(E #2) attempting to adjust toco. (E #2) able audibly to hear heart tones ranging in the 130s but briefly registering on the fetal monitor." There was no documentation of fetal heart rate on Pt. #1's fetal monitoring strip for this time.

At 12:00 PM - E #2's noted, "(MD #1) performing bedside ultrasound where (MD #1) reported to (E #2 and E #3) that (MD #1) was able to see cardiac activity on the monitor." *There was no documentation of Pt. #1's bedside ultrasound results in Pt. #1's clinical record.

There was no documentation of Pt. #1's fetal heart rate after 11:25 AM in Pt. #1's clinical record.

-At 12:44 PM - E #2 noted, "(Pt. #1) transported off unit via stretcher accompanied by ambulance staff. Vitals: blood pressure 156/92, heart rate 120, spO2[peripheral oxygen saturation] -99 %."

4. MD #1's triage notes (dated 2/16/2025) indicated, "(Pt. #1) came to the ER (emergency room) (gravida[the number of times a woman has been pregnant] 8 para[the number of times a woman has given birth to a baby at or beyond 20 weeks gestation] 7) complaining of abdominal pain with nausea, body aches and pain. (Pt. #1) sent to OB for further evaluation ... (Pt.#1's) heart rate is 120. Preterm labor?? Vaginal exam - cervix thick and uneffaced. Plan -OB labs, OB ultrasound, IV (intravenous) fluid bolus, IV Zofran (nausea medication), consult for possible transfer MFM (maternal fetal medicine) was done with (MD #3 from Hospital B). (MD #3) accepted for transfer to Hospital B."

5. On 5/7/2025, Pt. #1's clinical record (dated 2/16/2025 through 2/20/2025) from Hospital B was reviewed and indicated, "Hospital course -( Pt. #1) presented as a transfer of care with IUFD, found to be in DKA on admission and transferred to MICU (medical intensive care unit). While in MICU, (Pt. #1) underwent treatment for DKA and also had an induction of labor. (Pt.#1) delivered a male infant with no nuchal cord (no cord-around-the neck), demised (dead)."

6. On 5/5/2025 at 11:45 AM, an interview was conducted with MD #1. MD #1 stated that Pt. #1 was transferred to Hospital B due to preterm labor. MD #1 stated that Hospital A could deliver babies 37 weeks and older. MD #1 stated that MD #1 did not know about Pt. #1's high blood glucose level. MD #1 stated if MD #1 knew about Pt. #1's high blood glucose level, MD #1 would have treated Pt. #1 prior to discharge.

7. On 5/5/2025 at 12:00 PM, an interview was conducted with the OB Nurse (E #2). E #2 stated that E #2 will never forget Pt. #1. E #2 stated that MD #1 told E #2 about Pt. #1's high glucose level. E #2 stated that MD #1 stated that Pt. #1 was going to be transferred to Hospital B. E #2 stated that Pt. #1 waited for about 1 hour before the ambulance arrived and the ambulance staff do not monitor fetal heart tones.

8. On 5/5/2025 at 1:00 PM, an interview was conducted with the OB Medical Director (MD #4). MD #4 stated that pregnant patients must be stabilized prior to transfer. MD #4 stated that Pt. #1's blood sugar should have been stabilized prior to transfer. MD #4 stated that MD #4 reviewed Pt. #1's fetal monitoring. MD #4 stated that when Pt. #1 had "D cells (decelerations, which temporary decreases in the baby's heart rate - can be a sign of fetal distress). MD #4 stated that Pt. #1 should have had "resuscitative measures" such as placed on oxygen after the D cells were noted on the fetal monitoring strip. MD #4 stated that MD #3 (from Hospital B) discussed Pt. #1's case with MD #4. MD #3 suggested to MD #4 that an RCA (root cause analysis) be conducted regarding Pt. #1. MD #4 stated that MD #4 thinks an RCA was initiated but is not completed.

9. On 5/5/2025 at 3:00 PM, an interview was conducted with the Director of Quality & Chief Nursing Officer (E #4). E #4 stated that E #4 does not think this was any incident report for Pt. #1.

10. On 5/6/2025 at 9:30 AM, a confidential interview was conducted with Z#1. Z#1 stated that Pt. #1 should not have been transferred until Pt. #1's blood glucose was stabilized. Z#1 stated that there was no incident report regarding this incident. Z#1 stated that Pt. #1 was dumped on Hospital B without providing any treatment to stabilize Pt. #1's condition.

11. On 5/7/2025 at 9:00 AM, an interview was conducted with Pt. #1. Pt. #1 stated that Pt. #1 went to Hospital A's emergency room for nausea and vomiting. Pt. #1 stated that Hospital A did an ultrasound and sent Pt.#1 to the OB department. Pt. #1 stated that Pt. #1 remembers the nurses telling the doctor to do something, but Pt. #1 can't remember details. Pt. #1 stated that Pt. #1 kept vomiting while Pt. #1 was at Hospital A. Pt. #1 stated that Pt. #1 was dying and became disoriented. Pt. #1 stated that Pt. #1 was transferred to Hospital B and put into the intensive care unit at Hospital B. Pt. #1 stated that Pt. #1 had no idea that Pt. #1 was in preterm labor. Pt. #1 stated that Pt. #1's baby boy died."

A. Based on document review and interview, it was determined that for 1 of 4 OB(obstetric) triage (Pt. #2), and 3 of 3 emergency department (Pt. #6, Pt. #7, and Pt. #8) clinical records reviewed for transfers, the hospital failed to ensure that the medical record included documentation about the risks and benefits of transfer.

Findings include:

1. On 5/06/2025, the hospital's policy titled, "Transfer/Referral of a Patient" (reviewed on 5/2021) was reviewed and included, "... It is the policy of (Name of Transferring Hospital) to provide appropriate... transfer of patients who have presented with an emergency medical condition... Explanation... 1. on the attending physician's written certification... the potential benefit of the transfer outweighs the increased risks associate with the transfer..."

2. On 5/06/2025, the clinical record for Pt. #2 was reviewed. On 3/4/2025, Pt. #2 was brought to the hospital's OB triage with a chief complain of (pregnancy in) labor. On 3/4/2025, Pt. #2 was transferred to another hospital due to a need for higher level of care. The clinical record did not include documentation regarding the risk and benefits of transfer.

3. On 5/06/2025, the clinical record for Pt. #6 was reviewed. On 4/26/2025, Pt. #6 was brought to the hospital's ED (emergency department) due to aggressive behavior. On 4/28/2025, Pt. #6 was transferred to another hospital due to a need for higher level of care. The clinical record did not include documentation regarding the risk and benefits of transfer.

4. On 5/06/2025, the clinical record for Pt. #7 was reviewed. On 4/21/2025, Pt. #7 was brought to the hospital's ED due to abdominal pain. On 4/22/2025, Pt. #7 was transferred to another hospital due to a need for higher level of care. The clinical record did not include documentation regarding the risk and benefits of transfer.

5. On 5/06/2025, the clinical record for Pt. #8 was reviewed. On 4/18/2025, Pt. #8 was brought to the hospital's ED due to hand problem. On 4/19/2025, Pt. #7 was transferred to another hospital due to a need for higher level of care. The clinical record did not include documentation regarding the risk and benefits of transfer.

6. On 5/06/2025 at approximately 2:18 PM, findings were discussed with MD #5 (Chief Medical Officer). MD #5 stated that the above patients had emergency medical condition that required higher level of care. MD #5 stated that explanation regarding the risk and benefits of the transfer should have been explained and documented in the clinical records.

B. Based on document review and interview, it was determined that for 2 of 3 emergency department (Pt. #7 and Pt. #8) clinical records reviewed for transfers, the hospital failed to ensure that the receiving facility accepted the transfer.

Findings include:

1. On 5/06/2025, the hospital's policy titled, "Transfer/Referral of a Patient" (reviewed on 5/2021) was reviewed and included, "... It is the policy of (Name of Transferring Hospital) to provide appropriate... transfer of patients who have presented with an emergency medical condition..." The policy did not include ensuring availability of qualified personnel at the receiving hospital.

2. On 5/06/2025, the clinical record for Pt. #7 was reviewed. On 4/21/2025, Pt. #7 was brought to the hospital's ED (emergency department) due to abdominal pain. On 4/22/2025, Pt. #7 was transferred to another hospital due to a need for higher level of care. There was no documentation to ensure that the receiving hospital had agreed to accept the transfer.

3. On 5/06/2025, the clinical record for Pt. #8 was reviewed. On 4/18/2025, Pt. #8 was brought to the hospital's ED due to hand problem. On 4/19/2025, Pt. #7 was transferred to another hospital due to a need for higher level of care... There was no documentation to ensure that the receiving hospital had agreed to accept the transfer.

4. On 5/06/2025 at approximately 2:18 PM, findings were discussed with MD #5 (Chief Medical Officer). MD #5 stated that there should be documentation in the clinical record to indicate availability of accepting physician.

C. Based on document review and interview, it was determined that 1 of 4 OB triage (Pt. #2), and 2 of 3 emergency department (Pt. #6, and Pt. #7) clinical records reviewed for transfers, the hospital failed to ensure that the medical records were sent to the receiving hospital.

Findings include:

1. On 5/06/2025, the hospital's policy titled, "Transfer/Referral of a Patient" (reviewed on 5/2021) was reviewed and included, "... It is the policy of (Name of Transferring Hospital) to provide appropriate... transfer of patients who have presented with an emergency medical condition... 5. A photocopy of patient's medical record and other documents as required will be sent with the patient..."

2. On 5/06/2025, the clinical record for Pt. #2 was reviewed. On 3/4/2025, Pt. #2 was brought to the hospital's OB triage with a chief complain of (pregnancy in) labor. On 3/4/2025, Pt. #2 was transferred to another hospital due to a need for higher level of care. There was no documentation to indicate that the patient's medical record and other document were sent to the receiving hospital.

3. On 5/06/2025, the clinical record for Pt. #6 was reviewed. On 4/26/2025, Pt. #6 was brought to the hospital's ED (emergency department) due to aggressive behavior. On 4/28/2025, Pt. #6 was transferred to another hospital due to a need for higher level of care. There was no documentation to indicate that the patient's medical record and other document were sent to the receiving hospital.

4. On 5/06/2025, the clinical record for Pt. #7 was reviewed. On 4/21/2025, Pt. #7 was brought to the hospital's ED due to abdominal pain. On 4/22/2025, Pt. #7 was transferred to another hospital due to a need for higher level of care. There was no documentation to indicate that the patient's medical record and other document were sent to the receiving hospital.

5. On 5/06/2025 at approximately 2:18 PM, findings were discussed with MD #5 (Chief Medical Officer). MD #5 stated that the above patients required higher level of care. MD #5 stated that there should be a documentation to indicate that the medical records were sent to the receiving hospital.